1-24 osteoporotic fractures 10 minutes lecture

8/14/2019 1-24 Osteoporotic Fractures 10 Minutes Lecture

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EpidemiologyEpidemiology

**1.51.5million osteoporosis-relatedmillion osteoporosis-relatedfractures annuallyfractures annually

**700,000700,000vertebral fracturesvertebral fractures

**300,000300,000hip fractureship fractures

**250,000250,000distaldistalforearm/wrist/Colles' fracturesforearm/wrist/Colles' fractures

**$13.3$13.3billion in direct costsbillion in direct costs

annuallyannually**Projected $240 billion annually inProjected $240 billion annually in

osteoporosis costs by 2040osteoporosis costs by 2040


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**33%33%of women >65 yearsof women >65 yearsof age have vertebralof age have vertebralfracturesfractures

**32%32%of women and 17% ofof women and 17% of

men >90 years of agemen >90 years of age

have hip fractureshave hip fractures

**33%33%of men >80 years ofof men >80 years ofage have osteoporosisage have osteoporosis


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Special characters of FractureSpecial characters of Fracture

**Osteoporosis affects bone with high surface area so itOsteoporosis affects bone with high surface area so it

affects mostly cancellous boneaffects mostly cancellous bone

--Trabecular bone resorption 8% per yearTrabecular bone resorption 8% per year

--Cortical bone resorption 0.5% per yearCortical bone resorption 0.5% per year

--Affects commonly metaphyseal partAffects commonly metaphyseal part

--Low energy have considerable effect in fracture causationLow energy have considerable effect in fracture causation

**Falls from standing exceed femur strength by 50% in elderlyFalls from standing exceed femur strength by 50% in elderly


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Age-related changesAge-related changes

After age 60, subperiostealarea slowly increases butmedullary cavity enlargesfaster, resulting in netdecrease of corticalthickness and mass


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FRACTURESFRACTURES

**FRAGILITYFRAGILITYFRACTURESFRACTURES..

**MINOR TRAUMAMINOR TRAUMA..

COMMON SITESCOMMON SITES:*:*SpineSpine.-.-

--Proximal end ofProximal end offemurfemur..

--Distal end of radiusDistal end of radius..--Proximal end ofProximal end of

humerushumerus..


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Management of FracturesManagement of Fractures

--Anatomic reductionAnatomic reduction

--Stable internal fixationStable internal fixation

--Preservation of the blood supplyPreservation of the blood supplyusing atraumatic techniqueusing atraumatic technique

--Avoid excessive periosteal strippingAvoid excessive periosteal stripping

--Utilize indirect reduction techniquesUtilize indirect reduction techniques--Early active mobilizationEarly active mobilization


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Fractures of the SpineFractures of the Spine

**Types of spinalTypes of spinalfracturefracture

--CompressionCompressionfracturesfractures

--Burst fracturesBurst fractures

**Rarely neurologicRarely neurologiccompromisecompromise

**Rarely unstableRarely unstable


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**Indications of instabilityIndications of instability

Neurologic deficitNeurologic deficit

Kyphosis >30Kyphosis >30

Compression >50%Compression >50%

Translation >4 mmTranslation >4 mm

Interspinous-process wideningInterspinous-process widening


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Two types of back pain can beTwo types of back pain can be

distinguisheddistinguished::


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Hip FracturesHip Fractures

**25%25%of women >60of women >60years of age haveyears of age have

hip fractureship fractures

**12%12%to 20% mortalityto 20% mortality

**50%50%able to return toable to return to

independentindependent

ambulationambulation

**Incidence is clearlyIncidence is clearly

related torelated to

osteoporosisosteoporosis


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--ClosedClosed

reduction withreduction with

internalinternalfixationfixation

--80%80%good orgood or

excellent resultsexcellent results

--RequiresRequires

anatomicanatomic

reductionreduction


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**HemiarthroplastyHemiarthroplasty

indicationsindications

--Active householdActive household

or communityor community

ambulatorsambulators

--Patients withPatients with

severesevereosteoporosisosteoporosis

--If unable to obtainIf unable to obtain

stable reductionstable reduction

**H i th l tH i th l

t


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**Hemiarthroplasty vsHemiarthroplasty vspinningpinning

**Study of 215 displacedStudy of 215 displacedfractures treated withfractures treated withclosed reduction withclosed reduction with

internal fixationinternal fixation

6363))29%29%((had died by 2 yearshad died by 2 years

Nonunion in 39 patients )18%Nonunion in 39 patients )18%((

Avascular necrosis in 14Avascular necrosis in 14

patients )6.5%patients )6.5%((

Only 36 )17%( requiredOnly 36 )17%( required

reoperationreoperation


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Intertrochanteric FracturesIntertrochanteric Fractures

**Incidence of malunion andIncidence of malunion andvarus may be disablingvarus may be disabling

**Avoid shorteningAvoid shortening&&

external rotation deformityexternal rotation deformity

**Implant considerationsImplant considerationsLoad bearing -- fixedLoad bearing -- fixednail-nail-plate constructplate construct

Intermediate -- slidingIntermediate -- sliding

nail-plate constructnail-plate construct

Load sharing --Load sharing --

intramedullary nail-intramedullary nail-

screw constructscrew construct

**M di l di lM di l di l t


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**Medial displacementMedial displacementosteotomyosteotomy

