Epidemiology,DiagnosisPreventionandManagementofOsteoporoticFracturesKennethA.Egol,MDNYU-HospitalForJointDiseasesCreatedMarch2004;RevisedMay2006BackgroundOsteoporosis--adecreasedbonedensitywithnormalbonemineralizationWHODefinition(1994)BoneMineralDensity≥2.5SD’sbelowthemeanseeninyoungnormalsubjectsIncidenceincreaseswithage15%ofwhitewomenage50-5970%ofwhitewomenolderthanage80BackgroundRiskfactorsforosteoporosisFemalesexEuropeanancestrySedentarylifestyleMultiplebirthsExcessivealcoholuseBackground TheincidenceofosteoporoticfracturesisincreasingEstimatedthathalfofallwomenandone-thirdofallmenwillsustainafragilityfractureduringtheirlifetimeBy2050-->6.3millionhipfractureswilloccurgloballyEnormouscosttosocietyBackgroundThemostcommonfracturesintheelderlyosteoporoticpatientinclude:HipFracturesFemoralneckfracturesIntertrochantericfracturesSubtrochantericfracturesAnklefracturesProximalhumerusfractureDistalradiusfracturesVertebralcompressionfracturesBackgroundFracturesintheelderlyosteoporoticpatientrepresentachallengetotheorthopaedicsurgeonThegoaloftreatmentistorestorethepre-injuryleveloffunctionFracturecanrenderanelderlypatientunabletofunctionindependently--requiringinstitutionalizedcarePre-injuryStatusMedicalHistoryCognitiveHistoryFunctionalHistoryAmbulatorystatusCommunityAmbulatorHouseholdAmbulatorNon-FunctionalAmbulatorNon-AmbulatorLivingarrangementsPre-injuryStatusSystemicdiseasePre-existingcardiacandpulmonarydiseaseiscommonintheelderlyDiminishespatientsabilitytotolerateprolongedrecumbencyDiabetesincreaseswoundcomplicationsandinfectionMaydelayfractureunionPre-injuryStatus AmericanSocietyofAnesthesiologists(ASA)ClassificationASAI-normalhealthyASAII-mildsystemicdiseaseASAIII-Severesystemicdisease,notincapacitatingASAIV-severeincapacitatingdiseaseASAV-moribundpatientHipFracturesGeneralprinciplesWiththeagingoftheAmericanpopulationtheincidenceofhipfracturesisprojectedtoincreasefrom250,000in1990to650,000by2040Costapproximately$8.7billionannually20%higherincidenceinurbanareas15%lifetimeriskforwhitefemaleswholivetoage80HipFracturesEpidemiologyIncidenceincreasesafterage50Female:Maleratiois2:1FemoralneckandintertrochantericfracturesseenwithequalfrequencyHipFracturesRadiographicevaluationAnterior-posteriorviewCrosstablelateralInternalrotationviewwillhelpdelineatefracturepatternHipFracturesManagementPromptoperativestabilizationOperativedelayof>24-48hoursincreasesone-yearmortalityratesHowever,importanttobalancemedicaloptimizationandexpeditiousfixationEarlymobilizationDecreaseincidenceofdecubiti,UTI,atelectasis/respiratoryinfectionsDVTprophylaxisHipFracturesOutcomesFracturerelatedoutcomesHealingQualityofreductionFunctionaloutcomesAmbulatoryabilityMortality(25%atoneyear)Returntopre-fractureactivitiesofdailylivingHipFracturesFemoralneckfracturesIntracapsularlocationVascularSupplyMedialandlateralcircumflexvesselsanastamoseatthebaseoftheneckbloodsupplypredominatelyfromascendingarteries(90%)Arteryofligamentumteres(10%)HipFracturesFemoralneckfracturesDisplacedfracturesshouldbetreatedoperativelyTreatment:Openvs.ClosedReductionandInternalfixation30%non-unionand25%-30%osteonecrosisrateNon-unionrequiresreoperation75%ofthetimewhileosteonecrosisleadstoreoperationin25%ofcasesHipFracturesFemoralneckfracturesTreatment:HemiarthroplastyUnipolarVsBipolarCanleadtoacetabularerosion,dislocation,infectionHipFracturesFemoralneckfracturesTreatmentDisplacedfracturescanbetreatednon-operativelyincertainsituationsDemented,non-ambulatorypatientMobilizeearlyAcceptresultingnonormalunionHipFracturesIntertrochantericfracturesTreatmentUsuallytreatedsurgicallyImplantofchoiceisahipcompressionscrewthatslidesinabarrelattachedtoasideplateTheimplantallowsforcontrolledimpactionuponweightbearingHipFracturesIntertrochantericfracturesTreatmentPrimaryprostheticreplacementcanbeconsideredForcaseswithsignificantcomminutionAnkleFracturesCommoninjuryintheelderlySignificantincreaseintheincidenceandseverityofanklefracturesoverthelast20years

