orthopaedics and trauma

1. Epidemiology, Diagnosis
Prevention and Management of
Osteoporotic Fractures
Kenneth A. Egol, MD
NYU-Hospital For Joint Diseases

2. Background
• Elderly injuries = orthopaedic challenge
• Elderly sustain a disproportionate number
of fractures
• Goal : restore preinjury level of function
• Injury can render a patient unable to
function independently and require
institutionalized care

3. Background
• Common fractures in elderly include:
– Femoral neck fractures
– Intertrochanteric fractures
– Subtrochanteric fractures
– Ankle fractures
– Proximal humerus fracture
– Distal radius fractures
– Vertebral compression fractures
– Pathologic fractures

4. Preinjury Status
• Goal is to restore patient to preinjury level
of function
• Ambulatory level
– Community ambulator
– Household ambulator
– Non-functional ambulatory
– Non-ambulatory

5. Preinjury Status
• Medical History
• Cognitive History
• Functional History
– Ambulatory status
– Living arrangements

6. Preinjury Status
• Systemic disease
– Pre-existing cardiac and pulmonary disease is
common in the elderly
– Diminishes patients ability to tolerate
prolonged recumbency
– Diabetes increases wound complications and
infection
– May delay fracture union

7. Preinjury Status
• American Society of Anesthesiologists
(ASA) Classification
– ASA I- normal healthy
– ASA II- mild systemic disease
– ASA III- Severe systemic disease, not
incapacitating
– ASA IV- severe incapacitating disease
– ASA V- moribund patient

8. Preinjury Status
• Systemic disease
– Peripheral vascular disease
– Thromboembolic disease

9. Preinjury Status
• Cognitive Status
– Critical to outcome
– Conditions may render patient unable to
participate in rehabilitation
• Alzheimer’s
• CVA
• Parkinson's
• Senile dementia

10. Osteopenia
• Osteoporosis is a decreased bone density
with normal bone mineralization
• Osteomalacia is a decreased bone matrix
mineralization with or without a change in
bone density
• Some degree of osteopenia is found in
virtually all healthy elderly patients

11. Osteopenia
• Senile osteoporosis common
• Treatable causes should be investigated
– Nutritional deficiency
– Malabsorption syndromes
– Hyperparathyroidism
– Cushings disease
– Tumors

12. Osteopenia
• Risk factors
– Female sex
– European ancestry
– Sedentary lifestyle
– Multiple births
– Excessive alcohol use

13. Osteopenia
• Complicates fracture treatment and healing
• Internal fixation compromised
– Poor screw purchase
– Increased risk of screw pull out
– Augmentation with methylmethacrylate has been
advocated
• Increased risk of non-union
– Bone augmentation (bone graft, substitutes) may be
indicated

14. Hip Fractures
• General principles
– Approximately 250,000 hip fractures/ year
– Cost approximately $8.7 billion annually
– The number of hip fractures is expected to
double by the year 2050

15. Hip Fractures
• Epidemiology
– Incidence in U.S is 80/100,000
– Only 5.6/100,000 in S. African Bantus
– 20% higher incidence in urban areas
– 15% lifetime risk for white females who live to
age 80

16. Hip Fractures
• Epidemiology
– Incidence increases after age 50
– Female: Male ratio is 2:1
– Femoral neck and intertrochanteric seen with
equal frequency

17. Hip Fractures
• Radiographic evaluation
– Anterior-posterior view
– Cross table lateral
– internal rotation view will help delineate
fracture pattern

18. Hip Fractures
• Radiographic evaluation
– Occult hip fracture
• Technetium bone scanning is a sensitive indicator,
but may take 2-3 days to become positive
• Magnetic resonance imaging has been shown to be
as sensitive as bone scanning and can be reliably
performed within 24 hours

19. Hip Fractures
• Management
– Prompt operative stabilization
– Early mobilization
– DVT prophylaxis

20. Hip Fractures
• Outcomes
– Fracture related outcomes
• Healing
• Quality of reduction
– Functional outcomes
• Ambulatory ability
• Mortality (25% at one year)
• Return to prefracture activities of daily living

21. Hip Fractures
• Femoral neck fractures
– Intracapsular location
– Vascular Supply
• Medial and lateral circumflex vessels anastomose at
the base of the neck and blood supply predominately
from ascending arteries (90%)
• Artery of ligamentum teres (10%)

22. Hip Fractures
• Femoral neck fractures
– Numerous classification schemes
– Non-displaced and displaced most useful for
treatment and complications

23. Hip Fractures
• Femoral neck fractures
• Treatment
– Non-displaced/ valgus impacted fractures
• Non-operative 8-15% displacement rate
• Operative with cannulated screws
• Non-union 5% and osteonecrosis is approximately
8%

24. Hip Fractures
• Femoral neck fractures
– Displaced fractures should be treated
operatively
– Treatment: Open vs. Closed Reduction Internal
fixation
• 30% non-union and 25%-30% osteonecrosis rate
• Non-union requires reoperation 75% of the time
while osteonecrosis leads to 25% reoperation

