骨质疏松性骨折Osteoporotic-Fxs

Epidemiology, Diagnosis Prevention and Management of Osteoporotic Fractures,Kenneth A. Egol, MDNYU-Hospital For Joint DiseasesCreated March 2004; Revised May 2006,Background,Osteoporosis - a decreased bone density with normal bone mineralizationWHO Definition (1994)Bone Mineral Density 2.5 SDs below the mean seen in young normal subjectsIncidence increases with age15% of white women age 50-5970% of white women older than age 80,Background,Risk factors for osteoporosisFemale sexEuropean ancestrySedentary lifestyleMultiple birthsExcessive alcohol use,Background,Senile osteoporosis commonSome degree of osteopenia is found in virtually all healthy elderly patientsTreatable causes should be investigatedNutritional deficiencyMalabsorption syndromesHyperparathyroidismCushings diseaseTumors,Background,The incidence of osteoporotic fractures is increasingEstimated that half of all women and one-third of all men will sustain a fragility fracture during their lifetimeBy 2050 - 6.3 million hip fractures will occur globallyEnormous cost to society,Background,The most common fractures in the elderly osteoporotic patient include:Hip FracturesFemoral neck fracturesIntertrochanteric fracturesSubtrochanteric fracturesAnkle fracturesProximal humerus fractureDistal radius fracturesVertebral compression fractures,Background,Fractures in the elderly osteoporotic patient represent a challenge to the orthopaedic surgeonThe goal of treatment is to restore the pre-injury level of functionFracture can render an elderly patient unable to function independently -requiring institutionalized care,Background,Osteopenia complicates both fracture treatment and healingInternal fixation compromisedPoor screw purchaseIncreased risk of screw pull outAugmentation with methylmethacrylate has been advocated Increased risk of non-unionBone augmentation (bone graft, substitutes) may be indicated,Pre-injury Status,Medical HistoryCognitive HistoryFunctional HistoryAmbulatory statusCommunity AmbulatorHousehold AmbulatorNon-Functional AmbulatorNon-AmbulatorLiving arrangements,Pre-injury Status,Systemic diseasePre-existing cardiac and pulmonary disease is common in the elderlyDiminishes patients ability to tolerate prolonged recumbencyDiabetes increases wound complications and infectionMay delay fracture union,Pre-injury Status,American Society of Anesthesiologists (ASA) ClassificationASA I- normal healthyASA II- mild systemic diseaseASA III- Severe systemic disease, not incapacitatingASA IV- severe incapacitating diseaseASA V- moribund patient,Pre-injury Status,Cognitive StatusCritical to outcomeConditions may render patient unable to participate in rehabilitationAlzheimersCVA ParkinsonsSenile dementia,Hip Fractures,General principlesWith the aging of the American population the incidence of hip fractures is projected to increase from 250,000 in 1990 to 650,000 by 2040Cost approximately $8.7 billion annually20% higher incidence in urban areas15% lifetime risk for white females who live to age 80,Hip Fractures,EpidemiologyIncidence increases after age 50Female: Male ratio is 2:1Femoral neck and intertrochanteric fractures seen with equal frequency,Hip Fractures,Radiographic evaluationAnterior-posterior viewCross table lateralInternal rotation view will help delineate fracture pattern,Hip Fractures,Radiographic evaluationOccult hip fractureTechnetium bone scanning is a sensitive indicator, but may take 2-3 days to become positiveMagnetic resonance imaging has been shown to be as sensitive as bone scanning and can be reliably performed within 24 hours,Hip Fractures,ManagementPrompt operative stabilizationOperative delay of 24-48 hours increases one-year mortality ratesHowever, important to balance medical optimization and expeditious fixationEarly mobilizationDecrease incidence of decubiti, UTI, atelectasis/respiratory infectionsDVT prophylaxis,Hip Fractures,OutcomesFracture related outcomesHealingQuality of reductionFunctional outcomesAmbulatory abilityMortality (25% at one year)Return to pre-fracture activities of daily living,Hip Fractures,Femoral neck fracturesIntracapsular locationVascular SupplyMedial and lateral circumflex vessels anastamose at the base of the neckblood supply predominately from ascending arteries (90%)Artery of ligamentum teres (10%),Hip Fractures,Femoral neck fracturesTreatmentNon-displaced/ valgus impacted fracturesNon-operative 8-15% displacement rateOperative with cannulated screwsNon-union 5% and osteonecrosis is