@ebookers Osteoporotic Fracture PDF

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Distribution by Georg Thieme Verlag, Rüdigerstrasse 14, 70469 Stuttgart, Germany, and Thieme New York, 333 Seventh Avenue, New York, NY 10001, USA
ISBN: 978-313-242751-8
ISBN: 9783132000070 123456
e-ISBN: 978-313-242752-5
e-ISBN: 9783132000087
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Osteoporotic Fracture Care Michael Blauth, Stephen L Kates, Joseph A Nicholas
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e b oo e b oo b o o
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Steven A Olson, MD
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Professor in Orthopaedic Surgery
Duke University School of Medicine
Durham, NC 27710
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When Dr Kates asked me if I was interested in writing a
foreword for the Osteoporotic Fracture Care book, I could not ht tps
Multiple important topics are covered in this textbook in-
cluding societal impact of the clinical problem of osteopo-
refuse. Having worked with Dr Kates on issues involving rotic fractures as well as important current perspectives in
insufficiency fracture care as both a colleague and friend, I all aspects of patient care.
understand the passion and commitment that has been
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brought to this textbook.
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The outline of the book spans the entire scope of care in-
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cluding basic pathophysiology, clinical assessment, patient-
e b The care of the young male high-energy trauma patient

e b o specific considerations in determining treatment, and spe-
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often dominates the focus of trauma education. The care of
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the older adult with osteoporotic fractures often seems to
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cific recommendations for pre-, intra-, and postoperative
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care; it also covers templated order sets to facilitate the care e/e
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be of less interest in both trauma education and research.
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of the osteoporotic fracture patient and strategies for sec-
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This AO book entitled Osteoporotic Fracture Care provides an
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important reminder of why this area is of key importance
in healthcare today for all of us. A recent report found the htt ps:
ondary osteoporotic fracture prevention. This is a thorough
and well-written reference work for all musculoskeletal care
providers who treat patients with osteoporotic fractures. I
burden of hospitalization of women over age 55 in the US hope you find this textbook a useful reference.
for osteoporotic fractures is greater than the hospitalization
burden for myocardial infarction, stroke, or breast cancer [1]. Durham, November 2017
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b o ok 1. Singer A, Exuzides A, Spangler L, et al. Burden of illness for
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osteoporotic fractures compared with other serious diseases
ok b o o
e/ e Proc. 2015 Jan;90(1):53–62.
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among postmenopausal women in the United States. Mayo Clin
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The inspiration for this textbook comes from the vibrant
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Optimal outcomes for fragility fracture patients depend on
AOTrauma Care of the Geriatric Fracture Patient courses excellent surgical care of osteoporotic bone, incorporation
held across the world, as orthogeriatric care education has of geriatric medicine into the routine care pathways, and
been pushed to the forefront for orthopedic surgeons, med- construction of new systems of care. To address these areas,
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ical physicians, and other care teams involved in care of the
fragility fracture patient. These innovative and interactive
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this book is organized into three sections:
b o ok courses were launched in Rochester, NY, USA, in 2006 un-

der the leadership of Dr Stephen Kates and Dr Daniel Men-
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The Principles section outlines the unique medical, surgical,
and anesthesia needs of fragility fracture patients; these
b o o
e / e delson and introduced into the AO Courses in Davos in
e/ e chapters focus on practical approaches to the most common
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December 2007 by Drs Michael Blauth, Stephen Kates, and
Daniel Mendelson as the first truly interdisciplinary course
and important clinical issues facing the geriatric fracture
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patient. We aim to create a basic understanding of why
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in AO followed by a worldwide rollout. They continue to
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provide the best in evidence-based medicine, geriatric prin-
ciples, and clinical experience to promote better care for ht tps
older adult patients benefit significantly from an adapted
management and environment compared to younger adult
patients, analogous to the approach to pediatric patients.
older adults undergoing orthopedic surgery. From an aca-
demic standpoint, these courses bring together some of the In the section Improving the system of care, physicians and
most prominent orthopedic and geriatric medicine faculty administrators present chapters with local, regional, and
e r sin this emerging field. From an educational and clinical

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national health delivery changes that are necessary to op-
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standpoint, these courses are inspirational and invigorating, timize patient outcomes.
e b designed for clinicians to share current experiences, learn

e b o b o
e / new fracture reduction and fixation techniques, consider
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the unique physiology of geriatric patients, and begin to
t .
The majority of the textbook is devoted to Fracture manage-
ment; this section is focused on expert and specific surgical
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design systems of care that dramatically improve patient
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management of the wide array of fragility fractures as they
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outcomes and reduce system costs. The content of these
courses inevitably changes the way the faculty and the
attendees practice. This textbook aims to capture the e ssential htt ps:
present to most physicians and hospitals worldwide.
The impact of the dramatic demographic shift of the world’s

evidence and clinical principles so well identified during population and the explosion in fragility fractures demands
these courses. that health systems and physicians be willing to update their
clinical approaches, improve their understanding of the needs
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In order to develop innovative teaching methods for these
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of older adults, and develop interprofessional and interdis-
e
b o ok truly interdisciplinary courses, AO launched an Orthogeri-
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atric Task Force that is still active. Another product that ok
ciplinary systems to manage complex and frail patients
safely and efficiently.
b o o
e/ e / e
came out of this task force is an Orthogeriatric App about
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the management of osteoporosis, delirium, pain, and anti- We hope this textbook will support the necessary revolution
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coagulation that can be downloaded free of charge.
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in care for orthogeriatric patients, their families, and the
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t t p s clinicians caring for them.
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h Michael Blauth, MD
Stephen L Kates, MD
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Joseph A Nicholas, MD
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VI Osteoporotic Fracture Care Michael Blauth, Stephen L Kates, Joseph A Nicholas
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k e rs ke rs
e b oo e b oo b o o
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It would not have been possible to produce and publish the
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Osteoporotic Fracture Care textbook without the dedication
and support of an extensive list of contributors. From hard-
working AO surgeons donating their time and expertise, to
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colleagues volunteering case notes and images, to our staff
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within our own medical institutions, and to the teams at
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b o ok AOTrauma and AO Education Institute, we thank you for
assisting us in developing this publication.
bo ok b o o
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While there are many people to thank, we would espe-
cially like to mention these individuals:
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• Members of the AOTrauma Education Commission for
recognizing the importance and significance of this ht tps
educational opportunity and for approving the devel-
opment of this publication.
• Urs Rüetschi, Robin Greene, and Michael Cunningham
e r s from the AO Education Institute for their guidance and

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expertise and for enabling extensive resources and staff
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to prepare this publication and make it into the best
e o b o
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• The authors, our colleagues from around the world,
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who provided chapters, cases, and images.
/ /
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• Steven Olson for writing the Foreword to this book.
• Carl Lau, Manager Publishing, and Katalin Fekete,
Project Manager for this project, plus Michael Gleeson, htt ps:
Amber Parkinson, Irene Contreras, Jecca Reichmuth,
and Vidula Bhoyroo for their professional support.
• Tom Wirth from Nougat who was responsible for the
e rs overall layout of this book and for taking in the many

e r s
b o ok rounds of editorial corrections.
b o
• And lastly, to our families for their unwavering support ok b o o
e/ e and encouragement throughout this project.
e / e e /e
Michael Blauth, MD
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Stephen L Kates, MD
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Joseph A Nicholas, MD
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VII
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Editors
Michael Blauth, MD Stephen L Kates, MD Joseph A Nicholas, MD,
e rs Professor and Director

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Professor and Chair of
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MPH
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Department for Trauma Orthopaedic Surgery Associate Professor of
b o Surgery
Medical University
bo Virginia Commonwealth
University
Medicine
Geriatrics Division
b o o
e/ e Innsbruck
e/ e Department of University of Rochester
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Anichstrasse 35 O rthopaedic Surgery Highland Hospital
Innsbruck 6020
: // t 1200 E. Broad St
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Rochester, NY 14620
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Austria Richmond, VA 23298 USA
USA
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Authors
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Rohit Arora, PD Dr med Nemer Dabage, MD FACP Elizabeth B Gausden, MD, MPH
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Associate Professor
Deputy Director Department of Trauma Surgery
b o
Program Director at Blake Medical Center
2020 59th Street West
Orthopaedic Surgery Resident
Hospital for Special Surgery
b o o
e / e Medical University Innsbruck
e/ e
Bradenton, FL 34209 535 E 70th St
e/e
Anichstrasse 35
6020 Innsbruck
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USA New York, NY 10021
USA
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Austria Christian CMA Donken, MD, PhD
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Department of Orthopedic Surgery Andrea Giusti, MD
Reto Babst, Prof Dr med Sint Maartenskliniek ASL3
Vorsteher Department Chirurgie Hengstdal 3 Department of Locomotor System
Chefarzt Unfallchirurgie P.O. Box 9011 Via Casaregis 24/19
Klinik Orthopädie und Unfallchirurgie 6500 GM Nijmegen 16129 Genoa
Luzerner Kantonsspital The Netherlands Italy
e rs
6000 Lucerne 16
Switzerland Simon Euler, PD Dr med
e r s Lauren J Gleason, MD, MPH
b o ok Peter Brink
Facharzt für Unfallchirurgie
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Klinik für Unfallchirurgie und Sporttraumatologie
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Assistant Professor of Medicine
University of Chicago Medicine
b o o
e/ e Benzenrade 15c
6419 PG
e / e
Medizinische Universität Innsbruck
Anichstrasse 35
5841 S. Maryland Avenue, MC 6098
Chicago, IL 60637
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Heerlen
The Netherlands
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6020 Innsbruck
Austria
USA
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Claudia M Gonzalez Suarez, MD
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Adeela Cheema, MD Susan M Friedman, MD, MPH, AGS Thompson Health Family Practice Macedon
Geriatrics Fellow
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Section of Geriatrics & Palliative Medicine
5841 S. Maryland Ave
Associate Professor of Medicine
University of Rochester School of
Medicine and Dentistry
350 Parrish Street Canandaigua, NY 14424
1033 State Route 31
Macedon NY 14502-8218
Chicago, IL 60637 Department of Medicine USA
USA Highland Hospital
kers kers
1000 South Avenue, Box 58 Markus Gosch, Dr med univ
Colin Currie Rochester, NY 14620 Professor and Medical Director
b o o 17 Merchiston Gardens
Edinburgh EH10 5DD
USA
b o o Department for Geriatrics

Paracelsus Medical University Nuremberg, Germany
b o o
e /e e/e e/e
UK Nuremberg Hospital North
Prof.-Ernst-Nathan-Str. 1
/ /t . m Nuremberg 90419
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Germany
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Michael Götzen, Dr med, PhD Christian Kammerlander, PD Dr med Malikah Latmore, MD
Univ.-Klinik für Unfallchirurgie Vice Director Assistant Professor of Clinical Anesthesiology
Zentrum Operative Medizin Ludwig Maximilian University Munich Mount Sinai St. Luke’s and Mount Sinai West
Anichstrasse 35 Department for General, Trauma- & Hospitals
e rs
6020 Innsbruck Reconstructive Surgery
er s 1111 Amsterdam Ave
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Austria Marchioninistrasse 15 New York, NY 10025
b o Clemens Hengg, PD Dr med

81377 Munich
Germany
bo USA
b o o
e/ e Facharzt für Unfallchirurgie und Sporttraumatologie
e/ e Richard A Lindtner, MD, PhD
e/e
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Univ.-Klinik Innsbruck Alexander Keiler, Dr med Consultant
Anichstrasse 35
: // t Univ.-Klinik für Unfallchirurgie
: / /
Department of Trauma Surgery
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6020 Innsbruck Anichstrasse 35 Medical University of Innsbruck
Austria 6020 Innsbruck Anichstrasse 35
Alexander Hofmann, Dr med

Professor, Chefarzt
ht Austria
Marco Keller, Dr med

Austria ht
6020 Innsbruck
Klinik für Unfallchirurgie und Orthopädie 1 Department of Trauma Surgery Björn-Christian Link, Dr med
Westpfalz-Klinikum GmbH Medical University Innsbruck Leitender Arzt
e r s
Hellmut-Hartert Strasse 1
67655 Kaiserslautern
Anichstrasse 35
6020 Innsbruck
e r sKlinik für Orthopädie und Unfallchirurgie
Luzerner Kantonsspital Luzern
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Germany Austria Spitalstrasse
b b o 6000 Lucerne 16
b o o
e / e Timothy J Holahan, DO, CMD
Senior Clinical Instructor of Medicine
e/ e
Rashmi Khadilkar, MD
Senior Instructor of Medicine
Switzerland
e/e
University of Rochester Medical Center
Highland Hospital
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Department of Medicine
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Highland Hospital
Frank A Liporace, MD
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Chairman and Vice President
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1000 South Avenue 1000 South Avenue, Box HH 58 Chief Orthopedic Trauma and Adult Reconstruction
Rochester, NY 14620
USA
h t t p Rochester, NY 14620
USA
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Jersey City Medical Center
RWJ Barnabas Health Orthopedic Group
(Jersey City)
Hans-Christian Jeske, Prof Dr med Joon-Woo Kim, MD, PhD 377 Jersey Ave
Univ.-Klinik für Unfallchirurgie und Sportmedizin Assistant Professor Suite 280-A
Medizinische Universität Innsbruck Department of Orthopedic Surgery Jersey City, NJ 07302
e rs
Anichstrasse 35
6020 Innsbruck
School of Medicine
Kyungpook National University Hospital
e r sUSA
b o ok Austria 130, Dongduk-ro, Jung-gu
b o
Daegu, 41944 ok Dean G Lorich, MD
Associate Director of the Orthopedic Trauma Service
b o o
e/ e Herman Johal, MD, MPH, Phd(c) FRCSC
McMaster Orthopaedics / e
South Korea
e
Hospital for Special Surgery
535 E 70th St
e /e
Centre for Evidence-based Orthopaedics
293 Wellington Street North, Suite 110
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Franz Kralinger, PD Dr
Abteilungsleiter Unfallchirurgie
New York, NY 10021
USA
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Hamilton, Ontario
t t p s und Sporttraumatologie
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ht
Canada L8L 8E7 Wilhelminenspital Justinder Malhotra, MD
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Peter Kaiser, Dr med univ, PhD
Univ.-Klinik für Unfallchirurgie
Montlearstrasse 37
1160 Vienna
Austria
QueensCare Health Center
150 North Reno St
Los Angeles, CA 90026
Zentrum Operative Medizin USA
Medizinische Universität Innsbruck Dietmar Krappinger, PD, MD, PhD, MBA
kers kers
Anichstrasse 35 Head of Pelvic and Acetabular Surgery Edgar Mayr, Dr med, Dr h.c.
6020 Innsbruck Head of Bone Reconstruction Surgery Professor and Head of Trauma, Orthopaedics,
b o o Austria
b o o
Senior Consultant Spine Surgery
Plastic and Hand Surgery
Klinikum Augsburg
b o o
e /e e/e e/e
Medical University Innsbruck Stenglinstrasse 2
Anichstrasse 35 86156 Augsburg
/ /t . m 6020 Innsbruck Germany
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Austria
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Iain McFadyen, MBChB, MRCS (Ed), Chang-Wug Oh, MD Bernardo Reyes Fernandez, MD
FRCS (Tr & Orth) Professor Associate Director Internal Medicine Residency and
Consultant Orthopaedic Surgeon Department of Orthopedic Surgery Director of Geriatrics and Palliative Care
University Hospitals of North Midlands School of Medicine, Kyungpook National University Charles E. Schmidt College of Medicine
e rs
Newcastle Road Kyungpook National University Hospital
er s Florida Atlantic University
ok ok
Stoke-on-Trent 130 Dongdeok-ro, Jung-gu 777 Glades Road
b o Staffordshire ST4 6GQ

UK
Daegu 41944
South Korea
bo Boca Raton, FL 33431
USA
b o o
e/ e e/ e e/e
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Simon C Mears, MD, PhD Jong-Keon Oh Pol M Rommens, Dr med, Dr h.c.
Department of Orthopaedic Surgery
: // t Director, Department of Orthopaedic Surgery
: / /
Professor, Direktor Zentrum für
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University of Arkansas for Medical Services Korea University College of Medicine Orthopädie und Unfallchirurgie
4301 W Markham St Guro Hospital Director Department of Orthopaedics and
Little Rock, AR 72205
USA ht 97 Gurodong-gil, Guro-gu
Seoul 152-703
South Korea
Traumatology
ht
Universitätsmedizin der
Johannes Gutenberg-Universität Mainz
Daniel A Mendelson, MS, MD Langenbeckstrasse 1
Konar Professor, Division of Geriatrics Vajara Phiphobmongkol, MD 55131 Mainz
e r s
University of Rochester
Associate Chief of Medicine, Director of Palliative
Department of Orthopedic Sugery
Bangkok Hospital
e r s Germany
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Care & Co-Director of Geriatric Fracture Center 2 Soi Soonvijai 7, New Petchburi Rd. Krupa Shah, MD, MPH
b
Highland Hospital Huai Khwang
b o Associate Professor of Medicine
b o o
e / e 1000 South Avenue
Rochester, NY 14620-2733 Thailand
e/ e
Bangken, Bangkok, 10310 Highland Hospital
1000 South Avenue
e/e
USA
/ / t . m Giulio Pioli, MD, PhD

Department of Medicine, Box 58
Rochester, NY 14620
/ /t . m
ps: ps:
Paul J Mitchell, BSc (hons), CChem, MRSC Geriatrics Unit USA
htt htt
Adjunct Senior Lecturer Department of Neuromotor Physiology
School of Medicine ASMN – IRCCS Hospital Ali Shariat, MD
Sydney Campus Viale Risorgimento, 80 Clinical Assistant Professor of Anesthesiology
The University of Notre Dame Australia 42100 Reggio Emilia The Mount Sinai Hospital
140 Broadway Italy Mount Sinai St. Luke's and Mount Sinai West
Chippendale NSW Hospitals
k e s
Australia
r Philippe Posso, med pract
Luzerner Kantonsspital
e r s 1111 Amsterdam Ave
New York, NY 10025
b o o Jennifer D Muniak, MD
Senior Instructor of Medicine
Spitalstrasse 16
b
6000 Lucerne
o ok USA
b o o
e/e / e /e
Department of Medicine Switzerland Darby Sider, MD
Highland Hospital
. me Vice-Chair, Department of Internal Medicine,
. m e
://t t
1000 South Avenue Andrew J Pugely, MD Cleveland Clinic Florida
Rochester, NY 14620
s
Assistant Professor of
: / /
Program Director, Internal Medicine Residency,
p tps
USA Orthopedics and Rehabilitation Cleveland Clinic Florida
Carl Neuerburg, PD Dr med

h t t
Oberarzt, stellv. Leiter Alterstraumatologie
Office: 01025 John Pappajohn
University of Iowa
200 Hawkins Drive ht
2950 Cleveland Clinic Blvd
Dept of Internal Medicine
Weston, Florida 33331
Klinik für Allgemeine-, Unfall- und Iowa City, IA 52242 USA
Wiederherstellungschirurgie USA
Facharzt für Orthopädie und Unfallchirurgie Kerstin Simon, Dr med univ
k e rs
Klinikum der Universität München
Campus Grosshadern
Herbert Resch, Prof Dr med
ke
Dean, Paracelsus Medical University rs Trauma Surgery Resident
oo oo o
Marchioninistrasse 15 Strubergasse 21 Medical University Innsbruck
eb 81377 Munich 5020 Salzburg
e b Anichstrasse 35
b o
/ / e/e
Germany Austria 6020 Innsbruck
e t . m e Austria
t .m
/ / //
htt ps: htt ps:
X Osteoporotic Fracture Care Michael Blauth, Stephen L Kates, Joseph A Nicholas
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
Katrin Singler, PD Dr med, MME Joshua Uy, MD
Geriatric Department Associate Professor of Clinical Medicine
Associate Professor Geriatric medicine fellowship program director
Klinikum Nürnberg Nord Medical Director, Renaissance Healthcare &
e rs
Prof. Ernst Nathan Strasse 1
r s
Rehabilitation Center (formerly Park Pleasant)
e
ok ok
90419 Nürnberg University of Pennsylvania
b o Germany
bo
Ralston-Penn Center
3615 Chestnut Street
b o o
e/ e Christoph Sommer, Dr med
e/ e
Philadelphia, PA 19104
e/e
.m .m
Kantonsspital Graubünden USA
Chefarzt Allgemein- und Unfallchirurgie
: // t Steven Velkes
: / / t
tps tps
Departement Chirurgie
Loëstrasse 170 Head of Orthopedic Surgery
7000 Chur
Switzerland ht Rabin Medical Center
Petah Tikva 49100
Israel
ht
Karl Stoffel, Prof Dr med, FRACS (Orth),
FAOrth (Tr) Michael HJ Verhofstad, Dr med
e r s
Co-Chefarzt Orthopädie und Traumatologie
Kantonsspital Baselland
Professor
e r s
Chair of trauma and orthopedic trauma surgery
ook ok
Teamleiter Hüft/Beckenchirurgie und Department of Surgery
b
Leiter Traumatologie
b o
Erasmus MC, University Medical Center Rotterdam
b o o
e / e Facharzt für Orthopädie und Traumatologie
des Bewegungsapparates
P.O. Box 2040
e/ e
3000 CA Rotterdam
e/e
Fellow Royal Australasian College of Surgeons
Kantonsspital Baselland
/ / t . m The Netherlands
/ /t . m
ps: ps:
Standort Bruderholz Richard S Yoon, MD
htt htt
4101 Bruderholz Director, Orthopaedic Research
Switzerland Division of Orthopaedic Trauma and
Adult Reconstruction
Susanne Strasser, Dr med, PhD Department of Orthopaedic Surgery
Univ.-Klinik für Unfallchirurgie Jersey City Medical Center — RWJBarnabas Health
Medizinische Universität Innsbruck 377 Jersey Ave, Suite 280A
e s
Anichstrasse 35
r
6020 Innsbruck
Jersey City, NJ 07302
USA
e r s
b o ok Austria
b o ok b o o
e/ e Julie A Switzer, MD
Department of Orthopaedic Surgery
e / e e /e
Associate Professor, University of Minnesota
://t
Director, Geriatric Trauma Program, Regions Hospital . m : / / t .m
640 Jackson St
t t p s tps
ht
Mail stop: 11503L
St Paul, MN 55101
USA
h
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
XI
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Abbreviations
t . m e /
t . m e/e
/ / / /
AAOS
htt ps:
American Academy of Orthopaedic Surgeons CGC clinical practice guidelines
htt ps:
ABCDE airway, breathing, circulation, disability, CHF congestive heart failure
exposure/examination CI confidence interval
ACC American College of Cardiology COPD chronic obstructive pulmonary disease
e rs
ACCP
ACE
American College of Chest Physicians
angiotensin-converting enzyme
CPG
CPM
er s
clinical practice guidelines
continuous passive motion
b o ok ACEI
ACL
angiotensin-converting enzyme inhibitors
anterior cruciate ligament
bo ok
CRP
CRPS
cardiopulmonary resuscitation
complex regional pain syndrome
b o o
e/ e ADL activity of daily living
e/ e CSF cerebrospinal fluid
e/e
AF
AF atrial fibrillation
: / .m
ankle fracture (chapter 3.17 Ankle)
/ t CT
CVA
computed tomography
cerebrovascular accident
: / / t .m
AFF
AFN
AGS
tps
atypical femoral fracture
ht
antegrade femoral nail
American Geriatrics Society
CVD

DASH
cardiovascular disease
ht tps
Disabilities of the Arm, Shoulder and Hand
AHA American Heart Association DECT dual-energy computed tomography
ANZHFR Australian and New Zealand Hip Fracture Registry DEXA dual energy x-ray absorptiometry
AO Arbeitsgemeinschaft für Osteosynthesefragen DFF distal forearm fracture (chapter 3.6 Distal
e r s
AOCID AO Clinical Investigation and Documentation
e r s
forearm)
ook ok o
AP anteroposterior DFF distal femoral fracture (chapter 3.12 Distal
e b APL abductor pollicis longus

e b o femur)
b o
e / aPTT
ARIF
activated partial thromboplastin time
m e/
arthroscopy-assisted reduction and internal
t .
DFR
DHF
distal femoral replacement
distal humeral fracture
t . m e/e
fixation
/ / DFN distal femoral nail
/ /
ARB
ASA
ASBMR
ps:
angiotensin receptor blockers
htt
American Society of Anesthesiologists
American Society for Bone and Mineral
DHS
DM
DOSS
dynamic hip screw
diabetes mellitus
htt
Delirium Observation Screening Scale
ps:
Research DRF distal radial fracture
ASIS anterior superior iliac spine DRG diagnosis-related group
ASLS angular stable locking system DRUJ distal radioulnar joint
e rs
ATE arterial thromboembolism DSM-V
r s
Diagnostic and Statistical Manual of Mental
e
b o ok ATLS
AVN
advanced trauma life support
avascular necrosis
b o ok
DUF
Disorders
distal ulnar fracture
b o o
e/ e
BGS British Geriatrics Society
e / e DVT

deep vein thrombosis
e /e
BIPAP
://t . m
biphasic positive airway pressure EF external fixator
: / / t . m
BMD
s
bone mineral density
t t p
EFD elbow fracture dislocation
tps
ht
BMI body mass index EPL extensor pollicis longus
BOA
BP
h
British Orthopaedic Association
bisphosphonate

FAITH
Fixation using Alternative Implants for the
BPF best practice framework Treatment of Hip fractures
BPT Best Practice Tariff FCR flexor carpi radialis
k e rs

CAD coronary artery disease
FCU
k
FDA
e rs
flexor carpi ulnaris
Food and Drug Administration
eb oo CAM Confusion Assessment Method
e b oo
FFN Fragility Fracture Network
b o o
e/e
CCD caput-collum-diaphyseal (angle) FFP fragility fracture patient (all chapters except
e / CCI Charlson Comorbidity Index

m e / 3.7 Pelvic ring)
m
C-clamp
t .
compression clamp (for pelvis)
/ / FFP fragility fracture of the pelvic ring (only in
// t .
ps: ps:
CGA comprehensive geriatric assessment chapter 3.7 Pelvic ring)
XII
htt htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / FLS fracture liaison service
t . m e / LCL lateral collateral ligament
t . m e/e
s: / / / /
ps:
FRAX Fracture Risk Assessment LCP locking compression plate
http htt
FSF femoral shaft fracture LHB long head of the biceps
FWB full weight bearing LHS locking head screw
FWBAT full weight bearing as tolerated LISS less invasive stabilization system
LMWH low-molecular-weight heparin
GA general anesthesia LOS length of hospital stay
e s
GAF
r
GI
geriatric acetabular fracture
gastrointestinal
LP
LT
er s
locked plating
lesser tuberosity (chapter 3.1 Proximal
b o ok GCS
GORU
Glasgow Coma Scale
geriatric orthopedic rehabilitation unit
bo LT ok humerus)
lesser trochanter (chapters 3.13 Periprosthetic
b o o
e/ e GP general practitioner
e/ e fractures around the hip, 3.14 Periprosthetic
e/e
GT
humerus)
: // .m
greater tuberosity (chapter 3.1 Proximal
t
fractures around the knee)
: / / t .m
GT

tps
greater trochanter (chapter 3.13 Periprosthetic
ht
fractures around the hip)
MCD
MCL
MET
minimum common dataset
metabolic equivalentht tps

medial collateral ligament
HBR home-based rehabilitation MGF mechano growth factor

HO heterotopic ossification MI myocardial infarction
HRQoL health-related quality of life MIPO minimally invasive plate osteosynthesis
e r s
HSA head-shaft angle MIPPO
e r s
minimally invasive percutaneous
ook ok o
HTN hypertension extraperiostally plate osteosynthesis
e b HU Hounsfield Unit
e b o MIS minimally invasive surgery
b o
e /
IADL
m
instrumental activity of daily living
t . e/ MNA
MRI
Mini-Nutritional Assessment
magnetic resonance imaging
t . m e/e
ICD
/ /
implantable cardioverter defibrillator MVA motor vehicle accident
/ /
ICU
IGF
IKS
intensive care unit
htt ps:
insulin-like growth factor
International Knee Score

NA
NHFD
neuraxial
htt ps:
National Hip Fracture Database
IL interleukin NHFS Nottingham Hip Fracture Score
IM intramedullary NHS National Health Service
INR international normalized ratio NICE National Institute for Health and Care
e rs
IOF International Osteoporosis Foundation
r s
Excellence
e
b o ok IPCD
IQR
intermittent pneumatic compression devices
interquartile range
b o ok
NMS
NOAC
New Mobility Score
new oral anticoagulant
b o o
e/ e IR
IRF
internal rotation
inpatient rehabilitation facility
e / e NPWT negative-pressure wound therapy, also called
vacuum-assisted wound closure (VAC)
e /e
ISP
://t
Infraspinatus (muscle/tendon)
. m NRS numerical rating scale
: / / t . m
ISS
s
Injury Severity Score
t t p
NSAIDs
tps
nonsteroidal antiinflammatory drugs
ht
IU International units NOF National Osteoporosis Foundation
IV
IVC
intravenous h
inferior vena cava

OGU Orthogeriatric unit
ONJ osteonecrosis of the jaw
K-wire
Kirschner wire ONS oral nutrition supplements
k e rs
KSS

Knee Society Score ORIF
ke
OTA rs
open reduction and internal fixation
Orthopaedic Trauma Association
eb oo LAP locking attachment plate
e b oo

b o o
e/e
LBD local bone density PACU postanesthesia care unit
e / LBQ local bone quality

m e / PADL personal activity of daily living
m
LC-DCP
t .
limited-contact dynamic compression plate
/ / PCA patient-controlled analgesia
// t .
ps: ps:
LCP-DF
reversed distal femoral locking compression plate PCC prothrombin complex concentrate
htt htt XIII
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / PCM
t .
perioperative cardiac morbidity
m e / THA total hip arthroplasty
t . m e/e
s: / / / /
ps:
PDCA plan-do-check-act TIA transient cerebral ischemia attack
http htt
PDPH postdural puncture headache TKA total knee arthroplasty
PE pulmonary embolism TNF-α
tumor necrosis factor α
PET-CT
positron emission tomography combined with TSF tibial shaft fracture
computerized tomography TSH thyroid-stimulating hormone
PFN proximal femoral nail TUG Timed Up and Go test
e rs
PFNA
PHF
proximal femoral nail antirotation
proximal humeral fracture

UCS
er s
Unified Classification System
b o ok PHILOS
PMMA
proximal humerus internal locked system
polymethylmethacrylate
bo ok
UFH
UTI
unfractionated heparin
urinary tract infection
b o o
e/ e POMA
e/
performance-oriented mobility assessmente
e/e
PROM
PPHF
: / .m
patient-reported outcome measure
/ t
periprosthetic hip fracture
VAS
VDS
Visual Analog Scale
Verbal Descriptor Scale
: / / t .m
PPI
PPKF
PPS
tps
proton pump inhibitors
ht
periprosthetic fractures around the knee
prospective payment system
VTE

WBAT
venous thromboembolism
weight bearing as tolerated ht tps

PROM patient-reported outcome measures WHO World Health Organization
PRWE Patient-Rated Wrist Evaluation
PSIS posterior superior iliac spine
e r s
PTF proximal tibial fracture
e r s
ook ok o
PTH parathyroid hormone
e b PTS postthrombotic syndrome

e b o b o
e / PWB
PWBAT
partial weight bearing
m
partial weight bearing as tolerated
t . e/ t . m e/e

/ / / /
QALY

RA htt ps:
quality-adjusted life year
regional anesthesia htt ps:

RCRI Revised Cardiac Risk Index
RCT randomized controlled trial
ROI region of interest
e rs
ROM range of motion
e r s
b o ok RSA

reverse shoulder arthroplasty
b o ok b o o
e/ e SAHFE
SD / e
Standardized Audit of Hip Fracture in Europe
standard deviation
e e /e
SERM
://t . m
estrogens, selective estrogen receptor
: / / t . m
modulator
t t p s tps
ht
SHA shoulder hemiarthroplasty
SNF
SPPB
h
skilled nursing facility
short physical performance battery
SQ subcutaneous
SSC subscapularis
k e rs
SSP

supraspinatus (muscle/tendon)
ke rs
eb oo TAD tip-apex distance
e b oo b o o
e/e
Tc technetium
e / TEA total elbow arthroplasty

m e / m
TENS
t .
transcutaneous electrical nerve stimulation
/ / // t .
ps: ps:
TFCC triangular fibrocartilaginous complex
htt htt
TFN trochanteric femoral nail
XIV Osteoporotic Fracture Care Michael Blauth, Stephen L Kates, Joseph A Nicholas
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Online AO Educational Content
t . m e /
t . m e/e
/ / / /
htt ps:
Abundant online educational offerings from across AO are
htt ps:
accessible through the QR codes printed on each chapter
title page. Using a QR code scanner on a mobile device,
readers will be taken to specific chapter microsites that
e s
contain supplemental AO educational content curated by
r
the book editors specifically for that chapter topic.
er s
b o ok Links to supplemental AO educational content include:
bo ok b o o
e/ e • AO Surgery Reference
e/ e e/e
• Webinars and webcasts
• Lectures
: // t .m : / / t .m
• Teaching videos
• eLearning modules
• Mobile apps ht tps ht tps
As the array of online AO educational resources evolves and
develops, the offerings in the chapter microsites will be
e r sregularly reviewed and updated by the book editors. This

e r s
ook ok o
will ensure that readers are linked to the latest in AO
e b education.
e b o b o
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t .m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
XV
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Table of Contents
t . m e /
t . m e/e
/ / / /
Foreword
htt ps: V Section 1—Principles
htt ps: 1
1.1 P rinciples of orthogeriatric medical care
Preface VI Joseph A Nicholas 3
k e rs Acknowledgments VII
e s
1.2 P rinciples of orthogeriatric surgical care
r
ok
Michael Blauth 7
o o o 1.3 P rinciples of orthogeriatric anesthesia

o o
e/eb e/ e b e/eb
Contributors VIII Ali Shariat, Malikah Latmore 19
Abbreviations
: // t .m XII
1.4 P reoperative risk assessment and preparation
Joseph A Nicholas
: / / t .m 29
s tps
http ht
1.5 P rognosis and goals of care
Online AO Educational Content XV Joshua Uy 35
1.6 A nticoagulation in the perioperative setting

Table of contents XVI Lauren J Gleason, Adeela Cheema, Joseph A Nicholas 41

ke r s r s
1.7 Postoperative medical management
e
ok
Jennifer D Muniak, Susan M Friedman 51
b o o b o 1.8 Postoperative surgical management

b o o
e /e Section 1—Principles
t . me/ e 1 Michael Blauth, Peter Brink
1.9 Postacute care

t . m
59
e/e
s: / / / /
ps:
Section 2—Improving the system of care 115 Bernardo Reyes, Nemer Dabage, Darby Sider 71

http
Section 3—Fracture management 189
1.10 O steoporosis
Rashmi Khadilkar, Krupa Shah htt 77
1.11 S arcopenia, malnutrition, frailty, and falls

Claudia M Gonzalez Suarez 89
e rs e r s
1.12 Pain management
b o ok Index
b
593
o ok
Timothy Holahan, Daniel A Mendelson
1.13 Polypharmacy
97
b o o
e/ e e / e Bernardo Reyes, Justinder Malhotra
e /e
105
://t . m 1.14 D elirium
: / / t . m
ttps tps
Markus Gosch, Katrin Singler 109
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
XVI Osteoporotic Fracture Care Michael Blauth, Stephen L Kates, Joseph A Nicholas
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Section 2—Improving the system of care
t . m e /
115 Section 3—Fracture m
anagement
t . m 189 e/e
s: /
2.1 M odels of orthogeriatric care / 3.1 P roximal humerus
s: / /
2.2 O ht t p
Andrea Giusti, Giulio Pioli
vercoming barriers to implementation

117 Franz Kralinger, Michael Blauth
3.2 H umeral shaft ht t p 191
of a care model Clemens Hengg, Vajara Phiphobmongkol 243

Stephen L Kates 129
3.3 D istal humerus
k e rs 2.3 C linical practice guidelines

r s
Rohit Arora, Alexander Keiler, Michael Blauth
e
269
ok
Stephen L Kates, Michael Blauth 133
3.4 Elbow
o o 2.4 Elements of an orthogeriatric comanaged program

o o o
e/eb b b
Rohit Arora, Kerstin Simon, Marco Keller, Michael Blauth 283
Carl Neuerburg, Christian Kammerlander
e/ e
137
3.5 O lecranon
e/e
Edgar Mayr
: // t .m
2.5 A dapting facilities to fragility fracture patients
145
Peter Kaiser, Simon Euler
: / / t .m
297
s 3.6 D istal forearm

s
http http
2.6 O rthogeriatric team—principles, roles, Rohit Arora, Alexander Keiler, Susanne Strasser 315
and responsibilities
3.7 Pelvic ring
Markus Gosch, Michael Blauth 151
Pol M Rommens, Michael Blauth, Alexander Hofmann 339
2.7 P rotocol and order set development
3.8 A cetabulum
ke r s Stephen L Kates, Joseph A Nicholas
2.8 F racture liaison service and improving treatment

157
r s
Dietmar Krappinger, Richard A Lindtner, Herbert Resch
k e
373
boo o o
3.9 F emoral neck
rates for osteoporosis
b o Simon C Mears, Stephen L Kates 389

b o
e /e e/e e/e
Paul J Mitchell 165
3.10 Trochanteric and subtrochanteric femur
2.9 U se of registry data to improve care
/ / t . m /
Carl Neuerburg, Christian Kammerlander, Stephen L Kates
/ t . m
405
s: s:
Colin Currie 173
http http
3.11 F emoral shaft
2.10 L ean business principles
Elizabeth B Gausden, Dean G Lorich 421
Stephen L Kates, Andrew J Pugely 181
3.12 D istal femur
Jong-Keon Oh, Christoph Sommer 439
3.13 Periprosthetic fractures around the hip
e rs e r s
Steven Velkes, Karl Stoffel 461
b o ok b o ok
3.14 Periprosthetic fractures around the knee
b o o
e/ e e / e Frank A Liporace, Iain McFadyen, Richard S Yoon
3.15 P roximal tibia

