《骨质疏松性骨折》PPT课件.ppt

Epidemiology DiagnosisPreventionandManagementofOsteoporoticFractures KennethA Egol MDNYU HospitalForJointDiseasesCreatedMarch2004 RevisedMay2006 Background Osteoporosis adecreasedbonedensitywithnormalbonemineralizationWHODefinition 1994 BoneMineralDensity 2 5SD sbelowthemeanseeninyoungnormalsubjectsIncidenceincreaseswithage15 ofwhitewomenage50 5970 ofwhitewomenolderthanage80 Background RiskfactorsforosteoporosisFemalesexEuropeanancestrySedentarylifestyleMultiplebirthsExcessivealcoholuse Background SenileosteoporosiscommonSomedegreeofosteopeniaisfoundinvirtuallyallhealthyelderlypatientsTreatablecausesshouldbeinvestigatedNutritionaldeficiencyMalabsorptionsyndromesHyperparathyroidismCushingsdiseaseTumors Background TheincidenceofosteoporoticfracturesisincreasingEstimatedthathalfofallwomenandone thirdofallmenwillsustainafragilityfractureduringtheirlifetimeBy2050 6 3millionhipfractureswilloccurgloballyEnormouscosttosociety Background Themostcommonfracturesintheelderlyosteoporoticpatientinclude HipFracturesFemoralneckfracturesIntertrochantericfracturesSubtrochantericfracturesAnklefracturesProximalhumerusfractureDistalradiusfracturesVertebralcompressionfractures Background FracturesintheelderlyosteoporoticpatientrepresentachallengetotheorthopaedicsurgeonThegoaloftreatmentistorestorethepre injuryleveloffunctionFracturecanrenderanelderlypatientunabletofunctionindependently requiringinstitutionalizedcare Background OsteopeniacomplicatesbothfracturetreatmentandhealingInternalfixationcompromisedPoorscrewpurchaseIncreasedriskofscrewpulloutAugmentationwithmethylmethacrylatehasbeenadvocatedIncreasedriskofnon unionBoneaugmentation bonegraft substitutes maybeindicated Pre injuryStatus MedicalHistoryCognitiveHistoryFunctionalHistoryAmbulatorystatusCommunityAmbulatorHouseholdAmbulatorNon FunctionalAmbulatorNon AmbulatorLivingarrangements Pre injuryStatus SystemicdiseasePre existingcardiacandpulmonarydiseaseiscommonintheelderlyDiminishespatientsabilitytotolerateprolongedrecumbencyDiabetesincreaseswoundcomplicationsandinfectionMaydelayfractureunion Pre injuryStatus AmericanSocietyofAnesthesiologists ASA ClassificationASAI normalhealthyASAII mildsystemicdiseaseASAIII Severesystemicdisease notincapacitatingASAIV severeincapacitatingdiseaseASAV moribundpatient Pre injuryStatus CognitiveStatusCriticaltooutcomeConditionsmayrenderpatientunabletoparticipateinrehabilitationAlzheimer sCVAParkinson sSeniledementia HipFractures GeneralprinciplesWiththeagingoftheAmericanpopulationtheincidenceofhipfracturesisprojectedtoincreasefrom250 000in1990to650 000by2040Costapproximately 8 7billionannually20 higherincidenceinurbanareas15 lifetimeriskforwhitefemaleswholivetoage80 HipFractures EpidemiologyIncidenceincreasesafterage50Female Maleratiois2 1Femoralneckandintertrochantericfracturesseenwithequalfrequency HipFractures RadiographicevaluationAnterior posteriorviewCrosstablelateralInternalrotationviewwillhelpdelineatefracturepattern HipFractures RadiographicevaluationOcculthipfractureTechnetiumbonescanningisasensitiveindicator butmaytake2 3daystobecomepositiveMagneticresonanceimaginghasbeenshowntobeassensitiveasbonescanningandcanbereliablyperformedwithin24hours HipFractures ManagementPromptoperativestabilizationOperativedelayof 24 48hoursincreasesone yearmortalityratesHowever importanttobalancemedicaloptimizationandexpeditiousfixationEarlymobilizationDecreaseincidenceofdecubiti UTI atelectasis respiratoryinfectionsDVTprophylaxis HipFractures OutcomesFracturerelatedoutcomesHealingQualityofreductionFunctionaloutcomesAmbulatoryabilityMortality 25 atoneyear Returntopre fractureactivitiesofdailyliving HipFractures FemoralneckfracturesIntracapsularlocationVascularSupplyMedialandlateralcircumflexvesselsanastamoseatthebaseoftheneckbloodsupplypredominatelyfromascendingarteries 90 Arteryofligamentumteres 10 HipFractures FemoralneckfracturesTreatmentNon displaced valgusimpactedfracturesNon operative8 15 displacementrateOperativewithcannulatedscrewsNon union5 andosteonecrosisisapproximately8 HipFractures FemoralneckfracturesDisplacedfracturesshouldbetreatedoperativelyTreatment Openvs ClosedReductionandInternalfixation30 non unionand25 30 osteonecrosisrateNon