LowenergyinjuriesfollowingtwistingreflectingtherelativestrengthoftheligamentscomparedtoosteopenicboneAnkleFracturesEpidemiologyFinnishStudy(Kannusetal)Three-foldincreaseinthenumberofanklefracturesamongpatientsolderthan70yearsbetween1970and2000IncreaseinthemoresevereLauge-HansenSE-4fractureIntheUnitedStates,anklefractureshavebeenreportedtooccurinasmanyas8.3per1000MedicarerecipientsFigurethatappearstobesteadilyrising.AnkleFracturesPresentationFollowstwistingoffootrelativetolowertibiaPatientspresentunabletobearweightEcchymosis,deformityCarefulneurovascularexammustbeperformedAnkleFracturesRadiographicevaluationAnkletraumaseriesincludes:APLateralMortiseExamineentirelengthofthefibulaAnkleFracturesTreatmentIsolated,non-displacedmalleolarfracturewithoutevidenceofdisruptionofsyndesmoticligamentstreatednon-operativelywithfullweightbearingMyutilizewalkingcastorcastbraceAnkleFracturesTreatmentUnstablefracturepatternswithbimalleolarinvolvement,orunimalleolarfractureswithtalardisplacementmustbereducedTreatmentclosedrequiresalonglegcasttocontrolrotationmaybeaburdentoanelderlypatientAnkleFracturesTreatmentReductionsthatareunabletobeattainedclosedrequireopenreductionandinternalfixationTheskinovertheankleisthinandpronetocomplicationAwaitresolutionofedematoachieveatensionfreeclosureAnkleFracturesTreatmentFixationmaybesuboptimalduetoosteopeniaMayhavetoalterstandardoperativetechniquesCementAugmentationReportsinliteraturemixedEarlystudiesshowednodifferenceinoperativevsnon-optreatment--withoperativegroupshavinghighercomplicationratesMorerecentstudiesshowimprovedoutcomesinoperativelytreatedgroupGoalisreturntopre-injuryfunctionalstatusProximalHumerusBackgroundVerycommonfractureseeningeriatricpopulations112/100,000inmen439/100,000inwomenResultoflowenergytraumaGoalistorestorepainfreerangeofshouldermotionProximalHumerusEpidemiologyIncidencerisesdramaticallybeyondthefifthdecadeinwomen71%ofallproximalhumerusfracturesoccurinpatientsolderthan60AssociatedwithfrailfemalesPoorneuromuscularcontrolDecreasedbonemineraldensityProximalHumerusBackgroundArticulateswiththeglenoidportionofthescapulatoformtheshoulderjointFourpartsCombinationofbony,muscular,capsularandligamentousstructuresmaintainsshoulderstabilityStatusoftherotatorcuffiskeyProximalHumerusRadiographicevaluationAPScapulaYAxillaryCTscancanbehelpfulProximalHumerusTreatmentMinimallydisplaced(onepartfractures)usuallystabilizedbysurroundingsofttissues Nonoperative:91%goodtoexcellentresultsProximalHumerusTreatmentIsolatedlessertuberosityfracturesrequireoperativefixationonlyifthefragmentcontainsalargearticularportionorlimitsinternalrotationIsolatedgreatertuberosityassociatedwithlongitudinalcufftearsandrequireORIFProximalHumerusTreatmentDisplacedsurgicalneckfracturescanbetreatedclosedbyreductionunderanesthesiawithX-rayguidanceAnatomicneckfracturesarerarebuthaveahighrateofosteonecrosisIfacceptablereductionisnotattainedopenreductionshouldbeundertakenProximalHumerusTreatmentClosedtreatmentof3and4partfractureshaveyieldedpoorresultsFailureoffixationisaprobleminosteopenicboneLockedplatingversusprostheticreplacementProximalHumerusTreatmentRegardlessoftreatmentallrequireprolonged,supervisedrehabilitationprogrampoorresultsareassociatedwithrotatorcufftears,malunion,nonunionProstheticreplacementcanbeexpectedtoresultinrelativelypainfreeshouldersFunctionalrecoveryandROMvariableDistalRadiusBackgroundVerycommonfractureintheelderlyResultfromlowenergyinjuriesIncidenceincreaseswithage,particularlyinwomenAssociatedwithdementia,pooreyesightandadecreaseincoordinationDistalRadiusEpidemiologyIncreasinginincidenceEspeciallyinwomenPeakincidenceinfemales60-70Lifetimeriskis15%Mostfrequentcause:fallonoutstretchedarmDecreasedbonemineraldensityisafactorDistalRadiusRadiographicevaluationPALateralObliqueContralateralwristImportanttoevaluatedeformity,ulnarvarianceDistalRadiusTreatmentNon-displacedfracturesmaybeimmobilizedfor6-8weeksMetacarpal-phalangealandinterphalangealjointmotionmustbestartedearlyDistalRadiusTreatmentDisplacedfracturesshouldbereducedwithrestorationofradiallength,inclinationandtiltUsuallyaccomplishedwithlongitudinaltractionunderhematomablockIfsatisfactoryreductionisobtainedtreatmentinalongarmorshortarmcastisundertakenNostatisticaldifferenceinmethodWeeklyradiographsarerequiredDistalRadiusTreatment:OperativeifacceptablereductionnotobtainedregionalorgeneralanesthesiaMethodsORIFClosedreductionandpercutaneouspinningwithexternalfixationBonegraftingfordorsalcomminutionDistalRadiusTreatmentResultsarevariableanddependonfracturetypeandreductionachievedMinimallydisplacedandfracturesinwhichastablereductionhasbeenachievedresultingoodfunctionaloutcomesDistalRadiusTreatmentDisplacedfracturestreatedsurgicallyproducegoodtoexcellentresults70-90%Functionallimitsincludepain,stiffnessanddecreasedgripVertebralCompressionFracturesBackgroundNearlyallpost-menopausalwomenoverage70havesustainedavertebralcompressionfractureUsuallyoccurbetweenT8andL2KyphosisandscoliosismaydevelopmarkersforosteoporosisVertebralCompressionFracturesEpidemiologyMorecommonthanhipfractures117/100,000TwiceascommoninfemalesLifetimeriskina50yearoldwhitefemaleis32%VertebralCompressionFracturesBackgroundPresentwithacutebackpainTendertopalpationNeurologicdeficitisrarePatternsBiconcave(upperlumbar)Anteriorwedge(thoracic)Symmetriccompression(T-Ljunction)VertebralCompressionFracturesRadiographicevaluationAPandlateralradiographsofthespineSymptomaticvertebrae1/3heightofadjacentBonescancandifferentiateoldfromnewfracturesVertebralCompressionFracturesTreatmentSimpleosteoporoticvertebralcompressionfracturesaretreatednon-operativelyandsymptomaticallyProlongedbedrestshouldbeavoidedProgressiveambulationshouldbestartedearlyBackexercisesshouldbestartedafterafewweeksVertebralCompressionFracturesTreatmentAcorsetmaybehelpfulMostfractureshealuneventfullyKyphoplastyanoptionPreventionStrategiesfocusoncontrollingfactorsthatpredisposetofractureFallpreventionPreventionMultidisciplinaryprogramsMedicaladjustmentBehaviormodificationExerciseclassesControversialPreventionandTreatmentofBoneFragilityWellestablishedlinkbetweendecreasingbonemassandriskoffractureTreatmentofosteoporosisEstrogenCalcium/VitaminDSupplementsCalcitononinBisphosphonatesTeriparatide(Forteo)PreventionandTreatmentofBoneFragilityEstrogen2-3%bonelosswithmenopauseUnopposedorcombinedtherapyhasbeenshowntoreducehipfractureincidenceinwomenaged65-74by40-60%(Hendersonetal.1988)RiskofbreastandendometrialcancerincreasedinunopposedtherapyPreventionandTreatmentofBoneFragilityFosmaxShowntoincreasethebonedensityinfemoralneckinpostmenopausalwomenwithosteoporosis(Liebermanetal.NEJM1995)Reducedhipfracturerateby50%inwomenwhohadsustainedapreviousvertebralfracture.(Blacketal.Lancet1996)PreventionandTreatmentofBoneFragilityCalcium/VitaminDSupplementationRecommendedformostmenandwomen>50yearsCalciumAge<50--1,000mg/dayAge>50--1,200mg/dayVitaminDAge51-70--400IU/dayAge>70--600IU/dayCombiningVitaminDandcalciumsupplementationhasbeenshowntoincreasebonemineraldensityandreducetheriskoffracturePreventionandTreatmentofBoneFragilityCalcitoninInhibitsboneresorptionbyinhibitingosteoclastactivityApprovedfortreatmentofosteoporosisinwomenwhohavebeenpost-menopausalfor>5yearsDailyintranasalsprayof200IUTrialdemonstrated33%reductionofvertebralc