479
e /e
://t . m Michael Götzen, Michael Blauth
: / / t . m
501
t p s ps
htt
3.16 T ibial shaft
h t Björn-Christian Link, Philippe Posso, Reto Babst
3.17 A nkle
523
Christian CMA Donken, Michael HJ Verhofstad 535
3.18 A typical fractures
k e rs ke rs
Chang-Wug Oh, Joon-Woo Kim 559
b o o b oo
3.19 C hest trauma
b o o
e / e e /e Hans-Christian Jeske 571
e/e
: / /t . m 3.20 Polytrauma
// t .m
ps:
Julie A Switzer, Herman Johal 579
t p s
h t htt XVII
rs
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/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e boo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
XVIII Osteoporotic Fracture Care Michael Blauth, Stephen L Kates, Joseph A Nicholas
rs
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/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e boo b o o
/ / e/e
e
Section
p s: / / t . m 1 e
ps: / / t . m
htt htt
e rs
Principleser s
b o ok k
bo o b o o
e/ e e/e e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t .m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
e rs e rs
e b oo Section 1
k
e b oo k
b o o
e / Principles
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs
1.1 Principles of orthogeriatric medical care
Joseph A Nicholas
er s 3
b o ok 1.2 Principles of orthogeriatric surgical care

bo ok b o o
e / e Michael Blauth
e/ e 7
e/e
: // t
Ali Shariat, Malikah Latmore .m
1.3 Principles of orthogeriatric anesthesia
19
: / / t .m
ht tps
1.4 Preoperative risk assessment and preparation
Joseph A Nicholas 29 ht tps
1.5 Prognosis and goals of care
Joshua Uy 35
e r s 1.6 Anticoagulation in the perioperative setting
e r s
ook ok
Lauren J Gleason, Adeela Cheema, Joseph A Nicholas 41
b 1.7 Postoperative medical management

b o b o o
e / e Jennifer D Muniak, Susan M Friedman
e/ e 51
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1.8 Postoperative surgical management
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ps: ps:
Michael Blauth, Peter Brink 59
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1.9 Postacute care
Bernardo Reyes, Nemer Dabage, Darby Sider 71 htt
1.10 Osteoporosis
Rashmi Khadilkar, Krupa Shah 77
e rs
1.11 Sarcopenia, malnutrition, frailty, and falls
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b o ok Claudia M Gonzalez Suarez
b o ok 89
b o o
e/ e Timothy Holahan, Daniel A Mendelson
e / e 97
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1.13 Polypharmacy
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Bernardo Reyes, Justinder Malhotra
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105
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1.14 Delirium
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Markus Gosch, Katrin Singler 109 ht
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Joseph A Nicholas
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Joseph A Nicholas
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e rs er s
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e/ e 1 Introduction
e/ e 2 Key principles
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Despite the large amount of surgical care delivered to older 2.1
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lder adults are not simply adults with more
O
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adults [1], perioperative practice remains inappropriately
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anchored to the surgical experience of more robust and less
comorbid patients. At best, many common and accepted
illnesses
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Compared with younger adults, older adults have unique
physiologies, regardless of the presence or absence of spe-
approaches to specific illnesses are ineffective in older adults, cific comorbidities [9, 10]. Aging results in biological changes
and at worst, these practices contribute to serious morbid- that render the older adult more susceptible to the harms of
ity and mortality [2, 3]. The negative impact of usual medi- immobility, diagnostic tests, and medication effects. For this
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cal and surgical care is most pronounced in frail and medi-
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reason, many common medical practices can be ineffective
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cally complicated patients [4, 5]. or harmful in older adults. Examples include exaggerated
e b e b o hypotension in the presence of anesthetics and blood loss,

b o
e / patients for whom usual medical care is often the wrong
t . e/
The typical fragility fracture patient (FFP) is emblematic of
m
low thresholds for delirium, complications due to polyphar-
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macy, and rapid functional decline with immobility. This e/e
/ /
care. To those who treat and research this population, it is
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general decreased ability to respond to physiological stress
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not surprising that superior postoperative outcomes have
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been found through unique clinical and systems approach-
es to the geriatric patient [6, 7], strategies that often diverge
is best described as frailty [11].
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ip fracture surgery can be performed safely and
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from the types of medical investigations and treatments used effectively even on frail patients
in most care settings. High-performing hip fracture centers produce low short-
term mortality rates (ie, less than 2%), even in populations
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Fortunately, there is growing evidence that improved clinical
r s
with high degrees of frailty and comorbidity [6, 12]. Ad-
e
b o ok outcomes can be obtained in frail older adults with osteopo-
b o
rotic fractures through the incorporation of a relatively small ok
vances in anesthesia, implant technology allowing for e arly
weight bearing as tolerated, orthopedic procedural improve-
b o o
e/ e / e
number of standard approaches and clinical pathways [8].
e
The major barriers to implementing these approaches are not
ments, and orthogeriatric comanagement all contribute to
e /
rapid, safe, and effective repair of the overwhelming majoritye
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technological or financial but involve an understanding and
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of hip fracture patients. Urgent surgery in the optimized
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commitment to creating systems and expertise that focus on
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patient is now standard care to avoid the short-term harms
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standardizing care, avoiding adverse events, and adapting of ongoing pain, blood loss, and immobility.
older adult.
h
treatments to the unique physiology and prognosis of the
2.3 ge is not the most important indicator of risk or
A
prognosis in hip fracture patients
While the details of such care will change as the evidence While age is a general predictor for outcomes and complica-
k e rs
base expands, we expect the basic strategies outlined in this
book to remain relevant for years to come. In the chapters
ke rs
tions, it is more helpful to base risk assessments and treat-
ment decisions on functional status, cognitive status, and
eb oo that follow, readers will be introduced to the principles and
e b oo
comorbidity [13]. Asking patients about their day-to-day life
b o o
e/e
specifics of caring for the typical FFP, based on the improved can help estimate operative risk, recovery potential, and life
e / outcomes produced by orthogeriatric comanagement in or-

m e / expectancy better than disease-based assessments.
m
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ganized fracture center programs. To set the stage, there are
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a number of principles that are important to recognize.
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Section 1 Principles
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urgical delay and immobility leads to
S
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any geriatricians, internists, and specialists do
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s: / / / /
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irreversible muscle loss in the older adult not understand acute perioperative medicine
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Early surgery is superior [14] and essential for frail and co- Current medical training offers little focus on the periop-
morbid patients. The medical and surgical team must con- erative period. Other than performing outpatient preop-
stantly weigh the impact of functional decline and operative erative risk assessments in relatively robust patients or plan-
delay against operative risk. Even the frailest patients can ning an elective procedure, most internists, subspecialists,
usually be optimized quickly, repaired, and begin immedi- and geriatricians do not gain expertise in acute stabilization,
e rs
ate full weight bearing and rehabilitation [15].
er s
optimization, and recovery of patients undergoing urgent
surgery. Approaches to common medical issues are different
b o ok 2.5 G et the patient moving as soon as possible

Because rapid loss of muscle mass and function is a funda-
bo ok
in perioperative patients from those in typical medical ad-
missions [22].
b o o
e / e e/ e
mental issue resulting in poor overall outcomes [16], all care
e/e
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pathways should be optimized to support early mobility and
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rehabilitation. While surgical delay and bed rest orders are
2.9 ery little high-quality evidence is applicable to
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the care of older adults
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http
obvious factors, polypharmacy, excessive testing, frequent Most medical and surgical evidence is based on adults that
subspecialty consultation, and inadequate pain control are
all common barriers to mobilization that need to be mini-
mized. Early mobility provides the necessary physical and
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are very different from the geriatric fracture patient [23].
Geriatric populations do not experience the same balance
of benefits and harms younger, healthier, and more robust
emotional stimulation [17] for healing and recovery and adults do. Rather than trying to comply with multiple disease-
helps minimize skin breakdown, constipation, and neuro- specific guidelines, high-performing geriatric fracture centers
e r smuscular wasting. Mobility can be the difference between

e r s
create strategies based on general geriatric principles, like
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rapid recovery and prolonged hospitalization. avoiding polypharmacy, anticipating and managing delirium,
e b e b o and rapid restoration of mobility.

b o
e / 2.6 Less is often more
me/
Most FFPs have multiple comorbidities and abnormalities
t . 2.10 Recognize failing patients at the end of life
t . m e/e
/ /
on diagnostic testing, many of which are chronic, clinically
: / /
For many patients, falls and fragility fractures are the result
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irrelevant, or unable to be improved. Unfortunately, this
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often results in excessive testing and consultation, overdi-
agnosis, and polypharmacy. Organized programs work hard htt ps:
of decompensated medical illnesses and frailty, and many
will have a life expectancy of less than 6 months [24]. Failing
patients do not respond well to usual medical care, suffering
to avoid these distractions, and focus instead on key areas more harm than benefits from hospitalization, testing, and
like hemodynamic stability, pain control, prompt fracture treatment. Early recognition of failing patients is important
reduction, and mobilization [18]. to identify achievable goals, set realistic expectations for the
e rs e r s
family and the clinical team, and to focus future care appro-
b o ok 2.7 any surgeons, internists, and specialists do not

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understand typical geriatric medical physiology
b o ok
priately on end of life. Orthopedic surgery plays an essential
role in pain control and quality of life. All clinicians involved
b o o
e/ e / e
Regardless of professional training, unique geriatric respons-
e
es to therapies are not adequately emphasized in most
in the care of FFPs need to have an ability to recognize the
failing patient (ie, frailty).
e /e
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medical school and postgraduate training programs [19, 20].
: / / t . m
s
Clinical experiences in geriatrics often fail to focus on acute
t t p
2.11 Organized fracture programs work
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care approaches, and subspecialty training in many medical There is no single surgical technique, preoperative risk
h
and surgical disciplines does not typically promote adapta-
tion of clinical expertise to frail older adults [21]. Compe-
assessment tool, or standard medical consultation that will
produce ongoing results as good as an organized approach
tency in acute geriatric care does not require formal fellow- to the FFP. Investments in an organized program with ge-
ship training, but can be achieved with a continuing riatric comanagement will yield improvement in outcomes,
k e rs
medical education approach. Attending a course, viewing
educational media, or visiting an established geriatric frac-
ke rs
costs, and both patient and physician satisfaction [8, 25].
Organized programs are becoming the standard of care in
eb oo ture program can help develop competency in caring for
e b oo
many medical and surgical communities [26], and even for
b o o
e/e
older adults. other surgical problems [27, 28].
e / m e / m
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4 Osteoporotic Fracture Care Michael Blauth, Stephen L Kates, Joseph A Nicholas
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Joseph A Nicholas
k e rs ke rs
e b oo e b oo b o o
e / 3 References
t . m e /
t . m e/e
/ / / /
htt ps:
1. Centers for Disease Control and
Prevention. Number of discharges from
short-stay hospitals, by first-listed
10. Walston J, Hadley EC, Ferrucci L, et al.
Research agenda for frailty in older
adults: toward a better understanding
htt ps:
20. Sedhom R, Barile D. Teaching our
doctors to care for the elderly:
a geriatrics needs assessment targeting
diagnosis and age: United States, 2010. of physiology and etiology: summary internal medicine residents.
Available at: www.cdc.gov/nchs/data/ from the American Geriatrics Society/ Gerontol Geriatr Med.
nhds/3firstlisted/2010first3_ National Institute on Aging Research 2017 Jan–Dec;3:2333721417701687.
numberage.pdf. Accessed April 15, Conference on Frailty in Older Adults. 21. Potter JF, Burton JR, Drach GW, et al.
e rs 2017.
2. Gerstein HC, Miller ME, Byington RP,
J Am Geriatr Soc.
2006 Jun;54(6):991–1001.
er s Geriatrics for residents in the surgical
and medical specialties:
b o ok et al. Effects of intensive glucose

lowering in type 2 diabetes. N Engl J
bo ok
11. Fried LP, Tangen CM, Walston J, et al.
Frailty in older adults: evidence for a
implementation of curricula and
training experiences. J Am Geriatr Soc.
b o o
e/ e Med. 2008 Jun 12;358(24):2545–2559.
3. Mossello E, Pieraccioli M, Nesti N, et al.
e/ e
phenotype. J Gerontol A Biol Sci Med Sci.
2001 Mar;56(3):M146–M156.
2005 Mar;53(3):511–515.
22. Braude P, Partridge JS, Hardwick J,
e/e
.m .m
Effects of low blood pressure in 12. Brauer CA, Coca-Perraillon M, Cutler DM, et al. Geriatricians in perioperative
: // t
cognitively impaired elderly patients
treated with antihypertensive drugs.
et al. Incidence and mortality of hip
fractures in the United States. JAMA.
: / / t
medicine: developing subspecialty
training. Br J Anaesth.
tps tps
JAMA Intern Med. 2009 Oct 14;302(14):1573–1579. 2016 Jan;116(1):4–6.
ht ht
2015 Apr;175(4):578–585. 13. Semel J, Gray JM, Ahn HJ, et al. 23. Tinetti ME, Bogardus ST Jr, Agostini JV.
4. Odden MC, Peralta CA, Haan MN, et al. Predictors of outcome following Potential pitfalls of disease-specific
Rethinking the association of high hip fracture rehabilitation. PM R. guidelines for patients with multiple
blood pressure with mortality in elderly 2010 Sep;2(9):799–805. conditions. N Engl J Med.
adults: the impact of frailty. Arch Intern 14. Lefaivre KA, Macadam SA, Davidson DJ, 2004 Dec 30;351(27):2870–2874.
Med. 2012 Aug 13;172(15):1162–1168. et al. Length of stay, mortality, 24. Neuman MD, Silber JH, Magaziner JS,
e r s
5. Mosquera C, Spaniolas K, Fitzgerald TL.
Impact of frailty on surgical outcomes:
e r
fractures. J Bone Joint Surg Br.
s
morbidity and delay to surgery in hip et al. Survival and functional outcomes
after hip fracture among nursing home
ook ok
The right patient for the right 2009 Jul;91(7):922–927. residents. JAMA Intern Med.
b
procedure. Surgery.
2016 Aug;160(2):272–280.
b o
15. Keehan R, Rees D, Kendrick E, et al.
Enhanced recovery for fractured
2014 Aug;174(8):1273–1280.
25. Kates SL, Mendelson DA, Friedman SM.
b o o
e / e 6. Friedman SM, Mendelson DA, Bingham
KW, et al. Impact of a comanaged
e/ e
neck of femur: a report of 3 cases.
Geriatr Orthop Surg Rehabil.
The value of an organized fracture
program for the elderly: early results.
e/e
t
Geriatric Fracture Center on short-term
/ / . m 2014 Jun;5(2):37–42. J Orthop Trauma.
/ /t . m
ps: ps:
hip fracture outcomes. Arch Intern Med. 16. Visser M, Harris TB, Fox KM, et al. 2011 Apr;25(4):233–237.
2009 Oct 12;169(18):1712–1717. Change in muscle mass and muscle 26. Fisher AA, Davis MW, Rubenach SE,
htt htt
7. Kammerlander C, Gosch M, Blauth M, strength after a hip fracture: et al. Outcomes for older patients with
et al. The Tyrolean Geriatric Fracture relationship to mobility recovery. hip fractures: the impact of orthopedic
Center: an orthogeriatric co- J Gerontol A Biol Sci Med Sci. and geriatric medicine cocare. J Orthop
management model. Z Gerontol Geriatr. 2000 Aug;55(8):M434–M440. Trauma. 2006 Mar;20(3):172–178;
2011 Dec;44(6):363–367. 17. Kalisch BJ, Lee S, Dabney BW. discussion 179–180.
8. Friedman SM, Mendelson DA, Kates SL, Outcomes of inpatient mobilization: 27. Tadros RO, Faries PL, Malik R, et al.
et al. Geriatric co-management of a literature review. J Clin Nurs. The effect of a hospitalist
e rs proximal femur fractures: total quality 2014 Jun;23(11–12):1486–1501.
e r s comanagement service on vascular
ok ok
management and protocol-driven care 18. Nicholas JA. Preoperative optimization surgery inpatients. J Vasc Surg.
b o
result in better outcomes for a frail
patient population. J Am Geriatr Soc.
and risk assessment. Clin Geriatr Med.
b o
2014 May;30(2):207–218.
2015 Jun;61(6):1550–1555.
28. Montero Ruiz E, Rebollar Merino A,
b o o
e/ e 2008 Jul;56(7):1349–1356.
9. Cheitlin MD. Cardiovascular
e / e
19. Monette M, Hill A. Arm-twisting
medical schools for core geriatric
Rivera Rodriguez T, et al. Effect of
comanagement with internal medicine
e /e
physiology-changes with aging.
Am J Geriatr Cardiol.
://t . m training. CMAJ.

2012 Jul 10;184(10):E515–E516.
/ / t .
the Service of Otolaryngology.
: m
on hospital stay of patients admitted to
2003 Jan–Feb;12(1):9–13.
t t p s tps
Acta Otorrinolaringol Esp.
2015 Sep–Oct;66(5):264–268.
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Michael Blauth
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1.2 Principles of orthogeriatric surgical care
/ / /
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Michael Blauth
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e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e • Prevention of complications, such as reoperations,
e/e
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Fragility fracture patients (FFPs) represent up to 40% of delirium
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pneumonia, pressure sores, urinary tract infection, and
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patients in many orthopedic trauma units worldwide. This
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trend is increasing. As a consequence, over the last decade,
refined surgical care approaches have been developed from ht tps
Making the right therapeutic decisions is much more com-
plex than with younger patients. Fragility fracture patients
growing experience and close collaboration with geriatri- are functionally and physiologically variable (from non
cians in order to improve patient outcomes and lower health- ambulatory “No-goes” to ambulatory “Go-goes”) that the
care expenses. benefits and risks of treatment are not as clear as in younger
e r s e r s
patients. Therefore, it is essential to establish a consensus
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Similar to fracture care in children, geriatric fracture care for the treatment goals among all of the team members.
e b b
also differs in many aspects from the standard treatment of
e o b o
e / e/
middle-aged adults. Due to the relative paucity of random-
m
ized trial data for many treatments, many of the following
t .
Defining individual goals for each FFP is an important step
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which should be established and agreed upon as early as e/e
/ /
recommendations represent expert opinions with some based
/ /
possible by the interdisciplinary team. The individual goals
htt ps:
on biomechanical or clinical investigations.
The four AO Principles certainly apply to the care of fragil- htt ps:
influence diagnostic and therapeutic surgical and medical
measures and should be clearly communicated. Goal setting
avoids unnecessary steps and streamlines the treatment.
ity fractures and should be carefully adhered to: Goals may be adjusted during the treatment process.
1. Fracture reduction and fixation to restore anatomical First, treatment goals should be very specific, clear and easy.
e rs relationships
r s
Second, if you cannot measure it, you cannot manage it. Third,
e
b o ok 2. Stability by fixation or splinting, as the personality of
the fracture and the injury requires
b o ok
a goal needs to be attractive and acceptable to the patient and
the clinical team. Fourth, the goal should be realistic, mean-
b o o
e/ e / e
3. Preservation of blood supply to soft tissues and bone
e
by careful handling and gentle reduction techniques /
ing achievable or “doable”. Fifth, the timeline to achieve the
goal should be considered by setting a time frame.
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4. Early and safe mobilization of the part and the patient
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t t p s tps
It is useful to find short-term as well as long-term goals.
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Usually, the long-term goal is the expected outcome in sev-
2 Goal setting h eral weeks or months, like to live independently or to walk
without using a walking aid. When approaching a long-term
The entire patient must be considered including his/her goal, you need different short-term goals for each problem,
medical problems, medications, living situation, and goals like walking with a rolling walker after the first week, or
k e rs
for care. Overall, the following issues assume prominence
in care of FFPs:
ke rs
removing a urinary catheter within 2 or 3 days after surgery.
eb oo e b oo
The goals may be modified due to medical or surgical com-
b o o
e/e
• Pain relief plications or if patients become unwilling or unable to con-
e / • Prevention of functional decline

m e / tinue or if they progress more slowly or quickly than ex-
m
• Maintenance of independence
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pected. Goal setting should be integrated in the regular team
//
ps: ps:
meetings.
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k e rs ke rs
e b oo e b oo b o o
e / 3 Time matters
t . m e / The decision-making process regarding the definitive treat-
t . m e/e
s: / / / /
ps:
ment in complex situations or relative indications is often
http htt
Most studies suggest that performing surgery within the delayed for multiple reasons. Goal setting and standardized
first 24–48 hours of admission decreases the number of communication pathways help to avoid unnecessary delay
complications and mortality. Delays longer than 72 hours and expedite treatment.
are associated with an increased risk of multiple complica-
tions and mortality.
k e rs Surgical fixation reduces pain and blood loss significantly.

4
er s
Soft-tissue conditions
o o It is also unethical to unnecessarily delay surgery.

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The musculoskeletal system of older patients is more vulner-
o o
e/eb b b
able to problems and less tolerant of stress:
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The earlier surgical stabilization is performed, the better. e e/e
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This guiding principle is often violated because of the patient
condition, patient consent, or hospital system barriers. The
• Skin may be thin and less elastic due to atrophy or mal-
: / /
nutrition and making pressure sores and degloving inju- t .m
s tps
http
system of care must be optimized to avoid delay and iatro- ries more common. Wounds in older adults may also heal
genic problems.
The operating time should be as short as possible to reduce

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poorly for similar reasons. During positioning and drap-
ing, the surgeon must remember that the older patient’s
skin is fragile and can tear or be avulsed with minimal
the stresses of surgery and its burdens on the patient. shear stresses. Shear forces from manual traction, re-
moval of surgical drapes or localized pressure by splints
e r s e r s
and traction devices must be avoided (Fig 1.2-1). In surgery,
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meticulous positioning helps avoid skin breakdown.
e b e b o b o
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t . m e/ t . m e/e
/ / / /
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e rs e r s
b o ok b o ok b o o
e/ e a b c
e / e d e f g
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t t p s tps
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k e rs
h i
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eb oo Fig 1.2-1a–i
e b oo b o o
/ / e/e
a–c An 88-year-old woman with a type B2 periprosthetic femoral fracture.
e t . e
d–g Revision hemiarthroplasty (d), follow-up at 2 months (e–g).
m t .m
/
h After removing the covers, a degloving of the lower leg skin by gentle traction for intraoperative reduction became apparent.
/ //
ps: ps:
i Uneventful healing after 10 days.
8
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Michael Blauth
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
• Trophic changes: Arterial disease may result in ischemic 5 Bone quality
t . m e/e
s: / / / /
ps:
changes and poor healing while venous hypertension
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produces edema, ulcers, and chronic skin changes. Using Bony quality varies substantially from the typical wide os-
minimally invasive surgical (MIS) techniques may help teoporotic tube with thin cortices to a thickened but brittle
to reduce problems. cortex in atypical fractures. Thus, cortex perforation or
• Hematoma: Surgeons must take great care to lose as other iatrogenic damage generated by clamps or lag screws
little blood as possible. Meticulous hemostasis helps avoid is more likely to occur than in normal bone (Fig 1.2-2). Force-
e rs tipping the patient out of equilibrium. Subcutaneous he-

matoma should be evacuated even with active antico-
er s
ful reduction maneuvers and aggressive handling of bone
may result in extension of the injury beyond the original
b o ok agulation to avoid rapid skin breakdown.

• Muscles are frequently atrophied and weaker than in
bo ok
pattern. The use of clamps must be performed cautiously to
avoid additional damage (Fig 1.2-3). Avoid the use of crush-
b o o
e/ e e/
younger patients (sarcopenia). Any manipulations during e ing reduction forceps helps avert worsening the comminution.
e/e
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procedures are generally preferred. .m
surgery should be carried out gently. Minimally invasive
:
ring in the setting of a low-energy trauma.
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Fracture patterns are often complex, with impaction occur-
t
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Interestingly, the impact of osteoporosis as a standalone fac-
tor on “mechanical failures” of implants could not be shown
in several clinical studies. Quality of reduction and implant
placement are obviously even more important [1, 2]. In a
retrospective study of proximal humeral fractures, it was
e r s e r s
shown that the risk for mechanical failure increases signifi-
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cantly with the combination of several negative factors [3].
e b e b o b o
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t . m e/ t . m e/e
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a b htt ps: htt ps:
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c
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c d
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htFig 1.2-3a–e
a A 70-year-old woman with
a humeral shaft bending
wedge fracture (12B2 [14]).
Fig 1.2-2a–e b Open reduction and
a A 76-year-old woman with a simple 2-part fracture of the left retention with multiple
k e rs humerus.
b After anatomical reduction, a 3.5 mm titanium lag screw
ke rs clamps.
c More manipulation led to a
eb oo was used to provide absolute stability (not displayed).
b
After tightening the screw just a little bit too much, a
e oo multifragmentary situation
that was difficult to align
b o o
e /
t . m e /
multifragmentary situation emerged. The reduction was
challenging and a bridging type of construct was chosen.
and fix with a locking plate.
t .m
d–e Result with excellent
e/e
/ /
c–e Uneventful healing after 2 months (c, d) and 5 months (e).
/
clinical function after 3
/
ps: ps:
The patient did not even have osteopenia. d e months.
htt htt 9
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 6 Bone deformation
t . me /
t
Plate fixation can be a solution in bowed femoral fractures.
. m e/e
s: / / / /
ps:
In such cases, the plate may need to be contoured before
http htt
Anterior and lateral bowing of the femur have a clinical fixation, considering the contralateral, noninjured leg. Oth-
impact in geriatric fractures and may make it very challeng- erwise, the proximal or distal end of plate will step off the
ing to use standard intra and extramedullary implants [4]. bone, and it may be a source of malreduction when screws
A recent report also found that a significant increase in the are tightened [4].
lateral and anterior bow of the femur was associated with
e s
low-energy femoral shaft fractures. Therefore, the increased
r
bowing of femoral shaft should be recognized as an impor- 7
er s
Classification
b o ok tant risk factor of this injury [5].
bo ok
Classification of fragility fractures is often challenging be-
b o o
e/ e e/ e
Specifically, lateral bowing of the femoral shaft may be in- cause of different fracture patterns. Osteoporotic fractures
e/e
decreased bone mineralization.
: // t .m
creased in older adults as well as in younger patients with often occur in patterns not described in the currently used
: / / t
classification schemes. This frustrates attempts to classify .m
ht tps
Osteoporosis or osteomalacia induce a varus or bowing of
the femur. The lateral femoral shaft is subjected to tensile ht tps
the fractures and may result in incorrect procedure or im-
plant selection. The AO/OTA Fracture and Dislocation Clas-
sification is useful for many, but not all, fragility fractures.
strains during a variety of physical activities; walking has
the strongest impact. This effect will be pronounced with
bowing in osteoporotic patients [6]. Preexisting advanced 8 Indications for fixation
ke r s
varus knee osteoarthritis, with shifting the mechanical axis
e r s
b o o medially, has been considered as a minor reason for bowing
of the femoral shaft.
b o ok
Most fractures of the lower extremity should be surgically
managed. In a small group of bedridden, terminal patients,
b o o
e /e m e/ e
Although atypical femoral fractures have been associated
t .
nonoperative palliative management of hip and other low-
er leg fractures may be adequate. Those decisions should be
t . m e/e
/ /
with long-term use of bisphosphonates (BPs), it was also
/ /
team decisions made with the geriatrician, patient, family,
htt ps:
noted that these fractures may develop without BPs use,
especially in patients of Asian descent. In 2013, the Task
Force of the American Society for Bone and Mineral Research
and medical team.
htt ps:
For the upper extremity, the need to preserve function should
revised the definition of atypical femoral fracture, removing be considered to allow the patient to accomplish activities
specific diseases and drug exposures as one of the association of daily living like eating, self-care, grooming, and ambula-
from the minor features [7]. According to this definition, tion. Attaining these goals may involve taking more surgi-
e rs
stress fractures caused by femoral bowing deformity may
r s
cal and overall risk. Therefore, surgical treatment may only
e
b o ok also be classified as atypical femoral fractures.
b o ok
be indicated if it will result in a significant improvement in
function. In the proximal humerus, olecranon, and distal
b o o
e/ e Despite being the most commonly recommended implant
e / e
choice, intramedullary (IM) nails can be difficult to insert,
radius, nonsurgical management often leads to an acceptable
functional result [9–11].
e /e
://t . m
as the curvature of IM nail is different from that of the ra-
: / / t . m
t t p s
dius of bowed femur. In cephalomedullary nailing, the dis-
tps
Some nonsurgical approaches are not tolerated as well as
ht
tal end of nail may break or penetrate the anterior cortex in younger individuals. Casts interfere with functionality
h
of femur in the distal segment. and increase the risk of falls. Immobilization may render
old patients immediately dependent for basic activities like
Reaming is often difficult as well and must be performed eating and grooming, and promote accelerated functional
gently due to the narrow medullary canal and the brittle decline. In a sense casts are also tethers that patients have
k e rs
nature of the bone.
ke rs
difficulties to deal with. The cast will prevent a patient from
accomplishing daily activities like walking, and the patient
eb oo Also, the nailing may cause an inadvertent fracture or mal-
e b oo
may therefore require placement in a nursing home. Casts
b o o
e/e
reduction with a bony gap on the medial aspect of the bone, and braces tend to exacerbate delirium in older adults
e / e /
especially in the atypical femoral shaft fractures with bow-
m
(Fig 1.2-4).
m
t .
ing [8]. This effect may result in impaired fracture healing
/ / // t .
ps: ps:
or even nonunion.
10
htt htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
Michael Blauth
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
Complete recovery after trauma is typically the goal of treat- 10 Single shot surgery
t . m e/e
s: / / / /
ps:
ment below the age of 60 years. This does not apply to FFPs.
http htt
In this age group, we focus on the restoration of individual It is obvious that any kind of revision surgery must be avoid-
functional needs. Decision making can be difficult due to ed because of the limited patient reserves necessary to tol-
the variable physiological and functional nature of older erate and recover from surgery and functional decline. The
patients. It is often necessary to individualize treatment choice of treatment should be influenced by this principle.
approaches with the consensus of the orthogeriatric team Hemiarthroplasty instead of fracture fixation for femoral
e rs
and patients’ family.
er s
neck fractures and other primary joint replacement surger-
ies are good examples.
b o ok 9 Positioning
bo ok b o o
e/ e e/ e 11 eight bearing as tolerated and functional
W
e/e
: // .m
Correct intraoperative positioning avoids pressure sores and
t
skin damage: It is essential to carefully position the patient
aftertreatment
: / / t .m
tps
on the surgical table. Avoidance of pressure sores is of par-
ht
ticular importance as sores significantly interfere with re-
covery and take an extended time to heal. An infected pres- ht tps
Usually, the surgeon’s attention is focused on the intraop-
erative and immediate perioperative treatment period. Post-
operatively, if the wound healing is progressing normally
sure sore may actually result in sepsis and death in the and x-rays are satisfactory, limited attention is paid to re-
older fracture patient. habilitation options and progress. The communication among
surgeons, staff nurses, and physiotherapists regarding mo-
e r s
In most cases, the supine position is preferred to allow for
e r s
bilization issues is often poor.
ook ok o
overall care by the anesthetist. When under regional anes-
e b b
thesia, the patient can breathe easier when supine and this
e o Early postoperative mobilization and unrestricted weight
b o
e / position is usually more comfortable.
t . m e/ bearing as tolerated are important principles for a multitude
t . m
of reasons. Prolonged bed rest or “sitting mobilization” are e/e
/ / / /
not adequate options because of the following consequences:
htt ps: htt ps:

• Loss of muscle mass represents an independent risk fac-
tor for new falls and fractures in older adults.
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht Fig 1.2-4a–e
a A 92-year-old woman
with a humeral
fracture (12B3).
Bracing was not
tolerated well.
k e rs ke rs b–c After 10 days close

reduction and fixation
eb oo e b oo with a long multilock

nail.
b o o
e /
t . m e / d–e Uneventful healing
t .m
after 3 months. The
e/e
/ / /
function reached the
/
ps: ps:
a b c d e preinjury level.
htt htt 11
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
• Restriction of weight bearing inflicts a significant physi- Early weight bearing can promote fracture healing and union
t . m e/e
s: / / / /
ps:
ological burden on the geriatric patient. The energy ex- of the fracture without increasing loss of fixation [13, 14].
http htt
penditure for ambulation without full weight bearing Immobilization of joints is poorly tolerated in many older
increases fourfold, leading to rapid exhaustion [12]. patients; early functional range of motion prevents joints
• Fragility fracture patients are often physically unable to from stiffening. The daily loss of muscle mass during periods
perform partial weight bearing due to sarcopenia, lack of of bed rest is dramatic. Modern surgical procedures and
proprioception and weakness in the arms; or they are implants permit immediate unrestricted weight bearing for
e rs admitted with an already impaired functional deficit in

upper and lower extremities, preventing them from using
er s
most fractures.
b o ok crutches or walkers in a way that the affected lower ex-

tremity is effectively spared.
bo ok
Temporary external transarticular fixation can be a unique
solution in fractures around the knee if internal fixation
b o o
e / e • Patients develop unnecessary fear and get anxious about
e/ e does not seem to be stable enough for immediate mobiliza-
e/e
: // t .m
their inability to return to their preinjury functional sta-
tus. Consequently, motivation may drop. The altered gait
:
to apply implants directly to the bone (Fig 1.2-5) [15].
/ / .m
tion, if soft tissues have to settle down or if there is no chance
t
tps
mechanism needs cognitive input and may lead to com-
ht
plaints of overload or low back pain.
• Many FFPs have some degree of cognitive impairment. 12 Fixation techniques ht tps
They may not understand (or rapidly forget) instructions
and instead follow their own impulses. The major technical problem the surgeon faces is the dif-
• Partial weight-bearing protocols are not evidence-based ficulty producing secure fixation of the implant to the bone.
e r s but often the result of the surgeon’s own uncertainty.

e r s
There is less cortical and cancellous bone for the screw threads
ook ok o
• Even for patients on adequate pain medication, pain will to engage and the pullout strength of implants is signifi-
e b typically guide the patient to use the appropriate weight

e b o cantly lower in osteoporotic bone.
b o
e / bearing and safely progress with ambulation. Patients
m e/
with severely impaired cognitive function are more prone
t . Bone mineral density correlates linearly with the holding
t . m e/e
/ /
to fall, but they have the same self-protective mechanisms
: / /
power of screws. If the load transmitted at the bone-implant
h t t p s
as cognitively normal patients.
htt ps:
interface exceeds the strain tolerance of osteoporotic bone,
microfracture and resorption of bone with loosening of the
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo a b
e b c
oo d e
b o o
e / Fig 1.2-5a–e
t . m e /
a–b A 75-year-old woman with low periprosthetic fracture after total knee arthroplasty (TKA) and severe comorbidities.
t .m e/e
/
c Temporary transarticular fixation for 8 weeks.
/ //
ps: ps:
d–e Bony healing after 3 months. Final range of motion 0–10–100°.
12
htt htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
Michael Blauth
k e rs ke rs
e b oo e b oo b o o
e /
t . m e
implant and secondary failure of fixation will occur. The
/
t . m
gap must be closed as much as possible, ie, bone contact e/e
s: / / / /
ps:
common mode of failure of internal fixation in osteopo- must be achieved. Three to four holes should be left free
http htt
rotic bone is bone failure rather than implant failure. and three to four bicortical locking head screws (LHSs)
in each main fragment are needed.
Internal fixation must take the local bone mineral distribu- • Spiral-type 2-part fractures should be reduced and “adapt-
tion into account. This varies with fracture location, age, ed” as much as possible and preliminarily fixed with su-
and gender. ture or hardware cerclages or cables. If screws are used,
e rs
Proper preoperative planning, implant choice, fixation tech-
er s
they should be tightened with caution as “reduction
screws”. The first plate screw should be inserted at the
b o ok nique, and understanding of the biomechanical principles

are essential.
bo ok
end of the fracture line. Three to four bicortical LHSs in
each main fragment are necessary depending on the type
b o o
e/ e e/ e of bone (Fig 1.2-6).
e/e
: // t .m
The general principles of fracture management are applicable
to most fragility fractures, but the decrease in bone strength
: / / .m
• In comminuted fractures, the first screws should be placed
t
adjacent to the fracture zone. Four to five bicortical screws
ht tps
requires some adaption to decrease the risk of failure.
12.1 Minimally invasive surgery 12.3 Splinting the whole bone ht tps
in each main fragment are sufficient.
Minimally invasive surgery (MIS) techniques feature mul- Subsequent fractures adjacent to the end of plates, nails or
tiple “traditional” advantages that are even more helpful in prosthesis occur due to the stress riser between the stiff
FFPs than in younger patients. Many older adults are anti- implant and the soft bone. The frequency is not clear. If
e r s
coagulated and suffer already from muscle weakness. Tech-
e r s
possible, the whole bone should be protected at the first
ook ok o
nically, MIS is easy to perform as soft-tissue layers can be fixation including the femoral neck in case of the femur
e b separated easily. For more details, see Blauth et al [16].

e b o (Fig 1.2-7, Fig 1.2-8). To achieve this goal, sometimes a com-
b o
e / m e/
Specifically designed instruments for MIS are available. It
t .
bination of intramedullary with extramedullary implants
becomes necessary.
t . m e/e
/ /
is important to develop a familiarity with their use.
/ /
htt
12.2 Relative stability ps:
Thin cortices cannot withstand the compressive forces that
12.4 Angular stable implants and blades
htt ps:
Implants with locking head mechanism and fixed or variable
angle between screw and plate as well as angular stable
are needed to create absolute stability. Tightening lag screws locking options for intramedullary nails all have biome-
a little too much may create iatrogenic fractures that worsen chanically shown to provide superior stability in bone with
the situation significantly (Fig 1.2-2, Fig 1.2-3). In osteoporotic reduced cortical thickness.
e rs
bone it may not always be possible to obtain and maintain
e r s
b o ok anatomical reduction and compression with absolute stabil-
b o
ity because the weakened cortical and cancellous bone may ok
Locking head screws cannot be overtightened or overin-
serted rendering them unstable because the thread gets
b o o
e/ e / e
fail under compression. It is essential not to mix the principles
e
of relative and absolute stability in one fracture fixation.
destroyed. They should always be used in a bicortical mode
to improve their working length with thin cortices.
e /e
://t . m : / / t . m
t t p s
As a simple rule, intramedullary devices are preferred over
tps
In addition, locking screws have a larger core diameter than
ht
extramedullary devices if fracture patterns and soft tissues conventional screws, which results in a higher pullout
h
allow for it. Unfortunately, for metaphyseal fractures around
the knee, locking options are not yet optimized for osteo-
strength and overall strength. This is especially helpful in
metaphyseal bone where intramedullary nails may fail. The
porotic bone and thus nails are often not applicable. holding power of the LHS can further be increased by ori-
enting them in different directions: This method is used with
k e rs
Short plates with every screw hole filled will cause concen-
tration of forces, which may exceed the strain tolerance of
ke rs
the proximal humeral plate and the distal femoral and
proximal tibial plates.
eb oo osteoporotic bone. Basic rules have been previously estab-
e b oo b o o
e/e
lished in the literature [17, 18]: A blade for fixation of pertrochanteric fractures offers bio-
e / m e / mechanical advantages over a lag screw. The blade con-

m
/ /t .
• Simple transverse fractures are best addressed by intra-
t .
denses the bone around the implant, while screw insertion
//
ps: ps:
medullary implants. If this is not possible, the fracture always results in some bone loss.
htt htt 13
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
a b
: // t .m c d e
: / / t .m
f
Fig 1.2-6a–f
s tps
http ht
a–b a A 77-year-old woman with a pertrochanteric fracture (31A2).
b Fixation with proximal femoral nail antirotation.
c–d The nail was removed 1.5 years later because of lateral thigh pain.
Three years later, she sustained a spiral diaphyseal fracture
(32A1).
e–f Minimally invasive reduction in lateral position and preliminary
e r s fixation with suture wire. Definitive fixation in relative stability

with distal femoral plate, the first proximal screw starting at the
e r s
ook ok o
end of the fracture and 10 cortices. Uneventful healing with
e b b
small callus formation. Ideally, a longer plate to protect the
e o b o
/ e/ e/e
whole femur would have been indicated.
e t . m t . m
/ / / /
htt ps: a b htt c
ps: d
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
a b c e f g h
Fig 1.2-7a–c
rs rs
Fig 1.2-8a–h
a A 92-year-old woman with periprosthetic fracture type B2.
k e b–c Open reduction, fixation with cerclage wires and revision

ke
a–b An 80-year-old woman with a periprosthetic knee fracture.
c Two and a half months after fixation with a distal femoral plate
eb oo arthroplasty with a long-stemmed implant with locking options.