unionrequiresreoperation75 ofthetimewhileosteonecrosisleadstoreoperationin25 ofcases HipFractures FemoralneckfracturesTreatment HemiarthroplastyUnipolarVsBipolarCanleadtoacetabularerosion dislocation infection HipFractures FemoralneckfracturesTreatmentDisplacedfracturescanbetreatednon operativelyincertainsituationsDemented non ambulatorypatientMobilizeearlyAcceptresultingnonormalunion HipFractures IntertrochantericfracturesExtracapsular wellvascularized RegiondistaltotheneckbetweenthetrochantersCalcarfemoralePosteromedialcortexImportantmuscularinsertions HipFractures IntertrochantericfracturesTreatmentUsuallytreatedsurgicallyImplantofchoiceisahipcompressionscrewthatslidesinabarrelattachedtoasideplateTheimplantallowsforcontrolledimpactionuponweightbearing HipFractures IntertrochantericfracturesTreatmentPrimaryprostheticreplacementcanbeconsideredForcaseswithsignificantcomminution HipFractures SubtrochantericFracturesBeginatorbelowthelevelofthelessertrochanterTypicallyhigherenergyinjuriesseeninyoungerpatientsfarlesscommonintheelderly HipFractures SubtrochantericFracturesTreatmentIntramedullarynail highratesofunion Platesandscrews AnkleFractures CommoninjuryintheelderlySignificantincreaseintheincidenceandseverityofanklefracturesoverthelast20yearsLowenergyinjuriesfollowingtwistingreflectingtherelativestrengthoftheligamentscomparedtoosteopenicbone AnkleFractures EpidemiologyFinnishStudy Kannusetal Three foldincreaseinthenumberofanklefracturesamongpatientsolderthan70yearsbetween1970and2000IncreaseinthemoresevereLauge HansenSE 4fractureIntheUnitedStates anklefractureshavebeenreportedtooccurinasmanyas8 3per1000MedicarerecipientsFigurethatappearstobesteadilyrising AnkleFractures PresentationFollowstwistingoffootrelativetolowertibiaPatientspresentunabletobearweightEcchymosis deformityCarefulneurovascularexammustbeperformed AnkleFractures RadiographicevaluationAnkletraumaseriesincludes APLateralMortiseExamineentirelengthofthefibula AnkleFractures TreatmentIsolated non displacedmalleolarfracturewithoutevidenceofdisruptionofsyndesmoticligamentstreatednon operativelywithfullweightbearingMyutilizewalkingcastorcastbrace AnkleFractures TreatmentUnstablefracturepatternswithbimalleolarinvolvement orunimalleolarfractureswithtalardisplacementmustbereducedTreatmentclosedrequiresalonglegcasttocontrolrotationmaybeaburdentoanelderlypatient AnkleFractures TreatmentReductionsthatareunabletobeattainedclosedrequireopenreductionandinternalfixationTheskinovertheankleisthinandpronetocomplicationAwaitresolutionofedematoachieveatensionfreeclosure AnkleFractures TreatmentFixationmaybesuboptimalduetoosteopeniaMayhavetoalterstandardoperativetechniquesCementAugmentationReportsinliteraturemixedEarlystudiesshowednodifferenceinoperativevsnon optreatment withoperativegroupshavinghighercomplicationratesMorerecentstudiesshowimprovedoutcomesinoperativelytreatedgroupGoalisreturntopre injuryfunctionalstatus ProximalHumerus BackgroundVerycommonfractureseeningeriatricpopulations112 100 000inmen439 100 000inwomenResultoflowenergytraumaGoalistorestorepainfreerangeofshouldermotion ProximalHumerus EpidemiologyIncidencerisesdramaticallybeyondthefifthdecadeinwomen71 ofallproximalhumerusfracturesoccurinpatientsolderthan60AssociatedwithfrailfemalesPoorneuromuscularcontrolDecreasedbonemineraldensity ProximalHumerus BackgroundArticulateswiththeglenoidportionofthescapulatoformtheshoulderjointFourpartsCombinationofbony muscular capsularandligamentousstructuresmaintainsshoulderstabilityStatusoftherotatorcuffiskey ProximalHumerus RadiographicevaluationAPScapulaYAxillaryCTscancanbehelpful ProximalHumerus TreatmentMinimallydisplaced onepartfractures usuallystabilizedbysurroundingsofttissuesNonoperative 91 goodtoexcellentresults ProximalHumerus TreatmentIsolatedlessertuberosityfracturesrequireoperativefixationonlyifthefragmentcontainsalargearticularportionorlimitsinternalrotationIsolatedgreatertuberosityassociatedwithlongitudinalcufftearsandrequireORIF ProximalHumerus TreatmentDisplacedsurgicalneckfracturescanbetreatedclosedbyreductionunderanesthesiawithX rayguidanceAnatomicneckfracturesarerarebuthaveahighrateofosteonecrosisIfacceptablereductionisnotattainedopenreductionshouldbeundertaken