25. Hip Fractures
• Femoral neck fractures
• Treatment: Hemiarthroplasty
– Unipolar Vs Bipolar
– Can lead to acetabular erosion, dislocation,
infection

26. Hip Fractures
• Femoral neck fractures
• Treatment
– Displaced fractures can be treated non
-operatively in certain situations
• Demented, non-ambulatory patient
– Mobilize early
• Accept resulting non or malunion

27. Hip Fractures
• Intertrochanteric fractures
– Extracapsular (well vascularized)
– Region distal to the neck between the
trochanters
– Calcar femorale
– Posteromedial cortex
– Important muscular insertions

28. Hip Fractures
• Intertrochanteric fractures
– Numerous classifications exist
• Stable (posteromedial cortex intact) Vs unstable
(posteromedial cortex off)
– Key to treatment is obtaining a stable reduction

29. Hip Fractures
• Intertrochanteric fractures
– Treatment
• Usually treated surgically
• Implant of choice is a hip compression screw that
slides in a barrel attached to a sideplate
• The implant allows for controlled impaction upon
weightbearing

30. Hip Fractures
• Intertrochanteric fractures
– Treatment
• Primary prosthetic replacement can be considered
• For cases with significant comminution

31. Hip Fractures
• Subtrochanteric Fractures
– Begin at or below the level of the lesser
trochanter
– Typically higher energy injuries seen in
younger patients
– far less common in the elderly

32. Hip Fractures
• Subtrochanteric Fractures
– Treatment
• Intramedullary nail (high rates of union)
• Plates and screws

33. Ankle Fractures
• Background
– Common injury in the elderly
– low energy injuries following twisting
reflecting the relative strength of the ligaments
compared to osteopenic bone

34. Ankle Fractures
• Epidemiology
– Age specific incidence in women older than 50
has increased over past 30 years
– 187/100,000

35. Ankle Fractures
• Presentation
– Follows twisting of foot relative to lower tibia
– Patients present unable to bear weight
– Ecchymosis, deformity
– Careful neurovascular exam must be performed

36. Ankle Fractures
• Radiographic evaluation
– Ankle trauma series includes:
• AP
• Lateral
• Mortise
– Examine entire length of the fibula

37. Ankle Fractures
• Classification
– Lauge-Hansen
– Danis-Weber
• Beyond the scope of this talk

38. Ankle Fractures
• Treatment
– Isolated, non-displaced malleolar fracture
without evidence of disruption of syndesmotic
ligaments treated non-operatively with full
weight bearing
– My utilize walking cast or cast brace

39. Ankle Fractures
• Treatment
– Unstable fracture patterns with bimalleolar
involvement, or unimalleolar fractures with
talar displacement must be reduced
– Treatment closed requires a long leg cast to
control rotation
• may be a burden to an elderly patient

40. Ankle Fractures
• Treatment
– Reductions that are unable to be attained closed
require open reduction and internal fixation
– The skin over the ankle is thin and prone to
complication
– Await swelling reduction to achieve a tension
free closure

41. Ankle Fractures
• Treatment
– Fixation may be suboptimal due to osteopenia
– Reports in literature mixed
• Some no difference in operative Vs non-op
treatment
• Some better outcomes in operatively treated group
– Goal is return to preinjury functional status

42. Proximal Humerus
• Background
– Very common in geriatric populations
– 112/100,000 in men
– 439/100,000 in women
– Result of low energy trauma
– Goal is to restore pain free range of shoulder
motion

43. Proximal Humerus
• Epidemiology
– Incidence rises dramatically beyond the fifth
decade in women
– 71% of all proximal humerus fractures occur in
patients older than 60
– Associated with
• frail females
• Poor neuromuscular control
• Decreased bone mineral density

44. Proximal Humerus
• Background
– Articulates with the glenoid portion of the
scapula to form the shoulder joint
– Four parts
– Combination of bony, muscular, capsular and
ligamentous structures maintains shoulder
stability
– Rotator cuff key

45. Proximal Humerus
• Classification (Neer)
– 4 part system
• Head
• Shaft
• Greater tuberosity
• Lesser tuberosity

46. Proximal Humerus
• Radiographic evaluation
– AP
– Scapula Y
– Axillary
– CT scan can be helpful

47. Proximal Humerus
• Treatment
– Minimally displaced (one part fractures)
usually stabilized by surrounding soft tissues
• Non operative: 91% good to excellent results

48. Proximal Humerus
• Treatment
– Isolated lesser tuberosity fractures require
operative fixation only if the fragment contains
a large articular portion or limits internal
rotation
– Isolated greater tuberosity associated with
longitudinal cuff tears and require ORIF

49. Proximal Humerus
• Treatment
– Displaced surgical neck fractures can be treated
closed by reduction under anesthesia with X-
ray guidance
• Anatomic neck fractures are rare but have a high
rate of osteonecrosis
– If acceptable reduction is not attained open
reduction should be undertaken

