Current Management of Fragility Fractures in the Elderly

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Current Management of Fragility Fractures in the
Elderly

• Thomas M. Hupel MD, MSc, FRCS(C)
• Orthopaedic Surgeon
• Kitchener-Waterloo, Ontario

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Objectives

• Describe the types of fragility fractures
• Demonstrate the types of hip fractures
• Outline the treatment of hip fractures
• Post operative management of hip fractures

I declare no conflicts of interest in the
material presented
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Osteoporotic or Fragility Fracture

• Mechanical failure of bone due to the inability
  of the bone to sustain normal physiologic loads
• ½ of all women
• 1/3 of all men

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OSTEOPOROTIC BONE
NORMAL BONE
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Fragility Fractures

• Hip Fractures
• Vertebral compression fractures
• Pelvic Fractures
• Proximal humerus fractures
• Distal radius fractures

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Fragility Fractures in USA

• 250,000 hip fractures
• 250,000 distal radius fractures
• 700,000 vertebral fractures
• President of the United States 2002-2011
  Decade of the Bone and Joint

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Hip Fractures

• Most devastating consequence of osteoporosis
• silent epidemic asymptomatic until
  presentation

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Impact of Hip Fractures

• Expected patient survival reduced by 20
• 50 loose ability to walk
• One third become totally dependant or
  institutionalized

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Sub capital
Intertrochanteric
Sub trochanteric
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Subcapital Fractures

• Issue preserve or replace the hip ?
• Undisplaced 10 AVN
• Cannulated screws
• Displaced 30-50 AVN
• Moores
• Bipolar
• Total hip

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Intertrochanteric fractures
No risk of AVN
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Intertrochanteric Fractures

• Nail Screw device
• Gamma
• Trochanteric Fixation Nail (TFN)
• Plate screw device
• DHS (dynamic hip screw)
• AMBI

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Fig. 2 The Evans classification of
intertrochanteric hip fractures demonstrating the
importance of medial cortical stability12.
Lorich D. G. et.al. J Bone Joint Surg
200486398-410
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Fig. 4 Dynamic hip screw construct demonstrating
fracture impaction and sound femoral head screw
fixation.
Lorich D. G. et.al. J Bone Joint Surg
200486398-410
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Schematic of a first-generation Gamma nail,
demonstrating the 10 offset and the length of
the device
Lorich D. G. et.al. J Bone Joint Surg
200486398-410
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Fig. 15 Fixation of a reverse obliquity fracture
with a trochanteric femoral nail device.
Lorich D. G. et.al. J Bone Joint Surg
200486398-410
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Sub Trochanteric Fractures
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Fig. 1 Illustrations depicting the Russell-Taylor
system for the classification of subtrochanteric
fractures.
Robinson C. M. et.al. J Bone Joint Surg
2005872217-2226
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Subtrochanteric Hip Fractures
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Periprosthetic Fractures

• Fractures of the femur around a prosthesis
• Hip
• Femoral stem
• Acetabulum
• Total knee arthroplasty
• Issue is the prosthesis now loose ?

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Fig. 1 Kaplan-Meier survival curves for the
patient cohorts
Bhattacharyya T. et.al. J Bone Joint Surg
2007892658-2662
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Fig. 3-B Three months later, after a misstep,
the patient sustained a periprosthetic fracture
through an osteolytic defect.
LEWALLEN D. G., BERRY D. J. J Bone Joint Surg
1997791881-90
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Post Operative Management

• Housekeeping issues
• Perioperative anemia
• Electrolyte abnormalities
• Delirium
• Ulcers
• Co morbidities
• Physiotherapy
• Early mobilization
• Usually WBAT
• Disposition Issues

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Anticoagulation

• 50 DVT in non anticoagulated THA
• 1 risk of PE in first 6 months post THA
• Rates highest during index hospitalization
• Decreased after first 4 weeks

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Anticoagulation THA/hip

• LMWH
• 28-35days post op
• Warfarin 6-8 weeks
• Alternative to LMWH

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Anticoagulation - GRH

• THA
• 5 days of tinzaparin 75 iu/Kg/SQ/OD
• 9 days fondaparinux 2.5 mg SQ/OD
• Hip Fracture
• Tinzaparin 5 days or more depending on length of
  hospitalization
• Probably discharged to LTC on nothing
• Warfarin if used pre op for comorbidity