Distal femoral plate to protect the bone between the two
e b oo fracture adjacent to the proximal end of the plate.
b o o
e/e
d Application of a longer plate. Fixation in varus malalingment
e / prostheses.
m e / and with the fracture gap still open.
m
/ /t . // .
e The construct is too stiff and fails after another 2.5 months.
t
f–h Final solution with antegrade femoral nail. Distal locking with
ps: ps:
axial loading screws.
14
htt htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
Michael Blauth
k e rs ke rs
e b oo e b oo b o o
e / 12.5 Anatomical alignment
t . m e / 12.7 Augmentation with polymethylmethacrylate
t . m e/e
s: / / / /
ps:
Correct anatomical alignment represents an important pre- Fixation in osteoporotic bone can be improved by augment-
http htt
requisite for uneventful bone healing. Fixation of osteopo- ing the bone with cement. Augmented purchase of the im-
rotic bones is less tolerant for any deviation than in young- plant, in particular of screws, reduces the risk of hardware
er bone. Specifically varus malalignment should be avoided migration, cut out, cut through and pull out. It can also be
in femoral fractures. used as a void filler to support the bone structure, for ex-
ample, of a vertebral body or the tibial plateau, and prevent
e rs
Severe rotational malalignment is an underrecognized prob-
lem and occurs typically with very unstable proximal fem-
er s
it from collapsing.
b o ok oral fractures. Rotational malalignment should be avoided.
bo ok
Polymethylmethacrylate (PMMA) remains the material of
choice and may be used in different ways:
b o o
e / e 12.6 Bone impaction
e/ e e/e
: / .m
Bone impaction at the fracture site is a key element in the
/ t
surgical management of osteoporotic fractures as it reduces
: / / t .m
• For filling voids that mainly result after reduction of cancel-
lous bone. A typical example is vertebral body compression
s tps
http
the risk of implant failure. fracture treated with closed reduction with vertebroplasty
In many cases, like for example in the valgus-impacted frac-

ture of the femoral neck, impaction is created by the trauma
ht
or kyphoplasty. The same principle can be applied to prox-
imal tibial fractures; cement used as a void filler prevents
the articular surface from collapsing after elevation.
itself. Controlled impaction can be attained by tensioning • In standardized implant augmentation, the cement is
internal fixation devices. Implants, such as the dynamic hip typically injected with a specific cannula through perfo-
e r sscrew, which allow for controlled impaction of the fracture

e r s
rated implants to improve the bone-implant interface by
ook ok o
while preventing penetration of the joint by the hip screw. preventing high bone strain and distributing the force to
e b e b o the bone in a load-sharing rather than load-bearing con-

b o
e /
t . m e/ figuration (Fig 1.2-9).
t . m
• In nonstandardized implant augmentation, the cement e/e
/ / / /
is applied via the screw hole or cortical window before
htt ps: or after the implant is inserted.
htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
a b c d
rs rs
Fig 1.2-9a–d
k e a An 82-year-old man with a proximal femoral fracture (31A2).
ke
b Close reduction with traction table. After insertion of nail and blade, the decision was taken to augment the blade because of severe
eb oo e b oo
osteoporosis and a very low resistance while inserting the blade. Intraoperative contrast dye test demonstrated no arthrogram, ie, no
b o o
e/e
perforation into the hip joint.
e / m e /
c–d Injection of 4 mL of polymethylmethacrylate through a special cannula. Result after mobilization with center-center position of the head-
m
/ / .
neck-element and equally distributed cement.
t // t .
htt ps: htt ps:
15
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m
Standardized implant augmentation has been thoroughly e / 12.8 Autografts
t . m e/e
s: / / / /
ps:
studied in recent years: Corticocancellous bone autografts to assist fracture healing
http htt
and to fill gaps can also be harvested in older patients. Un-
• Many sites have been tested biomechanically. In the less used as avoid filler, grafts should be fixed to the bone
proximal femur, proximal humerus, proximal tibia and by cortical screws (Fig 1.2-10).
sacrum, augmentation with PMMA cement improved
cycles required to cause mechanical failure by ~ 100%; 12.9 Allografts
k e rs this applies only in osteoporotic bone.

• Small volumes of cement are sufficient. Larger quantities
er s
Allograft bone has good mechanical properties but less os-
teogenic potential compared to autografts. In osteoporotic
o o do not improve implant purchase significantly.

o ok
bone, allografts are used to fill metaphyseal voids and to
o o
e/eb b b
• Heat generation outside the cement does not exceed 42° C, prevent articular and other fragments from subsiding. This
e/ e
because the metallic implant serves as a heat sink for the can be helpful in fractures of the proximal and distal hu-
e/e
exothermic chemical reaction.
: // t .m
• No signs of cartilage damage next to the cement mass
merus, distal radius and proximal tibia.
: / / t .m
tps
were noted in sheep experiments.
ht
• Interference with bone healing has not been demon-
strated so far. ht tps
Allograft struts are also used in periprosthetic femoral frac-
tures with poor bone quality to enhance the mechanical
strength of the construct (Fig 1.2-11).
Standardized implant augmentation with PMMA limits the

negative effect of osteoporosis on implant fixation, “convert-
e r s
ing” osteoporotic bone into normal bone.
e r s
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e Fig 1.2-10a–g
a–c A 70-year-old woman with an
e /e
a b
://t . m c
: / / t .
unstable 3-part fracture.
d–e Fracture fixation was indicated
m
t t p s tps
despite the obvious risk for
h ht
avascular necrosis because a
stable reconstruction seemed to
be possible. Anatomical reduction
and fixation with PHILOS.
f S
tandardized implant
augmentation via cannulated
k e rs ke rs locking head screws with 0.5 mL

of polymethylmethacrylate each
eb oo e b oo to minimize the risk of mechanical

failure.
b o o
e /
t . m e / g Injection of cement is only
t .m
indicated and possible in
e/e
/ / /
osteoporotic bone. Follow-up after
/
ps: ps:
d e f g 3 months.
16
htt htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
Michael Blauth
k e rs ke rs
e b oo e b oo b o o
e / 12.10 Joint replacement
t . m e /
t . m
More rapid restoration of adequate function along with a e/e
s: / / / /
ps:
Joint replacement plays an important role in older patients. reduced life expectancy and fewer revision surgeries are
http htt
It is commonly used in the proximal femur, mainly with appealing arguments in favor of immediate joint replace-
femoral neck fractures. The indication for fracture arthro- ment.
plasty is not as clear in proximal humeral fractures. A reverse
shoulder arthroplasty is useful in cases where stable fixation There is a paucity of published evidence to inform clinical
is not possible. The use of an endoprosthesis in fractures of care in this area. If the general goals of fracture treatment
e s
the distal humerus, distal radius and proximal tibia remains
r
controversial.
er s
can be achieved without violation of the above-mentioned
principles, fracture fixation is usually preferred.
b o ok bo ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
k
a
e rs b c
e r s
b o o b o ok b o o
e/e . me / e
. m e /e
t p s ://t tps : / / t
h t ht
k e rs
d e f
ke rs g h
eb oo Fig 1.2-11a–h
e b oo b o o
e /
t . m
femoral neck -3.6 and a slender head fragment.
e /
a–c A 76-year-old woman with a displaced 2-part fracture of the proximal humerus. Severe osteoporosis with T-score lumbar spine -3.8,
t .m e/e
/
d–f Central void after open reduction (d) that is filled with a structural allograft from the bone bank (e–f).
/ //
ps: ps:
g–h Follow-up after 3 months.
htt htt 17
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 13 References
t . m e /
t . m e/e
/ / / /
htt ps:
1. Kralinger F, Blauth M, Goldhahn J, et al.
The influence of local bone density on
the outcome of one hundred and fifty
proximal humeral fractures treated
7. Shane E, Burr D, Abrahamsen B, et al.
Atypical subtrochanteric and
diaphyseal femoral fractures: second
report of a task force of the American
ps:
13. Koval KJ, Sala DA, Kummer FJ, et al.
htt
Postoperative weight-bearing after a
fracture of the femoral neck or an
intertrochanteric fracture. J Bone Joint
with a locking plate. J Bone Joint Surg Society for Bone and Mineral Research. Surg Am. 1998 Mar;80(3):352–356.
Am. 2014 Jun 18;96(12):1026–1032. J Bone Miner Res. 2014 Jan;29(1):1–23. 14. Joslin CC, Eastaugh-Waring SJ,
2. Muller MA, Hengg C, Krettek C, et al. 8. Oh CW, Oh JK, Park KC, et al. Hardy JR, et al. Weight bearing after
e rs Trabecular bone strength is not

an independent predictive factor for
er s
Prophylactic nailing of incomplete
atypical femoral fractures. Sci World J.
tibial fracture as a guide to healing.
Clin Biomech (Bristol, Avon).
ok ok
dynamic hip screw migration—a 2013. 2008 Mar;23(3):329–333.
b o prospective multicenter cohort study.

J Orthop Res.
bo
9. Duckworth AD, Bugler KE, Clement ND,
et al. Nonoperative management of
15. Krappinger D, Struve P, Schmid R, et al.
Fractures of the pubic rami:
b o o
e/ e 2015 Nov;33(11):1680–1686.
3. Krappinger D, Bizzotto N, Riedmann S,
e/ e
displaced olecranon fractures in
low-demand elderly patients. J Bone
a retrospective review of 534 cases.
Arch Orthop Trauma Surg.
e/e
: / t
fixation of proximal humerus fractures..m
et al. Predicting failure after surgical
/
Joint Surg Am. 2014 Jan 01;96(1):67–72.
10. Arora R, Lutz M, Deml C, et al.
: / / t
2009 Dec;129(12):1685–1690.
.m
16. Blauth M, Kates SL, Kammerlander C,
tps tps
Injury. 2011 Nov;42(11):1283–1288. A prospective randomized trial et al. Fragility fractures. In: Babst R,
ht ht
4. Hwang JH, Oh JK, Oh CW, et al. comparing nonoperative treatment Bavonratanavech S, Pesantez R, eds.
Mismatch of anatomically pre-shaped with volar locking plate fixation for Minimally Invasive Plate Osteosynthesis
locking plate on Asian femurs could displaced and unstable distal radial (MIPO). 2nd ed. Stuttgart New York:
lead to malalignment in the minimally fractures in patients sixty-five years of Thieme; 2012:651–678.
invasive plating of distal femoral age and older. J Bone Joint Surg Am. 17. Stoffel K, Dieter U, Stachowiak G, et al.
fractures: a cadaveric study. Arch Orthop 2011 Dec 07;93(23):2146–2153. Biomechanical testing of the LCP—how
Trauma Surg. 2012 Jan;132(1):51–56. 11. Twiss T. Nonoperative treatment of can stability in locked internal fixators
e r s
5. Sasaki S, Miyakoshi N, Hongo M, et al.
r s
proximal humerus fractures. In: Crosby
e
be controlled? Injury.
ook ok
Low-energy diaphyseal femoral LA, Neviaser RJ, eds. Proximal Humerus 2003 Nov;34(Suppl 2):B11–19.
b
fractures associated with
bisphosphonate use and severe curved
Fractures—Evaluation and Management.
b o
Switzerland: Springer International
18. Fulkerson E, Egol KA, Kubiak EN, et al.
Fixation of diaphyseal fractures with a
b o o
e / e femur: a case series. J Bone Miner Metab.
2012 Sep;30(5):561–567.
e/ e
Publishing; 2015:23–41.
12. Westerman RW, Hull P, Hendry RG,
segmental defect: a biomechanical
comparison of locked and conventional
e/e
6. Oh Y, Wakabayashi Y, Kurosa Y, et al.
Potential pathogenic mechanism
/ / t . m et al. The physiological cost of
restricted weight bearing. Injury.
/
2006 Apr;60(4):830–835.
/t .
plating techniques. J Trauma.
m
ps: ps:
for stress fractures of the bowed 2008 Jul;39(7):725–727.
htt htt
femoral shaft in the elderly:
mechanical analysis by the CT-based
finite element method. Injury.
2014 Nov;45(11):1764–1771.
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:26
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htt ps: htt ps:
Ali Shariat, Malikah Latmore
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/
/ / /
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htt ps:
e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e such as coronary artery disease (CAD) or congestive heart
e/e
: // t .m
This chapter examines age-related changes that render
: / / t .m
failure (CHF). These factors all contribute to a decrease in
cardiovascular reserve and lower the threshold at which
ht tps
older adults susceptible to adverse events in the periopera-
tive period and provide a summary of current best prac-
tices regarding anesthesia for fragility fracture patients (FFPs)
namic instability [4, 6].
ht tps
older adults develop cardiac complications and hemody-
[1]. The major complications related to anesthetic interven- 2.2 Pulmonary morbidity
tions in older adults include perioperative cardiovascular Normal aging results in clinically significant changes in the
morbidity, eg, hypotension, arrhythmias and acute coronary respiratory system, including loss of alveolar surface area,
e r s
syndromes, respiratory failure, kidney injury, and delirium.
e r s
decline in intercostal muscle mass and strength, kyphotic
ook ok o
thoracic spine changes, and calcification of rib cage cartilage
e b Despite these risks, high-performing geriatric fracture pro-

e b o [7]. These changes reduce chest wall compliance, elastic recoil
b o
e / e/
grams report remarkably low perioperative mortality rates
m
of less than 2%, even in highly comorbid and frail referral
t .
of the lungs, and the strength of the respiratory muscles [8, 9].
t . m
Normal central respiratory responses to hypoxia and hyper- e/e
/ /
populations [2, 3]. This chapter reviews relevant physiolog-
/ /
capnia are reduced by approximately 50% in older adults
ps:
ical changes in older adults, the assessment and preparation
htt
of fragility fracture patients for anesthesia and surgery, and
the risks and benefits of general anesthesia (GA), regional htt ps:
[10]. The cough reflex is less forceful and effective, increasing
the risk of aspiration pneumonia [9]. Older patients have
increased sensitivity to the respiratory depressant effects of
anesthesia (RA) and multimodal analgesia. Unique geriatric opioids due to an increase in the volume of distribution as
considerations with regard to anesthetic choice, intraop- well as a decrease in renal and hepatic clearance [9, 11].
erative positioning and teamwork are also examined.
e rs 2.3
r s
Cognitive dysfunction
e
b o ok 2 I mportant pathophysiological changes in older
b o ok
Older adults are especially susceptible to delirium in the
perioperative period, and there is concern that perioperative
b o o
e/ e adults
e / e delirium may also contribute to longer-term cognitive dys-
function [12] (see chapter 1.14 Delirium for more informa-
e /e
2.1 Cardiac morbidity
://t . m / t . m
tion on delirium). An abrupt decline in perioperative cogni-
: /
t t p s
Perioperative cardiac morbidity (PCM) is the leading cause
tps
tion is a robust predictor of increased mortality within the
ht
of death during and after surgery and includes myocardial first 3–12 months after surgery [12–14]. Theories explaining
h
infarction (MI), congestive heart failure (CHF), unstable
angina, serious dysrhythmia, and cardiac death [4, 5]. Stress-
the relationship between cognitive dysfunction and mortal-
ity include direct damage to the brain, inability of patients
ors such as perioperative pain, blood loss, anesthesia, and with cognitive impairment to care for their own health, and
fluid shifts all contribute to an imbalance between myocar- consideration of cognitive decline as an indirect marker of
k e rs
dial oxygen demand and supply [1]. In addition, the aging
process results in specific changes to the autonomic nervous
ke rs
systemic organ disease [14].
eb oo system including increased sympathetic nervous system
e b oo
Medical complications such as pneumonia, deep vein throm-
b o o
e/e
activation, decreased parasympathetic activity, and decreased bosis, pressure ulcers, MI, gastric ulcers, and depression are
e / e /
baroreceptor activity, limiting the ability of the older adult
m
more common in patients with postoperative delirium [15].
m
t .
to respond effectively to surgical stress [1]. Older patients
/ / // t .
ps: ps:
are more likely to have preexisting cardiac comorbidities,
htt htt 19
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rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
Since cognitive decline in the postoperative period can have
t
ifies cardiovascular risk based on the presence of six predic-
. m e/e
s: / / / /
ps:
an enormous impact on postoperative complications and tors of cardiac morbidity and mortality:
http htt
functional recovery, minimization of delirium in the peri-
operative period is an important goal. • High-risk surgery (typically vascular or intraperitoneal)
• History of ischemic heart disease
• History of CHF
3 Preoperative risk assessment and preparation • History of cerebrovascular disease
e rs
Poor preoperative preparation has been implicated in 40%
•
•
er s
Insulin-dependent diabetes
Preoperative serum creatinine > 2 mg/dL
b o ok of deaths attributed to surgery and anesthesia [16].
bo ok
The presence of two or more factors identifies patients with
b o o
e/ e e/ e
Most published guidelines concerning preoperative optimi- moderate to high risk for perioperative complications. These
e/e
: // t .m
zation are based on patients undergoing elective surgery.
Under elective conditions, preexisting systemic disease is
criteria have been used during elective surgical planning as
: / /
triggers to consider additional noninvasive testing, further t .m
tps
closely investigated in order to define the disease, quantify
ht
its severity, and optimize the patient’s condition for opera-
tive repair. Many of these practices and protocols can only ht tps
medical therapy, and/or invasive monitoring [17, 19]. These
factors are likely to also predict outcomes in the urgent
surgical setting.
be loosely extrapolated to urgent cases such as hip fracture,
as the risks of surgical delay resulting from hemodynamic History of unstable angina, CHF, significant dysrhythmias,
instability, delirium and immobility typically exceed the severe valvular disease, and pacemaker or an automated im-
e r s
benefits of further preoperative testing.
e r s
plantable cardioverter defibrillator (ICD) placement should
ook ok o
be determined [18]. If a patient has a pacemaker or an ICD,
e b Older age alone is no longer considered an important pre-

e b o a plan for perioperative management should be discussed.
b o
e / e/
dictor of perioperative risk. Rather, the overall physical and
m
functional status and the number and severity of comorbid
t .
Information to be obtained includes the type and manufac-
turer of the device as well as the underlying dysrhythmia or
t . m e/e
/ /
conditions are considered more robust predictors of outcome
/ /
other cardiac condition that led to the placement of the device.
ps:
[1]. Quantifying comorbidity and functional capacity are
htt
important tools to predict outcome. See chapter 1.4 Preo-
perative risk assessment and preparation for a more thorough htt ps:
Perioperative management of the device must be individual-
ized, with some devices requiring preoperative interrogation
and possibly reprogramming by the cardiology team [18].
discussion of preoperative risk assessment and preparation.
3.3 Procedure risk
3.1 Functional capacity In addition to risk stratification for patients, surgical proce-
e rs
Functional capacity is a more accurate predictor of intraop-
r s
dures may also be classified according to risk. High-risk
e
b o ok erative risk than most specific comorbid conditions or the
results of extensive diagnostic testing [17].
b o ok
procedures include emergent procedures, major vascular
procedures, and prolonged procedures with major fluid shifts
b o o
e/ e e / e
Functional capacity can be assessed in terms of metabolic
and blood loss. They are typically defined as having adverse
cardiac event risks greater than 5%. Low-risk procedures
e /e
://t . m
equivalents (METs) of activity. Ability to perform activities include endoscopy, breast surgery, and cataract surgery and
: / / t . m
t t p s
of greater than four METs is considered good functional
tps
have an adverse cardiac event risk lower than 1%. Most
ht
capacity; examples of such activities include climbing up a orthopedic procedures are considered intermediate risk and
h
flight of stairs, walking more than 6.4 km/h (4 mph), or
doing heavy household work [18]. This threshold (> 4 METs)
have an adverse cardiac event risk between 1% and 5% [18].
has been used to indicate adequate reserve for most ortho- 3.4 Routine preoperative testing
pedic and other intermediate-risk surgeries. Only after clinically significant diseases have been identified
k e rs
3.2 Cardiac risk
k rs
on a medical history and physical examination should further
e
testing be considered; this testing should only be pursued if
eb oo While the development of robust risk assessment tools is of
e b oo
it is likely to change management, improve outcomes, and
b o o
e/e
increasing relevance for elective surgical procedures, there provide benefits that outweigh the harms of surgical delay
e / e /
remains a dearth of studies to accurately estimate risk for
m
[18] (see also chapters 1.4 Perioperative risk assessment and
m
/ /t .
the typical FFP. The Revised Cardiac Risk Index [19] is the preparation and 2.6 Orthogeriatric team—principles, roles,
// t .
ps: ps:
most widely studied tool for hip fracture surgery and strat- and responsibilities). In hip fracture patients, operative delay
20
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rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
of more than 48 hours after admission increases the odds of
t . m
• Long-term antiplatelet therapy with aspirin, clopidogrel e/e
s: / / / /
ps:
a 30-day mortality by 41% and a 1-year mortality by 32% [20]. and other antiplatelet agents is typically stopped in the
http htt
preoperative period. For patients who have undergone
The American Society of Anesthesiologists in collaboration coronary stent implantation within the past 6 weeks,
with the American Board of Internal Medicine Foundation dual antiplatelet therapy with aspirin and P2Y12 platelet
recommend the following baseline preoperative laboratory inhibitor should be continued unless the risk of surgical
tests: complete blood count, basic or comprehensive meta- bleeding outweighs the risk of stent thrombosis [18].
e s
bolic panel (ie, electrolytes, renal function and glucose),
r
and coagulation studies for patients when significant blood
er s
Additional discussion of preoperative medication manage-
b o ok loss and fluid shifts are expected [21].
bo ok
ment can be found in chapter 1.4 Preoperative risk assessment
and preparation. Discussion of the management of long-term
b o o
e/ e e/ e
In patients with established heart disease, an electrocardio- anticoagulation during the perioperative period can be found
e/e
: // t .m
gram may provide important prognostic information about
short-term and long-term mortality, and provides a baseline
: / / .m
in chapter 1.6 Anticoagulation in the perioperative setting.
t
tps
against which perioperative changes may be judged [18].
ht
More advanced preoperative cardiac testing (eg, transtho-
4
ht tps
Intraoperative anesthetic choices
racic/esophageal echocardiography or cardiac stress testing) General and regional anesthesia each have potential advan-
in asymptomatic, stable patients with known cardiac disease tages and disadvantages for hip fracture patients, and anes-
(eg, CHF or valvular disease) is not recommended and is thetic choices require a thorough understanding of the
e r s
generally not appropriate for hip fracture patients in the
e r s
physiological changes related to trauma and the stress of
ook ok o
absence of signs and symptoms of significant active cardio- surgery. As will be discussed in topic 4.1, recent systematic
e b vascular compromise [21, 22].

e b o reviews and metaanalyses [24] do not support the superior-
b o
e / m e/
With the exception of concern for severe aortic stenosis,
t .
ity of one method of intraoperative anesthesia (ie, general
t . m
versus regional) over the other in the urgent repair of fragil- e/e
/ /
echocardiographic assessment of valvular function does not
/ /
ity fractures; reasonable differences in practice patterns ex-
3.5 Medication management

ps:
lead to clinically important changes in management [18].
htt
ist within institutions and worldwide.
4.1 Definitions and conceptshtt ps:

All preoperative medications must be correctly identified, General anesthesia is typically delivered through a combina-
recorded and considered for continuation or discontinuation tion of intravenous and inhalational agents and results in
during the perioperative period. The risk of intraoperative loss of consciousness, lack of response to stimuli and typi-
e rs
hypotension and excessive blood loss is elevated in older
r s
cally requires ventilatory support.
e
b o ok trauma patients, and teams must consider the potential im-
o
pact of home medications on blood pressure and bleeding.
b ok
Regional anesthesia encompasses neuraxial (NA) techniques
b o o
e/ e / e
Some common perioperative considerations include:
e
(eg, epidural and spinal anesthesia), and peripheral nerve
blockade. Regional anesthetic techniques can be combined
e /e
://t . m
• Long-term beta-blocker therapy should be continued
/ t . m
with systemic sedatives, but do not typically involve complete
: /
t t p s
perioperatively due to the benefits of heart rate control
tps
loss of consciousness or the need for complete ventilator
ht
and decreased myocardial oxygen consumption, and the support.
h
potential harm of withdrawal when abruptly stopped
[18]. In patients not receiving long-term beta-blocker The stress of surgery causes a cascade of neural and hu-
therapy, beta-blockers should not be initiated prior to moral mediators that trigger tachycardia, blood pressure
surgery due to the increased risk of hypotension, stroke, lability, and hypercoagulability, and can lead to MI, pulmo-
k e rs and death [18].

• Angiotensin-converting enzyme inhibitors (ACEIs) and
ke rs
nary infection, and thromboembolism [23]. Since pain plays
a central role in triggering this stress response, effective
eb oo angiotensin receptor blockers (ARBs) can lead to increased
e b oo
analgesia can mitigate the ensuing adverse effects on various
b o o
e/e
episodes of intraoperative hypotension and acute kidney organ systems and improve outcomes [25]. General anes-
e / e /
injury, particularly when used in association with diuret-
m
thesia modulates this response through the central nervous
m
/ /t .
ics [23]. Most experts recommend discontinuation of ACE
t .
system, while RA blocks this pathway at the level of periph-
//
ps: ps:
inhibitors/ARBs and diuretics preoperatively [17]. eral nerves or at the spinal cord [26].
htt htt 21
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rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m
Effective management of pain in the postinjury period ise / Compared to intravenous opioid therapy, NAs for pain con-
t . m e/e
s: / / / /
ps:
crucial, as uncontrolled pain may lead to both short-term trol decrease the incidence of new angina, dysrhythmia,
http htt
complications and chronic pain syndromes [26]. and CHF in high-risk patients [37]. A large systematic review
comparing NA to GA found a reduction of approximately
Unlike RA, adequate blockade of the surgical stress response 33% in the incidence of MI [35]. A further systematic review
under GA requires large doses of opioids given prior to inci- found a decrease in PCM and mortality when epidural an-
sion [25, 27]. Large doses of opioids increase the incidence algesia is continued for 24 hours after surgery [38]. Improved
e s
of opioid-related adverse effects such as respiratory depres-
r
sion, sedation, nausea, ileus, and pruritus.
er s
mortality rates and decrease pulmonary morbidity has been
validated in at least one large retrospective study of older
b o ok The addition of epidural anesthesia blocks the perioperative

bo ok
patients undergoing hip fracture surgery [39]. Opinions [40,
41] differ as to the extent of benefit conferred by regional
b o o
e/ e increases in adrenaline, cyclic adenosine monophosphate
e/ e anesthetic techniques, but improved outcomes seem to be
e/e
: // t .m
[28], renin, aldosterone, cortisol [29, 30], and vasopressin [31].
When epidural anesthesia is begun prior to surgery and
greatest for high-risk patients [37, 42].
: / / t .m
minimized [32].
ht tps
maintained for 24 hours after surgery, muscle catabolism is
ht tps
Due to a lower volume of cerebrospinal fluid (CSF), the
presence of spinal stenosis, and reduced myelination of the
nerves, older patients generally have a reduced latency time,
As noted previously, some aspects of this stress may be re- higher dermatomal level, and increased block density with
duced by the administration of RA [1]. spinal anesthetic than younger patients. For these reasons,
local anesthetic dosage should usually be reduced when
e r s
4.2 General versus neuraxial anesthesia
e r s
performing NA in geriatric patients [26].
ook ok o
General anesthesia is required for patients with contraindi-
e b b
cations to NAs (eg, coagulopathy, infection at site, increased
e o The presence of anticoagulation is often a limiting factor in
b o
e / e/
intracranial pressure), and may be preferred by some anes-
m
thesiologists and surgeons for patient-specific or procedure-
t .
the consideration of NA techniques for FFP. Epidural and
spinal hematomas are rare but devastating complications of
t . m e/e
/ /
specific issues. Some literature [33] suggests that regional
/ /
NA with the most significant risk factor being the presence
ps:
techniques are associated with less delirium and fewer peri-
htt
operative complications, but anesthetic practice varies
greatly worldwide, and there are no large randomized trials htt ps:
of anticoagulation [43]; anticoagulation is much more prev-
alent with the increased emphasis on perioperative throm-
boprophylaxis in recent years [44]. Prior to the placement
of FFP to definitively inform this question [1, 24, 34]. For of a neuraxial anesthetic, the patient’s coagulation status
fractures of or trauma to the lower extremity, spinal, epi- must be assessed, as NA is contraindicated in these patients.
dural, nerve blocks and GA may be used to provide anes- The American Society of Regional Anesthesia and Pain Man-
e rs
thesia and analgesia. Proximal humeral fractures typically
r s
agement guidelines are applied to patients receiving neur-
e
b o ok require GA in the FFP population.
b o ok
axial interventions as well as ‘deep plexus’ blocks or cath-
eters (eg, lumbar plexus block) [45].
b o o
e/ e 4.3 Neuraxial anesthesia
e /
A number of metaanalyses have compared outcomes of NA e The following regional techniques are contraindicated in
e /e
://t . m
versus GA alone in a variety of surgical procedures and anticoagulated patients:
: / / t . m
t t p s
patient populations, but there remains a paucity of high
tps
ht
quality literature as it applies to FFPs. In older cohorts, NA, • Neuraxial, ie, epidural or spinal
h
whether used by itself or in combination with GA, was as-
sociated with a 59% reduction in postoperative respiratory
• Paravertebral blocks
• Deep plexus blocks, ie, lumbar plexus and lumbar
depression. In studies focused on the use of NA in elective sympathetic plexus
nonorthopedic surgeries, the odds of postoperative pneu-
kers rs
monia are reduced by 39% and pulmonary embolism by Although these guidelines apply to all patients, older patients
o
55% [35]. The largest studies of hip fracture patients [36]
ke
are more likely to have comorbid cardiovascular disease
b o suggest decreased mortality and respiratory complications

b oo
requiring anticoagulation or antithrombotic therapy, mak-
b o o
e /e e e/e
with NA but are limited by their observational and retro- ing a focused evaluation of anticoagulation status especial-
spective nature.
m e / ly relevant.
m
/ /t . // t .
htt ps: htt ps:
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rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m
Postdural puncture headache (PDPH) is the most common e /
t . m
Issues to consider regarding lower extremity nerve blocks: e/e
s: / / / /
ps:
complication of spinal anesthesia and is caused by delayed
http htt
closure of the dura resulting in a continuous CSF leak and • The fascia iliaca block is performed in a region that is
decreased CSF volume and pressure. The incidence of PDPH distant from vascular and other vital structures,
diminishes significantly with increasing age and is rare in making it relatively safe. It has been widely studied as
the older adults [46]. a preoperative treatment of pain following hip fracture
with reductions in acute pain and delirium [47].
k e rs 4.4 Lower extremity peripheral nerve blocks

All peripheral nerve blocks that are used for surgery of the
er s
Recently, however, the distribution, reproducibility,
and utility of this block have come under question [48].
o o lower extremity can also be used for analgesia following

o ok
• The lumbar plexus block, consisting of L1–4 spinal
o o
e/eb b b
traumatic injury [26]. Femoral, sciatic, lumbar plexus and roots with a contribution from T12, lies in the psoas
e/ e
fascia iliaca blocks are all possible and their selection is de- muscle where these nerves can be blocked. The
e/e
:
ability to position the patient [26].
// t .m
pendent on the location of injury, type of operation and
: / / .m
terminal nerves of the lumbar plexus are the iliogastric
t
(L1), ilioinguinal (L1), genitofemoral L1/2), lateral
ht tps ht tps
femoral cutaneous nerve (L2/3), the femoral nerve
(L2-4) and the obturator nerve (L2–4) [49].
• Femoral block is useful for trauma of the femur or
patella (Fig 1.3-1) [49].
• The sciatic nerve block is widely used for surgery and/
or pain control of the entire leg below the knee with
e r s e r s
the exception of the cutaneous distribution of the
ook ok o
medial aspect of the lower leg [49].
e b e b o b o
e /
t . m e/ 4.5 Upper extremity peripheral nerve blocks
t . m
Issues to consider regarding upper extremity nerve blocks: e/e
/ / / /
htt ps: FA
htt ps:
• For trauma of the shoulder, lateral clavicle, or proximal
humerus, an interscalene block, performed at the level
of C5 and C6 roots or the upper trunk, can provide excel-
lent analgesia and/or anesthesia (Fig 1.3-2, Fig 1.3-3) [50].
Femoral nerve
This block can cause 100% hemidiaphragmatic paralysis
either due to local anesthetic coursing towards the phrenic
e rs
Fig 1.3-1 Ultrasound image of the femoral nerve.
e r s
ok ok
Abbreviation: FA, femoral artery.
b o b o b o o
e/ e e / e Sternocleidomastoid muscle
e /e
://t . m : / / t . m
t t p s tps
ht
Anterior
h scalene
muscle
Middle
Brachial scalene
rs rs
plexus muscle
k e ke
eb oo e b oo b o o
e / Fig 1.3-2 Ultrasound transducer and needle position for
t . m e /
performance of ultrasound-guided interscalene block in the out-of-
Fig 1.3-3 Ultrasound image of interscalene brachial plexus with
t .m
needle in the in-plane orientation. Arrows point to the incoming e/e
/ / //
ps: ps:
plane orientation. needle.
htt htt 23
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rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
nerve or due to cephalad spread of local anesthetic towards 4.5.2 Compartment syndrome
t . m e/e
s: / / / /
ps:
C3–5 roots and therefore must be considered with caution Treatment of pain following a traumatic injury to an extrem-
http htt
in patients who have limited respiratory reserve [51]. It ity with RA carries the risk of masking the pain of compart-
is contraindicated in patients with contralateral pneu- ment syndrome [56]. Performing RA after traumatic injury
mothorax or pneumonectomies, contralateral phrenic therefore remains a controversial topic with early case reports
nerve palsy, or contralateral recurrent laryngeal nerve indicating a delay in the diagnosis of compartment syndrome
palsies [52]. In such cases, GA is the preferred method of [57, 58]. However, more recent case reports show that break-
e rs anesthesia.
• For more distal injuries, supraclavicular, infraclavicular,
er s
through pain in the presence of a regional block is not masked
by peripheral nerve blocks [56, 59]. Moreover, the emergence
b o ok or axillary blocks may be used [26]. In trauma patients,
b
the cervical spine must often be cleared prior to remov-o ok
of breakthrough or crescendo pain, together with edema of
the affected extremity, in the presence of a continuous nerve
b o o
e/ e e/ e
al of the cervical collar and placement of an interscalene catheter has been suggested as evidence of compartment
e/e
block [26].
: // t .m
• Supraclavicular blocks also carry a risk of phrenic nerve
syndrome [60]. This topic remains controversial and requires
: /
an assessment of risks and benefits and close communication
/ t .m
ht tps
paralysis, albeit less than with the interscalene approach.
Pneumothorax is a risk when performing either supra-
clavicular or infraclavicular blocks [26]. Due to a decrease
between the orthopedic and anesthesia teams.
4.5.3 Effects of sedation ht tps

in nerve myelination in older patients, greater diffusion There has been some emerging evidence that patients who
of local anesthetics is possible utilizing lower volume. are more heavily sedated under RA have an increased risk
Therefore, as with NA, effective doses of local anesthet- of postoperative delirium and may even have an increased
e r s ics should be reduced when performing peripheral nerve

e r s
risk of mortality after 1 year than those who are more l ightly
ook ok o
blocks in geriatric patients [1]. sedated [61, 62]. However, these studies have not established
e b e b o a causative relation between anesthetic depth and mortal-

b o
e / 4.5.1 Nerve injury and peripheral nerve blocks
m e/
Nerve injury can result from a number of factors related to
t .
ity, have not been confirmed by other studies [63], and their
validity has been questioned [64]. Due to the susceptibility
t . m e/e
/ /
the patient (eg, preexisting trauma and/or neuropathy),
/ /
of the geriatric population to postoperative delirium, heavy
ps:
surgery (eg, mechanical, tourniquet), or the nerve block
htt
and most often involves a combination of factors [53]. Neu-
ral injury resulting from a nerve block is rare, occurring
sedation is likely not ideal in this population.
4.6 Multimodal analgesia htt ps:

with a frequency of 0.4 per 1,000 blocks [54] but can result Multimodal analgesia involves the use of a variety of anal-
from direct mechanical trauma of the needle, neurotoxic- gesic agents, each with different mechanisms, to treat pain
ity from the local anesthetic, or an intraneural injection of [26]. The use of multimodal analgesia has become a mainstay
e rs
local anesthetic [53]. According to the double crush hypoth-
r s
of perioperative pain management in order to reduce opioid
e
b o ok esis, patients with preexisting nerve injury or neural disease
b o
are at greater risk of developing a clinically significant neu- ok
use and related adverse effects including respiratory depres-
sion, sedation, nausea, ileus, and pruritus [65, 66]. Moreover,
b o o
e/ e / e
ropathy if a nerve is subsequently injured at a second loca-
e
tion along the neural pathway [55]. For this reason, nerve
when opioids are used as a single modality, higher doses
are required, increasing the risk of adverse effects [67–69].
e /e
://t . m
blocks following traumatic injury should be approached These adverse effects may be more pronounced in older
: / / t . m
t t p s
with caution and include a robust assessment of risks and
tps
adults due to impaired pharmacodynamics and pharmaco-
ht
benefits as well as discussion with the patient and the sur- kinetic handling of the drugs [70]. While opioid-sparing
h
gical team. Age-related changes in the somatic nervous sys-
tem include peripheral nerve deterioration and decreased
therapies are of potential benefit to older adults, the risks
of other pharmacological agents are not particularly well
myelinated nerve fiber conduction [1]. studied. Many nonopioid analgesic agents have limiting
adverse effects, particularly in the clinically unstable FFP.
k e rs
It is unclear whether such changes increase the older pa-
tient’s susceptibility to nerve injury due to the performance
ke rs
eb oo of RA. However, preoperative assessment and documenta-
e b oo b o o
e/e
tion of preexisting neural compromise are important.
e / m e / m
/ /t . // t .
htt ps: htt ps:
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
Specifically, nonsteroidal antiinflammatory drug use is lim- 5 Intraoperative positioning
t . m e/e
s: / / / /
ps:
ited in the immediate perioperative period due to concerns
http htt
with gastrointestinal bleeding and renal injury in the he- Careful patient positioning is of utmost importance during
modynamically tenuous older adult. Caution should also the intraoperative period, particularly in patients who are
be taken with the use of gabapentinoids due to dose-relat- deeply sedated, under GA, or have a regional anesthetic,
ed adverse effects such as sedation and dizziness, especially rendering them unable to alert physicians to early signs of
given the goals of early ambulation. injury [77]. Although patient positioning is an important
e rs
Recently, intravenous acetaminophen has become available
er s
consideration for all patients in the operating room, special
care must be taken when applied to the older patient due
b o ok in the United States and has produced promising results and
bo
few adverse effects. In patients having hip and knee arthro- ok
to increased incidence of osteoporosis, hypertension, dia-
betes mellitus, and peripheral vascular disease [78–81]. Isch-
b o o
e/ e plasties, reduced morphine consumption and improved
e/ e emic stroke is an especially feared complication in the beach
e/e
: // t .m
Visual Analog Scale pain scores have been noted with the
inclusion of acetaminophen [71]. The cost of intravenous
: / / .m
chair position [82]. The effect of gravity decreases venous
t
return, reducing cardiac output and cerebral perfusion pres-
tps
acetaminophen limits its use in many centers. Additionally,
ht
the N-methyl-D-aspartate antagonist ketamine has profound
analgesic properties and has been shown to be an effective ht tps
sure. Risk factors for stroke are far more common in older
patients, necessitating meticulous management of hemo-
dynamic factors, such as maintenance of blood pressure as
component of a multimodal analgesic regimen by diminish- close as possible to the patient’s baseline values [83]. For
ing opioid use, decreasing postoperative pain, and improv- these reasons, the regular use of hypotensive anesthesia for
ing time to reaching physical therapy goals in orthopedic improved visualization in arthroscopic shoulder surgery
e r s
patients [72–76]. But it requires additional study in older
e r s
should be either avoided or used with great caution in pa-
ook ok o
trauma patients due to the risk of dysphoria, sedation, hal- tients with risk factors for stroke, such as hypertension or
e b lucinations, and postoperative cognitive dysfunction.

