骨质疏松性骨折osteoporoticfxs.ppt

Background,Osteoporosis - a decreased bone density with normal bone mineralization WHO Definition (1994) Bone Mineral Density 2.5 SDs below the mean seen in young normal subjects Incidence increases with age 15% of white women age 50-59 70% of white women older than age 80,Background,Risk factors for osteoporosis Female sex European ancestry Sedentary lifestyle Multiple births Excessive alcohol use,Background,Senile osteoporosis common Some degree of osteopenia is found in virtually all healthy elderly patients Treatable causes should be investigated Nutritional deficiency Malabsorption syndromes Hyperparathyroidism Cushings disease Tumors,Background,The incidence of osteoporotic fractures is increasing Estimated that half of all women and one-third of all men will sustain a fragility fracture during their lifetime By 2050 6.3 million hip fractures will occur globally Enormous cost to society,Background,The most common fractures in the elderly osteoporotic patient include: Hip Fractures Femoral neck fractures Intertrochanteric fractures Subtrochanteric fractures Ankle fractures Proximal humerus fracture Distal radius fractures Vertebral compression fractures,Background,Fractures in the elderly osteoporotic patient represent a challenge to the orthopaedic surgeon The goal of treatment is to restore the pre-injury level of function Fracture can render an elderly patient unable to function independently -requiring institutionalized care,Background,Osteopenia complicates both 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,Pre-injury Status,Medical History Cognitive History Functional History Ambulatory status Community Ambulator Household Ambulator Non-Functional Ambulator Non-Ambulator Living arrangements,Pre-injury 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,Pre-injury 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,Pre-injury Status,Cognitive Status Critical to outcome Conditions may render patient unable to participate in rehabilitation Alzheimers CVA Parkinsons Senile dementia,Hip Fractures,General principles With the aging of the American population the incidence of hip fractures is projected to increase from 250,000 in 1990 to 650,000 by 2040 Cost approximately $8.7 billion annually 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 fractures 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 Operative delay of 24-48 hours increases one-year mortality rates However, important to balance medical optimization and expeditious fixation Early mobilization Decrease incidence of decubiti, UTI, atelectasis/respiratory infections DVT prophylaxis,Hip Fractures,Outcomes Fracture related outcomes Healing Quality of reduction Functional outcomes Ambulatory ability Mortality (25% at one year) Return to pre-fracture activities of daily living,Hip Fractures,Femoral neck fractures Intracapsular location Vascular Supply Medial and lateral circumflex vessels anastamose at the base of the neck blood supply predominately from ascending arteries (90%) Artery of ligamentum teres (10%),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 and Internal fixation 30% non-union and 25%-30% osteonecrosis rate Non-union requires reoperation 75% of the time while osteonecrosis leads to reoperation in 25% of cases,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 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,Common injury in the elderly Significant increase in the incidence and severity of ankle fractures over the last 20 years Low energy injuries following twisting reflecting the relative strength of the ligaments compared to osteopenic bone,Ankle Fractures,Epidemiology Finnish Study (Kannus et al) Three-fold increase in the number of ankle fractures among patients older than 70 years between 1970 and 2000 Increase in the more severe Lauge-Hansen SE-4 fracture In the United States, ankle fractures have been reported to occur in as many as 8.3 per 1000 Medicare recipients Figure that appears to be steadily rising.,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,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 resolution of edema to achieve a tension free closure,Ankle Fractures,Treatment Fixation may be suboptimal due to osteopenia May have to alter standard operative techniques Cement Augmentation Reports in literature mixed Early studies showed no difference in operative vs non-op treatment - with operative groups having higher complication rates More recent studies show improved outcomes in operatively treated group Goal is return to pre-injury functional status,Proximal Humerus,Background Very common fracture seen 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 Status of the rotator cuff is key,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 Locked plating versus prosthetic replacement,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 fracture in the elderly Result from 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,Radiographic evaluation PA Lateral Oblique Contralateral wrist Important to evaluate deformity, ulnar variance,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,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%,Vertebral Compression Fractures,Background Present with acute back pain Tender to palpation Neurologic deficit is rare Patterns Biconcave (upper lumbar) Anterior wedge (thoracic) Symmetric compression (T-L junction),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,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,Vertebral Compression Fractures,Treatment A corset may be helpful Most fractures heal uneventfully Kyphoplasty an option,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 Calcium/Vitamin D Supplements Calcitononin Bisphosphonates Teriparatide (Forteo),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,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),Prevention and Treatment of Bone Fragility,Calcium/Vitamin D Supplementation Recommended for most men and women 50 years Calcium Age 50 - 1,200 mg/day Vitamin D Age 51-70 - 400 IU/day Age 70 - 600 IU/day Combining Vitamin D and calcium supplementation has been shown to increase bone mineral density and reduce the risk of fracture,Prevention and Treatment of Bone Fragility,Calcitonin Inhibits bone resorption by inhibiting osteoclast activity Approved for treatment of