50. Proximal Humerus
• Treatment
– Closed treatment of 3 and 4 part fractures have
yielded poor results
– Failure of fixation is a problem in osteopenic
bone
– Prosthetic replacement has been recommended

51. Proximal Humerus
• Treatment
– Regardless of treatment all require prolonged,
supervised rehabilitation program
– poor results are associated with rotator cuff
tears, malunion, nonunion
– Prosthetic replacement can be expected to result
in relatively pain free shoulders
– Functional recovery and ROM variable

52. Distal Radius
• Background
– Very common in the elderly
– Low energy injuries
– Incidence increases with age, particularly in
women
– Associated with dementia, poor eyesight and a
decrease in coordination

53. Distal Radius
• Epidemiology
– Increasing in incidence
• Especially in women
– Peak incidence in females 60-70
– Lifetime risk is 15%
– Most frequent cause: fall on outstretched arm
– Decreased bone mineral density is a factor

54. Distal Radius
• Background
– Distal radius and ulna articulate with each other
and the carpal bones
– Many classifications based on fracture
geometry, degree of displacement ,
comminution, and articular involvement

55. Distal Radius
• Radiographic evaluIation
– PA
– Lateral
– Oblique
– Contralateral wrist
• Important to evaluate deformity

56. Distal Radius
• Treatment
– Non-displaced fractures may be immobilized
for 6-8 weeks
– Metacarpal-phalangeal and interphalangeal
joint motion must be started early

57. Distal Radius
• Treatment
– Displaced fractures should be reduced with
restoration of radial length, inclination and tilt
• Usually accomplished with longitudinal traction
under hematoma block
– If satisfactory reduction is obtained treatment in
a long arm or short arm cast is undertaken
• No statistical difference in method
– Weekly radiographs are required

58. Distal Radius
• Treatment: Operative
– if acceptable reduction not obtained
– regional or general anesthesia
– Methods
• ORIF
• Closed reduction and percutaneous pinning with
external fixation
– Bone grafting for dorsal comminution

59. Distal Radius
• Treatment
– Results are variable and depend on fracture
type and reduction achieved
– Minimally displaced and fractures in which a
stable reduction has been achieved result in
good functional outcomes

60. Distal Radius
• Treatment
– Displaced fractures treated surgically produce
good to excellent results 70-90%
– Functional limits include pain, stiffness and
decreased grip

61. Vertebral Compression Fractures
• Background
– Nearly all post menopausal women over age 70
have sustained a vertebral compression fracture
– Usually occur between T8 and L2
– Kyphosis and scoliosis may develop
• markers for osteoporosis

62. Vertebral Compression Fractures
• Epidemiology
– More common than hip fractures
– 117/100,000
– Twice as common in females
– Lifetime risk in a 50 year old white female is
32%

63. Vertebral Compression Fractures
• Background
– Present with acute back pain
– Tender to palpation
– Neurologic deficit is rare

64. Vertebral Compression Fractures
• Background
• Patterns
– Biconcave (upper lumbar)
– Anterior wedge (thoracic)
– Symmetric compression (T-L junction)

65. Vertebral Compression Fractures
• Radiographic evaluation
– AP and lateral radiographs of the spine
– Symptomatic vertebrae 1/3 height of adjacent
– Bone scan can differentiate old from new
fractures

66. Vertebral Compression Fractures
• Treatment
– Simple osteoporotic vertebral compression
fractures are treated non-operatively and
symptomatically
– Prolonged bedrest should be avoided
– Progressive ambulation should be started early
– Back exercises should be started after a few
weeks

67. Vertebral Compression Fractures
• Treatment
– A corset may be helpful
– Most fractures heal uneventfully

68. Prevention
• Strategies focus on controlling factors that
predispose to fracture
• Fall prevention

69. Prevention
• Multidisciplinary programs
– Medical adjustment
– Behavior modification
– Exercise classes
– Controversial

70. Prevention and Treatment of
Bone Fragility
• Well established link between decreasing
bone mass and risk of fracture
• Treatment of osteoporosis
– Estrogen
– Ca supplements
– Vit D
– Calcitononin
– Bisphosphonates

71. Prevention and Treatment of
Bone Fragility
• Estrogen
– 2-3% bone loss with menopause
– Unopposed or combined therapy has been
shown to reduce hip fracture incidence in
women aged 65-74 by 40-60% (Henderson et
al. 1988)
– Risk of breast and endometrial cancer increased
in unopposed therapy

72. Prevention and Treatment of
Bone Fragility
• Fosmax
– Shown to increase the bone density in femoral
neck in post menopausal women with
osteoporosis (Lieberman et al. NEJM 1995)
– Reduced hip fracture rate by 50% in women
who had sustained a previous vertebral fracture.
(Black et al. Lancet 1996)

73. Conclusions
• Prevention is multifaceted
• Cost containment also a joint effort between
orthopaedists, primary care physicians, PT and
social work
• Functional outcome is maximized by early
fixation and mobilization in operative cases
• Number of elderly is increasing all will have to
work together in difficult economic times
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