e b o cerebrovascular disease [82]. Alternatively, the beach chair
b o
e /
t . m e/ position can be avoided altogether.
t . m e/e
/ / / /
htt ps: 6
ps:
Partnering with anesthesiologists
htt
The practice of medicine in general, and anesthesia in par-
ticular, has often been compared with other high-stakes
professions such as aviation where evidence has long shown
that inadequate teamwork is one of the main reasons for
e rs e r s
preventable error [84]. Effective communication, mutual
b o ok b o ok
monitoring, and both giving and receiving feedback are all
essential elements of teamwork [82, 84] (see also chapter 2.6
b o o
e/ e e / e e /
Orthogeriatric team—principles, roles, and responsibilities).
e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
25
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 7 References
t . m e /
t . m e/e
/ / / /
htt
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ps:
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e/e
.m .m
Pain. 2005 Jan;113(1–2):61–70. 80. Richardson JK, Jamieson SC. Cigarette 84. Brindley PG. I. Improving teamwork
:
Postoperative analgesia and early
// t
75. Aveline C, Gautier JF, Vautier P, et al. smoking and ulnar mononeuropathy at
the elbow. Am J Phys Med Rehabil.
: / / t
in anaesthesia and critical care:
many lessons still to learn. Br J Anaesth.
tps tps
rehabilitation after total knee 2004 Sep;83(9):730–734. 2014 Mar;112(3):399–401.
ht ht
replacement: a comparison of
continuous low-dose intravenous
ketamine versus nefopam. Eur J Pain.
2009 Jul;13(6):613–619.
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
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rs
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htt ps: htt ps:
Joseph A Nicholas
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
1.4 Preoperative risk assessment / / / /
and preparation htt ps: htt ps:
Joseph A Nicholas
e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e 2 Unique perioperative aspects
e/e
: // t .m
Skilled preoperative assessment and optimization of the
: / / t .m
In addition to risk assessment and surgical planning, the
tps
geriatric fracture patient directly contributes to excellent
ht
outcomes. Although there is a paucity of relevant literature
on older adults undergoing urgent surgery, best practices ht tps
perioperative management of older adults is focused on
active efforts directed towards pain control, maintenance
of hemodynamic stability and avoidance of functional de-
are heavily informed by geriatric principles combined with cline. Early surgery is the most important way to achieve
evidence extrapolated from other populations and settings. these goals, and the preoperative medical assessment needs
The perioperative medical practices supported by much of to prioritize early surgery and early mobility over many
e r s
the existing literature require modification for the physi-
e r s
other chronic medical issues. For these reasons, high-per-
ook ok o
ologies and vulnerabilities of older adults, and geriatric frac- forming geriatric fracture centers have implemented clinical
e b b
ture care should not simply replicate practices patterns used
e o pathways that emphasize timely transition to operative re-
b o
e / for the stable and healthier elective surgery patient.
t . m e/ pair, even in highly comorbid or frail older adults. Many
t . m
notable comorbidities warranting more intensive preopera- e/e
/ /
Medical centers using a standardized geriatric medicine ap-
/ /
tive testing and consultation prior to elective surgery are
htt ps:
proach to preoperative care have reliably demonstrated
improved outcomes in mortality, length of stay and reduc-
tion in complications [1–3]. This chapter focuses on the strat- htt ps:
not vigorously pursued in the geriatric fracture setting.
egies used by many of these centers in the areas of risk 3 Preoperative risk assessment
assessment and optimization.
For almost all patients, the benefits of operative fracture
e rs
Key principles and goals:
r s
repair, including hemostasis, pain control and mobilization,
e
b o ok o
• Early surgical fixation, particularly for highly frail or
b ok
exceed the risks related to anesthesia and surgery. This is
due to both the improved safety of advanced anesthetic and
b o o
e/ e comorbid patients
e / e
• Optimization by a general medical service for surgery
surgical techniques and the excessive morbidity and mortal-
e /e
ity of hip fracture patients in the absence of surgical repair.
://t . m
in less than 24 hours for most patients, and many in
/ t .
Patient-specific risks can be roughly estimated with the
: / m
less than 6 hours
t t p s tps
careful use of preoperative risk calculators, and may allow
ht
• Pain control with parenteral opiates and regional nerve for better anticipation of patient-specific outcomes and com-
block techniques h
• Anticipation of hypotension in the intra and postop-
plications.
erative period; liberal use of intravascular hydration, 3.1 Risk calculators

and cessation or reduction of most antihypertensive The Nottingham Hip Fracture Score [4] is the best-validated
k e rs medications
• Avoidance of excessive perioperative testing, medical
ke rs
instrument for predicting 30-day and longer outcomes in
the hip fracture population, and incorporates measures of
eb oo consultation and polypharmacy
e b oo
comorbidity burden, functional status (ie, type of residence),
b o o
e/e
cognitive status (ie, mini-mental test score), nutritional sta-
e / m e / tus (ie, albumin), and key demographic factors (ie, age,

m
/ /t . t .
gender). Elements like institutionalization and mini-mental
//
ps: ps:
test score are not universally consistent across different
htt htt 29
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / international settings, but likely can be approximated and
t . m e / 3.2 Other assessments of prognostic importance
t . m e/e
s: / / / /
ps:
remain useful for estimating perioperative risk and short- Despite the historical emphasis on comorbidity scoring for
http htt
term outcomes (Table 1.4-1, Table 1.4-2). estimating surgical risk, functional and cognitive impairment
have long been recognized in geriatric medicine to predict
A number of additional calculators have been developed in many clinically significant perioperative complications and
the attempt to provide a reasonable estimate of serious com- mortality [10]. There are several tools to quickly classify cog-
plications in surgical patients; none are validated in older nitive and functional status into meaningful categories; these
e s
adults undergoing urgent orthopedic surgery. Three calcu-
r
lators that were examined in the most recent American
er s
can be easily incorporated into standard medical, surgical
or nursing assessments.
b o ok College of Cardiology/American Heart Association (ACC/

AHA) guidelines include the Revised Cardiac Risk Index
bo ok
3.2.1 Functional capacity
b o o
e/ e (RCRI) [6], the Myocardial Infarction or Cardiac Arrest cal-
e/ e The Parker Mobility Score is a simple measure of function
e/e
: // t
al Surgical Quality Improvement Program Surgical Risk .m
culator [7], and the American College of Surgeons’ Nation- that has been derived and validated in the hip fracture set-
:
ting, and evaluated in multiple settings and for multiple
/ / t .m
in Table 1.4-3.
ht tps
Calculator [8]. The key features of the RCRI are summarized
ht tps
important outcomes (Table 1.4-4). More extensive function-
al status evaluation can be helpful in the rehabilitation phase.
e r s e r s
/ e/ e/e
Variable Value Points
e Age, y 66–85
> 85
t . m
3
4
t . m
/ / / /
ps: ps:
Gender Male 1 Nottingham Hip Fracture Score Estimated 30-day mortality, %
htt htt
Admission hemoglobin ≤ 10 g/dL 1 1 1
Admission mini-mental test score ≤ 6 of 10 1 3 3
Living in an institution Yes 1 5 7–10
Number of comorbidities ≥ 2 1 7 16–23
Malignancy Yes 1 10 45–57
e rs
Table 1.4-1 Nottingham Hip Fracture Score, adapted from Maxwell
e r s
Table 1.4-2 Nottingham Hip Fracture Score and predicted mortality
b o ok et al [4].
b o ok
rates, adapted from Moppett et al [5].
b o o
e/ e Risk factors
e / e Points
e /e
://t . m
High-risk surgery (intraperitoneal, intrathoracic, suprainguinal vascular)
Ischemic heart disease history
1
1
: / / t . m
Heart failure history
t t p s 1 Mobility No difficulty With an aid

tps
With assistance Not at all
Diabetes requiring insulin h

Stroke or cerebrovascular ischemia history 1
1
Around house
Out of house
3
3
2
2 ht 1
1
0
0
Renal failure with creatinine > 2 mg/dL 1 Shopping 3 2 1 0
k e rs
Total points Risk of major cardiac event, %
e rs
Total (NMS)
k
1-year mortality, %
b o o 1
2
1.0
2.4
b oo
≤3
4–5
56
38
b o o
e/ e ≥ 3 5.4
e /e > 5 15
e/e
/ /t .
Table 1.4-3 Perioperative Risk Calculator: Revised Cardiac Riskm Table 1.4-4 New (Parker) Mobility Score (NMS) [11].
// t .m
Index, adapted from Devereux et al [9].
s: ps:
30
http htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
Joseph A Nicholas
k e rs ke rs
e b oo e b oo b o o
e / 3.2.2 Cognitive assessments
t . m e / –– Albumin
t . m e/e
s: / / / /
ps:
Impaired cognition is significantly associated with func- (to correct calcium and screen for malnutrition)
http htt
tional dependence and poor outcomes, and by itself is a • Metabolic bone evaluation:
marker of increased perioperative risks and postoperative –– Vitamin D levels
dependency [12]. For patients without a preexisting diagno- –– Parathyroid hormone (PTH) levels
sis, diagnostic assessment for dementia is often not possible –– Thyroid studies
during the preoperative period, due to the complicating
k e rs presence of delirium. In these situations historical features

can often suggest the presence of dementia; impairments in
er s
As part of a standard protocol, it may be helpful to perform
metabolic bone assessments (ie, calcium and phosphorus,
o o telephone use, handing of finances and medication self-

o ok
PTH, thyroid hormone, vitamin D levels) or help identify
o o
e/eb b b
administration best correlate with underlying dementia [13]. malnutrition (ie, albumin levels), although the results of
e/ e
For patients without delirium, the Mini-Cog test is a vali- these studies are not essential prior to proceeding to surgi-
e/e
: // t .m
dated, efficient tool with good ability to identify dementia
[14]. See chapter 1.14 Delirium for further discussion.
: / / .m
cal fixation. Standardized order sets and protocols can help
t
streamline this preoperative testing process and minimize
ht
3.2.3 Exercise capacity tps
Exercise capacity is used as a surrogate for functional capac-
inappropriate variation in care [16].
ht tps
Bedside clinical evaluation should focus on the assessment
ity and physiological reserve, and has been incorporated of intravascular volume status and the rapid identification
into the ACC/AHA guidelines to discriminate high- and low- of the few active medical conditions that warrant surgical
risk patients, using a threshold of 4 metabolic equivalents delay, including acute pulmonary edema, acute coronary
e r s
of task [15]. Common activities that meet this threshold in-
e r s
syndrome, sepsis, unstable arrhythmias, or acute stroke.
ook ok o
clude walking up a flight of stairs, walking up a hill, walking
e b at a minimum pace of 6.4 km/h (4 mph), or heavy housework

e b o b o
e /
t . m e/
like scrubbing floors and moving heavy furniture. For pa-
tients undergoing elective surgery, these guidelines suggest
5 Advanced investigations
t . m e/e
/ /
that patients who can perform this level of exertion do not
/ /
For most fragility fracture patients there is no demonstrat-
ps:
require additional cardiovascular testing preoperatively. This
htt
level of exercise capacity should be relatively reassuring for
the geriatric fracture patient as well. htt ps:
ed benefit to routine advanced investigations such as echo-
cardiography, noninvasive cardiovascular stress testing, or
prolonged preoperative cardiac rhythm monitoring. Retro-
spective studies suggest that routine advanced cardiovascu-
lar testing, including echocardiography, results in significant
4 Routine preoperative testing surgical delay without clinically important changes in man-
e rs e r s
agement [17, 18]. In addition, the preoperative care teams
b o ok The standard preoperative evaluation should be limited to
b o
bedside clinical evaluation, basic blood work and essential ok
should carefully avoid preoperative workup of otherwise
stable chronic comorbidities like chronic renal failure, chron-
b o o
e/ e / e
radiographic studies. Excellent perioperative outcomes can
e
be obtained with the following tests: radiography of the
ic stable coronary disease, or chronic neurological deficits;
there is no known benefit to more intensive workup and
e /e
://t . m
fracture, hemoglobin level and platelet count, basic serum
/ t . m
consultation prior to fracture fixation. Other routine tests
: /
t t p s
electrolytes and renal function, and a resting electrocardio-
tps
of uncertain preoperative impact include routine urinalysis,
ht
gram [3]. chest radiography and biomarker assays, ie, B-type natri-
h
Recommended preoperative tests include:
uretic peptide and troponin levels. The high incidence of
asymptomatic bacteriuria in older adults, particularly wom-
en, can prompt inappropriate antibiotic use, and nonspe-
• Standard: cific biomarker elevations may lead to acute interventions
k e rs –– Complete blood count

–– Basic electrolytes and renal function
ke rs
that promote hypotension, bleeding and surgical delay.
Until there is better prospective data supporting routine use
eb oo –– Serum calcium
e b oo
of biomarker assays in fragility fracture patients, these should
b o o
e/e
• Typically recommended: be limited in this setting to symptomatic patients.
e / –– Electrocardiogram
m e / m
–– Coagulation studies
/ /t . // t .
ps: ps:
(particularly for patients taking warfarin)
htt htt 31
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 6 Preoperative medical treatments
t . m e / assessment and management in older adults is more thor-
t . m e/e
s: / / / /
ps:
oughly covered in chapters 1.12 Pain management and
http htt
In addition to clinical assessments and risk stratification, 1.7 Postoperative medical management.
preoperative optimization typically requires a small set of
interventions to minimize surgical delay and intraoperative 6.3 Medication management
hypotension. One of the most nuanced areas in perioperative optimization
includes the management of long-term medications in old-
k e rs 6.1 Intravascular volume restoration

Almost all older adults with femoral fractures suffer from
er s
er adults. Each medication should be evaluated for its po-
tential efficacy or harm in the acute fracture setting, and
o o acute intravascular volume depletion and require volume

o ok
determine the risk of continuation, acute cessation or, in
o o
e/eb b b
restoration to minimize perioperative hypotension. Initial the case of some anticoagulants, reversal. This is optimally
e/ e
hemoglobin assessment prior to volume restoration can sig- done by a medical physician with experience in periopera-
e/e
: // t .m
nificantly underestimate the degree of anemia, and blood
loss will often continue until the fracture is reduced and in further detail in chapter 1.13 Polypharmacy.
: / / .m
tive care of older adults. Additional approaches are discussed
t
tps
fixed, especially in the patients with recent use of antithrom-
ht
botic or anticoagulant medications. 6.3.1 Antihypertensive medications
ht tps
The high risk of perioperative hypotension in the older frac-
Most published reviews support the initiation of isotonic ture patient makes the routine continuation of long-term
intravenous fluids as soon as possible for patients without blood pressure medications particularly dangerous in this
clinically significant acute pulmonary edema. Geriatric frac- setting. With the exception of beta-blockers and clonidine,
e r s
ture centers typically report preoperative hemoglobin targets
e r s
acute cessation of most other commonly used antihyper-
ook ok o
of 10 mg/dL, in anticipation of further blood loss during the tensive medications is not problematic.
e b perioperative period [19].

e b o b o
e / m e/
In general, it is easier to treat the consequences of pulmonary
t .
6.3.2 Beta-blockers
Perioperative beta-blocker recommendations have under-
t . m e/e
/ /
edema from overhydration than to manage those related to
: / /
gone dramatic changes over the past 10 years, and the ini-
6.2 Pain management h t p s

volume depletion (ie, hypotension, stroke and renal failure).
t longer recommended [21].
htt ps:
tiation of beta-blockers in patients prior to surgery is no
Acute pain control is another cornerstone of acute preop- Patients taking long-term beta-blockers should have them
erative care for fragility fracture patients. Inadequate pain continued in this setting, although dose attenuation may
control is associated with increased adrenergic drive and be required in patients with perioperative blood pressures
e rs
myocardial oxygen demand and contributes to a number of
r s
in the low-normal range. Other medications used for long-
e
b o ok complications including delirium, tachyarrhythmia and
myocardial infarction.
b o ok
term heart rate control, eg, diltiazem, verapamil, may also
need to be continued.
b o o
e/ e e / e
Pain control is one of the reasons that early surgical fixation 6.3.3 Angiotensin-converting enzyme inhibitors and
e /e
://t . m
is associated with improved postoperative complications. In angiotensin-receptor blockers
: / / t . m
t t p s
the preoperative phase, most published protocols use stan-
tps
Angiotensin-converting enzyme inhibitors (ACEIs) and
ht
dard doses of intravenous opioids to achieve adequate pain angiotensin-receptor blockers (ARBs) are known to cause
h
control. Morphine sulfate, hydromorphone and oxycodone
have all been shown to be effective and safe when used in
hypotension and acute kidney injury in the perioperative
setting [22, 23], as well as contribute to acute kidney injury
adjusted doses for frail older adults. In addition, there is a in hemodynamically unstable patients [24]. In the typical
growing body of literature on the safety and efficacy of blocks fragility fracture patient with increased risks for hypotension
k e rs
of the femoral nerve other local nerve blocks, particularly
with ultrasound guidance [20]. Successful nerve blocks can
ke rs
and acute renal failure, routine cessation of ACEIs/ARBs in
the preoperative period is usually appropriate.
eb oo produce faster time to analgesia and result in less opioid use
e b oo b o o
e/e
for the duration of the block. Intravenous acetaminophen/ 6.3.4 Statins
e / e /
paracetamol has not been well studied in this population,
m
Both the ACC/AHA and the European Society of Cardiol-
m
/ /t .
but is expected to be helpful as well, although its use may ogy guidelines support the continuation of statin therapy
// t .
ps: ps:
be limited by cost in many institutions. Techniques for pain for patients already taking them. There is no evidence for
32
htt htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
Joseph A Nicholas
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
the acute initiation of statin therapy in patients undergoing 7.1 Delirium
t . m e/e
s: / / / /
ps:
urgent nonvascular surgery. Delirium is an acute, waxing and waning change in mental
http htt
status marked by deficits in attention, and often compli-
6.3.5 Diuretics cated by agitation, lethargy or disorganized thinking [26]. It
In light of concern for intravascular volume depletion, all is common in hospitalized older adults, particularly in those
diuretics are typically held in the preoperative period. with underlying cognitive disorders including dementia.
Delirium can be provoked by underlying medical issues,
e s
6.3.6 Noncardiovascular medications
r
Oral diabetic medications typically should be held preop-
er s
which should always be sought. In the preoperative setting,
uncontrolled pain should be strongly considered, particu-
b o ok eratively to avoid clinically significant hypoglycemia in the
b
perioperative phase. Patients using insulin will also needo ok
larly in patients with no other obvious cause. Initial attempts
at management should include treating underlying clinical
b o o
e/ e e/ e
attenuation of long-term insulin doses; the use of frequent issues, optimizing pain control and attempting nonpharma-
e/e
: // t .m
blood glucose monitoring and the use of short-acting insu-
lin is the safest approach in the dynamic perioperative pe-
: / / .m
cological supports like gentle reorientation, decreasing ex-
t
cessive stimulation, and restoring eyeglasses and hearing
tps
riod. Patients receiving long-term psychiatric medications
ht
will often need these continued, although dose attenuation
or temporary cessation in the event of excessive sedation ht tps
aids. For severe agitation or distress, low-dose haloperidol
(0.5 mg intravenously or orally) can be administered safely
in most patients. Delirium is not a contraindication to sur-
or other side effects may need to be considered. Patients on gical fixation; fracture reduction and mobilization may be
long-term opioid or benzodiazepine therapy are at risk for necessary to promote resolution.
withdrawal with abrupt cessation, and parenteral replace-
e r s
ment may be necessary if patients are not able to take oral 7.2
e r s
Urinary retention
ook ok o
medications. Patients receiving long-term opiate therapy Urinary retention can be due to a number of contributing
e b may need to have augmented doses of opiates to overcome

e b o factors, including pain, delirium, and prostatic hypertrophy
b o
e / e/
tolerance and achieve effective pain relief. Overall, patients
m
require routine monitoring for acute toxicity and complica-
t .
and is a common adverse effect of opioid medications. Bed-
t . m
side physical examination and ultrasonic bladder scan can e/e
/ /
tions of long-term medications in the perioperative setting.
/ /
assist with the diagnosis. Urinary catheterization carries
htt ps:
6.3.7 Antithrombotic and anticoagulants
Management of anticoagulation in the perioperative setting
and should be used judiciously.
htt ps:
risks such as infection, urinary tract bleeding and delirium,
is as much art as science, and the impact of the use or ces- 7.3 Polypharmacy
sation of anticoagulant medication needs to be closely mon- In light of the number of competing acute and chronic issues
itored until the patient has recovered. In the preoperative faced by older adults, polypharmacy and its effects can be
e rs
setting, almost all antithrombotic and anticoagulant medi-
r s
viewed as a distinct clinical issue. Polypharmacy is defined
e
b o ok cations should be held or reversed, depending on the at-
b o
tainment of adequate hemostasis and on the risk of throm- ok
as the use of six to nine medications at once and has been
associated with a high likelihood of drug-drug interactions.
b o o
e/ e / e
bosis for particular indications [25]. This issue is more
e
thoroughly covered in chapter 1.6 Anticoagulation in the
Polypharmacy is associated with delirium, functional decline
and poor surgical outcomes. In addition to avoiding poorly
e /e
perioperative setting.
://t . m / t . m
tolerated classes of medications like anticholinergic agents
: /
t t p s tps
and benzodiazepines, careful reduction in the number and
ht
doses of other medications may be helpful in optimizing
7 h
Other preoperative issues outcomes. See chapter 1.13 Polypharmacy for a more thor-
ough discussion.
There are a number of common perioperative medical com-
plications that impact postsurgical outcomes; many of these
k e rs
develop or require intervention in the postoperative period.
Comanagement with a general medical service with experi-
ke rs
eb oo ence with common geriatric syndromes is essential to opti-
e b oo b o o
e/e
mal outcomes. Some of these issues emerge in the preop-
e / erative phase and are introduced here.

m e / m
/ /t . // t .
htt ps: htt ps:
33
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 8 References
t . m e /
t . m e/e
/ / / /
htt ps:
1. Folbert EC, Smit RS, van der Velde D,
et al. Geriatric fracture center:
a multidisciplinary treatment approach
10. Penrod JD, Litke A, Hawkes WG, et al.
Heterogeneity in hip fracture patients:
age, functional status, and comorbidity.
htt ps:
20. Brenner S. Nerve Blocks for Pain
Management in Patients with Hip
Fractures: a Rapid Review. Toronto:
for older patients with a hip fracture J Am Geriatr Soc. Health Quality Ontario; 2013.
improved quality of clinical care and 2007 Mar;55(3):407–413. 21. Fleisher LA, Fleischmann KE, Auerbach
short-term treatment outcomes. 11. Parker MJ, Palmer CR. A new mobility AD, et al. 2014 ACC/AHA guideline on
Geriatr Orthop Surg Rehabil. score for predicting mortality after hip perioperative cardiovascular evaluation
e rs 2012 Jun;3(2):59–67.
2. Fisher AA, Davis MW, Rubenach SE, 1993 Sep;75(5):797–798.
er
fracture. J Bone Joint Surg Br.
s and management of patients undergoing
noncardiac surgery: a report of the
b o ok et al. Outcomes for older patients with

hip fractures: the impact of orthopedic
bo ok
12. Seitz DP, Adunuri N, Gill SS, et al.
Prevalence of dementia and cognitive
American College of Cardiology/
American Heart Association Task Force
b o o
e/ e and geriatric medicine cocare.
J Orthop Trauma. 2006 Mar;20(3):
e/ e
impairment among older adults with
hip fractures. J Am Med Dir Assoc.
on practice guidelines. J Am Coll Cardiol.
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e/e
.m .m
172–178; discussion 179–180. 2011 Oct;12(8):556–564. 22. Cittanova ML, Zubicki A, Savu C, et al.
3. Friedman SM, Mendelson DA, Bingham
KW, et al. Impact of a comanaged
: // t 13. Cromwell DA, Eagar K, Poulos RG. The
performance of instrumental activities
: /
converting enzyme impairs
/ t
The chronic inhibition of angiotensin-
tps tps
Geriatric Fracture Center on short-term of daily living scale in screening for postoperative renal function. Anesth
ht ht
hip fracture outcomes. Arch Intern Med. cognitive impairment in elderly Analg. 2001 Nov;93(5):1111–1115.
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Development and validation of a 14. Borson S, Scanlan JM, Chen P, et al. converting enzyme inhibitors/
preoperative scoring system to predict The Mini-Cog as a screen for dementia: angiotensin receptor blockers is
30 day mortality in patients undergoing validation in a population-based associated with increased risk for acute
e r s hip fracture surgery. Br J Anaesth.

2008 Oct;101(4):511–517.
sample. J Am Geriatr Soc.
2003 Oct;51(10):1451–1454.
e r s kidney injury after cardiovascular
surgery. Clin J Am Soc Nephrol.
ook ok
5. Moppett IK, Parker M, Griffiths R, et al. 15. Jette M, Sidney K, Blumchen G. 2008 Sep;3(5):1266–1273.
b
Nottingham Hip Fracture Score:
longitudinal and multi-assessment.
b o
Metabolic equivalents (METS) in
exercise testing, exercise prescription,
24. Onuigbo MA. Reno-prevention vs.
reno-protection: a critical re-appraisal
b o o
e / e Br J Anaesth. 2012 Oct;109(4):546–550.
6. Lee TH, Marcantonio ER, Mangione CM,
e/ e
and evaluation of functional capacity.
Clin Cardiol. 1990 Aug;13(8):555–565.
of the evidence-base from the large
RAAS blockade trials after
e/e
et al. Derivation and prospective
/ / t . m 16. Friedman SM, Mendelson DA, Kates SL, ONTARGET—a call for more
/ /t . m
ps: ps:
validation of a simple index for et al. Geriatric co-management of circumspection. QJM.
prediction of cardiac risk of major proximal femur fractures: total quality 2009 Mar;102(3):155–167.
htt htt
noncardiac surgery. Circulation. management and protocol-driven care 25. Douketis JD, Spyropoulos AC,
1999 Sep 7;100(10):1043–1049. result in better outcomes for a frail Spencer FA, et al. Perioperative
7. Gupta PK, Gupta H, Sundaram A, et al. patient population. J Am Geriatr Soc. management of antithrombotic
Development and validation of a risk 2008 Jul;56(7):1349–1356. therapy: antithrombotic therapy and
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after surgery. Circulation. et al. The medical and economic impact American College of Chest Physicians
2011 Jul 26;124(4):381–387. of preoperative cardiac testing in Evidence-Based Clinical Practice
e rs
8. American College of Surgeons’ National
r s
elderly patients with hip fractures.
e
Guidelines. Chest.
ok ok
Surgical Quality Improvement Program Injury. 2007 Sep;38 Suppl 3:S49–S52. 2012 Feb;141(2 Suppl):e326S–e350S.
b o
(ACS NSQIP). Surgical Risk Calculator.
Available at: http://riskcalculator.facs.
18. O’HEireamhoin S, Beyer T, Ahmed M,
b o
et al. The role of preoperative cardiac
26. Inouye SK. Delirium in older persons.
N Engl J Med.
b o o
e/ e org/RiskCalculator/.
Accessed June 2016.
e / e
investigation in emergency hip surgery.
J Trauma. 2011 Nov;71(5):1345–1347.
2006 Mar 16;354(11):1157–1165.
e /e
9. Devereaux PJ, Goldman L, Cook DJ,
et al. Perioperative cardiac events in
://t . m
19. Nicholas JA. Preoperative optimization
and risk assessment. Clin Geriatr Med.
: / / t . m
t p s
patients undergoing noncardiac
surgery: a review of the magnitude of
t
2014 May;30(2):207–218.
tps
h
the problem, the pathophysiology of
the events and methods to estimate and
communicate risk. CMAJ.
2005 Sep 13;173(6):627–634.
ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
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htt ps: htt ps:
Joshua Uy
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt
Joshua Uy
ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e at any given age [3]. For example, life expectancy for 85-year-
e/e
: // t .m
For older adults, a hip fracture is often a life-altering event.
old men can range as much as fourfold, from about 2 to 8
: / / t .m
years. To further refine patient-specific estimates of life ex-
tps
Even after successful surgical repair, there remain significant
ht
consequences for life expectancy, impaired function, and
diminished quality of life. Hip fracture outcomes vary w idely, ht
bidities and personal functional trajectory. tps
pectancy, it is important to also consider a patient’s comor-
from full recovery to end-of-life decline. In addition, other 2.2 Comorbidities

fragility fractures of the spine, pelvis and ribs are also associ- As expected, patients with more comorbidities have lower
ated with similar prognostic implications, including high rates life expectancies and experience more surgical complications.
e r s
of 1-year mortality [1]. Incorporating patient-specific estimates
e r s
The Charlson Comorbidity Index (CCI) [4] is a well-known
ook ok o
of prognosis into routine practice can lead to better anticipa- example of a pure comorbidity scale used for prognostication.
e b b
tion of complications, more realistic goals for rehabilitation,
e o The CCI assigns a weighted point value to a number of com-
b o
e / communication and identification of palliative needs.
t . e/
appropriate care of comorbidities, better patient and family
m
mon diseases and can also be age-stratified by assigning a
point for age for every decade after 40 (see Table 1.5-1).
t . m e/e
/ / / /
2
htt ps:
rognostication of outcomes—general
P
approaches
ps:
Higher scores correlate with higher mortality. A hospitalized
htt
patient with a score of 0 will have a 1-year predicted mor-
tality of 12%; patients with scores of 3–4 have a 1 year
mortality of 52%, and scores greater than 5 predict an 85%
Outcome prognostication in the older adult can be very 1-year mortality [4].
challenging, but useful estimates are possible. The literature
e rs
offers many tools that can be used to adequately separate
e r s
b o ok older adults who have a good estimated prognosis from
o
those who are likely to do poorly in the immediate future.
b ok
Charlson Comorbidity Index Points assigned
b o o
e/ e / e
These tools range from complex calculators that incorporate
e
15–20 different health history and physical examination
Myocardial infarction 1
e /e
://t . m
parameters to single items such as gait speed or grip strength.
Congestive heart failure
Peripheral vascular disease
1
1
: / / t . m
t t p s
Generally speaking, prognostication in older adults is best
Cerebrovascular disease
Dementia
1
1
tps
ht
achieved by routinely evaluating the three different patient
h
factors age, comorbidities, and functional status.
Chronic pulmonary disease
Connective tissue disease
Ulcer disease
Mild liver disease
1
1
1
1
2.1 Age Diabetes 1
Age alone is a good but clinically insufficient predictor of Hemiplegia 2
k e rs
life expectancy with consistent trends of decreasing life ex-
pectancy as a person ages [2]. A 65-year-old man in the
ke rs
Moderate or severe renal disease
Diabetes with end organ damage
2
2
oo oo o
Any tumor 2
eb
United States will live an average of 18 more years compared
e b
Leukemia 2
Table 1.5-1
Charlson
b o
e/e
to nearly 21 years for the typical 65-year-old woman. By Lymphoma 2
e / e
age 85, life expectancy drops to 6.1 and 7.3 years for men
m / Moderate or severe liver disease 3
Comorbidity
m
Index scoring
/ t .
and women in the US, respectively. Despite these general
/ Metastatic solid tumor 6
// t .
(without age
s: ps:
AIDS 6
estimates, there is a wide distribution in the life expectancy score).
http htt 35
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t .
In hip fracture patients, a CCI is also an independent predic-
m e /
t .
er than 70 years comorbidities are better at predicting mortal-
m e/e
s: / / / /
ps:
tor of 30-day mortality; patients with a CCI > 6 are more ity [9]. Other studies have used function to predict survival
http htt
than twice as likely to die during this time frame [5]. in cancer, heart failure, surgeries and dementia [10–14].
2.3 Functional status The most valid predictors of postsurgical outcomes come
It addition to age and comorbidity assessment, it has been from comprehensive tools that incorporate elements of age,
increasingly recognized that function is an important inde- comorbidity and function. The best studied of these in the
e s
pendent prognostic indicator in older adults. Functional
r
debility is a common pathway for any disease, as it increas-
er s
hip fracture population is the Nottingham Hip Fracture Score
(NHFS), which assigns points for age, gender, number of
b o ok es in severity and is typically easy to assess. The most com-

mon geriatric functional scale is the Barthel Index of Ac-
bo ok
comorbidities, cognitive impairment, anemia, institutional-
ization and malignancy [15]. Patients can be grouped as low
b o o
e/ e tivities of Daily Living [6], in which patients are assessed for
e/ e risk (NHFS ≤ 4) or high risk (NHFS > 5) with differences in
e/e
: // t .m
independence in the following daily abilities: toileting, con-
tinence (bowel and bladder), transferring, mobility, stair
survival at 30 days (96.5% versus 86.3%) and 1 year (84.1%
: / / t
versus 54.5%) [16]. Table 1.5-4 summarizes the NHFS scoring. .m
tps
use, feeding, grooming, bathing and dressing. Lower scores
ht
reflect increased dependency, which is also an independent
predictor of mortality (Table 1.5-2, Table 1.5-3). ht tps
Despite the presence of procedure-specific outcome esti-
mates, it is critical to recognize that individual older adults
will have a wide range of responses to medical and surgical
Functional assessment is most important in the oldest patients. treatments. Assessing age, comorbidities and function allows
Function correlates more closely with mortality than comor- for a more individualized assessment and care plan.
e r sbidities for those older than 80 years, while for those young-
e r s
ook ok o
Without individualizing care based on prognosis and frailty,
e b e b o the clinician is at great risk for overtreatment of some pa-

b o
e / Activity Scoring range (points)
. m
0 = dependent
t e/ tients, and undertreatment in others. Individualizing care

based on patient-specific assessment allows for a treatment
t . m e/e
/ / / /
plan that is tolerable, purposeful, effective, and consistent
ps: ps:
Toileting 0–2
Bowel continence 0–2 with a patient’s goals of care.
Bladder continence
Grooming
Feeding
htt 0–2
0–1
0–2 3
htt
Functional prognosis for hip fracture patients
Dressing 0–2
In addition to significant mortality associations, hip and
e rs
Transferring
Mobility
0–3
0–3
e r s
other fragility fractures have specific prognostic implications
b o ok Stairs
Bathing
0–2
0–1
b o ok
for functional outcomes. Understanding these implications
allows patients, families and care teams to have realistic
b o o
e/ e e / e expectations for the future, and to anticipate and prepare
for upcoming needs.
e /e
Table 1.5-2 Barthel Index of Activities of Daily Living [7].
://t . m : / / t . m
t t p s tps
ht
Performance of ADL Median life expectancy in years Variable Value Points
No difficulty with ADLs
h
Able to do all ADLs with some difficulty and
bathe and walk with a lot of difficulty
10.6
6.5
Age, y 66–85
> 86
3
4
Gender Male 1
Able to toilet, dress and transfer with a lot of 5.1 Admission hemoglobin ≤ 10 g/dL 1
difficulty and unable to bathe or walk
kers kers
Mini-mental test score ≤ 6 of 10 1
Able to perform only one ADL, unable for all 3.8
others Living in an institution Yes 1
b o o Complete dependency in ADLs 1.6
b o o
Comorbidities > 2 1
b o o
e /e Table 1.5-3 Median life expectancy for community adults older
m e /e Malignancy Yes 1
m e/e
t .
than 70 years, based on the Barthel Index of Activities of Daily Living
://
Table 1.5-4 Nottingham Hip Fracture Score.
// t .
ps:
assessment [8].
t p s
Abbreviation: ADL, activity of daily living.
36
h t htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
Joshua Uy
k e rs ke rs
e b oo e b oo b o o
e / 3.1 Mortality
t . m e /
t . m
among those with moderate disability, around 87% of those e/e
s: / / / /
ps:
About 25% of older adults with hip fractures die within the experiencing a prefracture progression of disability will have
http htt
year. Mortality rates are nearly 50% higher for men than no recovery compared to only 14% of those with stable
women and more than double for those older than 85 years disability.
[17]. Other factors associated with higher 1-year mortality
include cognitive impairment (91% higher), prefracture gait Together, all this information suggests that for most patients
instability (up to seven times higher), and nursing home the year after a hip fracture is highly dynamic and challeng-
e rs
residence (75% higher).
er s
ing. Patients and families may have to contend with the
likelihood of a slow recovery taking place over several dif-
b o ok 3.2 Functional outcomes