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Perioperative Mortality Hip

• 4 die at initial hospitalization
• 8.2 die in first 30 days
• 25-30 die in first year
• Rate of mortality 2X higher in men

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Other Osteoporotic Fractures

• Hip fracture risk
• Distal radius 3.22 X (15 years earlier)
• Proximal humerus 5.76 X
• Ankle 1.3 X
• Hip 10 X
• Vertebral fracture
• 50 will have another vertebral fracture in next
  3 years

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Pelvic Fractures

• Low energy falls
• Usually stable
• Hospitalization for support
• Analgesia
• Physiotherapy
• Early mobilization (WBAT)
• Prognosis excellent for fracture healing in 6-8
  weeks

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Fig. 2-A FIgs. 2-A through 2-E A
seventy-eight-year-old woman had an insidious
onset of right-sided pain in the posterior and
anterior aspects of the pelvis and severe
instability that necessitated the use of a walker
Mears D. C., Velyvis J. H. J Bone Joint Surg
200284-A721-728
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Distal Radius Fractures

• Common
• Usually non operative
• Closed reduction in ER and casting
• Malunion most common outcome
• Radial shortening
• Radial deviation
• Prominent ulnar head
• Permanent loss of motion
• Functional outcome usually obtained
• Surgery sometimes required

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Figs. 4-A and 4-B Fig. 4-A A comminuted
intra-articular fracture, with a step-off of gt2 mm
Simic P. M., Weiland A. J. J Bone Joint Surg
200385-A552-564
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Figs. 3-A and 3-B Fig. 3-A A dorsally displaced
fracture, with severe comminution of both the
volar and dorsal cortices
Simic P. M., Weiland A. J. J Bone Joint Surg
200385-A552-564
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Fig. 1 Earlier external fixation devices tended
to be bulky and awkward and limited the ability
to manipulate and fine-tune positioning
Simic P. M., Weiland A. J. J Bone Joint Surg
200385-A552-564
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Fig. 17 Fractures of the volar rim can be
stabilized with use of a contoured buttress plate.
TRUMBLE T. E. et.al. J Bone Joint Surg
199880582-600
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Figs. 6-A and 6-B Fig. 6-A An intra-articular
fracture with severe volar and dorsal comminution
Simic P. M., Weiland A. J. J Bone Joint Surg
200385-A552-564
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Proximal Humerus Fractures

• Common
• Low energy falls
• 80 non operative
• Early range of motion
• Malunion common
• Permanent loss of motion
• Functional range of motion usually achieved

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Classification Parts
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Fig. 1-A Fig. 1-B Fig. 1-A Anteroposterior
shoulder radiograph of a seventy-two-year-old
woman who fell in her bathtub and sustained a
four-part valgus-impacted proximal humeral
fracture
Owsley K. C., Gorczyca J. T. J Bone Joint Surg
200890233-240
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Fig. 1-A Fig. 1-B Fig. 1-A Anteroposterior
shoulder radiograph of a seventy-two-year-old
woman who fell in her bathtub and sustained a
four-part valgus-impacted proximal humeral
fracture
Owsley K. C., Gorczyca J. T. J Bone Joint Surg
200890233-240
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Proximal Humerus Fractures
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Primary Hemiarthroplasty

• Indications
• anatomic neck (AVN)
• fracture dislocations
• 4 part fractures
• head split fractures

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Fig. 2 Classification of osteoporotic vertebral
structure and deformity. a A normal vertebral
body. b A wedge fracture. c A biconcave
fracture. d A crush fracture.
Rao R. D., Singrakhia M. D. J Bone Joint Surg
200385-A2010-2022
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Fig. 5 Restoration of vertebral height during
vertebroplasty. a A fractured vertebral body
with an intravertebral mobile cleft. b Extension
positioning opens the cleft within the vertebral
body, allowing some restoration of vertebral body
height. c Methylmethacrylate injection
stabilizes the fracture in this position.
Rao R. D., Singrakhia M. D. J Bone Joint Surg
200385-A2010-2022
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Role of the Ortho Surgeon

• More than operative management
• Ministry sponsored programs
• Identify patients with osteoporosis
• Make patients primary care physician aware
• Appropriate investigations and treatment initiated

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Thank You