--Puts fracture in most stablePuts fracture in most stableconfigurationconfiguration

--Less stress on implantLess stress on implant

--Results in shortened limbResults in shortened limb

and weak abductorsand weak abductors


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Techniques toTechniques toenhance fixationenhance fixation

**Screw must be centralScrew must be central

in head/neckin head/neck

**Must engageMust engagesubchondral bonesubchondral bonewithin 11 to 25 mmwithin 11 to 25 mm

rangerange

--Valgus screw/plateValgus screw/plate140 is optimal140 is optimal


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**PolymethylmethacrylPolymethylmethacryl

ate used to augmentate used to augment

fixation allows earlyfixation allows early

weight bearingweight bearing

**Reduce posteromedialReduce posteromedial

(lesser trochanter)(lesser trochanter)fragment to increasefragment to increase

strength of constructstrength of construct


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Failures in Hip FracturesFailures in Hip Fractures

**Causes ofCauses of

redisplacement andredisplacement and

reoperationreoperation::

--OsteoporosisOsteoporosis--Fracture displacementFracture displacement

--Collapse of femoralCollapse of femoral

headhead

--Bone mineral contentBone mineral content


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Supracondylar interlocking nailSupracondylar interlocking nail


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Proximal Humerus FractureProximal Humerus Fracture

**5%5%of osteoporotic fracturesof osteoporotic fractures

**80%80%nondisplacednondisplaced

--Nondisplaced fractures --Nondisplaced fractures --

immobilization in sling andimmobilization in sling andearly motion as painearly motion as pain

subsidessubsides

--Full passive range of motionFull passive range of motionencouraged by 3 to 4encouraged by 3 to 4

weeks, active range ofweeks, active range of

motion at 5 to 6 weeksmotion at 5 to 6 weeks


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Surgical optionsSurgical options

--Closed reduction, percutaneous pinningClosed reduction, percutaneous pinning

--Pinning less effective in poor bone qualityPinning less effective in poor bone quality--Greater tuberosity fracture needs reductionGreater tuberosity fracture needs reduction

and possibly rotator cuff repairand possibly rotator cuff repair

--Comminuted fracturesComminuted fractures

--Open reduction with internal fixation usingOpen reduction with internal fixation usingscrews and tension band wiring if possiblescrews and tension band wiring if possible

--33or 4 part fractures should be treated withor 4 part fractures should be treated with

HemiarthroplastyHemiarthroplasty

--Repair rotator cuffRepair rotator cuff


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Colles' FractureColles' Fracture

**Involves dorsalInvolves dorsal

displacement of thedisplacement of the

radiusradius

**May or may not involveMay or may not involve

the ulnathe ulna

**Often results in an ulnarOften results in an ulnar

styloid fracturestyloid fracture

**Fractures intra- and/orFractures intra- and/or

extra-articularextra-articular


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Closed reduction and castingClosed reduction and casting

Adequate reductionAdequate reductionNeutral angulationNeutral angulation

No radial shorteningNo radial shortening

All types of deformity betterAll types of deformity better

tolerated in elderly so usetolerated in elderly so use

judgmentjudgment


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**Long arm cast 2 to 4 weeksLong arm cast 2 to 4 weeks

**Short arm cast another 4 to 6Short arm cast another 4 to 6

weeksweeks**Incidence of reflexIncidence of reflex

sympathetic dystrophysympathetic dystrophy,,

stiffness, malunionstiffness, malunion

--52%52%complicationcomplicationrate with plasterrate with plastermostlymostlydeformity recurrencedeformity recurrence


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**PercutaneousPercutaneous

pinning fixation pinning fixation

--Unstable, severelyUnstable, severelycomminutedcomminuted

fracturesfractures

--80%80%to 90% goodto 90% good

or excellentor excellent

results inresults in

functionalfunctionaloutcomeoutcome

--15%15%to 60%to 60%

complication ratecomplication rate


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**Open reduction withOpen reduction with

internal fixationinternal fixation

--Reserved for grossly displacedReserved for grossly displaced

intra-articular fracturesintra-articular fractures

--Augment with bone graftAugment with bone graft

--Research into injection ofResearch into injection of

hydroxyapatite to augmenthydroxyapatite to augment

fracturefracture


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Osteoporotic Fracture ManagementOsteoporotic Fracture Management

SummarySummary

Prevention better thanPrevention better than

treatmenttreatmentOperative treatment use isOperative treatment use is

common but is difficultcommon but is difficult

**Internal fixationInternal fixation


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*Internal fixationInternal fixation

--Standard indicationsStandard indications

--Use wide perchase screws ( cancellousUse wide perchase screws ( cancellous))

--Augmentation with polymethyl-Augmentation with polymethyl-

methacrylate or hydroxyapatitemethacrylate or hydroxyapatite

--Structural grafting or bone substituteStructural grafting or bone substitute

--Polysegmental fixationPolysegmental fixation

--Less of reduction or fixation or of correctionLess of reduction or fixation or of correction

is expectedis expected

--Postoperative plaster or bracing is betterPostoperative plaster or bracing is better--Maximize preoperative medical treatmentMaximize preoperative medical treatment

--Consider discharge program & careConsider discharge program & care


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1-24 osteoporotic fractures 10 minutes lecture

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