Functional outcomes may be more important than mortal-
bo ok
ferent systems of healthcare, with intensive financial re-
quirements, significant risks of mortality, rehospitalization
b o o
e / e e/ e
ity to patients and families. The recovery from a hip fracture and permanent loss of function, and the redefinition of fam-
e/e
: // t .m
takes months and postfracture dependence can develop in
more areas than just ambulation. Most patients will require
: / / .m
ily relationships to include difficult caregiving roles and the
t
shifting of expectations. The healthcare team at each site of
tps
rehabilitation in a nursing facility (about 60%) or an acute
ht
rehabilitation facility (about 25%) after the hospital stay. A
small minority will be discharged directly home (15%) [18]. ht tps
care, ie, hospital, acute rehabilitation, nursing home and
home health, should play essential roles in educating and
preparing families for these transitions.
Maximum recovery of cognition (ie, resolution of delirium),

depression and upper extremity activities of daily living 4 Identifying goals of care
ke r s
(ADLs) is most often seen at about 4 months. Maximum
e r s
b o o recovery of gait and balance will be seen at about 9 months.
Maximum recovery of lower extremity ADLs, instrumental
b o ok
Hip fractures often occur within the wider context of frail-
ty and functional decline. As described in chapter 1.11 Sar-
b o o
e /e t . m e/
ADLs, and social function will be seen at 11 months [19].
e copenia, malnutrition, frailty, and falls, frailty is a complex
t . m
state where outcomes of standard medical and surgical treat- e/e
/ /
Some functional loss will be permanent. For many hip frac-
/ /
ments are less predictable and typically inferior to those
ps:
ture patients, achieving complete independence is not pos-
htt
sible. Functions that are unlikely to recover include: ability
to climb 5 steps (10% achieve recovery), getting in and out htt ps:
seen in younger, more robust patients. In frailty, therapeu-
tic windows between harms and benefits are often smaller
or nonexistent, and achieving traditional disease-specific
of a shower (17%), getting on and off the toilet (34%) and goals may lead to actual harms.
housekeeping (38%). Functions that are more likely to re-
cover include putting on pants (80% achieve recovery), A medical example for this is using glucose-lowering med-
e rs
cooking (76%), using a telephone (78%), getting in and
r s
ications to obtain glycosylated hemoglobin target less than
e
b o ok out of a bath (69%), walking 3 meters (~ 10 feet) (60%),
b o
and shopping (58%). The consequence of this slow func- ok
7 in patients with diabetes, a standard recommendation that
is associated with harms in frail older adults. A surgical
b o o
e/ e / e
tional recovery is that between 15% and 33% of patients
e
with hip fractures will still be in a nursing home 1 year
example is attempting a functionally unnecessary surgical
fracture reduction and developing a postoperative deterio-
e /e
after their fracture [20].
://t . m / t .
ration of the kidney function necessitating dialysis.
: / m
t t p s tps
ht
The major predictor for the degree of functional recovery is 4.1 Value-based decisions
h
the patient’s prefracture level of function [21]. For example,
for a patient without preexisting disability, nearly half will
Because frail patients have a more problematic response to
standard therapy, patients and families often have to make
experience a rapid recovery (over approximately 3–6 months). value-based decisions, and prioritize amongst competing
On the other hand, for those with even mild prefracture treatments and outcomes. These patient-specific values and
k e rsdisability the prognosis changes considerably; almost none

are expected to recover rapidly, half will experience a gradual
ke rs
priorities are referred to as goals of care. Defining these goals
with each patient helps to clarify a clinically meaningful
eb oo recovery (over approximately 6–9 months), and half will
e b oo
target for all medical care. For example, a hip fracture patient
b o o
e/e
experience little or no recovery. who lives alone and has a high fall risk may make a decision
e / m e / to prioritize safety and longevity over independence by mov-

m
/ /t .
The trajectory and pace of prefracture functional decline
t .
ing in with one of their children. Another patient with
//
ps: ps:
can also be a big determinate for recovery. For example, similar function and fall risk may prioritize independence
htt htt 37
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
over safety and choose to live alone. Patients and families undergoing hip repair, and shared decision making between
t . m e/e
s: / / / /
ps:
often choose to prioritize comfort, longevity or a chance for the surgeon and patient is necessary. Some recommenda-
http htt
independence differently. These priorities should inform tions for phrasing resuscitation status discussions are listed
the medical and surgical treatment plans, so that the patient in Table 1.5-5.
has the best chance of meeting his or her individual goals.
4.3 Other limits of care
Goals of care are best assessed with open-ended questions In addition to resuscitation, older adults may wish to place
e s
[22] such as “What should we consider when making deci-
r
sions about your care?” Assessing goals of care is a bedside
er s
other limits on the intensity of hospital or posthospital care,
to place limits on a range of interventions while they are
b o ok clinical skill that develops over time. Learning to ask and
bo
learning to actively listen will help guide the older adult and ok
still alive. For some patients this may mean a firm desire to
avoid intensive care unit admissions, for others it may mean
b o o
e/ e e/ e
their family through a potentially challenging life transition. allowing the surgeon to operate on them as many times as
e/e
: // t .m
In the setting of a hip fracture, there are several specific
it takes to have the best possible outcome. In any case, the
care team should not assume that patients are willing to
: / / t .m
tps
issues related to goals of care, including resuscitation status,
ht
acceptable functional outcomes, and willingness to endure
treatment plans.
undergo management of any and every complication that
ht tps
may develop after a surgery, a concept known as surgical
buy-in [27].
4.2 Resuscitation
Formal ascertainment and documentation of resuscitation
e r s
wishes (ie, code status) are appropriately required in most
e r s
ook ok o
healthcare systems. A hip fracture is a good time to verify
e b patients’ expectations and wishes about cardiopulmonary

e b o b o
e / e/
resuscitation (CPR). Here too, clinicians should have some
m
general information about the effectiveness of CPR in this
t .
Discussing resuscitation status
Introduction questions:
t . m e/e
population.
s: / / / /
ps:
• Do you have an advance directive or a Sometimes patients have already made
http
living will? decisions and documented them. Simply
htt
asking is an easy way to start. For other
The efficacy of resuscitation is significantly limited in older • I would like to ask you a question that patients, asking permission to talk about
adults and particularly in those with frailty or functional some patients may find difficult or other do code status decreases the pressure already
impairment. Postcardiopulmonary resuscitation survival to not have the answer to. inherent in the question and allows the
discussion to be more collaborative.
hospital discharge in previously independent older adults
How to ask about code status:
is estimated at 13–18% with lower rates of survival in those
k rs
with dependency. As many as 30% of survivors of CPR are
e
left with new neurological impairments [23, 24]. In light of to life?
k e r s
• If you were to die unexpectedly, would
you want us to attempt to bring you back
Emphasizes that a code status is only
relevant when someone has actually died
and that there is no guarantee of success.
b o o the low likelihood of independent survival, many patients

b o o • Do you want us to allow a natural death? While not as relevant for a surgical code
b o o
e/e /e e
status, this can prompt a person to think
may opt to forgo any attempts at resuscitation.
me about what is natural to them.
m e /
://t .
Resuscitation in the operating room or anesthesia areas is
Phrasing to avoid:
• Do you want us to do everything?
: / / t .
This is biased toward an affirmative
t t p s
expected to be more successful than elsewhere in the hos-
tps
answer, is very vague, and focuses on the
ht
intervention instead of the goal.
pital, and patients may elect to suspend “Do Not Resuscitate”
h
during the surgical and immediate postoperative period. • Do you want to be resuscitated? The setting is unclear (that the person
is dead) and can mean everything from
intravenous fluids to CPR.
The American College of Surgeons [25] supports exploring • If your heart stops, do you want us to Focusing on an organ distracts from the
a person’s goals and limits in the context of the operating restart it? If you stop breathing, do you big picture that the person has died.
k e rs
room, as patients likely have different desires for attempts
at resuscitation in this situation. Some tools used in resus-
ke rs
want to be on a breathing machine? Asking if someone wants their heart
restarted makes it sound simple and easily
oo oo o
successful. Asking if they want to be on a
eb
citation such as intubation, for instance, are already a part
e b
breathing machine can apply while they
b o
e/e
of surgery and may not be uniquely burdensome. Others are alive apart from a code status.
e / e /
like chest compressions or electrical cardioversion likely
m Table 1.5-5 Suggestions for framing discussions about
m
: / /t .
carry a greater potential burden and worse prognosis. No cardiopulmonary resuscitation [26].
// t .
s ps:
single model or protocol is appropriate for all older adults Abbreviation: CPR, cardiopulmonary resuscitation.
h t t p htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
Joshua Uy
k e rs ke rs
e b oo e b oo b o o
e /
t . m e
When older adults undergo an urgent surgery, the decision
/ Compared to disease-specific therapies, the most efficacious
t . m e/e
s: / / / /
ps:
about how to manage future potential complications may approaches to multimorbidity are poorly understood. While
http htt
not yet have been made. It is important to routinely reassess there are guidelines to help set priorities in medically com-
goals after an urgent surgery to prevent the potentially faulty plex and frail patients [29], managing multimorbidity is of-
assumption of surgical buy-in [28]. ten more of an art than a science. The challenge of multi-
morbidity is that sometimes treating one disease can cause
Regularly assessing limits on care is important because what another disease to get worse. For example, using nonste-
e s
a person is willing to undergo may depend on the likelihood
r
of a patient-defined successful outcome.
er s
roidal antiinflammatory drugs for osteoarthritis can worsen
heartburn or congestive heart failure. While a full discussion
b o ok bo ok
of balancing risks and harms of medical treatments is beyond
the scope of this article, an approach to prioritization of
b o o
e/ e 5 Managing multimorbidity in frail patients
e/ e competing issues is offered in Table 1.5-6. As one moves up
e/e
: // t .m
Finally, in addition to coming to decisions on CPR and oth-
the prioritization framework from primary prevention to
active symptoms, the medical problems become a bigger
: / / t .m
tps
er potential limits on interventions, the hip fracture admis-
ht
sion is an appropriate time for the medical team to reevalu-
ate a person’s entire medical treatment plan to align with ht tps
threat to health and mortality. It is worth focusing on low-
er priority issues only if the higher priority issues are resolved.
For example, there is no justification for tight control of
the patient’s goals of care, as elicited from the patient or diabetes (priority 3) if the older adult is suffering from re-
their surrogate decision makers. After a hip fracture, two current falls (priority 2). In this sense, it may be wise to
things can change: reduce the intensity of diabetes treatment by minimizing
e r s e r s
medications. Lower priority items also typically have a lon-
ook ok o
• Quality of life goals may take priority over continued ger time frame to clinical benefit than higher priority items.
e b compliance with standard therapies

e b o Last, the overarching priority is to individualize a plan that
b o
e / • Long-term disease-specific treatment benefits may
t . m
become irrelevant due to shortening overall life e/ is consistent with the patient’s own goals and values.
t . m e/e
expectancy.
/ / 5.1 Hospice
/ /
htt ps:
The anticipated benefits of many chronic disease therapies
like in hypertension, hyperlipidemia, diabetes mellitus or htt ps:
Hospice plays an important role for patients with hip frac-
tures, both for patients who suffer hip fractures while already
receiving hospice therapy, and for the many for whom the
coronary artery disease are typically small or nonexistent hip fracture is either a cause or consequence of an end-of-
during the last years of life and can easily be overwhelmed life decline. For patients near the end of life, pain control is
by the harms of treatment with polypharmacy, multiple con- of utmost importance. For patients with a life expectancy
e rs
sultations and diagnostic tests as well as medicalization of life.
r s
of weeks to months, hip fracture repair often offers the best
e
b o ok A suggested framework for evaluating chronic disease thera-
b o
pies in the frail older adult is outlined in the following list: ok
chance at pain control, particularly for patients who are
trying to minimize the sedation associated with high doses
b o o
e/ e e / e
1. Is the intervention known to be effective in older adults?
e /e
://t . m
2. Is it expected to produce a patient-desired clinical
: / / t . m
end point?
t t p s Priority Category
tps
Clinical examples
ht
3. Is the patient expected to live long enough to benefit
from the therapy?h
4. What is the chance of achieving the anticipated
Highest Active symptoms/acute
medical illness
Pain, dyspnea, nausea
Hip fracture, pneumonia,
CHF exacerbation
benefit of the intervention? Syndromes affecting Falls, weight loss, cognitive decline,
quality of life functional decline, polypharmacy
5. What are the potential harms of treatment
kers kers
Secondary prevention of CHF, COPD, DM, HTN, osteoporosis
(ie, adverse effects, costs, healthcare encounters, chronic disease complications
need for monitoring)?
b o o 6. Is the intervention likely to achieve the patient’s goal?

boo
Lowest Primary prevention of
chronic disease
Cancer screening, dietary restrictions
b o o
e /e e e/e
7. Is it a priority among the patient’s other medical
problems?
m e / Table 1.5-6 Prioritization framework for multimorbid patients
Abbreviations: CHF, congestive heart failure; COPD, chronic
m
/ /t .
8. Is there a cultural or spiritual belief that needs to be obstructive pulmonary disease; DM, diabetes mellitus; HTN,
// t .
considered?
s: hypertension.
ps:
http htt 39
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m
of opiates and other medications. It is not uncommon for e / As palliative concepts in surgery begin to mesh more and
t . m e/e
s: / / / /
ps:
some hip fracture patients to transition during the postsur- more with palliative concepts in medicine, it is clear that even
http htt
gical period to hospice care, particularly if persistent delir- for hospice patients and patients heading toward hospice,
ium or dysphagia complicate the postoperative period. In surgery still has an important palliative, noncurative role [30].
order to counter a sense among clinicians and families that
hospice and withdrawal of ongoing medical care is not ap-
propriate following a successful surgical fixation, an ex-
e s
plicit time-limited trial for recovery can be useful to negoti-
r
ate a more humane and realistic treatment plan in patients
er s
b o ok with poor prognosis [28].
bo ok b o o
e/ e e/ e e/e
6 References
: // t .m : / / t .m
ht tps
1 Gosch M, Druml T, Nicholas JA, et al.
Fragility non-hip fracture patients are
at risk. Arch Orthop Trauma Surg.
12. Robinson TN, Eiseman B, Wallace JI,
et al. Redefining geriatric preoperative
assessment using frailty, disability
ht tps
21. Gill TM, Murphy TE, Gahbauer EA, et al.
The course of disability before and after
a serious fall injury. JAMA Intern Med.
2015 Jan;135(1):69–77. and co-morbidity. Ann Surg. 2013 Oct 28;173(19):1780–1786.
2. Centers for Disease Control and 2009 Sep;250(3):449–455. 22. Mahon MM. An advance directive in
Prevention. Publications and 13. Hamel MB, Henderson WG, Khuri SF, two questions. J Pain Symptom Manage.
e r s Information Products. Available at:

www.cdc.gov/nchs/products/life_
e
aged 80 and older: morbidity and
r s
et al. Surgical outcomes for patients 2011 Apr;41(4):801–807.
23. Abbo ED, Yuen TC, Buhrmester L, et al.
ook ok o
tables.htm. Accessed February 1, 2016. mortality from major noncardiac Cardiopulmonary resuscitation
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3. Monahan RH. Editorial: Joint
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surgery. J Am Geriatr Soc. outcomes in hospitalized community-
b o
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Commission on Allied Health 2005 Mar;53(3):424–429. dwelling individuals and nursing home
e / Personnel in Ophthalmology.
Arch Ophthalmol. 1975 Jul;93(7):471.
m e/
14. Sclan SG, Reisberg B. Functional
assessment staging (FAST) in
residents based on activities of daily
living. J Am Geriatr Soc.
m
4. Charlson ME, Pompei P, Ales KL, et al.
/ / t . Alzheimer’s disease: reliability, validity, 2013 Jan;61(1):34–39.
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A new method of classifying prognostic and ordinality. Int Psychogeriatr. 24. Girotra S, Nallamothu BK, Spertus JA,
comorbidity in longitudinal studies: 1992;4 Suppl 1:55–69. et al. Trends in survival after in-
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J Chronic Dis. 1987;40(5):373–383. Development and validation of a 2012 Nov 15;367(20):1912–1920.
5. Kirkland LL, Kashiwagi DT, Burton MC, preoperative scoring system to predict 25. American College of Surgeons.
et al. The Charlson Comorbidity Index 30 day mortality in patients undergoing Statement of the American College of
Score as a predictor of 30-day mortality hip fracture surgery. Br J Anaesth. Surgeons on Advance Directives by
after hip fracture surgery. Am J Med 2008 Oct;101(4):511–517. Patients: “Do Not Resuscitate” in the
e rs Qual. 2011 Nov-Dec;26(6):461–467.

6. Mahoney FI, Barthel DW. Functional
e r
Nottingham Hip Fracture Score as a
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16. Wiles MD, Moran CG, Sahota O, et al. Operating Room. Bull Am Coll of Surg.
2014 Jan;99(1):42–43.
ok ok
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b o Md State Med J. 1965 Feb;14:61–65.

7. Collin C, Wade DT, Davies S, et al. The
b o
patients undergoing surgical repair of
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resuscitate status. J Clin Oncol.
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e/ e Barthel ADL Index: a reliability study.
Int Disabil Stud. 1988;10(2):61–63.
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17. Smith T, Pelpola K, Ball M, et al.
27. Paul Olson TJ, Schwarze ML. Failure-
to-pursue rescue: truly a failure?
e /e
8. Stineman MG, Xie D, Pan Q, et al.
://t
All-cause 1-, 5-, and 10-year mortality . m Pre-operative indicators for mortality
following hip fracture surgery:
t .
Ann Surg. 2015 Aug;262(2):e43–44.
: / /
28. Neuman MD, Allen S, Schwarze ML, m
t t p s
in elderly people according to activities a systematic review and meta-analysis.
tps
et al. Using time-limited trials to
ht
of daily living stage. J Am Geriatr Soc. Age Ageing. 2014 Jul;43(4):464–471. improve surgical care for frail older
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2012 Mar;60(3):485–492.
9. Lee SJ, Go AS, Lindquist K, et al.
Chronic conditions and mortality
18. Bentler SE, Liu L, Obrizan M, et al.
The aftermath of hip fracture:
discharge placement, functional status
adults. Ann Surg.
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10. Oken MM, Creech RH, Tormey DC, et al. 19. Magaziner J, Hawkes W, Hebel JR, et al. the care of older adults with
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Eastern Cooperative Oncology Group.
ke rs
Recovery from hip fracture in eight
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clinicians:. J Am Geriatr Soc.
oo oo o
Am J Clin Oncol. 1982 Dec;5(6):649–655. Med Sci. 2000 Sep;55(9):M498–M507. 2012 Oct;60(10):E1–E25.
eb 11. The Criteria Committee of the New York

b
20. Marks R. Hip fracture epidemiological
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30. Dunn GP. Surgical palliative care:
b o
/ / e/e
Heart Association. Nomenclature and trends, outcomes, and risk factors, recent trends and developments.
e Criteria for Diagnosis of Diseases of the

Heart and Great Vessels. 9th ed, Boston:
t . m e
1970–2009. Int J Gen Med.
2010 Apr 08;3:1–17.
Anesthesiol Clin. 2012 Mar;30(1):13–28.
t .m
Little, Brown & Co; 1994:253–256.
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
Lauren J Gleason, Adeela Cheema, Joseph A Nicholas
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/
1.6 Anticoagulation in the perioperative
/ / /
setting htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e pated consequences of bleeding if anticoagulants are resumed
e/e
: // t .m
The common presence of anticoagulant and antiplatelet
: / / t .m
during this time. For example, percutaneous screw fixation
has a much lower risk of bleeding than that of hip arthro-
tps
agents in fragility fracture patients (FFPs) presents unique
ht
challenges in the perioperative period. Management deci-
sions typically involve balancing short-term bleeding and ht tps
plasty, and the harm of continuation or early resumption of
long-term anticoagulation is presumed to be lower than for
patients treated with arthroplasty or implant fixation [5].
thrombosis risks and considering the use of bridging anti-
coagulant therapy. Delaying surgery to manage the effects 2.2 Anticoagulants and antiplatelet agents
of these medications can increase the likelihood of adverse Both anticoagulants and antiplatelet agents interfere with
e r s
events, such as delirium, pneumonia, pressure ulceration,
e r s
thrombus formation. Anticoagulant medications (eg, war-
ook ok o
and mortality [1–3]. In the immediate perioperative period, farin, heparin, apixaban, dabigatran, and rivaroxaban) in-
e b the risks of bleeding often outweigh the risks of thrombosis

e b o terfere with the coagulation cascade and clotting factors,
b o
e / for most older adults.
t . m e/ while antiplatelet agents (eg, aspirin, and clopidogrel) tar-
t . m
get platelets. While all of these agents can contribute to e/e
/ /
Standards of care and published guidelines in this area vary
/ /
clinically significant blood loss, anticoagulants are gener-
ps:
widely throughout the world. This chapter reflects the prin-
htt
ciples for anticoagulation management in the perioperative
period, with specific recommendations based on current US htt ps:
ally more potent at preventing venous, arterial or intracar-
diac thrombosis, and are also more likely to cause serious
postoperative bleeding. Specific indications and issues are
and European approaches. Consultation with local guidelines detailed below. Figure 1.6-1 shows the mechanism of action
may be necessary to align practice with other national or of some of these agents.
regional standards.
e rs 2.3
r s
Reasons for use
e
b o ok 2 Perioperative anticoagulant management
b o ok
In order to assess the risk of short-term cessation of antico-
agulant or antiplatelet medications, it is important to deter-
b o o
e/ e 2.1 General approach
e / e mine the a priori indication for their use.
e /e
://t . m
There are four considerations in the management of anti-
/ t . m
Older adults are often anticoagulated for various medical con-
: /
t t p s
thrombotic agents in the perioperative period [4]:
tps
ditions including atrial fibrillation (AF), venous thromboem-
ht
bolism (VTE) (eg, hypercoagulable states, deep vein throm-
h
1. The short-term risk of acute thromboembolism if the
anticoagulation/antiplatelet agent is discontinued
bosis [DVT], pulmonary embolism [PE]), and prosthetic heart
valves, each of these indications having a different short-term
2. The risk of major bleeding from the procedure if the risk of thrombosis during the perioperative period.
anticoagulation/antiplatelet agent is continued
kers rs
3. The effectiveness, availability and safety of reversal 2.4 Thrombotic risk assessment by indication
o
agents (eg, plasma and vitamin K)
ke
After confirming the indication for anticoagulation, it is
b o 4. The overall need to minimize surgical delay and

b oo
important to determine the short-term risk of thrombosis
b o o
e /e e e/e
maximize mobility when stopping an anticoagulant. Note that the risk of throm-
m e / boembolism for these indications is typically reported as an

m
/ /t .
Additionally, part of the preoperative assessment should
t .
annual risk; for most patients the short-term risk during a
//
ps: ps:
include the procedure-specific bleeding risk, and the antici- typical perioperative period is assumed to be much lower.
htt htt 41
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
1.6 Anticoagulation in the perioperative setting
k e rs ke rs
e b oo e b oo b o o
e / 2.4.1 Atrial fibrillation
t . m e / tiation of therapy [8]. This risk also varies depending on
t . m e/e
s: / / / /
ps:
The most common indication for anticoagulant use in the whether the VTE was provoked, unprovoked, or resolved.
http htt
older adult population is for prevention of thromboembol-
ic strokes in nonvalvular AF. 2.4.3 Mechanical heart valves
Patients with mechanical heart valves are at significantly
The risk of thromboembolism varies and can be estimated increased long-term risk for embolic stroke. The risk varies
by the CHADS2 and the enhanced CHA2 DS2 -VASC scores by the type, number, and location of prosthetic valve and
e rs
[6, 7]. The relevant criteria and associated risk of stroke are
shown in Table 1.6-1 and Table 1.6-2.
er s
associated medical conditions (Table 1.6-3) [9].
b o ok 2.4.2 Venous thromboembolism

bo ok b o o
e/ e In those with venous thromboembolism, the risk of recur-
e/ e Risk factor Point CHA2DS2- Stroke
e/e
: // .m
rent thrombosis, thrombus propagation, and embolization
t
is greatest in the first 3 months after the diagnosis and ini-
value
: / / t .m
VASC total
score
risk, %
per year
ht tps C
H
Congestive heart failure
(or left ventricular systolic dysfunction)
Hypertension—blood pressure consistently ht tps
1
1
0
1
0
1.3
above 140/90 mm Hg
Risk factor Point Total Annual stroke
(or treated hypertension on medication)
value score risk, %
A Age: ≥ 75 years 2 2 2.2
C Congestive heart failure 1 0 1.9
ke
H
r s Hypertension—blood pressure consistently
above 140/90 mm Hg
1 1 2.8
D
S2
k e r s
Diabetes mellitus
Prior stroke or TIA or thromboembolic event
1
2
3
4
3.2
4
b o o A
(or treated hypertension on medication)
Age ≥ 75 years 1 2 4
b o o V Vascular disease (eg, peripheral artery
disease, myocardial infarction, aortic plaque)
1 5 6.7
b o o
e /e D Diabetes mellitus 1 3
m e 5.9
/e A Age: 65–74 years 1 6
m
9.8
e/e
S2 Prior stroke or TIA or thromboembolism
: / /
2
t .
4 8.5 Sc Female gender 1
/
7
/t . 9.6
ps:
5 12.5 8 12.5
p s
htt htt
6 18.2 9 15.2
Table 1.6-1 The CHADS2 can be used to estimate the risk of Table 1.6-2 CHA 2DS2-VASC score and stroke risk to estimate the
thromboembolism. risk of thromboembolism.
Abbreviation: TIA, transient cerebral ischemia attack. Abbreviation: TIA, transient cerebral ischemia attack.
e rs e r s
b o ok Risk category
High
Mechanical heart valve
b o ok
Atrial fibrillation Venous thromboembolism
b o o
e/ e • > 10%/year risk of ATE
OR
e / e
• Any mechanical mitral valve
• Older aortic valve
• CHADS2 score of 5 or 6
• Recent (< 3 months) stroke or TIA
• Recent (< 3 months) VTE
• Severe thrombophilia
e /e
• > 10%/month risk of VTE
Moderate
://t . m
• Recent (< 6 months) stroke or TIA • Rheumatic valvular heart disease
: / / t . m
• 4–10%/year risk of ATE
t t p s Bileaflet aortic valve and one of the following: • CHADS2 score of 3 or 4
tps
• VTE within past 3–12 months
ht
OR • Atrial fibrillation • Recurrent VTE
• 4–10%/month risk of VTE
h • Prior stroke/TIA
• Hypertension
• Diabetes
• Nonsevere thrombophilic conditions
• Active cancer
• Heart failure
• Age > 75 years
rs rs
Low
o k e • < 4%/year risk of ATE

OR
• Bileaflet aortic valve without atrial
fibrillation and no other risk factors for
ke
• CHADS2 score of 0–2
(and no prior stroke or TIA)
• Single VTE within past 12 months
AND
eb o • < 2%/month risk of VTE stroke
e b oo • No other risk factors
b o o
e/ Reproduced from Douketis et al [10] with permission of the ACCP.
t . e /
Table 1.6-3 American College of Chest Physicians (ACCP) suggested risk stratification for perioperative thromboembolism.
m t .m e/e
/
Abbreviations: ACCP, American College of Chest Physicians; ATE, arterial thromboembolism; TIA, transient cerebral ischemic attack;
/ //
ps: ps:
VTE, venous thromboembolism.
42
htt htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 2.5 Bleeding risk assessment
t . m e / There are multiple options to reverse warfarin:
t . m e/e
s: / / / /
ps:
Older adults are prone to bleeding in general and many adults
http htt
at relatively high risk for thrombosis also have an elevated • Oral and intravenous (IV) vitamin K have been shown
risk for bleeding. Cardiovascular aging, comorbidity and some to have equivalent efficacies in reducing INR values over
medications can result in friable blood vessels and prolonged a 24-hour period. Oral vitamin K has been shown to be
postoperative bleeding after orthopedic surgery. In addition more effective than subcutaneous dosing when lowering
to procedure-specific risk estimates, there are different pre- an elevated INR value, and is typically used in doses rang-
e s
diction tools to evaluate bleeding risk in individual patients
r
[11–13]. The HAS-BLED score [12] evaluates 1-year risk of
er s
ing from 2.5 to 10 mg [18]. While the optimal dose of
vitamin K to lower INR values is unclear, the use of 3 mg
b o ok major bleeding (defined as intracranial bleeding, bleeding

requiring hospitalization, hemoglobin decrease > 2 g/L, and/
bo ok
intravenously has been shown to be safe and effective in
one study [19, 20]. The use of oral vitamin K over IV vi-
b o o
e/ e or transfusion) in patients with AF (see Table 1.6-4). There
e/ e tamin K is advantageous as it avoids the risk of fatal
e/e
: // t .m
are no well-validated predictors for short-term bleeding risks,
but the risk factors in the HAS-BLED tool are likely relevant
anaphylaxis, which has been reported previously with
: / / t .m
older preparations [21]. Subcutaneous and intramuscular
in the perioperative setting as well.
2.6 ht tps
anagement of long-term anticoagulation in
M
absorption and should be avoided.
ht tps
vitamin K administration is associated with unpredictable
• Fresh frozen plasma is an alternative and/or adjunct to

preparation for surgery vitamin K to correct coagulopathy [22]. This is human
Most hip fracture surgery is considered urgent and requires plasma that contains many plasma proteins including
reversal of anticoagulation within 24–48 hours. Approach- coagulation factors. One proposed formula to obtain an
e r ses to preparing patients for safe fracture fixation vary by

e r s
INR of less than 1.5 recommends:
ook ok o
agent. –– 1 unit for an INR of 1.5–1.9
e b e b o –– 2 units for an INR of 2.0–3.0

b o
e / 2.7 Warfarin
t . m
Warfarin anticoagulation results in a prolonged interna- e/ –– 3 units for an INR of 3.0–4.0
–– 4 units for an INR of 4.0–8.0
t . m e/e
/ /
tional normalized ratio (INR). For hip fracture repair, the
/ /
–– More than 4 units for an INR of more than 8.0 [23]
ps:
INR should be reduced to a subtherapeutic threshold; most
htt
experts recommend achieving an INR of ≤ 1.5 prior to sur-
gery [14–16]. htt ps:
Each unit of plasma has a volume of 190–240 mL. The
challenges with plasma include its short duration of action
(ie, 4–6 hours) and risks including adverse transfusion
effects (eg, infection, acute lung injury) and volume over-
An elevated INR prior to surgery increases the risk of intra- load and the associated risk of congestive heart failure.
operative bleeding and associated complications like spinal
e rs
or epidural catheter bleeding as well as wound hematoma,
e r s
b o ok infection, and possible need for reoperation [17].
b o ok b o o
e/ e e / e e /e
Risk factor
://t . m Point value HAS-BLED total score
: / / t . m
Bleeds per 100-patient years
H Hypertension
t t p s 1 0
tps
1.13
ht
(systolic blood pressure > 160 mm Hg)
A h
• Abnormal renal function (long-term dialysis, renal transplant, serum creatinine > 2.4 mg/dL)
• Hepatic function (chronic hepatitis, bilirubin > 2× upper normal with liver enzymes > 3× upper
normal)
1
1
1 1.02
S History of stroke 1 2 1.88
kers kers
B Bleeding (ie, major bleeding history) 1 3 3.74
L Labile INRs (ie, therapeutic range < 60% of time) 1 4 8.7
b o o E Elderly (≥ 65 years old)
b o o 1 5 12.5
b o o
/e /e e/e
D • Drugs (concomitant antiplatelet, NSAIDs) 1 > 5 Insufficient data
e • Alcohol consumption > 8 drinks/week
t . m e (each)
t .m
s:// /
Table 1.6-4 HAS-BLED score to evaluate 1-year risk of major bleeding.
Abbreviations: INR, international normalized ratio; NSAID, nonsteroidal antiinflammatory drug.
ps: /
http htt 43
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m
• The combination of vitamin K and fresh frozen plasma e / 2.8 Direct oral anticoagulants
t . m e/e
s: / / / /
ps:
has been shown to be safe in hip fracture patients in two In the past several years, numerous new oral anticoagulants
http htt
retrospective cohort studies [24, 25]. This approach pro- (eg, direct thrombin and factor Xa inhibitors) have been
vides both rapid reversal (plasma) and more prolonged introduced. These newer agents are often used in place of
reversal (vitamin K) of anticoagulation to minimize on- warfarin for their convenience, simplicity in dosing, and the
going postoperative bleeding. lack of routine monitoring.
• Prothrombin complex concentrate (PCC) is another op-
k e rs tion for reversal in cases of severe bleeding. Prothrombin

complex concentrates are plasma products from human
er s
These characteristics complicate perioperative management
due to the difficulty in accurately measuring the degree of
o o donors. Four-factor PCC contains all vitamin K–dependent

o ok
anticoagulation in each patient. In addition, there are cur-
o o
e/eb b b
coagulation factors; 3-factor PCCs contain factors II, IX, rently no well-established reversal agents available, limiting
e/ e
and X, but relatively little factor VII. Four-factor PCC is the ability to actively manage patients to expedite surgery
e/e
: // t .m
capable of restoring individual clotting factor activity in
nearly 100% of patients within minutes of administra-
and potentially increasing the risk of preoperative blood
: / /
loss. While there are no standard guidelines for how best to t .m
tps
tion, whereas 3-factor PCCs must be supplemented with
ht
FFP or a low dose of recombinant factor VIIa to more
optimally lower the INR. Inactivated 4-factor PCC contains ht tps
manage patients on these agents who require urgent surgery,
most recommendations involve balancing the risks of op-
erative delay, the risks of bleeding, and using pharmacoki-
factors II, VII, IX, and X and is indicated for the treatment netic data to best guide therapy [30]. Patients on these agents
of major warfarin-associated bleeding in conjunction with may require hematology consultation for optimal surgical
vitamin K. If unavailable, FFP can be used in its place or timing and preoperative planning.
e r s a 3-factor prothrombin complex concentrate (missing

e r s
ook ok o
factor VII) with a supplemental dose of FFP or recombi- 2.8.1 Dabigatran
e b nant activated factor VII as per the American College

e b o Key features of dabigatran:
b o
e / Chest Physicians (ACCP) guidelines 2012 [26, 27].
Advantages of PCC use include:
t . m e/ • Direct thrombin inhibitor (Fig 1.6-1) typically requiring a
t . m e/e
–– No cross-matching required
: / / / /
waiting period of at least 48 hours from the last dose for
surgery
h t p s
–– Rapid INR reversal achieved in case of emergent
t
–– Less volume administrations sometimes preferred
adequate clearance.
htt ps:
• The majority of dabigatran’s excretion is renal ( 80–85%).
It typically has a half-life of 12–18 hours in those with
for patients in fluid overload, acute kidney injury, creatinine clearance greater than 50 mL/min. However,
and heart failure in moderately severe renal dysfunction (creatinine clear-
Disadvantages include: ance of 30–50 mL/min, present in most fracture patients),
e rs –– Cost
r s
the half-life extends to about 18–28 hours.
e
b o ok –– Possibly thrombogenic
b o
–– Limited high-quality studies for risks and benefits ok
• Measuring the activated partial thromboplastin time
(aPTT) can be clinically useful, as an abnormal aPTT can
b o o
e/ e in fracture patients.
e / e
• Discontinuation of warfarin with a watch-and-wait ap-
indicate the continued presence of dabigatran. However,
a normal aPTT does not exclude significant persistent
e /e
://t . m
proach is a poor option given that warfarin has a half-life
/
anticoagulation due to dabigatran. In addition, it is im-
: / t . m
t t p s
of > 1.5 days (or 40 hours) and there is a wide interpatient
tps
portant to note that aPTT elevations do not correlate well
ht
variation with INR decrease [28]. Very often, the older with the degree of anticoagulation, as values often plateau
h
and frailer a person is, the longer it will take for the
warfarin to be eliminated.
at high concentrations and may underestimate suprath-
erapeutic concentrations [31, 32].
• Is potentially dialyzable in extreme situations.
Two common concerns exist when reversing anticoagula- • Currently, there are no official guidelines or recommen-
k e rs
tion. First, there is a potential for aggressive reversal to cause
increased risk of thromboembolism and second, after rever-
ke rs
dations for time to surgery for emergent or urgent pro-
cedures for patients on dabigatran; most approaches are
eb oo sal with vitamin K, there can be a delay in anticoagulation
e b ooextrapolated from elective surgery data and the need to

b o o
e/e
when warfarin is resumed postoperatively. While it may balance the risks of bleeding from that of excessive surgi-
e / e /
take longer to achieve a therapeutic level of warfarin after
m
cal delay. Recommendations for elective procedures or
m
/ /t .
vitamin K reversal, this has not been shown to delay dis- surgeries with critically high bleeding are to wait 2–4
// t .
ps: ps:
charge [29]. days after stopping the medication to ensure clearance [33].
44
htt htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m
For most fracture patients, a delay of approximately 48 e / 2.8.3 Reversal agents
t . m e/e
s: / / / /
ps:
hours after the last dose is required to minimize bleeding In a recent development, the US Food and Drug Administra-
http htt
risks. Additionally, given that dabigatran is renally cleared, tion has approved idarucizumab for reversal of dabigatran
it is critical to monitor renal function and maintain ad- in emergency bleeding situations [34]. Two other agents
equate hydration in fracture patients presenting on this currently under development include andexanet alfa (a po-
medication. tential reversal agent for Xa inhibitors and low-molecular-
weight heparin [LMWH]) and ciraparantag (a potential
e s
2.8.2 Rivaroxaban and apixaban
r
Key features of rivaroxaban and apixaban:
er s
reversal agent for several different classes of anticoagulant
drugs) [35–37].
b o ok • Direct factor Xa inhibitors (Fig 1.6-1) with no efficient way

bo ok
There is a paucity of clinical data to evaluate the effective-
b o o
e/ e to measure the degree of anticoagulation in current clin-
e/ e ness, risks and benefits of these agents as of this writing.
e/e
: // t .m
ical practice. A waiting period of approximately 48 hours
from the last dose is typically required for adequate clear-
Hematology consultation may be required for optimal man-
agement.
: / / t .m
ance.
ht tps
• There is less renal clearance than dabigatran with half-
lives ranging between 9 and 12 hours, but can be longer ht tps
in older adults.
• Rivaroxaban can affect prothrombin time values and this
can be monitored prior to surgery. Both of these medica-
e r s tions can have rapid onset of action like dabigatran and

e r s
ook ok o
the same approach should be used with these patients as
e b in dabigatran-treated patients.
e b o b o
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
Factor Xlla Factor Xla Factor Vlla Tissue factor
e rs e r s
b o ok Warfarin
b o
Factor lXa ok
Factor Vllla
b o o
e/ e e / e e /
Rivaroxaban
e
://t . m Factor Xa
: / / t . m
Fondaparinux
Apixiban
Edoxaban
t t p s tps
Otamixaban
ht
Factor Va Betrixaban
h Bivalirudin
Unfractionated heparins Dabigatran
Thrombin
Low-molecular-weight heparins Lepirudin
Argatroban
k e rs ke rs
eb oo Fig 1.6-1 Sites of action of various anticoagulant medications.
e b oo Fibrin
b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
45
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 3
t . m
Perioperative management of antiplatelet agents e /
t . m
(ie, the entire lifespan of the platelets). Inhibiting plate- e/e
s: / / / /
ps:
let aggregation can increase the risk of serious bleeding
http htt
Antiplatelet agents typically have a different set of indica- in patients undergoing surgery.
tions, potency, half-life, and bleeding risk than anticoagulants. • Because of the prolonged effect of these agents, surgical
Most older adults take these agents for preexisting vascular delay for medication clearance is typically not an option
disease, including coronary artery disease with or without for the acute fracture patient. As with the anticoagulants,
stenting, peripheral arterial disease or cerebrovascular dis- the risks of cessation depend on the indication.
e s
ease. These medications are used to limit the development
r
of local thrombosis or progression of a vascular stenosis.
er s
3.2.1 Thrombotic risk assessment
b o ok Rapid reversal of these agents is not typically possible or

necessary in the setting of fracture repair. Recent coronary
bo ok
Patients using clopidogrel and other nonaspirin antiplatelet
agents after coronary artery stent placement can be at in-
b o o
e / e e/
stent placement is a unique consideration where the risks e creased risk for stent thrombosis. The risk of coronary artery
e/e
:
agents should be strongly considered.
// t .m
and benefits of perioperative continuation of antiplatelet
: / /
is relatively low but may be catastrophic. The ACCP recom- .m
stent thrombosis after the premature cessation of clopidogrel
t
3.1
ht tps
Aspirin and aspirin/dipyridamole
Aspirin inhibits the production of thromboxane, which binds
tps
mends that for those who have had a bare metal stent with-
ht
in the past 6 weeks or a drug-eluting stent in the past
6 months, both aspirin and clopidogrel be continued peri-
platelet molecules together to create a patch over damaged operatively [38, 40].
walls of blood vessels. Aspirin is prescribed to help prevent
myocardial infarction, strokes, and blood clots. The 2012 Elective surgery should be postponed whenever possible
ke r s
guidelines from the ACCP recommend continuing aspirin
e r s
until the minimum period of therapy with P2Y12 receptor
b o o around the time of surgery for patients at moderate to high

risk for cardiovascular events who are undergoing noncar-
b o ok
blocker therapy is completed.
b o o
e /e diac surgery [38].
t . m e/ e 3.2.2 Management for surgery

There is no reversal agent for clopidogrel and other anti-
t . m e/e
/ /
Dipyridamole reversibly inhibits platelet aggregation with
: / /
platelet agents. In general, there should be no surgical delay
h t p s
a half-life of 12 hours and duration of action of approxi-
t
mately 2 days after discontinuation. The combination of
aspirin and dipyridamole does not substantially increase the htt
ticulous surgical hemostasis can be helpful. ps:
for patients undergoing general anesthesia, although me-
risk of clinically important postprocedural bleeding [39]. Staff managing clopidogrel for FFP should take into consid-
eration the following:
Like other agents discussed, the decision to continue or
e rs
withhold aspirin and aspirin/dipyridamole should reflect a
r s
• A single retrospective study assessed the perioperative
e
b o ok balance of the consequences of perioperative hemorrhage
versus the risk of perioperative vascular complications.
b o ok
bleeding risks and clinical outcome after early hip fracture
surgery on patients taking clopidogrel. In this cohort,
b o o
e/ e 3.2
e / e
Clopidogrel, prasugrel, ticagrelor, and ticlopidine
patients taking clopidogrel were not at substantially in-
creased risk for bleeding, bleeding complications, or mor-
e /e
://t
Key features of nonaspirin antiplatelet agents:
. m /
tality. In this cohort the clopidogrel group did have a
: / t . m
t t p s tps
greater number of comorbidities, American Society of
ht
• Prescribed for treatment of symptomatic atherosclerosis Anesthesiologists scores and postoperative length of stay
h
in acute coronary syndrome without ST segment elevation,
ST elevation myocardial infarction, cerebrovascular disease,
[41].
• Due to the risk of bleeding, spinal anesthesia is often
and peripheral vascular disease. contraindicated in those taking clopidogrel.
• The use of these agents has gone up with the increase in • Perioperative platelet transfusion has been suggested, as
k e rs drug-eluting coronary artery stenting procedures.