approximately 8%,Hip Fractures,Femoral neck fracturesDisplaced fractures should be treated operativelyTreatment: Open vs. Closed Reduction and Internal fixation30% non-union and 25%-30% osteonecrosis rateNon-union requires reoperation 75% of the time while osteonecrosis leads to reoperation in 25% of cases,Hip Fractures,Femoral neck fracturesTreatment: HemiarthroplastyUnipolar Vs BipolarCan lead to acetabular erosion, dislocation, infection,Hip Fractures,Femoral neck fracturesTreatmentDisplaced fractures can be treated non -operatively in certain situationsDemented, non-ambulatory patientMobilize earlyAccept resulting non or malunion,Hip Fractures,Intertrochanteric fracturesExtracapsular (well vascularized)Region distal to the neck between the trochantersCalcar femoralePosteromedial cortexImportant muscular insertions,Hip Fractures,Intertrochanteric fracturesTreatmentUsually treated surgicallyImplant of choice is a hip compression screw that slides in a barrel attached to a sideplateThe implant allows for controlled impaction upon weightbearing,Hip Fractures,Intertrochanteric fracturesTreatmentPrimary prosthetic replacement can be considered For cases with significant comminution,Hip Fractures,Subtrochanteric FracturesBegin at or below the level of the lesser trochanterTypically higher energy injuries seen in younger patientsfar less common in the elderly,Hip Fractures,Subtrochanteric FracturesTreatmentIntramedullary nail (high rates of union)Plates and screws,Ankle Fractures,Common injury in the elderlySignificant 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,EpidemiologyFinnish Study (Kannus et al)Three-fold increase in the number of ankle fractures among patients older than 70 years between 1970 and 2000Increase in the more severe Lauge-Hansen SE-4 fractureIn the United States, ankle fractures have been reported to occur in as many as 8.3 per 1000 Medicare recipientsFigure that appears to be steadily rising.,Ankle Fractures,PresentationFollows twisting of foot relative to lower tibiaPatients present unable to bear weightEcchymosis, deformityCareful neurovascular exam must be performed,Ankle Fractures,Radiographic evaluationAnkle trauma series includes:APLateralMortiseExamine entire length of the fibula,Ankle Fractures,TreatmentIsolated, non-displaced malleolar fracture without evidence of disruption of syndesmotic ligaments treated non-operatively with full weight bearingMy utilize walking cast or cast brace,Ankle Fractures,TreatmentUnstable fracture patterns with bimalleolar involvement, or unimalleolar fractures with talar displacement must be reducedTreatment closed requires a long leg cast to control rotationmay be a burden to an elderly patient,Ankle Fractures,TreatmentReductions that are unable to be attained closed require open reduction and internal fixationThe skin over the ankle is thin and prone to complicationAwait resolution of edema to achieve a tension free closure,Ankle Fractures,TreatmentFixation may be suboptimal due to osteopeniaMay have to alter standard operative techniquesCement AugmentationReports in literature mixedEarly studies showed no difference in operative vs non-op treatment - with operative groups having higher complication ratesMore recent studies show improved outcomes in operatively treated groupGoal is return to pre-injury functional status,Proximal Humerus,BackgroundVery common fracture seen in geriatric populations112/100,000 in men439/100,000 in womenResult of low energy traumaGoal is to restore pain free range of shoulder motion,Proximal Humerus,EpidemiologyIncidence rises dramatically beyond the fifth decade in women71% of all proximal humerus fractures occur in patients older than 60Associated with frail femalesPoor neuromuscular controlDecreased bone mineral density,Proximal Humerus,BackgroundArticulates with the glenoid portion of the scapula to form the shoulder jointFour partsCombination of bony, muscular, capsular and ligamentous structures maintains shoulder stabilityStatus of the rotator cuff is key,Proximal Humerus,Radiographic evaluationAPScapula YAxillaryCT scan can be helpful,Proximal Humerus,TreatmentMinimally displaced (one part fractures) usually stabilized by surrounding soft tissues Non operative: 91% good to excellent results,Proximal Humerus,TreatmentIsolated lesser tuberosity fractures require operative fixation only if the fragment contains a large articular portion or limits internal rotationIsolated greater tuberosity associated with longitudinal cuff