ProximalHumerus TreatmentClosedtreatmentof3and4partfractureshaveyieldedpoorresultsFailureoffixationisaprobleminosteopenicboneLockedplatingversusprostheticreplacement ProximalHumerus TreatmentRegardlessoftreatmentallrequireprolonged supervisedrehabilitationprogrampoorresultsareassociatedwithrotatorcufftears malunion nonunionProstheticreplacementcanbeexpectedtoresultinrelativelypainfreeshouldersFunctionalrecoveryandROMvariable DistalRadius BackgroundVerycommonfractureintheelderlyResultfromlowenergyinjuriesIncidenceincreaseswithage particularlyinwomenAssociatedwithdementia pooreyesightandadecreaseincoordination DistalRadius EpidemiologyIncreasinginincidenceEspeciallyinwomenPeakincidenceinfemales60 70Lifetimeriskis15 Mostfrequentcause fallonoutstretchedarmDecreasedbonemineraldensityisafactor DistalRadius RadiographicevaluationPALateralObliqueContralateralwristImportanttoevaluatedeformity ulnarvariance DistalRadius TreatmentNon displacedfracturesmaybeimmobilizedfor6 8weeksMetacarpal phalangealandinterphalangealjointmotionmustbestartedearly DistalRadius TreatmentDisplacedfracturesshouldbereducedwithrestorationofradiallength inclinationandtiltUsuallyaccomplishedwithlongitudinaltractionunderhematomablockIfsatisfactoryreductionisobtainedtreatmentinalongarmorshortarmcastisundertakenNostatisticaldifferenceinmethodWeeklyradiographsarerequired DistalRadius Treatment OperativeifacceptablereductionnotobtainedregionalorgeneralanesthesiaMethodsORIFClosedreductionandpercutaneouspinningwithexternalfixationBonegraftingfordorsalcomminution DistalRadius TreatmentResultsarevariableanddependonfracturetypeandreductionachievedMinimallydisplacedandfracturesinwhichastablereductionhasbeenachievedresultingoodfunctionaloutcomes DistalRadius TreatmentDisplacedfracturestreatedsurgicallyproducegoodtoexcellentresults70 90 Functionallimitsincludepain stiffnessanddecreasedgrip VertebralCompressionFractures BackgroundNearlyallpost menopausalwomenoverage70havesustainedavertebralcompressionfractureUsuallyoccurbetweenT8andL2Kyphosisandscoliosismaydevelopmarkersforosteoporosis VertebralCompressionFractures EpidemiologyMorecommonthanhipfractures117 100 000TwiceascommoninfemalesLifetimeriskina50yearoldwhitefemaleis32 VertebralCompressionFractures BackgroundPresentwithacutebackpainTendertopalpationNeurologicdeficitisrarePatternsBiconcave upperlumbar Anteriorwedge thoracic Symmetriccompression T Ljunction VertebralCompressionFractures RadiographicevaluationAPandlateralradiographsofthespineSymptomaticvertebrae1 3heightofadjacentBonescancandifferentiateoldfromnewfractures VertebralCompressionFractures TreatmentSimpleosteoporoticvertebralcompressionfracturesaretreatednon operativelyandsymptomaticallyProlongedbedrestshouldbeavoidedProgressiveambulationshouldbestartedearlyBackexercisesshouldbestartedafterafewweeks VertebralCompressionFractures TreatmentAcorsetmaybehelpfulMostfractureshealuneventfullyKyphoplastyanoption Prevention StrategiesfocusoncontrollingfactorsthatpredisposetofractureFallprevention Prevention MultidisciplinaryprogramsMedicaladjustmentBehaviormodificationExerciseclassesControversial PreventionandTreatmentofBoneFragility WellestablishedlinkbetweendecreasingbonemassandriskoffractureTreatmentofosteoporosisEstrogenCalcium VitaminDSupplementsCalcitononinBisphosphonatesTeriparatide Forteo PreventionandTreatmentofBoneFragility Estrogen2 3 bonelosswithmenopauseUnopposedorcombinedtherapyhasbeenshowntoreducehipfractureincidenceinwomenaged65 74by40 60 Hendersonetal 1988 Riskofbreastandendometrialcancerincreasedinunopposedtherapy PreventionandTreatmentofBoneFragility FosmaxShowntoincreasethebonedensityinfemoralneckinpostmenopausalwomenwithosteoporosis Liebermanetal NEJM1995 Reducedhipfracturerateby50 inwomenwhohadsustainedapreviousvertebralfracture Blacketal Lancet1996 PreventionandTreatmentofBoneFragility Calcium VitaminDSupplementationRecommendedformostmenandwomen 50yearsCalciumAge50 1 200mg dayVitaminDAge51 70 400IU dayAge 70 600IU dayCombiningVitaminDandcalciumsupplementationhasbeenshowntoincreasebonemineraldensityandreducetheriskoffracture PreventionandTreatmentofBoneFragility CalcitoninInhibitsboneresorptionbyinhibitingosteoclastactivityA