• Antiplatelet agents work to block adenosine diphosphate
ke rs
the transfused platelets may be effective in forming a
viable plug, but clinical effectiveness of this approach has
eb oo subtype P2Y12 and prevent the activation of platelets
e b oonot been studied. Platelet transfusions are not standard

b o o
e/e
and eventual cross-linking by the protein fibrin, thus of care and should be reserved for selected very high-risk
e / e /
preventing platelet aggregation and clot formation. Plate-
m
or excessively bleeding patients (see chapter 2.3 Clinical
m
/ /t .
let inhibition can be demonstrated 2 hours after a single practice guidelines).
// t .
ps: ps:
dose of oral clopidogrel, and the effect lasts for 5–9 days
46
htt htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 4 Prophylaxis against venous thromboembolism
t . m e / 4.1 onpharmacological options for
N
t . m e/e
s: / / / /
ps:
thromboprophylaxis
http htt
Hip fracture patients are at high risk for VTE for multiple Thromboprophylaxis with intermittent pneumatic compres-
reasons related to Virchow’s triad [42]. Venous stasis occurs sion devices (IPCDs) have the potential advantage of reduc-
after hip fracture due to immobility. At the time of fracture ing the incidence of VTE without the risk for increased
or surgery, vascular intimal injury may occur. Last, a hy- bleeding. The ACCP guidelines list IPCDs as an alternative
percoagulable state may occur from the release of tissue to pharmacological prophylaxis [45]. Intermittent pneu-
e rs
factors.
er s
matic compression devices can cause skin breakdown, pro-
mote falls, and contribute to delirium in geriatric patients.
b o ok The risk of VTE following hip fracture repair is high and

reported rates often vary depending on when the study was
bo ok
Inferior vena cava (IVC) filter has historically been consid-
ered in those patients who have contraindications to both
b o o
e / e conducted and the type of measurement used. The incidence
e/ e pharmacological and mechanical thromboprophylaxis, but
e/e
: / .m
of proximal DVT has been estimated at 27% without pro-
/ t
phylaxis and the risk of fatal PE has been estimated at 1.9%
: / / t .m
has fallen out of favor in most circumstances. The risks of
IVC filter placement include DVT at the insertion site, oc-
[43, 44].
ht tps
The ACCP recommends routine VTE prophylaxis in fracture ht tps
clusion of the IVC due to thrombosis below the filter, migra-
tion of the filter, and failure to remove and/or complications
with removal. There is no evidence that routine use in this
patients [45]. There are several options available and should population produces better outcomes, and the ACCP sug-
be chosen based on patient characteristics (Table 1.6-5). Low- gests against using IVC filter placement for primary preven-
molecular-weight heparin is a preferred agent and should tion over no thromboprophylaxis in patients with an in-
e r sbe started 12 or more hours postoperatively. Other options

e r s
creased bleeding risk or contraindications to both
ook ok o
include warfarin (goal INR of 1.8–2.5), low-dose unfraction- pharmacological and mechanical thromboprophylaxis [45].
e b ated heparin (UFH), fondaparinux, and aspirin. Prophy-

e b o Inferior vena cava filters that are removable may have iso-
b o
e / laxis duration with pharmacological agents is recommend-
m
ed for up to 35 days after surgery. Furthermore, extended
t . e/ lated use if PE or proximal DVT has occurred within the
previous 4 weeks [39].
t . m e/e
/ /
prophylaxis (28–35 days) with LMWH reduces the rate of
/ /
htt ps:
VTE without excess bleeding. Aspirin was added to the list
of pharmacological options in 2008. Aspirin has been shown
to be effective in reducing VTE risk in hip fracture, but is
4.2 Bridging therapy
htt ps:
For patients needing to interrupt long-term warfarin ther-
apy for surgery, the use of short-acting parenteral antico-
less effective than LMWH and not used in most high-per- agulation such as LMWH or UFH until long-term antico-
forming geriatric fracture centers [46]. Aspirin is usually agulation is achieved is termed bridging therapy. The use
considered for orthopedic patients who have undergone a of bridging therapy reflects an attempt to minimize throm-
e rs
total hip or knee replacement and are not candidates for
r s
botic complications with agents or doses that can be quick-
e
b o ok other anticoagulants.
b o ok
ly reversed or cleared if excessive bleeding occurs. Bridging
therapy can contribute to excessive perioperative blood loss,
b o o
e/ e e / e and an individualized approach to balance risks and benefits
is necessary.
e /e
Agent
://t . m
Grade of evidence
: / / t . m
• Enoxaparin 40 mg SQ daily
t t p s
Low-molecular-weight heparin, for example: 1B
tps
In terms of risk of thrombosis, the ACCP divides long-term
ht
anticoagulated patients into three categories:
Fondaparinux (2.5 mg daily)

h
• Dalteparin 5,000 units SQ daily
Warfarin (goal INR 1.8–2.5) 1B
1B
• High (> 10% annual risk of arterial thromboembolism
[ATE])
Low-dose UFH (5,000 units SQ 2–3 times daily) 1B
• Moderate (5–10% annual risk ATE)
Aspirin 1B
k e rsPatient (some agents may require renal adjustment)
ke rs
• Low (< 5% risk ATE)
eb oo Table 1.6-5 Preferred thromboprophylaxis agents for prophylaxis in
e b oo
Note that the risk of thromboembolism is typically reported
b o o
e/e
as an annual risk; for most patients the short-term risk dur-
e / the fragility fracture patients.

Abbreviations: SQ, subcutaneous; UFH, unfractionated heparin.
m e / ing a typical perioperative period is assumed to be much

m
/ /t . lower.
// t .
htt ps: htt ps:
47
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / m e /
High-risk groups should be considered most strongly for
t . was 0.4% in the no bridging and 0.3% in the bridging group;
t . m e/e
/ /
bridging therapy (Table 1.6-3) [38]. This includes:
: / /
the incidence of major bleeding was 1.3% in the no bridg-
•
• ht t p s
Artificial mitral valve replacement
Older aortic valves (caged ball, tilting disk)
ing and 3.2% in the bridging group [48].
htt ps:
There is no clear evidence to guide the exact timing or dos-
• Atrial fibrillation with CHADS2 ≥ 5 ing for bridging. Once adequate hemostasis has been
• Stroke or transient cerebral ischemia attack (TIA) with- achieved, options depend on renal function and include:
in the past 6 months
k e rs • Rheumatic valvular heart disease

r s
• Full dose LMWH, aiming for complete therapeutic
e
o o • Patients or providers unwilling to accept any risk for
ATE
o ok
anticoagulation
• Lower dose LMWH (eg, doses often used for VTE
o o
e/eb e/ e b e/eb
prophylaxis)
In moderate-risk patients the decision to use bridging ther- • Unfractionated heparin to target PTT (1.5–2 normal)
/ t .m
apy and the degree of intensity of bridging therapy should
: / : / / t .m
tps tps
be individualized. Even in patients at high risk for a thromboembolic event,
ht ht
the relatively high risk of bleeding may outweigh a smaller
Bridging in moderate and low-risk patients should be un- risk of thrombosis occurring over the 2–3 postoperative days
dertaken cautiously in light of the high sensitivity of older until hemodynamic stability and hemostasis are achieved.
adults to typical anticoagulant doses, and the high prevalence Clinicians should be prepared to stop bridging therapy if
of renal and hepatic dysfunction and other risk factors for there is evidence of significant postoperative bleeding.
e r s
bleeding [47].
e r s
ook ok
Warfarin can often be resumed the night after surgery, and
b
A large randomized, double-blind placebo control study
b o almost always within 24 hours after surgery [38]. If there is
b o o
e / e looked at bridging patients with AF and a mean CHADS2
e/ e
score of 2.3, who had warfarin treatment interrupted for an
no evidence of active bleeding, bridging therapy should be
continued until the target INR has been reached for 48 hours.
e/e
t . m
elective operation or other elective invasive procedure. The
/ / / /t . m
ps: ps:
study found that forgoing bridging anticoagulation was non- Bridging therapy should be considered in a patient-specific
htt htt
inferior to perioperative bridging with LMWH, and associ- fashion with the input from both the surgical and medical
ated with less bleeding. In this study, the incidence of ATE teams.
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 5 References
t . m e /
t . m e/e
/ / / /
ps: ps:
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htt htt
Risk factors for preoperative and A novel user-friendly score (HAS- Pharmacologic reversal of warfarin-
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25. Gleason LJ, Mendelson DA, Kates SL,
ok ok
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: // t .m Anticoagulation management in hip

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/ / .m
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t
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/t .
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ok ok
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32. Douxfils J, Mullier F, Robert S, et al./e
Thromboembolic and bleeding
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://t . m elective surgery—using low-dose
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t .
Impact of dabigatran on a large
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panel of routine or specific m
t t p s
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e r s
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
Jennifer D Muniak, Susan M Friedman
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
1.7 Postoperative medical management / / / /
htt ps:
htt ps:
e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e This chapter outlines a practical approach to the postopera-
e/e
: // t .m
The early postoperative period after hip fracture repair is
: / / t .m
tive period following hip fracture repair. Emphasis is placed
upon proactive, collaborative care and understanding the
ht tps
characterized by dynamic physiological changes in indi-
viduals with little functional reserve. Traditional approach-
es to postoperative care are typically poorly coordinated and
nerable time.
ht tps
unique challenges faced by the older adult during this vul-
primarily reactive to medical complications as they arise. Key points are:

These approaches put geriatric patients at risk for multiple
adverse events, excessive testing and consultations, and • Postoperative care using geriatric principles is essential
ke r s
polypharmacy (Fig 1.7-1) [1].
e r s
to optimal outcomes
b o o In contrast, high-performing geriatric fracture centers can

b o ok
• Early mobilization, pain control, restoration of ad-
equate intravascular volume, and avoidance of
b o o
e /e lower complication rates, length of hospital stay, and mor-
m
tality following hip fracture repair. Best practice strategies
t . e/ e iatrogenic harm are essential
• Some home medications may not be appropriate to
t . m e/e
/ /
require collaborative surgical and medical management,
/ /
resume during the postoperative period, particularly
ps:
standardized protocols to address common clinical issues, a
htt
focus on early mobility, and early discharge planning [2].
Frequent medical assessments enable tailored symptom
those that lower blood pressure
larly important htt ps:

• Discharge communication and handoffs are particu-
control, early recognition and treatment of postoperative

complications and optimal postoperative recovery.
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s Indwelling
tps
ht
Antibiotics UTI urinary
h catheter
Delirium Poor mobility
k e rs ke rs
eb oo Decreased oral intake Restraint use
e b oo b o o
e /
t . m e /
t .m
Fig 1.7-1 Example of interrelated postoperative
e/e
Dehydration Constipation
: / / Urinary retention complications.

//
s ps:
Abbreviation: UTI, urinary tract infection.
h t t p htt 51
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 2
t
Management of postoperative anemia
. m e /
t .
It is unlikely that a single threshold will be appropriate for
m e/e
s: / / / /
ps:
all patients, and clinicians should consider the proportion
http htt
Maintaining adequate intravascular volume is an important and rate of blood loss in addition to the absolute hemoglo-
goal of the early postoperative period. Older adults are bin value. Signs and symptoms due to anemia warrant trans-
likely to need blood and volume resuscitation postopera- fusion regardless of threshold. Tachycardia, hypotension,
tively, but the timing and the amount should be tailored to altered mental status, chest pain, and dyspnea can suggest
the individual based on baseline and perioperative circum- symptomatic anemia. Expected hemodynamic changes can
e s
stances. In the early perioperative period, the risks of hy-
r
povolemia include orthostasis and syncope, acute stroke
er s
be suppressed by comorbidity or medications, eg, beta-
blocker blunting tachycardia. Higher transfusion thresholds
b o ok and acute kidney injury. In the late perioperative period,

edema and hypervolemia can complicate wound healing
bo ok
may be needed for patients with a bleeding predisposition,
those with large volume intraoperative blood loss, or high-
b o o
e/ e e/ e
and postoperative recovery. For most patients, maintaining er prefracture hemoglobin levels from chronic pulmonary
e/e
: // t .m
adequate intravascular volume to support standing blood
pressure and end organ perfusion is the first priority, par-
disease.
: / / t .m
2.1 Isotonic fluids
tps
ticularly in the first 48 hours after surgery.
ht 3 Early mobility
ht tps
Early mobilization is a cornerstone in prevention of post-
• Isotonic fluids, eg, 0.9% sodium chloride solution, can operative complications, including pressure ulcers, prolonged
help maintain perioperative intravascular volume. pain, and functional decline. Some factors may limit early
e r s
• Continuous fluid infusion is generally started prior to
e r s
mobility, such as delirium, tethers, and medical illness. All
ook ok o
hip fracture surgery and discontinued on the first or medical plans should be evaluated with mobility in mind.
e b second postoperative day, after reestablishing stable

e b o b o
e / intravascular volume and resuming oral intake.
m e/
• Daily assessments of volume status and monitoring for
t .
Many patients will have nonmodifiable risk factors such as
sarcopenia, motor weakness, gait disturbance, bradykinesia,
t . m e/e
/ /
signs of hypovolemia are necessary.
/ /
impulsivity, poor proprioception, and low vision/blindness.
2.2
htt
Blood transfusion ps:
Standards for transfusion are in flux as emerging data has htt ps:
Physical therapy consultation on the first postoperative day
and every day thereafter is necessary for promoting early
shed light on the lack of benefit and in some cases harm physical recovery.
with liberal transfusion policies. The best data at the time
of this writing comes from the FOCUS trial [3] and suggests Physician orders should be written in a manner to encour-
e rs
that typical hip fracture patients can be safely managed with
r s
age activity unless there is a special mobility consideration.
e
b o ok a transfusion blood hemoglobin threshold of 8 g/dL.
b o ok
A surgical repair that allows for weight bearing as tolerated
will help to facilitate this process.
b o o
e/ e / e
Patients in the FOCUS trial who were transfused at the
e
8 g/dL threshold received 65% fewer blood products than 3.1 Limiting tethers and excessive monitoring
e /e
://t . m
those transfused at a threshold of 10 g/dL with similar rates Medical equipment used for monitoring and treating hos-
: / / t . m
t t p s
of death, acute coronary syndrome, and the ability to am-
tps
pitalized patients also “tethers” them to the bed and repre-
ht
bulate at 60 days. sent functional restraints. Tethers significantly limit mobil-
h
Harm has also been found with liberal transfusion policies
ity and can lead to complications when removed by patients.
A restrained patient is more likely to develop delirium.
in nonhip fracture populations, though the severity of this
remains largely unknown. A recent study of patients with Clinicians should evaluate the need for such tethers on ev-
k e rs
acute gastrointestinal bleeding found significantly higher
all-cause mortality at 6 weeks with a transfusion threshold
ke rs
ery visit and remove them as soon as possible.
eb oo of 9 g/dL compared to 7 g/dL [4]. Volume overload is the
e b oo b o o
e/e
most common risk of transfusion, and this risk increases
e / m e /
with higher volumes of infused red cells or a history of heart
m
failure [5].
/ /t . // t .
htt ps: htt ps:
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
More specific issues concerning common tethers include: 4 Delirium
t . m e/e
s: / / / /
http
• Urinary catheters are most appropriate for patients await-
ing hip fracture surgery in order to accurately measure
htt ps:
Delirium is the most common complication of hip fracture
surgery and characterized by acutely disordered thinking
urine output and provide comfort to the bedridden patient and altered levels of alertness, often with fluctuating sever-
who cannot toilet himself. Postoperatively, catheters hin- ity. It is an independent predictor of in-hospital as well as
der mobility, lead to infection and can often be removed postdischarge mortality [8]. Prompt recognition and treat-
e rs within the first 2 postoperative days. See topic 10.2 in

this chapter for further discussion of urinary catheters.
er s
ment of delirium is important for early and effective reha-
bilitation as well as other aspects of recovery.
b o ok • Continuous intravenous infusions represent a major bar-
b
rier to mobility and are cumbersome for both nurses ando ok
For further discussion of delirium, see chapter 1.14 Delirium.
b o o
e/ e e/ e
patients, often distracting from the most important post-
e/e
: // t .m
operative care goals. Most infusions can be stopped on
postoperative day 1 or 2, once the patient is hemody- 5 Malnutrition
: / / t .m
tps
namically stable. If intravenous infusions are necessary,
ht
consider giving intermittently to avoid conflicts with
activity or physical therapy sessions. ht tps
Many older patients are malnourished at the time of the hip
fracture; this can negatively impact their recovery as well
• Continuous cardiac monitoring is only indicated in pa- as 1-year mortality [9]. Not surprisingly, older adults also
tients with unstable or newly diagnosed cardiac arrhyth- struggle to maintain adequate nutrition during the postop-
mias and is not indicated as part of standard postoperative erative period. Appetite can be reduced from anesthesia-
e r s care.
e r s
induced gut stasis. The act of eating may be hindered by
ook ok o
• Supplemental oxygen should only be used to treat target lethargy, throat discomfort following intubation, lack of
e b b o
signs or symptoms, and should be discontinued in patients
e
dentures, undesirable food choices, or new or worsened
b o
e / with adequate oxygenation.
m e/
• Frequency of obtaining vital signs should weigh the use-
t .
dysphagia. Poor in-hospital nutrition is associated with in-
creased mortality and functional decline [10, 11].
t . m e/e
/ /
fulness of this information with the burden to the patient.
/ /
ps:
If the patient is hemodynamically stable, consider abstain-
htt
ing from vital sign checks for an 8-hour period at night
to promote sleep. htt ps:
It remains unclear whether optimized in-hospital nutrition
can mitigate or neutralize these negative outcomes; how-
ever, optimizing in-hospital nutrition remains an important
• Physical restraints should be avoided due to their ability goal with at least theoretical benefits of improvements in
to cause significant physical and psychological harm. Re- gut motility, intravascular volume, and mood.
straints do not prevent falls, and can promote agitation
e rs and cause significant injury and death as restrained in-

r s
Older adults consume more food when diets do not impose
e
b o ok dividuals attempt to escape [6, 7]. Avoiding restraint use
b o
in hospitalized older adults can best be achieved through ok
severe restrictions in salt, refined sugar, or saturated fat [12].
Similarly, oral consumption generally improves when small,
b o o
e/ e / e
the prevention or prompt treatment of delirium see chap-
e
ter 1.14 Delirium. Alternatives to physical restraints in-
high-calorie portions are available throughout the day. Feed-
ing conditions should be optimized and tailored to the needs
e /e
://t . m
clude companion or family sitters, changes to the patient’s
/ t .
of the patient (eg, meal set-up, proper positioning, hand
: / m
t t p s
environment (eg, lighting and noise), and low-dose an- feeding).
tps
ht
tipsychotic medications when necessary.
h Nutritional supplements do not have a well-defined role in
hospital care of older adults. They do not appear to reduce
complications or mortality in hip fracture patients [13].
kers rs
Dysphagia is relatively common in older adults, and can wors-
o ke
en in the perioperative period. Ensure that the appropriate
b o b oo
diet consistency is ordered and that feeding assistance is giv-
b o o
e /e e e/e
en (ie, meal supervision is sometimes necessary). If clinicians
m e / are unsure about the safety of oral intake, a swallowing eval-

m
/ /t . t .
uation can be helpful. For further discussion of malnutrition
//
ps: ps:
see chapter 1.11 Sarcopenia, malnutrition, frailty, and falls.
htt htt 53
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 6
t
Avoidance of pressure ulcerations
. m e / most older adults. Consider 650–1,000 mg of acetaminophen
t . m e/e
s: / / / /
ps:
three times daily for at least 2–3 weeks postoperatively in
http htt
Pressure ulcers are a predictable, costly, and dangerous com- patients without liver dysfunction. Ensure that the patient
plication of immobility. is not taking any other acetaminophen-containing products.
Frail geriatric patients are among the most likely to incur a Most patients will need low-dose opioid medications in the
pressure ulcer [14, 15]. Odds are high for a fragility fracture first days to weeks after hip fracture. Patients who are not
e s
patient to develop or exacerbate a pressure ulcer, as tissue
r
damage can occur within a few days of bed rest [16, 17].
er s
chronically dependent upon opioids may only need occa-
sional, low-dose opioid therapy, most often with activity
b o ok Tenets of ulcer prevention align with other best practices of

hospital care, including minimizing the total time of im-
bo ok
and at night. Geriatric patients will typically tolerate a reg-
imen of oxycodone immediate release 2.5 mg every 3 hours
b o o
e/ e e/
mobility, optimizing nutrition and maintaining adequate e as needed. Encourage nursing staff to offer an opioid dose
e/e
: // t .m
hygiene. Nursing staff are instrumental in recognizing at-risk
patients and providing the mainstay of skin care.
30 minutes prior to physical therapy sessions or transfers.
: / /
For further discussion of pain management, see chapter 1.12t .m
ht tps
Mechanical offloading of pressure from the sacrum and heels
is crucial in ulcer prevention and becomes more important
Pain management.
ht tps
in a patient unable or unwilling to ambulate after surgery. 8 Avoidance of constipation
Offloading is best accomplished by daily transfer to a chair
in combination with frequent repositioning while in bed. Patients undergoing hip fracture repair are at high risk for
ke r s
Repositioning should occur at least every 4 hours, although
e r s
constipation due to gut stasis from surgical stress and de-
b o o the optimum frequency is not yet established [18]. Socks or

padded boots are preferred for offloading the heels.
b o ok
creased mobility. Without careful attention to bowel func-
tion, patients are at risk for ileus and possibly fatal obstruc-
b o o
e /e m e/ e
Skin should be kept dry and protected. Dress existing sacral
t .
tion.
t . m e/e
/ /
ulcers to prevent contamination with urine and stool. Avoid
/
The care team should aggressively treat constipation and
/
htt ps:
friction and shear forces with protective dressings and care-
ful repositioning and transferring of patients.
htt ps:
ensure a bowel movement has occurred prior to hospital
discharge. Other aspects of postoperative care will promote
return of normal bowel function, such as early mobility and
Nurse-administered risk assessment tools are helpful for oral nutrition/hydration, and limiting tethers. Polyethylene
identifying patients at high risk of developing a pressure glycol is an osmotic laxative that is powerful, generally well
ulcer. The scores they generate help nurses allocate resourc- tolerated, and has the ability to be titrated. Consider giving
e rs
es and create effective care plans, although they have not
r s
17 g of polyethylene glycol orally daily or twice daily in the
e
b o ok been found to decrease the incidence of pressure ulcers [19].
b o
The Braden Scale and the Norton Scale are the most widely ok
early postoperative period. Often, a rectal suppository is also
needed to facilitate the first bowel movement following
b o o
e/ e / e
used tools and both are recommended by the Agency for
e
Healthcare Research and Quality to be used in the hospital
surgery.
e /e
://t . m
and nursing home settings [20]. Optimal frequency of risk
: / / t . m
s
assessment continues to be debated but repeated assessment
t t p
9 olypharmacy—when to stop or restart
P
tps
ht
at least at admission and after 48–72 hours is recommended medications
[21].
h The stress of surgery and rapid physiological shifts of the
early postoperative period increase the patient’s vulnerabil-
7 Pain management ity to medication effects, even with medications that were
k e rs
Effective pain control facilitates early mobilization and re-
ke rs
well tolerated in the outpatient setting. It is wise to prescribe
the fewest and lowest possible doses of usual medications
eb oo duces risk for delirium. Frequent assessment of pain and
e b oo
in the early postoperative setting. Only a handful of medi-
b o o
e/e
adequate medication dosing is essential. cations have well-described withdrawal effects (eg, beta-
e / m e / blockers, clonidine, long-term opioids, and long-term ben-

m
/ /t .
Routinely scheduled acetaminophen provides a safe and zodiazepines); these may need to be continued at current
// t .
ps: ps:
well-tolerated foundation for postoperative pain control in or attenuated doses. Otherwise patients should demonstrate
54
htt htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
a physiological need for a medication prior to it being pre- 10 Avoidance of serious medical problems
t . m e/e
s: / / / /
ps:
scribed or restarted. This strategy is likely to reduce poly-
http htt
pharmacy and adverse medication effects. See chapter 1.13 10.1 Pneumonia
Polypharmacy for a detailed description of polypharmacy Patients at highest risk for developing pneumonia in the
and its management. postoperative period are those who are older, malnourished
(as defined by albumin < 3.5), dependent in activities of
9.1 Blood pressure medications daily living (ADLs), have a history of congestive heart fail-
e s
Antihypertensive therapy is often stopped prior to hip frac-
r
ture repair in anticipation of perioperative hypotension. It
er s
ure and those with chronic pulmonary problems such as
chronic obstructive pulmonary disease [22]. Collectively,
b o ok is reasonable to continue holding angiotensin-converting

enzyme inhibitors (ACEIs), angiotensin-receptor blockers
bo ok
“lung expansion modalities”, eg, incentive spirometry and
deep breathing, have the strongest evidence base for pneu-
b o o
e/ e e/ e
(ARBs), and diuretics in the early postoperative period as monia prevention in the postoperative setting, as found by
e/e
: // t .m
hydration status is often tenuous and renal perfusion sub-
optimal. When blood pressure does necessitate treatment
: / / .m
the American College of Physicians [22], and are strongly
t
recommended, although the magnitude and relative effec-
ht
sider an attenuated dose. tps
with an antihypertensive, restart agents slowly and con-
ht tps
tiveness of each method has yet to be elucidated. Focused
efforts to achieve early mobility, adequate pain control, and
head of the bed elevation are simple to do and have addi-
Beta-blockers are an exception, as they are usually contin- tional benefits.
ued in the perioperative period for cardioprotection and to
reduce the risk of rebound tachycardia. Similarly, some 10.2 Urinary tract infection
ke r s
calcium channel blockers that are used for rate control may
e r s
Indwelling urinary catheters place hip fracture patients at
b o o need to be continued in the perioperative period.
b o ok
risk for developing urinary tract infection (UTI), especially
when left for more than 2 days following surgery [23]. Cath-
b o o
e /e 9.2 Anticoagulants
t . m e/ e
Following hip fracture surgery, clinicians must weigh the
eters should be removed on the first postoperative day un-
t . m
less there is an extenuating circumstance. Urinary retention e/e
/ /
risk for postsurgical bleeding and transfusion with the po-
/ /
is a common barrier to catheter removal but risk of this can
ps:
tential benefits of antithrombotics and anticoagulants. Deci-
htt
sion making should reflect consensus between the medical
and surgical services. Prophylactic dosing of low-molecular- htt ps:
be mitigated by preventing constipation, early mobility, and
avoidance of anticholinergic medications. If clinically sig-
nificant retention persists, continued urinary catheterization
weight heparin is usually effective as a single agent for pre- may be necessary.
vention of venous thromboembolism in the early postop-
erative period when the bleeding risk is highest. After Clinicians should avoid screening for UTI in asymptomatic
e rs
hemostasis is achieved, it is reasonable to consider resump-
r s
patients, and if asymptomatic bacteriuria is found in a urine
e
b o ok tion of additional anticoagulants. For consideration of special
b o
anticoagulation needs, see chapter 1.6 Anticoagulation in ok
sample, this does not necessitate treatment with antibiotics.
Any antibiotic has the potential for adverse reactions, in-
b o o
e/ e the perioperative setting.
e / e teractions with other medications, and Clostridium difficile
infection.
e /e
9.3 Diuretics
://t . m : / / t . m
s
Most patients who use diuretics over extended periods will
t t p
10.3 Heart failure
tps
ht
not have normal urine output until these are resumed. Most Accurate diagnosis of postoperative heart failure can be dif-
h
patients are able to resume diuretics by postoperative day
3–4 when the need for postoperative hydration is over and
ficult in older patients. Physical examination findings such
as pulmonary crackles, elevated jugular venous pressure
the patient is taking adequate fluid by mouth. and peripheral edema are often nonspecific in the older
adult. Often, a trial of diuresis is necessary as a diagnostic
k e rs ke rs
and therapeutic tool [1]. In cases of newly discovered heart
failure, echocardiography and cardiology consultation may
eb oo e b oo
be warranted to evaluate for potentially correctable causes
b o o
e/e
such as valvular problems, arrhythmia, or ischemia.
e / m e / m
/ /t . // t .
htt ps: htt ps:
55
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 10.4 Hyponatremia
t . m e / Components of a proper hospitalization summary are:
t . m e/e
s: / / / /
ps:
In the surgical setting, hyponatremia is often caused by neu-
http htt
rohormonal stress with antidiuretic hormone release, result- • Baseline functional status and chronic medical prob-
ing in expanded intravascular volume [24]. Usually the con- lems
dition is mild and resolves without specific treatment. • Surgical details, ie, date, surgeon, type of procedure,
Consultation with nephrology is warranted in patients with and complications
falling sodium despite volume equilibration. Sodium stabi- • Details of postoperative complications and their
e rs
lization needs to occur prior to hospital discharge. treatment
er s
• Results (summarized) of any major tests
b o ok 10.5 Myocardial infarction and elevated troponins

Following hip fracture repair, clinically diagnosed myocar-
bo ok
• Names, roles and contact information of consulting
physicians
b o o
e / e e/ e
dial infarction is rare. However, elevation of the cardiac • Discharge medication list, complete with doses,
e/e
: / .m
biomarker troponin is relatively common and has been linked
/ t
to increased cardiac and all-cause mortality at 6 months [25].
frequency, route, and indication:
:
–– Note discontinued (or dose attenuated) medications
/ / t .m
tps
As a result, routine troponin monitoring has been proposed
ht
as a routine practice to aid in prognostication [26]. The im-
pact of such monitoring on clinical outcomes remains unclear
and the reason
–– Plan for osteoporosis treatment ht

–– Note added medications and the reason tps
and needs further study to quantify the risks and benefits • Instructions for the accepting care team, ie, wound
of this approach. care, activity level, diet
• Pending laboratory tests and dates/times of follow-up
e r s e r
appointmentss
ook ok o
11 Discharge planning and safe handoffs • Goals of care including resuscitation status and desires
e b e b o for life-sustaining therapies

b o
e / e/
Successful handoffs require a proactive, coordinated team
m
effort, especially when caring for medically complex patients.
t . Further discussion of postacute care can be found in chap-
t . m e/e
/ /
Patients undergoing fragility fracture repair are particu-
: ter 1.9 Postacute care.
/ /
h t p s
larly vulnerable to poorly executed handoffs, which con-
t
tribute to rehospitalization, adverse events, and patient
dissatisfaction [27]. Fracture programs effective at reducing 12 htt ps:
Prognostic discussions with patients and families
the length of stay have standardized protocols for discharge
planning that begin on admission, anchored by automatic Anticipatory guidance is an important part of a clinician’s
social work and physical therapy consultations to determine role, especially when the patient is expected to have a change
e rs
the discharge destination [2]. Discharge destination depends
r s
in functional trajectory. About 20% of patients with hip
e
b o ok on both patient care needs and the services available in a
specific healthcare system.
b o ok
fracture will die within a year of repair, and 25% of com-
munity-dwelling patients will need nursing home care [29].
b o o
e/ e e / e
The hospitalization summary is a critical piece of medical
Still more will not regain their functional abilities, needing
additional help with ambulation and ADLs [30]. Estimation
e /e
://t . m
communication to accepting care teams, especially when
/ t
of the patient’s clinical trajectory is often possible early in
: / . m
t t p s
caring for medically complex patients. This document should
tps
the postoperative course, taking into account the patient’s
ht
be composed by a physician, physician’s assistant or nurse prior level of function, surgical and perioperative complica-
h
practitioner who has an active role in the patient’s care
while hospitalized and should be written through the lens
tions, and progress with rehabilitation. Discussing these
findings with patients and families is important for framing
of facilitating effective posthospital care. The summary should long-term care goals and preparing them for the possibility
be completed prior to discharge and ideally accompanied of an adverse event or new disability. The postoperative
k e rs
by a phone call to the accepting care provider. Standard-
izing the patient handoff with a checklist likely improves
ke rs
hospital stay is an ideal time to do this, as patients are en-
gaged in their medical care and generally open to anticipa-
eb oo the quality of the communicated information [28].
e b oo
tory guidance. Further discussion of prognosis and goals of
b o o
e/e
care can be found in chapter 1.5 Prognosis and goals of care.
e / m e / m
/ /t . // t .
htt ps: htt ps:
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 13 References
t . m e /
t . m e/e
/ / / /
1. Nicholas JA. Management of
htt ps:
postoperative complications:
cardiovascular disease and volume
management. Clin Geriatr Med.
11. Zisberg A, Shadmi E, Gur-Yaish N, et al.
Hospital-associated functional decline:
the role of hospitalization processes
beyond individual risk factors.
ps:
21. Bergstrom N, Braden B, Boynton P,
htt
et al. Using a research-based
assessment scale in clinical practice.
Nurs Clin North Am.
2014 May;30(2):293–301. J Am Geriatr Soc. 2015 Jan;63(1):55–62. 1995 Sep;30(3):539–551.
2. Friedman SM, Mendelson DA, Kates SL, 12. Dorner B, Niedert KC, Welch PK. 22. Lawrence VA, Cornell JE, Smetana GW.
et al. Geriatric co-management of Position of the American Dietetic Strategies to reduce postoperative
e rs proximal femur fractures: total quality

management and protocol-driven care
er s
Association: liberalized diets for older
adults in long-term care. J Am Diet
pulmonary complications after
noncardiothoracic surgery: systematic
ok ok
result in better outcomes for a frail Assoc. 2002 Sep;102(9):1316–1323. review for the American College of
b o patient population. J Am Geriatr Soc.

2008 Jul;56(7):1349–1356.
bo
13. Avenell A, Handoll HH. Nutritional
supplementation for hip fracture
Physicians. Ann Intern Med.
2006 Apr 18;144(8):596–608.
b o o
e/ e 3. Carson JL, Terrin ML, Noveck H, et al.
Liberal or restrictive transfusion in
e/ e
aftercare in older people. Cochrane
Database Syst Rev. 2006 (4):CD001880.
23. Wald HL, Ma A, Bratzler DW, et al.
Indwelling urinary catheter use in the
e/e
N Engl J Med. 2011 Dec
: / t .m
high-risk patients after hip surgery.
/
14. Allman RM, Goode PS, Patrick MM,
et al. Pressure ulcer risk factors among
: / / t .m
postoperative period: analysis of the
national surgical infection prevention
tps tps
29;365(26):2453–2462. hospitalized patients with activity project data. Arch Surg.
ht ht
4. Villanueva C, Colomo A, Bosch A, et al. limitation. JAMA. 2008 Jun;143(6):551–557.
Transfusion strategies for acute upper 1995 Mar 15;273(11):865–870. 24. Lane N, Allen K. Hyponatraemia
gastrointestinal bleeding. N Engl J Med. 15. Houwing R, Rozendaal M, Wouters- after orthopaedic surgery. BMJ.
2013 Jan 3;368(1):11–21. Wesseling W, et al. Pressure ulcer risk 1999 May 22;318(7195):1363–1364.
5. Li G, Rachmale S, Kojicic M, et al. in hip fracture patients. Acta Orthop 25. Ausset S, Minville V, Marquis C, et al.
Incidence and transfusion risk factors Scand. 2004 Aug;75(4):390–393. Postoperative myocardial damages after
for transfusion-associated circulatory 16. Barton A, Barton M. The Management hip fracture repair are frequent and
e r s overload among medical intensive care

r s
and Prevention of Pressure Sores. London:
e
associated with a poor cardiac outcome:
ook ok
unit patients. Transfusion. Faber and Faber; 1981. a three-hospital study. Age Ageing.
b
2011 Feb;51(2):338–343.
6. Lofgren RP, MacPherson DS, Granieri R,
17. Versluysen M. How elderly patients
b o
with femoral fracture develop pressure
2009 Jul;38(4):473–476.
26. van Waes JA, Nathoe HM, de Graaff JC,
b o o
e / e et al. Mechanical restraints on the
medical wards: are protective devices
e/ e
sores in hospital. Br Med J (Clin Res Ed).
1986 May 17;292(6531):1311–1313.
et al. Myocardial injury after
noncardiac surgery and its association
e/e
safe? Am J Public Health.
1989 Jun;79(6):735–738.
/ / t . m 18. Krapfl LA, Gray M. Does regular
repositioning prevent pressure ulcers?
/ /t . m
with short-term mortality. Circulation.
2013 Jun 11;127(23):2264–2271.
ps: ps:
7. Miles SH, Irvine P. Deaths caused by J Wound Ostomy Continence Nurs. 27. Coleman EA, Boult C. Improving the
htt htt
physical restraints. Gerontologist. 2008 Nov–Dec;35(6):571–577. quality of transitional care for persons
1992 Dec;32(6):762–766. 19. Pancorbo-Hidalgo PL, Garcia- with complex care needs. J Am Geriatr
8. Witlox J, Eurelings LS, de Jonghe JF, Fernandez FP, Lopez-Medina IM, et al. Soc. 2003 Apr;51(4):556–557.
et al. Delirium in elderly patients and Risk assessment scales for pressure 28. Halasyamani L, Kripalani S, Coleman E,
the risk of postdischarge mortality, ulcer prevention: a systematic review. et al. Transition of care for hospitalized
institutionalization, and dementia: J Adv Nurs. 2006 Apr;54(1):94–110. elderly patients—development of a
a meta-analysis. JAMA. 20. Agency for Healthcare Research and discharge checklist for hospitalists.
e rs 2010 Jul 28;304(4):443–451.

