骨質(zhì)疏松性骨折osteoporoticfxs

1、Background,Osteoporosis -- a decreased bone density with normal bone mineralizationWHO Definition (1994)Bone Mineral Density ≥2.5 SD’s below the mean seen in young normal subjectsIncidence increases with age15% of wh

2、ite 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 comm

3、onSome degree of osteopenia is found in virtually all healthy elderly patientsTreatable causes should be investigatedNutritional deficiencyMalabsorption syndromesHyperparathyroidismCushings diseaseTumors,Backgroun

4、d,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 occu

5、r globallyEnormous cost to society,Background,The most common fractures in the elderly osteoporotic patient include:Hip FracturesFemoral neck fracturesIntertrochanteric fracturesSubtrochanteric fracturesAnkle fract

6、uresProximal 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

7、 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 healingI

8、nternal 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 in

9、dicated,Pre-injury Status,Medical HistoryCognitive HistoryFunctional HistoryAmbulatory statusCommunity AmbulatorHousehold AmbulatorNon-Functional AmbulatorNon-AmbulatorLiving arrangements,Pre-injury Status,System

10、ic 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,Pr

11、e-injury Status,American Society of Anesthesiologists (ASA) ClassificationASA I- normal healthyASA II- mild systemic diseaseASA III- Severe systemic disease, not incapacitatingASA IV- severe incapacitating diseaseAS

12、A V- moribund patient,Pre-injury Status,Cognitive StatusCritical to outcomeConditions may render patient unable to participate in rehabilitationAlzheimer’sCVA Parkinson'sSenile dementia,Hip Fractures,General pr

13、inciplesWith 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 ar

14、eas15% 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

15、Fractures,Radiographic evaluationAnterior-posterior viewCross table lateralInternal rotation view will help delineate fracture pattern,Hip Fractures,Radiographic evaluationOccult hip fractureTechnetium bone scanning

16、 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,ManagementPro

17、mpt operative stabilizationOperative delay of > 24-48 hours increases one-year mortality ratesHowever, important to balance medical optimization and expeditious fixationEarly mobilizationDecrease incidence of decu

18、biti, UTI, atelectasis/respiratory infectionsDVT prophylaxis,Hip Fractures,OutcomesFracture related outcomesHealingQuality of reductionFunctional outcomesAmbulatory abilityMortality (25% at one year)Return to pre

19、-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 as

20、cending arteries (90%)Artery of ligamentum teres (10%),Hip Fractures,Femoral neck fracturesTreatmentNon-displaced/ valgus impacted fracturesNon-operative 8-15% displacement rateOperative with cannulated screwsNon-u

21、nion 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% os

22、teonecrosis 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 ac

23、etabular erosion, dislocation, infection,Hip Fractures,Femoral neck fracturesTreatmentDisplaced fractures can be treated non -operatively in certain situationsDemented, non-ambulatory patientMobilize earlyAccept res

24、ulting non or malunion,Hip Fractures,Intertrochanteric fracturesExtracapsular (well vascularized)Region distal to the neck between the trochantersCalcar femoralePosteromedial cortexImportant muscular insertions,Hip

25、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 wei

26、ghtbearing,Hip Fractures,Intertrochanteric fracturesTreatmentPrimary prosthetic replacement can be considered For cases with significant comminution,Hip Fractures,Subtrochanteric FracturesBegin at or below the level

27、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 scr

28、ews,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 t

29、he 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

30、 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,Pres

31、entationFollows twisting of foot relative to lower tibiaPatients present unable to bear weightEcchymosis, deformityCareful neurovascular exam must be performed,Ankle Fractures,Radiographic evaluationAnkle trauma ser

32、ies includes:APLateralMortiseExamine entire length of the fibula,Ankle Fractures,TreatmentIsolated, non-displaced malleolar fracture without evidence of disruption of syndesmotic ligaments treated non-operatively wi

33、th 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

34、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 o

35、ver 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 tech

36、niquesCement 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 outco

37、mes 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

38、 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

39、 60Associated with frail femalesPoor neuromuscular controlDecreased bone mineral density,Proximal Humerus,BackgroundArticulates with the glenoid portion of the scapula to form the shoulder jointFour partsCombinati

40、on 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 Hume

41、rus,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

42、 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,TreatmentDisp

43、laced 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 re

44、duction 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 replacemen

45、t,Proximal Humerus,TreatmentRegardless of treatment all require prolonged, supervised rehabilitation programpoor results are associated with rotator cuff tears, malunion, nonunionProsthetic replacement can be expected

46、 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

47、 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 caus

48、e: fall on outstretched armDecreased bone mineral density is a factor,Distal Radius,Radiographic evaluationPALateralObliqueContralateral wristImportant to evaluate deformity, ulnar variance,Distal Radius,Treatment

49、Non-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 radi

50、al 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

51、 in methodWeekly radiographs are required,Distal Radius,Treatment: Operativeif acceptable reduction not obtainedregional or general anesthesiaMethodsORIFClosed reduction and percutaneous pinning with external fixat

52、ionBone 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 res

53、ult 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 F

54、ractures,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 Compr

55、ession 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 pa

56、inTender to palpationNeurologic deficit is rarePatternsBiconcave (upper lumbar)Anterior wedge (thoracic)Symmetric compression (T-L junction),Vertebral Compression Fractures,Radiographic evaluationAP and lateral ra

57、diographs 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 tr

58、eated 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

59、corset may be helpfulMost fractures heal uneventfullyKyphoplasty an option,Prevention,Strategies focus on controlling factors that predispose to fractureFall prevention,Prevention,Multidisciplinary programsMedical ad

60、justmentBehavior modificationExercise classesControversial,Prevention and Treatment of Bone Fragility,Well established link between decreasing bone mass and risk of fractureTreatment of osteoporosisEstrogenCalcium/

61、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 fractu

62、re 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

63、 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 an

64、d 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 Vitami

65、n 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 acti

66、vityApproved for treatment of osteoporosis in women who have been post-menopausal for > 5 yearsDaily intranasal spray of 200 IUTrial demonstrated 33% reduction of vertebral compression fractures with daily therapy

67、(Chesnut Am J Med 2000)No effect on hip fractures demonstrated,Prevention and Treatment of Bone Fragility,BisphosphonatesInhibits bone resorption by reducing osteoclast recruitment and activityBone formed while on bis

68、phosphonate therapy is histologically normalAvailable formulationsAlendronateRisendronateIbandronateStrongest evidence for rapid fracture risk reductionDecreasing the incidence of both vertebral and nonvertebral fr

69、actures,Prevention and Treatment of Bone Fragility,Teriparatide (Forteo)Recombinant formulation of parathyroid hormoneStimulates the formation of new bone by increasing the number and activity of osteoblastsOnce daily