g16 osteoporotic fxs

Epidemiology, Diagnosis Prevention and Management of

Osteoporotic Fractures

Kenneth A. Egol, MDNYU-Hospital For Joint Diseases

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

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

Preinjury Status

• Goal is to restore patient to preinjury level of function

• Ambulatory level– Community ambulator– Household ambulator– Non-functional ambulatory– Non-ambulatory

Preinjury Status

• Medical History• Cognitive History• Functional History

– Ambulatory status– Living arrangements

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

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

Preinjury Status

• Systemic disease– Peripheral vascular disease– Thromboembolic disease

Preinjury Status

• Cognitive Status– Critical to outcome– Conditions may render patient unable to

participate in rehabilitation• Alzheimer’s• CVA• Parkinson's• Senile dementia

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

Osteopenia

• Senile osteoporosis common• Treatable causes should be investigated

– Nutritional deficiency– Malabsorption syndromes– Hyperparathyroidism– Cushings disease– Tumors

Osteopenia

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

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

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

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

Hip Fractures

• Epidemiology– Incidence increases after age 50– Female: Male ratio is 2:1– Femoral neck and intertrochanteric seen with

equal frequency

Hip Fractures

• Radiographic evaluation– Anterior-posterior view– Cross table lateral– internal rotation view will help delineate

fracture pattern

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

Hip Fractures

• Management– Prompt operative stabilization– Early mobilization– DVT prophylaxis

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

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%)

Hip Fractures

• Femoral neck fractures– Numerous classification schemes– Non-displaced and displaced most useful for

treatment and complications

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%

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

Hip Fractures

• Femoral neck fractures• Treatment: Hemiarthroplasty

– Unipolar Vs Bipolar– Can lead to acetabular erosion, dislocation,

infection

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

Hip Fractures

• Intertrochanteric fractures– Extracapsular (well vascularized)– Region distal to the neck between the

trochanters– Calcar femorale– Posteromedial cortex– Important muscular insertions

Hip Fractures

• Intertrochanteric fractures– Numerous classifications exist

• Stable (posteromedial cortex intact) Vs unstable (posteromedial cortex off)

– Key to treatment is obtaining a stable reduction

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

Hip Fractures

• Intertrochanteric fractures– Treatment

• Primary prosthetic replacement can be considered • For cases with significant comminution

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

Hip Fractures

• Subtrochanteric Fractures– Treatment

• Intramedullary nail (high rates of union)• Plates and screws

Ankle Fractures

• Background– Common injury in the elderly– low energy injuries following twisting

reflecting the relative strength of the ligaments compared to osteopenic bone

Ankle Fractures

• Epidemiology– Age specific incidence in women older than 50

has increased over past 30 years– 187/100,000

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

Ankle Fractures

• Radiographic evaluation– Ankle trauma series includes:

• AP• Lateral• Mortise

– Examine entire length of the fibula

Ankle Fractures

• Classification– Lauge-Hansen– Danis-Weber

• Beyond the scope of this talk

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

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

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

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

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

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

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

Proximal Humerus

• Classification (Neer)– 4 part system

• Head• Shaft• Greater tuberosity• Lesser tuberosity

Proximal Humerus

• Radiographic evaluation– AP– Scapula Y– Axillary– CT scan can be helpful

Proximal Humerus

• Treatment– Minimally displaced (one part fractures)

usually stabilized by surrounding soft tissues

• Non operative: 91% good to excellent results

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

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

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

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

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

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

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

Distal Radius

• Radiographic evaluIation– PA– Lateral– Oblique– Contralateral wrist

• Important to evaluate deformity

Distal Radius

• Treatment– Non-displaced fractures may be immobilized

for 6-8 weeks– Metacarpal-phalangeal and interphalangeal

joint motion must be started early

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

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

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

Distal Radius

• Treatment– Displaced fractures treated surgically produce

good to excellent results 70-90%– Functional limits include pain, stiffness and

decreased grip

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


• 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%


• Background– Present with acute back pain– Tender to palpation– Neurologic deficit is rare


• Background• Patterns

– Biconcave (upper lumbar)– Anterior wedge (thoracic)– Symmetric compression (T-L junction)


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

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


• Treatment– A corset may be helpful– Most fractures heal uneventfully

Prevention

• Strategies focus on controlling factors that predispose to fracture

• Fall prevention

Prevention

• Multidisciplinary programs– Medical adjustment– Behavior modification– Exercise classes– Controversial

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


• 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


• 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)

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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