9. Koval KJ, Maurer SG, Su ET, et al.
Quality (Quality AfHRa). Preventing
e r s
Pressure Ulcers in Hospitals: What Are
J Hosp Med. 2006 Nov;1(6):354–360.
29. Braithwaite RS, Col NF, Wong JB.
b o ok The effects of nutritional status on

outcome after hip fracture. J Orthop
b o ok
the Best Practices in Pressure Ulcer
Prevention that We Want to Use?
Estimating hip fracture morbidity,
mortality and costs. J Am Geriatr Soc.
b o o
e/ e Trauma. 1999 Mar–Apr;13(3):164–169.
10. Sullivan DH, Sun S, Walls RC.
e / e
Available at: http://www.ahrq.gov/
professionals/systems/long-term-care/
2003 Mar;51(3):364–370.
e
30. Magaziner J, Hawkes W, Hebel JR, et al.
/e
Protein-energy undernutrition among
elderly hospitalized patients:
a prospective study. JAMA.
://t . m resources/pressure-ulcers/
pressureulcertoolkit.
Accessed February 19, 2015.
: / / t . m
Med Sci. 2000 Sep;55(9):M498–M507.
p s
1999 Jun 2;281(21):2013–2019.
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k e rs ke rs
eb oo e b oo b o o
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t . m e /
t .m e/e
/ / //
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57
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rs 26.07.18 10:26
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k e rs ke rs
e b oo e b oo b o o
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t . m e /
t . m e/e
/ / / /
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e rs er s
b o ok bo ok b o o
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: // t .m : / / t .m
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/ / / /
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e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
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h ht
k e rs ke rs
eb oo e b oo b o o
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/ / //
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rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
Michael Blauth, Peter Brink
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
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/
/ / /
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htt ps:
e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e When extrapolating this to a whole-body level, merely
e/e
: // t .m
The postoperative period has not been a primary focus for of muscle tissue.
: / / t .m
5 days of bed rest would result in the loss of roughly 1 kg
ht tps
many surgeons, at least not to the same degree as the in-
traoperative one. As long as wound healing is progressing
normally and postoperative x-rays are satisfactory, little
•
ht tps
Skeletal muscle atrophy is caused by a variety of stressors
including decreased external loading and neural activa-
tion (ie, disuse), inflammatory cytokines and glucocor-
attention is usually paid to other important issues that im- ticoids, and malnutrition [2]. A combination of unloading
pact postsurgical recovery, rehabilitation, and overall func- and reduced neural activity occurs frequently in clinical
tional outcomes. The communication between surgeons, settings following limb immobilization, bed rest, spinal
e r s
staff nurses, and physiotherapists regarding common post-
e r s
cord injury and partial/complete peripheral nerve dam-
ook ok o
operative recovery is often poor. age, resulting in significant loss of muscle mass and force
e b e b o production [2].
b o
e /
t . m
of tools that focus on functional outcomes of individuale/
This is partly due to the lack of availability and application • Older adults display a marked reduction in their ability
t . m
to regain lost muscle tissue following a period of disuse, e/e
/ /
patients. In addition, surgical and medical providers may
/ /
even with an intensive, supervised, resistance-type ex-
ps:
not know how to best influence the rehabilitation progress.
htt
Postoperative management seems as important as surgical
•
ercise training schedule [4–6].
htt ps:
Substantial muscle atrophy occurs during short-term
disuse, with higher rates of muscle loss during more pro-
treatment in producing optimal outcomes. Surgeons’ advice longed disuse. This suggests that the mechanisms respon-
has an enormous influence on the patient, relatives, nurses, sible for the early loss of muscle during disuse differ from
and physiotherapists, and can positively influence the qual- those occurring in prolonged disuse [3].
e rs
ity of care in these areas. In this chapter we will focus on •
r s
Older adults reduce their normal daily activity following
e
b o ok the importance of early mobility and rehabilitation, wound
and skin management, and the prevention and treatment
b o ok
a period of bed rest. Even with structured, supervised
training, older adults spend the majority of their day
b o o
e/ e of pressure sores.
e / e completely inactive [7].
e /e
://t . m : / / t . m
2
s
The impact of immobilization
t t p tps
2.1 h
Loss of muscle mass
Loss of muscle mass and muscle strength is common in older
ht
adults and is highly associated with frailty, functional decline,
immobility, and falls (Fig 1.8-1) [1]. This age-related decline of
k e rs
human muscle mass and strength is known as sarcopenia (see
chapter 1.11 Sarcopenia, malnutrition, frailty, and falls) and
ke rs
eb oo may be exacerbated by short periods of immobilization [2]:
e b oo b o o
e / e /
• Wall et al [3] have generated pilot data from eight older
t . m
adults demonstrating that 5 days of limb immobilization
a b
t .m e/e
s: / / //
Fig 1.8-1a–b Difference in muscle mass of the upper leg between
ps:
leads to a 1.5% loss of quadriceps cross-sectional area. two men aged 25 and 81 years, matched for length and body weight.
http htt 59
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
• Structured and prolonged resistance training is effective 3 Rehabilitation
t . m e/e
s: / / / /
ps:
for muscle mass gain in older adults [8, 9] and should be
http htt
considered vital to their recovery. Most current clinical Each surgical intervention in fragility fractures should en-
practice does not mandate such a rehabilitation program able the patient to make immediate use of the injured ex-
following a period of immobility, and older adults gener- tremity. Undertaking the risk of surgery while still being
ally show low adherence to nonsupervised, structured restricted in postoperative range of motion or active mobi-
resistance-type exercise training [10–12]. lization often results in unacceptable overall functional
e rs
Composition of the slow, oxidative muscle fibers (type 1)
outcomes.
er s
b o ok and the fast, glycolytic muscle fibers (type 2) changes with
b
age. Due to a natural loss of type 2 fibers, older adults areo ok
Why are we afraid that we might overload our fracture/
implant construct? Biomechanical studies show that con-
b o o
e / e e/
unable to react adequately to an unforeseen situation and e structs fail at distinct levels typically above physiological
e/e
: // t .m
fall easily. Both walking speed and coordination are de-
creased, which results in increased risk of falling and fracture.
loads, even in cadaveric bone without soft tissue and active
:
muscles to support the construct. We have an incomplete
/ / t .m
tps
During immobilization, this process continues and the loss
ht
of fast twitch fibers progresses. Both the number and the
volume of the fibers diminish. ht tps
understanding of the in vivo forces during partial, full, and
non-weight bearing as well as of forces emerging with upper
extremity movements.
Since there is a direct relation between muscle mass and Surprisingly, forces in the hip joint measured in patients
muscle strength, this loss of muscle mass represents an in- lying in bed and lifting their buttocks are higher than in the
e r sdependent risk factor for new falls and fractures. Restoration

e r s
same hip joint during full weight bearing (FWB), using two
ook ok o
of muscle mass will improve performance during mobiliza- crutches [14]. In light of these biomechanical and clinical
e b tion after fracture treatment [13].

e b o realities, immediate weight bearing as tolerated (WBAT)
b o
e / m e/
There is clear evidence that considerable muscle atrophy
t .
using support should be promoted.
t . m e/e
/ /
occurs during the early phase of immobilization and is at-
/
The same reasoning applies, if nonoperative treatment is
/
htt ps:
tributed to a rapid increase in muscle protein breakdown
accompanied by a decline in muscle protein synthesis [3]. A
persistent catabolic state hampers the improvement of this
chosen.
Some general remarks: htt ps:

situation, so nutritional intake (1.25–1.5 mg of protein per
kilogram of body weight per day) together with active mo- • Patients usually enjoy mobilization and use of their ex-
bilization is essential to regain muscle power and coordina- tremities. It makes them less dependent on help and re-
e rs
tion. Both are a challenge in older adults.
r s
duces frustration noted with activity restrictions.
e
b o ok o
Early mobilization by itself is not sufficient to prevent a
b ok
• Patients may be afraid of pain. It is always helpful if the
surgeon assists in the early postoperative phase with mov-
b o o
e/ e / e
decline in function. There is increasing evidence that strength
e
training for the frail geriatric patient is an effective way to
ing joints, sitting and standing in front of the bed, to
reassure patients about the safety of mobilization during
e /e
://t . m
restore muscle function and to eliminate muscle strength pain.
: / / t . m
t t p s
asymmetry after surgery within 3 months [1].
tps
• Walking exercises should be supervised by the surgeon
ht
to enable him/her to interpret utterances and questions
h
In order to regain prefracture level of function and inde-
pendence, early active mobilization with resistance exer-
with regard to pain. Never rely on reports from other
healthcare providers. There is no way around a person-
cises and adequate protein intake is essential. al visit and observation of the patient.
• Giving patients individually tailored tips and tricks to
k e rs ke rs
safely improve mobilization may give them emotional
support and be extremely helpful.
eb oo e b oo
• Talking to the patients, touching their hands, and answer-
b o o
e/e
ing concerns may also help and encourage them.
e / m e / • Pain management is critical. Timing, drug selection and

m
/ /t . t
dosage all influence patients’ ability and willingness to
// .
ps: ps:
get mobilized and to cooperate.
60
htt htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
Patients should feel comfortable while being mobilized, and
t . m
Even though high-level evidence is lacking, the authors list e/e
s: / / / /
ps:
different walking aids should be offered. Canes or walking a few thoughts:
http htt
sticks are usually more difficult to use and require arm force
and coordination. A walker with or without wheels may be • Failures typically occur between the 2nd and 3rd months
easier to use at the beginning or even permanently but may after surgery, and there is no evidence that they occur
not allow for enough independence. more often in patients with weight-bearing permission.
• Restriction of weight bearing inflicts a significant physi-
k e rs 3.1 Lower extremity

Based on traditional teaching, anecdotal information and
er s
ological burden on the older patient. The energy expen-
diture for ambulation without FWB increases fourfold,
o o fear of loss of reduction, many surgeons are hesitant to

o ok
which leads to rapid exhaustion [16].
o o
e/eb b b
permit FWB after reduction and stable fixation of fractures • Most fragility fracture patients (FFPs) are not physically able
of the pelvis and/or lower limb.
e/ e to perform PWB due to sarcopenia, lack of proprioception
e/e
: // t .m
No or limited weight bearing for some time is supposed to
: / / t .m
and arm weakness. Many have preexisting impaired func-
tion of the upper and lower extremities which prevents
tps
limit forces on the reconstructed bone and fixation mate-
ht
rial and to prevent loosening, hardware failure and second-
ary displacement of the fracture and implant. Of course, if ht tps
them from using crutches or walkers in a way that effec-
tively and safely spares the affected lower extremity. This
makes implementation of a nonweight-bearing or PWB
such an event occurs, it is a disaster for patient and physician. protocol impossible and forces the patient to prolonged bed
Traditionally, limited weight bearing only is allowed for a rest and its well-known negative ramifications, predomi-
time span of 6, 8 or 12 weeks after surgery. nantly a rapid loss of muscle mass. In addition, it makes
e r s e r s
non-weight bearing risky and increases the likelihood for
ook ok o
One origin of this time-based protocol for weight bearing is another injury.
e b the AO Principles of Fracture Management by Müller et al [15]

e b o • Patient motivation may drop due to fear and anxiety of
b o
e / that advocates a limited weight-bearing recommendation
m e/
with 3 months of 5–10 kg load for hip fractures, unfortu-
t .
failure to make functional progress.
t . m
• The altered gait mechanism can lead to complaints of e/e
/ /
nately without any support from evidence-based literature. overload or low back pain.
/ /
ps:
It is remarkable that these classic protocols are still in use,
htt
while at least some evidence promoting a less restricted
weight-bearing protocol has existed since the end of the last htt ps:
• Many FFPs have cognitive impairment, and may not un-
derstand or remember weight-bearing instructions.
• Partial weight-bearing protocols are not evidence-based.
century. • Even in the presence of appropriate doses of pain medi-
cation, pain will guide the patient to bear weight safely
Failures of fixation are mostly associated with biomechan- and appropriately. Patients with severely impaired cogni-
e rs
ical flaws including suboptimal reduction and/or fixation.
r s
tive function typically have the same self-protective
e
b o ok 3.1.1 Partial weight bearing is not an option
b o ok
mechanisms as cognitively intact patients.
• Early weight bearing can promote fracture healing and
b o o
e/ e / e
In the authors’ opinions, immediate postoperative WBAT is
e
the only reasonable option in geriatric patients with lower
union of the fracture without increasing loss of fixation
[17–19].
e /e
://t . m
extremity injuries. This applies to all kinds of fixations and
: / / t . m
t t p s
joint replacements. Biomechanically sound constructs and
tps
There is no evidence that PWB after operative treatment of
ht
close observation of the patient are prerequisite for this fractures of the pelvis and lower extremity has any advan-
regimen. h tages for the patient over FWB. Since there are many ad-
vantages of immediate full WBAT, this should be the stan-
If a fixation is deemed to be ‘not stable enough’, it could mean dard approach. It may help to diminish adverse effects of
weeks to months of bed rest and/or partial weight bearing sustaining a fracture such as loss of independence, less sar-
k e rs
(PWB) until fracture healing has taken place. Usually, bone
resorption at the fracture site renders the stability of the bone-
ke rs
copenia, less fear of falling and is expected to lead to a bet-
ter outcome.
eb oo implant-construct even weaker in the first weeks.
e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
61
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 3.1.2 Recommendations
t . m e /
t . m
• There is no solid proof for an earlier onset of osteoarthri- e/e
s: / / / /
ps:
The following recommendations regarding weight bearing tis in general, and it is hardly an issue in this population.
http htt
should serve to produce optimal outcomes for typical FFPs: It is not the timing of weight bearing, but inadequate
articular reduction that predicts the outcome. The few
• Surgical treatment should be adapted and extended to studies of early weight bearing in geriatric acetabular frac-
make fixation as safe as possible. Additional implant aug- ture patients showed results similar to nonweight-bearing
mentation, the use of long, splinting constructs with studies with no secondary loss of reduction [21]. One should
e rs relative stability, and joint replacement instead of an

unstable osteosynthesis requiring PWB are examples.
er s
realize that in acetabular fractures most forces are ex-
erted posteriorly during transfers and sitting while axial
b o ok • Patients should be mobilized with WBAT as soon as pos-
bo
sible after surgery. Usually, bedside sitting and standing ok
compression during walking transmits force to the ace-
tabular roof which is relatively robust even in severe os-
b o o
e/ e e/ e
in front of the bed with equal weight on both legs should teoporosis. Even nonoperatively treated acetabular frac-
e/e
be the initial approach.
: // t .m
• Use a walker to assist with WBAT. More specific walkers
tures patients can tolerate weight bearing (Fig 1.8-2).
: / / t .m
• Similar principles apply to fractures of the tibial plateau.
tps
with support for both upper extremities and the upper
ht
part of the body make patients feel safe with regard to
falling or becoming so weak that walking is no longer ht tps
After adequate reduction and plate fixation early weight
bearing does not predict malunion or nonunion. Some
physicians use locked plates and/or postoperative braces,
possible. but superiority for these have not been proven yet [22–24].
• Create a safe environment to improve patient confidence
and reduce the risk of falling. 3.2 Immobilization
ke r s
• Stress body awareness to help patients identify situations
e r s
3.2.1 Immobilization by cast and splint
b o o where overload may occur.
b
• For most intraarticular fractures reduced and fixed with
o ok
In nonoperative treatment of lower leg/ankle fractures, an
external bracing technique (mostly using plaster of Paris)
b o o
e /e m e/ e
an implant, there is no need to restrict weight bearing.
Even though cartilage is damaged, anatomy is restored.
t .
is used to hold the reduction, to reduce pain and to gain
time for consolidation. In intrinsic stable fracture types,
t . m e/e
/ /
Axial loading helps circulation in the joint and the car-
/ /
weight bearing is permitted if, after reduction of the swell-
ps:
tilage and facilitates joint healing and strength.
htt
• Surgeons should intermittently observe the postoperative
patient during mobilization and ambulation and pay spe- htt ps:
ing, a proper external immobilization is possible. In less
stable fracture types the initiation of weight bearing is de-
layed, until signs of bone healing are detected. The well-
cial attention to any barriers to rehabilitation. Little re- known drawbacks of external immobilization, including
marks, tips and encouragement from the surgeon can be muscle loss and joint stiffness, is the reason to promote
extremely important for optimal outcomes. internal fixation whenever possible.
e rs e r s
b o ok 3.1.3 Evidence
b o
Literature review indicates that WBAT is safe for most post- ok
External bracing using plaster of Paris or splints today is
often used as an adjunct to support the construct inside in
b o o
e/ e fixation FFPs.
e / e osteoporotic bone. In addition to the known drawbacks of
both internal fixation and nonoperative treatment in com-
e /e
://t . m
• Koval et al [17] demonstrated that older adults encouraged
/
bination, there is no evidence to support this combination
: / t . m
t t p s
to perform FWB initiated PWB up to 50% in the first
tps
management approach. Considering the additional skin and
ht
week and increased up to 87% in 3 months without any mobility issues in older adults with external bracing, the
tolerated from day 1.

h
loss of fixation if they were allowed to bear weight as use of external fixation with plaster should be an exception
and not a rule.
• The use of bathroom scales to instruct the patient with
a biofeedback system is useful for standing but not for If internal fixation is poor due to the quality of the bone, an
k e rs walking [20].
• We do not know the actual amount of axial load delivered
ke rs
external fixator could be used as a temporary adjunct. Real-
ize that when plate-screw fixation is poor, the pins for the
eb oo to the implant-bone construct. We know that patient
e b oo
external fixator will not hold for an extended period of time.
b o o
e/e
compliance to follow precise instructions is fairly low and
e / m e /
implant constructs rarely fail. So why employ a restricted
m
t .
weight-bearing protocol and not shift to a protocol for
/ / // t .
ps: ps:
weight bearing as tolerated?
62
htt htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 3.2.2 Immobilization by traction
t . m e /
t . m
applies to distal radial fractures. Surgeons argue about re- e/e
s: / / / /
ps:
Preoperative traction of lower extremity fractures is no lon- duced bone quality and potential wound healing problems.
http htt
ger common, and in the older adult traction entails specific
risks. If skin traction is used, a traction weight of more than Postoperative management after surgery of the upper extrem-
1 kg can easily damage the skin in older adults. The use of ity (mostly proximal humerus or distal radius) is less contro-
pins has disadvantages including nerve injury, loosening, versial than of the lower extremity. Again, internal fixation
and the risk of infection. For these reasons, early definitive after reduction of the fracture, either open or closed, should
e s
surgery is recommended. If the soft tissue does not allow
r
early surgery, a temporary external fixator might be safer
er s
not be routinely combined with immobilization. For example,
plate fixation of the proximal humerus does not need an
b o ok than traction.
bo ok
extended time of restricted functional therapy. In the operat-
ing room the stability of the construct is tested, using the
b o o
e/ e 3.3 Upper extremity
e/ e image intensifier. If the surgeon can safely move the shoulder
e/e
: // t .m
Patients are often kept in a sling for 3 weeks or more after
fractures of the proximal humerus and the humeral shaft.
: / / .m
in all directions in the operating room, the patient and/or
t
physiotherapist should be able to tolerate the same, at least
tps
Fractures of the olecranon and the distal humerus, disloca-
ht
tions and fracture dislocations of the elbow are often im-
mobilized in a plaster despite surgical fixation. The same ht tps
using passive motion. Early mobilization is the best way to
reduce pain and helps the patient to regain confidence in the
injured extremity, and also applies to both the elbow and
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
k
a
e rs b
k e r s c
b o o b o o b o o
e/e t . me / e
t . m e /e
s : / / : / /
h t t p ht tps
k e rs ke rs
eb oo d e
e b f
oo b o o
e / Fig 1.8-2a–f
t . m e /
a–c Right acetabular fracture in a 91-year-old woman. Immediate pain adapted mobilization with walker.
t .m e/e
/
d–e After 2 months slight displacement of fracture fragments but almost pain free with callus formation.
/ //
ps: ps:
f Same situation after 3 months.
htt htt 63
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m
distal radius. After wound healing, stimulation of movement e / 4.2 Wound management
t . m e/e
s: / / / /
ps:
of the fingers and wrist is only possible if the plaster is re- Infection prevention is one of the cornerstones of postop-
http htt
moved. Only when K-wires are used for the distal radius, erative care of older adults. The skin becomes more friable
which are actually contraindicated in osteoporotic bone, is a with age, dehydration, medication effects, malnutrition,
plaster of Paris mandatory for support of the construct. immobility, and comorbidities.
3.4 Combined injuries There is no generally accepted standard for wound closure
e s
In patients with combined injuries of both the upper and
r
lower limb, rehabilitation is especially problematic. Adapta-
er s
in trauma regardless of age. To prevent wound infection,
adequate attention to wound closure is important. Control
b o ok tion of the crutch on the injured side, using an elbow crutch,

might be a solution if the wrist is injured. The rehabilitation
bo ok
of obvious bleeding, limitation of dead spaces, removal of
any dead soft tissue in the wound before closure are basic
b o o
e/ e program should be individualized in these patients in order
e/ e surgical principles, especially in older adults.
e/e
serve weight bearing.
: // t .m
to find the best way to promote early movement and pre-
: / /
Closure is done by using staples or sutures, according to thet .m
4 ht tps
Skin and wound management ht tps
surgeon’s preference. It is not clear whether staples or su-
tures are better. Studies comparing staples with sutures,
especially regarding hip replacement in older adults, are
conflicting. One metaanalysis shows fewer infections in the
4.1 Perioperative skin management sutured group compared with staples [25] while another
The skin of older adults is extremely fragile and vulnerable review could not demonstrate a difference [26].
e r s
to injury compared to younger individuals. Older adults are
e r s
ook ok o
at increased risk for degloving injuries which can occur dur- After suturing of the wound, protection of the wound using
e b ing positioning on the operating room table by pulling the

e b o adhesive strips is one way to reduce tension on the wound.
b o
e / phase, care should be taken when wound dressings have to
t . e/
leg for hip joint reduction (Fig 1.8-3). In the postoperative
m
It is advisable, however, to use the strips in full length par-
allel to the wound instead of perpendicular. Several studies
t . m e/e
/ /
be removed. A simple bandage instead of an adhesive wound
/ /
have shown that perpendicular stripping resulted in blisters
ps:
dressing should be used in patients with fragile skin. If a
htt
superficial skin deglovement occurs, the use of small but-
terfly bandages are preferred instead of stitches to replace htt ps:
in 10–41% of patients after hip surgery, which was related
to postoperative swelling and increased local stress on the
skin [27–29]. Dry dressings are adequate to absorb drainage
and fix the skin. of blood and fluids and will help to avoid the creation of a
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
a
h b
ht
k e rs ke rs
eb oo e b oo b o o
e/e
c d
e / Fig 1.8-3a–d
m e / m
t .
a–b Unnoticed intraoperative degloving of the right lower leg in a periprosthetic hip fracture.
/ / // t .
ps: ps:
c–d Uneventful healing over the next weeks.
64
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rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
warm, high fluid-saturated environment that can promote
t . m
intensively. In the case of a hematoma, evacuation is only e/e
s: / / / /
ps:
bacterial growth. Care should be taken to avoid blister for- recommended if the tension on the skin might cause skin
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mation, which can cause pain and disrupt the skin barrier. necrosis or if it is draining. Pain can be a sign of exces-
In general, after 48 hours, bandages are not necessary to sively high pressure. There is no evidence that infection
cover sutured wounds. In cases of urinary incontinence, an rates increase in closed hematomas (Fig 1.8-4) [33].
occlusive bandage is recommended. Keeping the wound
clean and dry is the best way to prevent wound problems.
k e rs Sometimes clear exudate drains from the wound for sev-

5
er s
Prevention of thromboembolic events
o o eral days. A dry sterile bandage is needed to absorb the

o ok
Surgeons know the benefits of prophylactic anticoagulation
o o
e/eb b b
fluid. It could be either extracellular fluid due to local or treatment for their patients and consider this to be good
e/ e
systemic edema, fat necrosis from stripping the fascia, or a clinical practice. In older adults, the fear of adverse effects
e/e
: // t .m
sterile reaction to suture material (eg, polylactin). In some
cases, this represents a suture-related pseudoinfection (ie,
: / / .m
of anticoagulation (ie, bleeding) might cause inappropriate
t
underuse of these medications [36, 37]. Aging is regarded as
ht
eign body reaction) [30]. tps
negative culture and positive histological samples with for-
ht tps
one of the strongest and most prevalent risk factors for
thromboembolic events [38]. Comorbid conditions and a lack
of mobility are thrombogenic factors as well [39]. Immobi-
4.2.1 Wound drainage and hematoma management lization and type of surgery both contribute to the risk for
To drain or not to drain, that has been a general question thromboembolic complications. Geriatric fracture patients
for many years now and is also a controversial topic in ge- may have a period of bed rest from injury until the first
e r s
riatric fracture care. Closed suction drainage after operative
e r s
attempt to mobilize the patient after surgery and have a
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treatment of proximal femoral fractures was promoted since moderate risk of 10–40% developing a venous thromboem-
e b b o
the early 1960s [31]. The rationale seems logical, that is to
e
bolism. A hip fracture surgery or major trauma increases
b o
e / prevent wound hematomas and to decrease the risk for
wound infection.
t . m e/ this risk to 40–80% [40].
t . m e/e
/ / 5.1 Venous thromboembolism prophylaxis
/ /
ps:
There are a small number of relevant studies of wound
htt
drainage in fracture treatment [32–34]. Varley and Milner
[32] found that using two drains, high vacuum for < 48 htt ps:
Venous thromboembolism (VTE) prophylaxis should be
given at all ages, unless absolute contraindications exist like
significant gastrointestinal, intracranial, wound or intraab-
hours did not produce statistically significant reductions in dominal bleeding. In these situations mechanical prophy-
wound infections. The more recent studies [33, 34] showed laxis with intermittent pneumatic compression devices or
no relation between hematoma formation and infection, venous foot pump and/or graduate compression stockings
e rs
suggesting that the use of drains is unnecessary. There is
r s
are recommended options [40]. A comprehensive review of
e
b o ok insufficient evidence from randomized trials to support the
b o
routine use of closed suction drainage in orthopedic surgery ok
anticoagulation can be found in chapter 1.6 Anticoagulati-
on in the perioperative setting.
b o o
e/ e / e
[35], so larger studies may be helpful in the future. At this
e
time, the routine use of suction drains in hip fracture sur-
e /e
gery is not recommended.
://t . m : / / t . m
t t p s tps
ht
Subcutaneous hematoma can lead to discomfort for the pa-
h
tient but could also jeopardize the wound and healthy skin
due to diminished circulation of the surrounding tissue
(Fig 1.8-4). It should be noted that sterile hematoma resorp-
tion will produce inflammatory signs, including a subfebrile
k e rs
rise of body temperature. Opening of the wound should
only be considered when inflammation is combined with
ke rs
eb oo laboratory signs indicating that an infection is likely.
e b oo b o o
e /
t . m e /
In hip surgery, the fascia lata protects the implants but may
also cover an ongoing infection for some time. Pain and
t .m e/e
s: / / //
Fig 1.8-4 Subcutaneous hematoma with skin at risk for necrosis.
ps:
raised temperature are signs to evaluate the hardware more Evacuation should be considered.
http htt 65
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 5.2 Compression stockings
t . m e /
t
the use of vitamin K antagonists (with a target internation-
. m e/e
s: / / / /
ps:
The use of compression stockings for geriatric patients after al normalized ratio of 2.0–3.0) is an alternative way to reduce
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trauma surgery could either be indicated for prophylaxis or the risk for thromboembolic complications, but the risk of
treatment of VTE but carry the additional risks of skin break- major bleeding is a concern. Overanticoagulation should be
down and arterial compression. Their use in geriatric patients avoided to minimize hemorrhagic complications. Be aware
must be done with care. Elastic compression stockings coun- of the risk for major bleeding in patients already receiving
teract the effect of increased intravenous hydrostatic pres- antiplatelet therapy (eg, aspirin and clopidogrel). Since there
e s
sure. The reduction of the venous pressure gradient improves
r
the reabsorption of fluids from connective tissue.
er s
is no evidence that antiplatelet therapy is superior to anti-
coagulant therapy, except in case of a prosthetic heart valve,
b o ok A Cochrane review shows that graduated compression stock-

bo ok
it is safer to stop antiplatelet therapy temporarily.
b o o
e/ e e/ e
ings are effective in diminishing the risk of DVT in hospital- For patients undergoing a surgical procedure for fracture
e/e
lactic therapy [41].
: // t .m
ized patients, especially in combination with other prophy- reduction and fixation the authors recommend:
: / / t .m
ht tps
If compression stockings reduce the incidence of postthrom-
botic syndrome (PTS), particularly severe postthrombotic ht tps
• For patients not undergoing immediate surgery, adminis-
ter LMWH no closer to surgery than12 hours. Postopera-
tively, LMWH can be started 6 hours or more after fixation.
syndrome is still under debate. The only multicenter ran- • Continue for 10–15 days and in case of hip surgery up to
domized placebo-controlled trial [42] shows no benefit, prob- 5 weeks.
ably due to a lack of compliance.
e r s e r s
In case of isolated lower leg injuries requiring leg immobi-
ook ok o
Be careful that the stocking does not roll down, as pero- lization, there is no proof that anticoagulant therapy is ben-
e b neal nerve palsy due to compression may occur [43].

e b o eficial unless the patient belongs to a high-risk group.
b o
e / 5.3
m
harmacological approaches to venous
P
t . e/ t . m e/e
/
thromboembolism prophylaxis
/ 6 Management of urinary bladder disorders
/ /
ps:
To prevent thromboembolic complications in the FFP with
htt
a fracture of the lower limb, temporary bed rest, surgery
and/or staged mobilization, consider the following pharma- htt ps:
Many FFPs have urinary incontinence during the periop-
erative period, due to preexisting urinary tract dysfunction
cological options: and temporary factors including delirium, pain, positioning,
constipation, and medication adverse effects. With age, blad-
• Low-molecular-weight heparins (LMWHs), subcutaneous der capacity, contractility decrease, and involuntary detru-
e rs both for intermediate and high-risk patients. The advan-

r s
sor contractions increase. Moreover, almost 90% of all pa-
e
b o ok tage of an LMWH offers the possibility to continue med-
b o
ication after discharge from the hospital. For typical dos- ok
tients with a hip fracture have an acute urinary retention
which could lead to overflow incontinence [47]. Immobility,
b o o
e/ e / e
age recommendations, see the Orthogeriatrics App [44]
e
about anticoagulation and chapter 1.6 Anticoagulation
the use of analgesics and opiates and increased intravenous
fluid intake are all factors promoting urinary retention [47].
e /e
in the perioperative setting.
://t . m : / / t . m
t t p s
• Factor Xa inhibitors (eg, idraparinux, fondaparinux) by
tps
For this reason an indwelling urinary catheter is used peri-
ht
subcutaneous route. Fondaparinux is very effective in operatively. The optimal management includes removal of
h
the prevention of thromboembolic events but increases
the chance of (mainly) surgical site bleeding [45].
the urinary catheter no more than 48 hours after surgery
followed by intermittent catheterization that is repeated at
• New oral anticoagulants (NOACs) (eg, rivaroxaban, dab- regular intervals if necessary. After surgery, it is the cogni-
igatran, apixaban) are tablets. Their definitive role in the tive state of the patient and not the fracture itself that is
k e rs prevention of thromboembolic diseases in older patients

is not clear yet.
ke rs
correlated with urinary retention; these cognitively impaired
patients need extra attention to avoid bladder distention
eb oo e b oo
[48]. To avoid catheter-related urinary infections, the adapt-
b o o
e/e
All LMWHs and fondaparinux have been proven to be safe ed protocol of Tenke et al [49] is recommended:
e / m e /
and effective in geriatric patients [37]. For prophylaxis LM-
m
/ /t .
HWs are still the first choice [46]. In case of extended use of 1. Catheters should be introduced under antiseptic
// t .
s:
anticoagulant therapy in older patients after hip surgery, conditions.
ps:
66
http htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m
2. The catheter system should remain closed. e /
t . m
ing wet dressings or sheets are simple measures that can e/e
s: / / / /
ps:
3. Unnecessary catheterizations should be avoided. be taken by all healthcare providers.
http htt
4. The duration of catheterization should be as short as • Patients should be encouraged to sit and walk shortly
possible. after surgery. When bed rest is unavoidable, the patient
5. The use of a nurse-based electronic catheter reminder should be repositioned every 2 hours. Sliding should be
system is recommended. prevented and the elevation of the head of the bed should
6. Educational programs targeting best practices for be less than 30° [51].
e rs urinary catheter insertion and maintenance should be

provided to all relevant staff.
er s
• Daily inspection of areas at risk like sacrum, coccyx, is-
chium, or greater trochanter is mandatory.
b o ok 7. The use of hydrophilic-coated catheters is recom-

mended for clean intermittent catheterization.
bo ok
Furthermore, the heels should be inspected daily and these
b o o
e/ e e/ e areas should be staged, using the staging system developed
e/e
: // t
ther discussion on catheters and tethers..m
See chapter 1.7 Postoperative medical management for fur- by the National Pressure Ulcer Advisory Panel [55]:
: / / t .m
7 ht tps
Prevention and treatment of pressure ulcers
nonblanchable redness
ht tps
Stage 1 Nonblanchable erythema: intact skin with
Stage 2 Partial thickness: partial thickness, loss of dermis

presenting as a shallow open ulcer with a red
Pressure ulcers, also called sores, are a common problem in pink wound bed, without slough.
geriatric patients in hospitals, and the prevalence might be May also present as an intact or open/ruptured
e r s
underestimated [50]. It is not only a burden during the hos-
e r s
serum-filled or serosanguineous-filled blister
ook ok o
pital stay but many stage 3 and 4 pressure ulcers become Stage 3 Full thickness of skin or tissue loss: subcutaneous
e b b o
chronic wounds, decreasing the quality of life [51]. Pressure
e
fat may be visible, but bone, tendon, or muscle
b o
e / e/
ulcers might develop within several hours, but they may
m
take years to heal. The presence of a pressure ulcer is the
t .
are not exposed
Stage 4 Full thickness tissue loss with exposed bone,
t . m e/e
/ /
outcome of a multifactorial pathological condition. It is the tendon or muscle
/ /
ps:
cumulative effect of impairment due to immobility, nutri-
htt
tional deficiency, and chronic diseases which predisposes
the aging skin to increased vulnerability [51]. htt ps:
Stage 2 and deeper ulcers require an appropriate dressing
that absorbs fluids but maintains moisture and encourages
granulation tissue formation. Additives like silver ions,
Recommended actions to prevent pressure sores are: topical analgesics or activated charcoal to neutralize odor
are available and can be used according to local practice.
e rs
• Prevention should start in the emergency department.
r s
Treatment should be based on the stage of the pressure
e
b o ok • Early use of pressure relief devices. Both dynamic support
b o
surfaces like alternating pressure mattresses, low-air loss ok
ulceration and may require surgical debridement (Fig 1.8-5).
b o o
e/ e / e
beds, spacer mattresses, air fluidized mattresses and sur-
e
face improvement like specialized foam or sheepskin have
e /e
://t . m
been proven to be better than a standard mattress to
: / / t . m
t t p s
prevent pressure ulcers [52].
tps
ht
• Involvement of a multiprofessional team including nurs-
h
ing staff, aides, physician, dietician, occupational and
physical therapist, and social worker.
• Early mobilization is the most important action to be
taken while immobility is the most significant risk factor
k e rs for development of pressure ulcers [53].

• The four most common external physical forces are ax-
ke rs
eb oo ial pressure, shearing pressure, friction and excessive
e b oo b o o
e/e
moisture [54]. Besides the treatment of the patient-relat-
e / e /
ed internal factors, paying attention to these external
m m
Fig 1.8-5 Mostly stage 2 but centrally stage 3 pressure ulcer in a
factors is extremely important.
: / /t . // t .
patient with a hip fracture and multiple comorbidities, which makes
s ps:
• Frequent repositioning in bed, early mobilization, avoid- early mobilization difficult.
h t t p htt 67
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
In case of a stage 3 or 4 pressure ulcer, debridement, start-
t
be beneficial [51]. Surgery for pressure ulcers (eg, excision
. m e/e
s: / / / /
ps:
ing with surgical debridement and followed by autolytic of prominent/necrotic bone or flap surgery) is rarely per-
http htt
debridement, is a common technique. There is little evidence formed in debilitated patients and will not be the solution
concerning best practice for cleansing of pressure ulcers [56]. when immobility still exists [51].
The use of topical antibacterial creams does not appear to
e rs
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e r s Syst Rev. 2013 Mar 28(3):CD004983.
ok ok
population. Arch Intern Med.
b o
2004 Nov 08;164(20):2260–2265.
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Bernardo Reyes, Nemer Dabage, Darby Sider
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
1.9 Postacute care / / / /
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e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e 2.1 Facility-based rehabilitation
e/e
: // t .m
For most hip fracture patients, the goal of postacute reha-
: / / t .m
Facility-based rehabilitation is common, effective and typi-
cally resource intensive. Most healthcare systems attempt
tps
bilitation is the restoration of preinjury function and, when
ht
possible, functional independence. Postacute care includes
not only physical rehabilitation but patient-specific multi- ht tps
to balance costs and benefits, so it is essential to assess the
functional ability of the patient to determine if clinically
appropriate care can be delivered in a lower intensity s etting.
disciplinary treatment of medical, social, nutritional and The most common facility settings for rehabilitation are
psychological contributors to disability, and typically pro- described below:
duces significant benefits for most patients [1, 2]. Evidence
e r s
on the comparative effectiveness of specific postacute reha-
e r s
• When patients receive rehabilitation in inpatient geriatric
ook ok o
bilitation settings is limited, but most successful programs wards, ie, in the same facility where the acute care was
e b involve more intensive exercise and multidisciplinary care

e b o provided, placement in a geriatric care-based unit for the
b o
e / e/
than is available in many acute care hospital and outpatient
m
settings. While rehabilitation following hip and other fragil-
t .
entire hospitalization appears to be superior to a 2-step
t . m
model of postoperative transfer from an orthopedic sur- e/e
/ /
ity fractures begins in the perioperative period, it is pre-
/ /
gical ward to a geriatric rehabilitation ward. This ward
ps:
dominantly delivered in postacute care settings like skilled
htt
nursing facilities (SNFs), inpatient rehabilitation facilities
(IRFs), rehabilitation with home health services, and out- htt ps:
model can be more expensive but minimizes the risk of
institutional transitions of care [5, 6]. Inpatient ward based
rehabilitation is more common in European healthcare
patient settings [3, 4]. systems.
• Inpatient rehabilitation facilities can be located within a
hospital or exist as standalone facilities. Patients that are
e rs
2 Postacute care settings
r s
managed in these facilities can typically tolerate intensive
e
b o ok o
Depending on the structure and financing of the local health-
b ok
rehabilitation, ie, more than 3 hours per day, while still
receiving access to comprehensive nursing care. These
b o o
e/ e / e
care system, postfracture rehabilitation can occur in the
e
same acute care facility where the fracture was treated, in
settings are appropriate if the intensity, frequency, and
duration of therapeutic activities make it impractical to
e /e
://t . m
distinct postacute care facilities, or at home. Most studies
/ t . m
obtain the services in a less intensive setting. While younger
: /
t t p s
have demonstrated that the outcomes after rehabilitation
tps
and more robust patients may get superior outcomes from
ht
are similar regardless of the care setting. IRF-based rehabilitation, many fragility fracture patients
h
Decisions regarding the setting where postacute care will be
(FFPs) cannot tolerate this intensity of services.
• A skilled nursing facility or postacute care setting is a
delivered often depend on factors including the patient’s abil- setting of care where staff manages, observes and evalu-
ity to participate in physical rehabilitation activities, insurance ates care including routine medication administration,
k e rs
coverage and regulations, and local resources. Irrespective of
these issues, a patient-specific rehabilitation plan is the best
ke rs
postsurgical care, and rehabilitation. This is the most
common FFP rehabilitation setting in North American
eb oo tool to promote optimal recovery, with a focus on high fre-
e b oo healthcare systems, with multidisciplinary staff including

b o o
e/e
quency rehabilitation; attendance of more than five physical nurses, physical and occupational therapists, social service
e / e /
therapy and occupational therapy sessions per week has been
m
workers, nutritionists and recreational therapists. Medi-
m
/ /t .
associated with better health outcomes [2].
t .
cal providers are not onsite at all times, and acute onsite
//
ps: ps:
medical evaluation is not always possible.
htt htt 71
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htt ps: htt ps:
1.9 Postacute care
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
As suggested above, patients admitted to geriatric wards and 3 Postacute care assessments and evaluations
t . m e/e
s: / / / /
ps:
IRFs should be generally able to participate in, and be like-
http htt
ly to benefit from, at least 3 hours of rehabilitation activities The primary assessment method during the postacute care
per day, five times per week. In many of these settings a phase is called the comprehensive geriatric assessment (CGA).
physician specialized in rehabilitation sees the patient at The CGA is a structured survey and evaluation process
least three times per week. commonly used to assess for medical, functional and socio-
psychological issues that impact health and function. The
e s
Patients admitted to IRFs usually have shorter lengths of
r
stay than those admitted to SNFs. In addition, IRF patients
er s
components of the CGA vary depending on the specific setting
and clinician preference, but typically cover the major areas
b o ok typically receive more physical and occupational therapy

than patients admitted to SNFs. Some reports suggest that
bo ok
above, as well as patient-specific goals of care and advance
directives. The CGA requires time to complete and its results
b o o
e/ e e/ e
this comes at a higher cost without a significant change in can be temporarily altered by acute illness. During the acute
e/e
functional outcomes [2, 7].
: // t .m hospitalization, the results of the CGA can be influenced by
: /
many factors including pain, medications, and electrolyte
/ t .m
ht tps
Patients can be transitioned to a less resource-intensive
level of care from IRFs when all functional rehabilitation
goals have been achieved or when therapy services are no ht
has been associated with improved outcomes [11]. tps
abnormalities. Despite all this, using the CGA in these settings
longer required to meet rehabilitation goals. Patients should During postacute recovery many of the complicating acute
also be considered for transfer if further progress toward medical circumstances have resolved, allowing for a more
rehabilitation goals is not expected or can be achieved at a appropriate assessment of patient factors to plan for optimal
e r s
less resource-intensive level of care [8].
e r s
rehabilitation and restoration of health. Moreover, as the
ook ok o
length of stay is longer in this setting, there is a greater a bility
e b Most organized healthcare systems offer a predetermined