tears and require ORIF,Proximal Humerus,TreatmentDisplaced surgical neck fractures can be treated closed by reduction under anesthesia with X-ray guidanceAnatomic neck fractures are rare but have a high rate of osteonecrosisIf acceptable reduction is not attained open reduction should be undertaken,Proximal Humerus,TreatmentClosed treatment of 3 and 4 part fractures have yielded poor resultsFailure of fixation is a problem in osteopenic boneLocked plating versus prosthetic replacement,Proximal Humerus,TreatmentRegardless of treatment all require prolonged, supervised rehabilitation programpoor results are associated with rotator cuff tears, malunion, nonunionProsthetic replacement can be expected to result in relatively pain free shouldersFunctional recovery and ROM variable,Distal Radius,BackgroundVery common fracture in the elderlyResult from low energy injuriesIncidence increases with age, particularly in womenAssociated with dementia, poor eyesight and a decrease in coordination,Distal Radius,EpidemiologyIncreasing in incidenceEspecially in womenPeak incidence in females 60-70Lifetime risk is 15%Most frequent cause: fall on outstretched armDecreased bone mineral density is a factor,Distal Radius,Radiographic evaluationPALateralObliqueContralateral wristImportant to evaluate deformity, ulnar variance,Distal Radius,TreatmentNon-displaced fractures may be immobilized for 6-8 weeksMetacarpal-phalangeal and interphalangeal joint motion must be started early,Distal Radius,TreatmentDisplaced fractures should be reduced with restoration of radial length, inclination and tiltUsually accomplished with longitudinal traction under hematoma blockIf satisfactory reduction is obtained treatment in a long arm or short arm cast is undertakenNo statistical difference in methodWeekly radiographs are required,Distal Radius,Treatment: Operativeif acceptable reduction not obtainedregional or general anesthesiaMethodsORIFClosed reduction and percutaneous pinning with external fixationBone grafting for dorsal comminution,Distal Radius,TreatmentResults are variable and depend on fracture type and reduction achievedMinimally displaced and fractures in which a stable reduction has been achieved result in good functional outcomes,Distal Radius,TreatmentDisplaced fractures treated surgically produce good to excellent results 70-90%Functional limits include pain, stiffness and decreased grip,Vertebral Compression Fractures,BackgroundNearly all post-menopausal women over age 70 have sustained a vertebral compression fractureUsually occur between T8 and L2Kyphosis and scoliosis may developmarkers for osteoporosis,Vertebral Compression Fractures,EpidemiologyMore common than hip fractures117/100,000Twice as common in femalesLifetime risk in a 50 year old white female is 32%,Vertebral Compression Fractures,BackgroundPresent with acute back painTender to palpationNeurologic deficit is rarePatternsBiconcave (upper lumbar)Anterior wedge (thoracic)Symmetric compression (T-L junction),Vertebral Compression Fractures,Radiographic evaluationAP and lateral radiographs of the spineSymptomatic vertebrae 1/3 height of adjacent Bone scan can differentiate old from new fractures,Vertebral Compression Fractures,TreatmentSimple osteoporotic vertebral compression fractures are treated non-operatively and symptomaticallyProlonged bedrest should be avoidedProgressive ambulation should be started earlyBack exercises should be started after a few weeks,Vertebral Compression Fractures,TreatmentA corset may be helpfulMost fractures heal uneventfullyKyphoplasty an option,Prevention,Strategies focus on controlling factors that predispose to fractureFall prevention,Prevention,Multidisciplinary programsMedical adjustmentBehavior modificationExercise classesControversial,Prevention and Treatment of Bone Fragility,Well established link between decreasing bone mass and risk of fractureTreatment of osteoporosisEstrogenCalcium/Vitamin D SupplementsCalcitononinBisphosphonatesTeriparatide (Forteo),Prevention and Treatment of Bone Fragility,Estrogen2-3% bone loss with menopauseUnopposed 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,FosmaxShown 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 SupplementationRecommended for most men and women 50 yearsCalcium Age 50 - 1,200 mg/dayVitamin DAge 51-70 - 400 IU/dayAge 70 - 600 IU/dayCombining 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,CalcitoninInhibits bone resorption by inhibiting osteoclast activityApproved for treatm