e b o to make and evaluate changes in long-term medications,
b o
e /
t . m e/
number of covered rehabilitation days per eligibility period
for patients to use when needed. Hip fracture patients ad-
promote recovery of lost function, and improve social factors.
t . m e/e
/ /
mitted to SNFs can typically receive rehabilitation services This CGA can help identify medical, functional, environ-
/ /
ps:
at least five times per week. As the literature suggests, hip
htt
fracture patients admitted to SNFs have similar levels of
recovery as those admitted to inpatient rehabilitation hos- htt ps:
mental, and social contributors to the original injury, and
it can identify issues that might affect the ability of the pa-
tient to thrive in their home setting. Environmental and
pitals and at a lower cost. other nonmedical issues like lack of bathroom bars and rails,
inappropriate height of a bed, environmental clutter, limited
The main difference between an acute rehabilitation hos- access to groceries, and inappropriately complex drug regi-
e rs
pital and an SNF is the level of staffing, the frequency of
r s
mens can negatively impact outcomes as much as any spe-
e
b o ok physician evaluation, and the intensity of the rehabilitation
b o
services. In the US, most insurers authorize payment for ok
cific medical condition. In addition, the CGA helps identify
social issues, including inadequate support systems to assist
b o o
e/ e / e
rehabilitation of FFPs in SNFs due to their lower opera-
tional cost.
e
with activities of daily living (ADLs), or respond to an acute
illness [12].
e /e
://t . m : / / t . m
2.2
t t p s
ome and outpatient-based rehabilitation
H 3.1 Multidisciplinary rehabilitation team
tps
ht
programs Once a comprehensive evaluation of the patient’s needs has
h
Among patients who have completed standard rehabilitation
after hip fracture, the use of a home-based functionally fo-
been completed, an individualized plan of care should be
designed for each patient with the input of a multidisciplinary
cused exercise program can provide some added improvement team. Team members often include physical and occupa-
to mobility. Using home-based services as the only mode of tional therapists, medical providers, nurses, nutritionists
k e rs
rehabilitation after a hip fracture should be reserved for those
with very high functional status in the immediate postfrac-
ke rs
and social workers. As mobility is the best overall predictor
of a successful outcome, physical therapists play a central
eb oo ture period or those that have a support system that allows
e b oo
role in the rehabilitation process. Occupational therapists
b o o
e/e
them to receive adequate services in this setting [9, 10]. assist in specific ADL achievement, overall functioning, and
e / m e / reducing fall risk. If cognitive impairment is affecting

m
/ /t . communication or swallowing, a speech therapist can be
// t .
ps: ps:
helpful. The optimal degree of direct involvement of c ertified
72
htt htt
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rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
therapists has yet to be determined. When local resources
t . m
In the US, where most of the rehabilitation occurs in post- e/e
s: / / / /
ps:
permit, physicians with experience in geriatrics and reha- acute facilities, a basic array of follow-up home services is
http htt
bilitation typically manage the ongoing medical comorbid- arranged. Such services include home physical therapy, home
ities and rehabilitation program. nursing for ongoing medical monitoring and wound care,
and home aides to assist with specific ADLs. When in need,
Nursing care typically focuses on symptom assessment, pain a social worker can assist with social issues such as trans-
control, managing medications and preventing pressure portation, assistance with meals, and advanced care planning.
e s
ulcers. Nurses involved in the care of FFPs should be familiar
r
with common geriatric syndromes (eg, delirium, dementia,
er s
b o ok falls, and incontinence).
bo 5
okCommunication, transitions, and quality of care
b o o
e / e Nutritional enhancement in those who are malnourished
e/ e Frail geriatric patients experience several potentially danger-
e/e
: // t .m
or undernourished can improve outcomes [13]. Nutritionists
are best suited to evaluate and recommend dietary regimens.
: / / .m
ous transitions of care between their home, the hospital and
t
rehabilitation settings. Coordinating continuity of care and
ht tps
Social workers play an essential role in assisting with social
or financial issues affecting long-term care needs. Moreover,
to optimize patient outcomes.
ht tps
effective handoffs across these transitions is critical in order
the spouse, family, or caregivers play a significant role in Handoffs should be structured and standardized to include
providing psychological support and motivation to the pa- all essential medical, functional and social information
tient. The medical and orthopedic providers are responsible necessary for the next care setting. Accurate information
e r sfor supervising the medical plan of care, monitoring clinical

e r s
about the patient’s medical conditions and comorbidities,
ook ok o
progress, and striving to avoid medical complications [14]. vision, hearing, language, and their prefracture functional
e b e b o status and limitations determine the approaches that the

b o
e / 4 Disposition after postacute care
t . m e/ rehabilitation team will take [19].
t . m e/e
/ / / /
Significant and valuable information that helps in clinical
ps:
Most hip fracture patients experience some degree of dis-
htt
ability even after postacute rehabilitation. Many studies
indicate that a significant number of patients are still in need htt ps:
decision making includes the mechanism of injury, type of
surgical intervention, functional restrictions, and the re
commended weight-bearing status. It is important to provide
of further assistance with ADLs following their completion essential information in a structured written and verbal
of a formal rehabilitation program. These needs, along with format during care handoff [20]. The ability for the reha-
the patient’s existing support system, determine the dispo- bilitation team to access the acute electronic healthcare
e rs
sition of a patient after a postacute admission [15]. Even for
r s
record improves the efficiency greatly [21].
e
b o ok those who do not require assistive devices for ambulation
o
at the time of postacute discharge, there is often persistent
b ok
Including families in the handoff and plan of care, and face-
b o o
e/ e / e
need for assistance with some ADLs like putting on socks
e
and shoes. Up to 25% of hip fracture patients will require
to-face or verbal “warm hand-off communication” is anec-
dotally more successful. Providing a written plan of care to
e /e
://t . m
long-term care placement in a nursing facility or transition
/ t .
the family members may yield better outcomes as well as
: / m
t t p s
to hospice after postacute rehabilitation. For the remaining
tps
higher satisfaction for patients and family members.
ht
75%, key functional items including cognition, balance and
h
gait may take up to 1 year to fully recover, and the degree
of assistance with ADLs will determine the extent of home-
More recently healthcare systems have invested in develop-
ing clinical care pathways that protocol acute and postacute
based services they require [16]. needs and account for common barriers to recovery includ-
ing pain, delirium, and cardiorespiratory status. Older adults
k e rs
In some parts of Europe, the first phase of the rehabilitation
process occurs in acute care facilities. The implementation
ke rs
have less predictable responses to standard therapy, and the
care team needs to individualize treatment plans according
eb oo of a geriatric multiprofessional home rehabilitation program
e b oo
to each patient’s prognosis, goals of care and particular vul-
b o o
e/e
focused on supported discharge and independence in daily nerabilities [22].
e / m e /
activities results in an improvement in balance confidence,
m
t .
independence and physical activity in previously commu-
/ / // t .
ps: ps:
nity-dwelling older adults [17, 18].
htt htt 73
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
1.9 Postacute care
k e rs ke rs
e b oo e b oo b o o
e / 6
t . m
ommon clinical issues in the rehabilitation
C e / 6.3 Hypotension
t . m e/e
s: / / / /
ps:
setting Orthostatic hypotension often reflects degenerative impair-
http htt
ments of the neuro-cardiovascular reflexes and can result
Given the high morbidity and mortality associated with hip in significant transient periods of hypotension. Hypotension
fractures, there should be intense focus on limiting postop- is an important predictor of adverse outcomes in hip fracture
erative complications, preventing readmissions, future falls patients and can be poorly recognized by patients and care-
and fractures, and regaining prefracture level of physical givers, as vital signs are often checked in the supine position.
e rs
and cognitive functioning [23].
er s
Orthostasis increases risk of falls and refracture and can also
contribute to delirium among selected subpopulations. In
b o ok The best predictor of overall achievement in walking ability
b
after early surgical repair is how quickly rehabilitation iso ok
the postacute setting, patients with dementia and a recent
fall are more likely to suffer orthostatic hypotension [30].
b o o
e / e e/ e
initiated postoperatively. Weight bearing within hours after
e/e
: // t .m
surgery is a positive prognostic indicator of future outcome
for walking ability. Negative predictors in regaining mobil-
In the immediate postoperative period, blood pressure is
:
often attenuated by new anemia and opioids, and most pa-
/ / t .m
s tps
http
ity include low preinjury functional ability, cognitive deficit, tients will not require their prefracture antihypertensive
postoperative delirium, age, male gender, and the presence
of pressure ulcers [24, 25]. ht
medications. In the postacute setting blood pressure goals
should be revised depending on age and function. Current
evidence [30] favors a systolic blood pressure < 150 mm Hg
6.1 Delirium among those who are 80 years or older and evaluation for
Acute confusion or delirium is seen in 30% of hospitalized orthostasis before and after administration of medications.
e r solder patients. Delirium symptoms may last for weeks or

e r s
If necessary, home blood pressure medications can be re-
ook ok o
months in some patients and can interfere with the ability sumed at lower doses and slowly titrated to standing blood
e b b o
to maximally participate in rehabilitation [26]. The prevalence
e
pressure targets.
b o
e / e/
of delirium in older patients is approximately 23% in post-
m
acute care facilities. Half of the patients that develop de-
t . 6.4 Constipation
t . m e/e
/ /
lirium during postacute care remain delirious a week later,
: Constipation is frequently unrecognized by patients and
/ /
h t p s
and only 14% have complete resolution of symptoms.
t
Patients with worsened delirium have more difficulty with
their ADLs. Since delirium can persist in some instances up htt ps:
caregivers alike and can contribute to anorexia, urinary
retention, hospital readmission and poor outcomes. For those
patients that report constipation in the first postoperative
to 6 months, and there is variability in how patients day, more than half will report the same problem 30 days
recover, delirium does not mean that patients need to be later [31]. Many common medications, such as opioids, cal-
hospitalized; the management is best individualized [26]. cium supplements, and some antihypertensives, can con-
e rsSee chapter 1.14 Delirium for more details on the diagnosis

r s
tribute to constipation [32, 33]. Bowel regimens should be
e
b o ok and management of delirium.
b o ok
started in acute settings and continued during the postacute
phase. For most patients a scheduled laxative should be part
b o o
e/ e 6.2 Postoperative pain
e / e
Poorly controlled postoperative hip pain can affect func-
of the bowel regimen [34]. Moreover, the use of simple
strategies such as stool charts for all patients and local dis-
e /e
://t . m
tional outcomes significantly. Patients with uncontrolled
/ t
semination of audits usually result in a significant reduction
: / . m
t t p s
pain in the postacute setting are less likely to participate in of constipation in the postacute setting [35].
tps
ht
physical therapy and ambulate. Good pain control reduces
h
the risk of delirium as well [27]. The level of pain can be
affected by the type of fracture and surgical repair [28]. Bi-
6.5 Malnutrition
In the US, malnutrition occurs in approximately 20% of
modal pain regimens that include scheduled doses of acet- hospitalized older patients and in almost 40% of nursing
aminophen and doses of opioids as needed have been used home residents [36]. Malnutrition is associated with an im-
k e rs
in several settings with acceptable results [29]. See chapter
1.12 Pain management for more on pain management.
ke rs
paired functional status and higher morbidity and mortal-
ity. In FFPs, proper nutrition is essential for recovery [37].
eb oo e b oo
In the malnourished patient with dementia, smaller and
b o o
e/e
more frequent meals sometimes result in better calorie intake
e / m e / [38].
m
/ /t . // t .
htt ps: htt ps:
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rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
Nutritional interventions with fortified food do not provide
t . m
Although oral antidepressants appear to be effective in the e/e
s: / / / /
ps:
a significant benefit on nutritional and functional status in treatment of depression in community-dwelling older adults,
http htt
nursing home residents at risk of malnutrition, as standard their effect seems to be limited to SNF residents with ad-
nursing home food usually provides sufficient energy intake. vanced dementia [30]. Moreover, there is an increased risk
Nonetheless, such interventions might result in fewer days of falls and fractures among geriatric patients using these
with delirium and decreased risk of pressure ulcers [39, 40]. medications [43]. Note that such increased risk appears to
be dose-dependent, suggesting that pharmacological treat-
k e rs 6.6 Depression
Depression has a significantly negative impact on rehabili-
er s
ment of depression should be initiated with the lowest ef-
fective dose in patients that are most likely to benefit [44].
o o tation during and after a postacute admission and is associ-

o ok o o
e/eb b b
ated with worse adverse outcomes at 1 year [41].
e/ e e/e
: // t .m
Regarding the effectiveness of treatment, the involvement
of a specialist such as a psychiatrist or a psychologist has not
: / / t .m
ht tps
been shown to clearly improve outcomes of hip fracture
patients suffering from depression [42].
ht tps
7 References
e r s e r s
ook ok o
1. Kramer AM, Steiner JF, Schlenker RE, 8. Premera Blue Cross. Criteria for Acute 14. NHS Choices. Hip Fracture—Recovery.
e b
et al. Outcomes and costs after hip
e b o
Inpatient Rehabilitation Care: Recovering from a hip fracture.
b o
e/e
fracture and stroke. A comparison of Guideline for Admission and Available at: http://www.nhs.uk/
e / rehabilitation settings. JAMA.

1997 Feb 5;277(5):396–404.
m e/
Transition of Care. Available at:
https://www.premera.com/
Conditions/hip-fracture/Pages/
m
recovery.aspx. Updated July 18,
2. Hoenig H, Rubenstein LV, Sloane R,
/ / t . medicalpolicies/11.01.522.pdf.
/t .
2014. Accessed March 15, 2015.
/
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et al. What is the role of timing in the Accessed December 21, 2017. 15. Magaziner J, Hawkes W, Hebel JR, et al.
surgical and rehabilitative care of 9. Latham NK, Harris BA, Bean JF, et al. Recovery from hip fracture in eight
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community-dwelling older persons Effect of a home-based exercise areas of function. J Gerontol A Biol Sci
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e rs Cochrane Database Syst Rev.

2011 Mar 16(3):CD001704.
Design and implementation of a
home-based exercise program
e r s 1980 Oct(152):173–184.
17. Ziden L, Frandin K, Kreuter M.
ok ok
4. Handoll HH, Cameron ID, Mak JC, et al. post-hip fracture: the Baltimore hip Home rehabilitation after hip fracture.
b o Multidisciplinary rehabilitation for

older people with hip fractures.
b o
studies experience. PM R.
2009 Apr;1(4):308–318.
A randomized controlled study on
balance confidence, physical function
b o o
e/ e Cochrane Database Syst Rev.
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5. Adunsky A, Lusky A, Arad M, et al.
://t
A comparative study of rehabilitation . m comprehensive geriatric assessment
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18. Ziden L, Kreuter M, Frandin K.
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Long-term effects of home m
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rehabilitation after hip fracture—1-year
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patients: the advantage of a Hip Fracture trial. BMC Geriatr. follow-up of functioning, balance
h
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k
study. J Am Geriatr Soc.
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emergency department—the DEED II care of pediatric patients with cystic
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7. Dobson A, DaVanzo JE, El-Gamil A, 2004 Sep;52(9):1417–1423. Phys Ther J. 2013 Mar;24(1):24–30.
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b
13. Gunnarsson AK, Lonn K, Gunningberg L.
e
20. Marks R. Hip fracture epidemiological
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Cost-Effective Placement (CACEP): Does nutritional intervention for trends, outcomes, and risk factors,
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Efficiency. Final Report, 2012.
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postoperative complications and
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t .m
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//
ps: ps:
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htt htt 75
rs
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htt ps: htt ps:
1.9 Postacute care
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e b oo e b oo b o o
e / 21. Bukata SV, Digiovanni BF,
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29. Aubrun F, Marmion F. The elderly
.
38. Alzheimer’s Society. Eating and
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Friedman SM, et al. A guide to
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/ /
drinking. Available at: http://www.
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improving the care of patients with treatment. Best Pract Res Clin alzheimers.org.uk/site/scripts/
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22. Lau TW, Fang C, Leung F.
Anaesthesiol. 2007 Mar;21(1):109–127.
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Thomas DR, et al. Clinical update on
htt
documents_info.php?documentID=149.
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Accessed March 15, 2015.
The effectiveness of a geriatric hip nursing home medicine: 2013. 39. Smoliner C, Norman K, Scheufele R,
fracture clinical pathway in reducing J Am Med Dir Assoc. et al. Effects of food fortification on
hospital and rehabilitation length of 2013 Dec;14(12):860–876. nutritional and functional status
stay and improving short-term 31. Trads M, Pedersen PU. Constipation in frail elderly nursing home residents
e rs mortality rates. Geriatr Orthop Surg

Rehabil. 2013 Mar;4(1):3–9.
er s
and defecation pattern the first 30 days
after hip fracture. Int J Nurs Pract.
at risk of malnutrition. Nutrition.
2008 Nov–Dec;24(11–12):1139–1144.
b o ok 23. Marks R. Physical activity and hip

fracture disability: a review. J Aging Res.
2015 Oct;21(5):598–604.
bo ok
32. Callard G, Schlinger B, Pasmanik M.
40. Olofsson B, Stenvall M, Lundstrom M,
et al. Malnutrition in hip fracture
b o o
e/ e 2011 Apr 26;2011:741918.
24. Duke RG, Keating JL. An investigation
e/ e
Nonmammalian vertebrate models
in studies of brain-steroid interactions.
patients: an intervention study. J Clin
Nurs. 2007 Nov;16(11):2027–2038.
e/e
.m .m
of factors predictive of independence J Exp Zool Suppl. 1990;4:6–16. 41. Morghen S, Bellelli G, Manuele S, et al.
:
fracture. Arch Phys Med Rehabil.
// t
in transfers and ambulation after hip 33. Prince RL, Devine A, Dhaliwal SS, et al.
Effects of calcium supplementation on
: / / t
Moderate to severe depressive
symptoms and rehabilitation outcome
tps tps
2002 Feb;83(2):158–164. clinical fracture and bone structure: in older adults with hip fracture.
ht ht
25. Vergara I, Vrotsou K, Orive M, et al. results of a 5-year, double-blind, Int J Geriatr Psychiatry.
Factors related to functional prognosis placebo-controlled trial in elderly 2011 Nov;26(11):1136–1143.
in elderly patients after accidental hip women. Arch Intern Med. 42. Burns A, Banerjee S, Morris J, et al.
fractures: a prospective cohort study. 2006 Apr 24;166(8):869–875. Treatment and prevention of depression
BMC Geriatr. 2014 Nov 26;14:124. 34. Pappagallo M. Incidence, prevalence, after surgery for hip fracture in older
26. Lee HB, Mears SC, Rosenberg PB, et al. and management of opioid bowel people: randomized, controlled trials.
e r s Predisposing factors for postoperative

delirium after hip fracture repair in
dysfunction. Am J Surg.
2001 Nov;182(5A Suppl):11S–18S.
e r s J Am Geriatr Soc. 2007 Jan;55(1):75–80.
43. Iaboni A, Seitz DP, Fischer HD, et al.
ook ok
individuals with and without dementia. 35. Neighbour C, Weerasuriya N, Initiation of Antidepressant Medication
b
J Am Geriatr Soc.
2011 Dec;59(12):2306–2313.
McCulloch R. Evaluating the Effect
b o
of Orthogeriatric Intervention on
After Hip Fracture in Community-
Dwelling Older Adults. Am J Geriatr
b o o
e / e 27. Morrison RS, Magaziner J,
McLaughlin MA, et al. The impact
e/ e
Bowel Care and Analgesia Following
Hip Fracture. Age Ageing.
Psychiatry. 2015 Oct;23(10):1007–1015.
44. Bakken MS, Engeland A, Engesaeter LB,
e/e
of post-operative pain on outcomes
/ / t . m 2014 Jun 1;43(suppl 1):i2.

t . m
et al. Increased risk of hip fracture
/ /
ps: ps:
following hip fracture. Pain. 36. Guigoz Y, Lauque S, Vellas BJ. among older people using
2003 Jun;103(3):303–311. Identifying the elderly at risk for antidepressant drugs: data from the
htt htt
28. Singelyn FJ, Deyaert M, Joris D, et al. malnutrition. The Mini Nutritional Norwegian Prescription Database and
Effects of intravenous patient- Assessment. Clin Geriatr Med. the Norwegian Hip Fracture Registry.
controlled analgesia with morphine, 2002 Nov;18(4):737–757. Age Ageing. 2013 Jul;42(4):514–520.
continuous epidural analgesia, and 37. Bukata SV, Digiovanni BF, Friedman SM,
continuous three-in-one block on et al. A guide to improving the
postoperative pain and knee care of patients with fragility fractures.
rehabilitation after unilateral total Geriatr Orthop Surg Rehabil.
e rs knee arthroplasty. Anesth Analg. 2011 Jan;2(1):5–37.
e r s
ok ok
1998 Jul;87(1):88–92.
b o b o b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
Rashmi Khadilkar, Krupa Shah
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
1.10 Osteoporosis / / / /
htt ps:
htt ps:
e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e There is a strong correlation between BMD and fragility frac-
e/e
: // t .m
Osteoporosis is the most common bone disease of older adults
ture risk. In a 1993 study, each decrease of 1 SD in bone
: / / t .m
density at the femoral neck increased the risk of hip fracture
tps
and is a major public health problem worldwide. Osteopo-
ht
rosis is characterized by low bone mass, deterioration of
bone microstructure, and compromised bone strength re- ht tps
by a factor of 2.5, and women in the lowest quartile of BMD
had an 8.5-fold greater risk of hip fracture compared to w
omen
in the highest quartile [4]. However, more fragility fractures
sulting in an increased risk of fracture. Typically, patients occur in patients with osteopenia than in those with osteo-
with osteoporosis experience no symptoms until they sustain porosis because of the greater prevalence of osteopenia.
a fracture, making diagnosis and primary fracture preven-
e r s
tion challenging.
e r s
At the age of 50 years, the lifetime risk of sustaining any
ook ok o
fragility fracture is estimated at 40% for women and 13% for
e b e b o men in the US; 46% and 22%, respectively, in Sweden, and

b o
e / 2 Epidemiology and economic impact
t . m e/ 42% overall in Australia [3]. The risk of hip fracture for a

50-year-old Caucasian American woman is 17% [5]; the cor-
t . m e/e
/ /
The World Health Organization (WHO) defines osteoporo-
/
responding risk is 23% in Sweden and 17% in Australia [3].
/
ps:
sis as a bone mineral density (BMD) at the spine or hip of
htt
≤ 2.5 standard deviations (SDs) below the mean BMD of a
young woman, as measured by dual-energy x-ray absorp- htt ps:
This risk increases with aging. For each decade after age 50,
the risk of hip fracture doubles, and a 90-year-old woman
tiometry (DEXA) (Table 1.10-1). A BMD between 2.5 and 1 has approximately a 30% chance of sustaining a hip fracture
SDs below the mean represents osteopenia. in her remaining lifetime [6]. As the population ages, the
worldwide incidence of hip fracture is projected to increase
e rs
A T-score of -1.0 represents a BMD 1 SD below the mean
r s
from 1.7 million in 1990 to 6.3 million in 2050 [7], with the
e
b o ok BMD for a young adult reference population.
b o ok
largest increase expected in Asia and Latin America. Cur-
rently, age- and gender-adjusted 10-year rates of hip fracture
b o o
e/ e / e
The presence of a fragility fracture is diagnostic of osteopo-
e
rosis even in the absence of a measurable decrease in BMD.
are highest in Scandinavia [8]. The shifting demographics of
aging will decrease the worldwide proportion of hip fractures
e /e
://t . m that occur in North America and Europe from 50% in 2005
: / / t . m
t t p s
In the US, 10.2 million adults over 50 years of age are esti- to 25% by 2050 [3].
tps
ht
mated to have osteoporosis and 43.4 million to have osteo-
h
penia [1]. These numbers will rise in the coming decades as
the population ages, with 14 million older adults projected
to have osteoporosis and 47 million to have osteopenia by
2020 [2]. Diagnosis Criteria
kers kers
Normal T-score at the spine of hip of -1.0 and above
The presence of osteoporosis or osteopenia increases the Osteopenia (low bone mass) T-score between -1.0 and -2.5
b o o risk of fragility fractures which are defined as fractures

b o o Osteoporosis T-score -2.5 and below
b o o
e /e e/e e/e
secondary to a fall from standing or lower height and at a Severe osteoporosis T-score -2.5 and below with one of more fractures
site associated with decreased BMD, including the hip,
t . m
spine, and wrist. Such fractures increase in incidence after
/ /
Table 1.10-1 World Health Organization’s definitions of
// t .m
s: ps:
osteoporosis based on dual-energy x-ray absorptiometry criteria.
the age of 50 years [3].
http htt 77
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
1.10 O steoporosis
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
Hip fractures comprise only about 14% of fragility fractures,
t
Twenty percent of hip fracture patients die within 1 year
. m e/e
s: / / / /
ps:
and vertebral and wrist fractures also have significant sequel- of the fracture event; hip fractures confer a five- to eight-
http htt
ae. At age 50, a Caucasian American woman has a 32% risk fold increase in all-cause mortality in the first 3 months
of sustaining a clinical or radiographic vertebral fracture and following the event, and this risk is higher for men.
a 15% chance of sustaining a wrist fracture during her lifetime. Vertebral fractures have been shown to have similar
A Swedish woman’s risk is 15% and 21%, respectively; an mortality to hip fractures [5]. This mortality risk is likely
Australian woman’s risk is 10% and 13%, respectively [3]. both a cause and a consequence of the fragility fracture.
e s
As with hip fractures, the incidence of vertebral and wrist
r
fractures increase with age.
er s
Functionally failing patients are likely to have fragility
fracture as part of their terminal decline.
b o ok bo
Fragility fractures result in significant healthcare expendi- ok b o o
e/ e e/ e
tures. In the US, osteoporosis contributes to 2 million frac- 4 ractical considerations for the
P
e/e
: // .m
tures per year, resulting in about 430,000 hospital admis-
t
sions, 2.5 million office visits, and 180,000 nursing home
perioperative period
: / / t .m
ht tps
admissions and incurring costs of USD 18 billion per year.
Despite comprising a minority of fragility fractures, hip frac-
tures make up 72% of fracture cost; in 2002, a single hip
4.1 Diagnostic testing
ht tps
Because the presence of a fragility fracture indicates osteo-
porosis even in the absence of a measurable decrease in
fracture was estimated to cost USD 34,000–43,000 accord- BMD, DEXA is not warranted during the inpatient evalua-
ing to 2005 US governmental data [9]. By 2025, the annual tion of the acute fracture patient. For patients without a
cost of fracture care in the US is projected to be USD 25.3 prior study, DEXA at 6–12 weeks postfracture is reasonable
e r s
billion [9]. Worldwide, the cost of hip fractures alone is es-
e r s
to establish a baseline from which to monitor disease pro-
ook ok o
timated to rise to USD 131.5 billion by 2050 [10]. gression and efficacy of treatment. Diagnostic measures in
e b e b o the inpatient setting, particularly in men, should focus on

b o
e / 3 Clinical impact
t . m e/ the identification of modifiable risk factors and secondary
causes of osteoporosis. Laboratory testing should include
t . m e/e
/ / / /
serum calcium (corrected for albumin), alkaline phosphatase,
ity and mortality:

htt ps:
Osteoporosis and fragility fractures carry significant morbid-
htt ps:
complete blood count, renal function, 25-hydroxyvitamin D,
thyroid-stimulating hormone, serum protein electrophore-
sis (for patients with vertebral fractures and suspicion for
• At 1 year more than 50% of patients with hip fractures multiple myeloma), and testosterone (for men). There is no
continue to have significant functional limitations, with role for measurement of markers of bone resorption in the
more than half of previously independent patients unable inpatient setting.
e rs to walk one block, climb five stairs, get in and out of the
e r s
b o ok shower, sit on the toilet, or rise from an armless seated
position unassisted [11].
b o
4.2
ok reatment of osteoporosis and secondary
T
fracture prevention
b o o
e/ e / e
• About 30% of hip fracture sufferers require long-term
e
nursing home care [12], and only 40% fully regain their
Following fragility fracture, all patients should receive care-
ful medication review, counseling on risk factor modification
e /e
prior level of functioning [2].
://t . m and fall prevention, and calcium and vitamin D supplemen-
: / / t . m
t t p s
• Vertebral fractures can cause chronic pain; difficulty bend- tation.
tps
ht
ing and reaching overhead; kyphosis and subsequent
h
decreases in pulmonary function; and alterations in ab-
dominal anatomy with resulting constipation, early sa-
In the absence of contraindications, patients with fragility
fractures and a life expectancy greater than 1 year should
tiety, and decreased oral intake. be considered for bisphosphonate therapy [13]. In addition
• All fractures increase the risk of depression and cognitive to improving BMD and reducing bone turnover markers,
k e rs impairment.
• A patient who sustains any type of fragility fracture is
ke rs
both intravenous and oral bisphosphonates are associated
with reduced risk for subsequent fractures and mortality
eb oo 50–100% more likely to sustain another, and fracture
e b oo
following hip fracture [14, 15]. However, no consensus exists
b o o
e/e
patients often develop a fear of falling, which in itself regarding the optimal timing of bisphosphonate therapy for
e / increases fracture risk.

m e / secondary prevention. On the one hand, the majority of
m
/ /t .
• Fractures are also associated with increased mortality.
t .
patients who have sustained fragility fractures fail to receive
//
ps: ps:
• Hip fracture surgery carries an overall mortality of 4%. adequate osteoporosis treatment as late as 2 years following
78
htt htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m
the fracture. Early initiation of medication may reduce e / 5
t . m
asics of bone metabolism and pathophysiology
B e/e
s: / / / /
ps:
lapses in prescribing that can occur during transitions of of age-associated bone loss
http htt
care, underscore the importance of therapy, and maximize
therapeutic benefit. On the other hand, the mechanism of Bone remodeling is the normal homeostatic process by which
action of bisphosphonates has raised concerns about wheth- old bone is resorbed and replaced by new bone in order to
er these agents may delay fracture healing. Recent meta- maintain a healthy skeleton. This process occurs in several
analyses [16, 17] suggest that bisphosphonate administration stages:
e s
within 3 months of fracture does not appear to clinically or
r
radiographically impair fracture healing. Most osteoporosis
er s
• Activation—osteoclast precursors arrive at the surface
b o ok experts support initiation of bisphosphonates between 6 and

12 weeks after fracture. It is reasonable to begin with weekly
bo ok
of formed bone.
• Resorption—osteoclast precursors convert to active
b o o
e/ e dosing of oral bisphosphonates (eg, alendronate 70 mg
e/ e osteoclasts and create an acidic environment, thus
e/e
: / .m
weekly). Intravenous bisphosphonates, eg, zolendronic acid
/ t
and ibandronate) may offer advantages in compliance or
dissolving the mineral content of bone.
: /
• Reversal—osteoclasts undergo apoptosis and are
/ t .m
tps
inpatients who have gastrointestinal contraindications to
ht
oral agents. For patients with contraindications to bisphos-
phonate therapy, other therapies such as teriparatide and
replaced by osteoblast precursors.
ht tps
• Bone formation—osteoblast precursors undergo
activation to osteoblasts and deposit collagen.
denosumab can be considered in consultation with an os- • Mineralization—osteocytes embedded within the
teoporosis expert. collagen matrix contribute to its mineralization and
hardening into new bone.
e r s
4.3 Ongoing management
e r s
ook ok o
Postoperative management of osteoporosis lies within the Bone remodeling occurs under the control of various hor-
e b scope of quality primary care and does not routinely involve

e b omones and cytokines, including estrogens and androgens,
b o
e / therapy or disease refractory to oral therapy, subspecialist
t . e/
specialist referral. For patients with contraindications to oral
m
vitamin D, parathyroid hormone (PTH), osteoprotegerin, and
t . m
receptor activator of nuclear factor-κB (RANK) and its ligand e/e
consultation may be warranted.
/ / / /
(RANK-L). Many of these factors have provided targets for
htt ps: htt ps:

the pharmacological treatment of osteoporosis. A schematic
of the bone remodeling process is shown in Fig 1.10-1.
Osteoblast
OPG OPG
e rs e r s
o ok ok o
/ebo o
RANK Glucocorticoids
e/ e b Proosteoclast
RANK-L
e
Vitamin D
Estrogens
e /e b
NF-κB
://t . m
PTH
Vitamin D
: / / t . m
t t p s Glucocorticoids
tps
ht
Inflamatory cytikines
h
Osteoblast
rs rs
Osteoclast
k e ke
eb oo e b oo
Collagen deposition
Mineralization
Fig 1.10-1 Schematic
of the key players in the
b o o
e / Resorption
t . m e / Formation
bone modeling process.
t .m
Abbreviations: OPG,
e/e
: / / //
osteoprotegerin; PTH,
s ps:
Time parathyroid hormone.
h t t p htt 79
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
1.10 O steoporosis
k e rs ke rs
e b oo e b oo b o o
e /
t . m
The remodeling process favors new bone formation untile / 6 steoporosis risk assessment, diagnosis, and
O
t . m e/e
s: / / / /
ps:
the 20s, when an individual’s bone mass peaks. African evaluation
http htt
Americans achieve the highest peak bone mass with Cau-
casians reaching lower peaks and Asians the lowest. A trend Any fracture at a major skeletal site, particularly at the hip
toward bone loss begins immediately after peak bone mass or spine, in an adult 50 years or older should be considered
is reached. In women, bone loss accelerates after menopause, osteoporosis-related unless clinical circumstances point to
when lower estrogen levels allow increased bone resorption another clear etiology for the fracture, and the patient should
e rs
by osteoclasts without a corresponding increase in bone
deposition by osteoclasts. In the seventh decade of life, age-
er s
be evaluated accordingly.
b o ok related decreases in calcium absorption lead to a secondary

hyperparathyroidism, which also increases bone resorption.
bo ok
In addition, the National Osteoporosis Foundation (NOF)
suggests assessment of osteoporosis and fall risk in all post-
b o o
e / e e/
Finally, in the very old, renal vitamin D production de- e menopausal women and all men older than 50 years. Com-
e/e
: // t .m
creases while resistance to endogenous vitamin D increases,
resulting in a further net increase in bone resorption. As
mon risk factors for low BMD are listed in the following:
: / / t .m
from peak level.
ht tps
she ages, a woman’s bone mass may decrease by 30–40% •
•
•
Increasing age
Early menopause
Caucasian or Asian race ht tps
Osteoporosis represents a pathological imbalance between • Personal or family history of fragility fracture
bone resorption and bone formation, with the former pre- • Inadequate calcium and vitamin D intake
dominating. In addition to decreased bone mass, osteopo- • Excessive alcohol or tobacco use
e r srosis is characterized by disruptions in the microarchitecture •

e r s
Low level of physical activity
ook ok o
of bone, with fewer, more fragile bone trabeculae, as well • Medications:
e b as decreased viability of the osteocytes that maintain bone

e b o –– Glucocorticoids
b o
e / of normal and osteoporotic bone.
t . e/
mineralization. Figure 1.10-2 depicts the microscopic structure
m
–– Anticonvulsants
–– Heparin
t . m e/e
/ / –– Excessive thyroid hormone
/ /
htt ps: –– Proton pump inhibitors
htt ps:
Patients deemed to be at high risk for osteoporosis or falls
should undergo BMD determination. The contribution of
falls to fracture risk is discussed separately in chapter 1.11
Sarcopenia, malnutrition, frailty, and falls. Regardless of
e rs e r s
risk factors and fall and fracture history, the US Preventive
b o ok b o ok
Services Task Force recommends screening DEXA in all
women 65 years and older; the NOF suggests screening in
b o o
e/ e e / e men 70 years and older as well.
e /e
://t . m Central DEXA as measured at the total hip, femoral neck,
: / / t . m
t t p s tps
or spine is the most common method of BMD determina-
ht
tion. A given patient’s BMD, expressed in units of grams of
h mineral per square centimeter scanned (g/cm2), is compared
to two databases, one comprising an age-, gender-, and
ethnicity-matched population and another comprising a
young adult, gender-matched population. The SDs of the
k e rs ke rs
patient’s BMD from these two database norms yield Z- and
T-scores, respectively. As shown in Table 1.10-1, DEXA-based
eb oo e b oo
diagnoses of osteoporosis and osteopenia are defined by
b o o
e/e
T-scores. Methods other than central DEXA also exist for
e / m e / the determination of BMD, but these have limitations. Quan-

m
a b
/ /t . titative computed tomography, for example, involves in-

// t .
ps: ps:
Fig 1.10-2a–b Normal (a) and osteoporotic bone (b) creased radiation exposure and cost compared to central
80
htt htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
DEXA. Heel ultrasonography and peripheral DEXA, which 7 Osteoporosis in men
t . m e/e
s: / / / /
ps:
measures BMD at the forearm, heel, and fingers, are por-
http htt
table but do not correlate as well with fracture risk as do Although osteoporosis is more common in women than in
central DEXA measurements. men, a significant number of men are affected—in the US,
1.5 million older than 65 years, with another 3.5 million at
Vertebral fractures define osteoporosis even in the absence risk [19]. One in eight American men sustains an osteopo-
of a DEXA diagnosis. These fractures often produce no symp- rotic fracture in his lifetime. Men are twice as likely as
e s
toms and may go undiagnosed for months or years, but their
r
presence is an indication for pharmacological treatment of
er s
women to die as a result of their fractures but less than half
as likely to be evaluated for osteoporosis and less than one-
b o ok osteoporosis. Therefore, some groups recommend yearly
bo
measurement of height in older patients. In addition, ver- ok
fifth as likely to be treated for osteoporosis following a frac-
ture [20]. Despite the unclear validity of T-scores in men,
b o o
e/ e tebral imaging should be considered in:
e/ e DEXA remains the diagnostic method of choice. Approxi-
e/e
: // t .m
• Women older than 70 and men older than 80 years
: / / t .m
mately half of men with osteoporosis have a secondary cause
or contributing factor, most commonly alcohol abuse, and
with DEXA-defined osteopenia
ht tps
• Women from 65–69 years and men from 70–79 years
with T-scores of less than -1.5 ht tps
most men diagnosed with osteoporosis should therefore
undergo further evaluation. The treatment of osteoporosis
in men follows principles similar to those in women.
• Postmenopausal women and men older than 50 years
with low-trauma fracture during adulthood, height
loss of 4 cm or more or long-term treatment with 8 N onpharmacological treatment of osteoporosis
ke r s
glucocorticoids [18]
e r s
b o o The majority of postmenopausal women with osteoporosis
b o ok
The treatment of osteoporosis involves a multimodal
approach including education, fall prevention strategies,
b o o
e /e m e/
and premenopausal women may have an underlying treat-
t .
e
have no identifiable secondary cause. However, 50% of men exercise, calcium and vitamin D supplementation, and phar-
t . m
macological therapy. Unfortunately, despite the increased e/e
/ /
able condition, as the list of selected causes of secondary
/ /
prevalence of osteoporosis, osteopenia, and fragility fractures,
osteoporosis shows:
htt ps:
• Medications, eg, glucocorticoids, anticonvulsants, htt ps:
evidence suggests that many at-risk patients fail to receive
education and treatment for decreased BMD. Time con-
straints often limit the amount of education that can be
lithium, proton pump inhibitors, and others done during a routine office visit or hospitalization, and in
• Rheumatic disease, eg, rheumatoid arthritis, systemic one study of about 2,800 women with fragility fractures,
lupus erythematosus, and ankylosing spondylitis only 4.6% were started on pharmacological treatment of
e rs
• Endocrinopathies, eg, cushing syndrome, hyperthy-
r s
osteoporosis immediately after the fracture, only 8.4% had
e
b o ok roidism, hyperparathyroidism, hypogonadism, type 2
diabetes, and others
b o ok
BMD testing and only 42.4% received treatment in the
2 years following the fracture [21]. Fortunately, guidelines
b o o
e/ e / e
• Other medical conditions, ie, cystic fibrosis, chronic
e
obstructive pulmonary disease, human immunodefi- /
do exist for the therapy of patients with or at risk for osteo-
e
porosis or osteopenia. Please see chapter 2.8 Fracture liaison e
://t . m
ciency virus infection, renal insufficiency, and liver
/ t .
service and improving treatment rates for osteoporosis.
: / m
disease
t t p s tps
ht
• Nutritional factors, eg, excessive alcohol intake, All postmenopausal women, men older than 50 years, and
h
anorexia, celiac disease, and vitamin D deficiency other patients at risk for accelerated bone loss should be
counseled on risk factor modification, such as smoking ces-
While no formal guidelines exist for further evaluation, a sation and moderation of alcohol consumption. Patients
careful clinical evaluation followed by laboratory testing should also receive education on fall prevention strategies,
k e rs
may be warranted in patients suspected of having a second-
ary etiology of osteoporosis.
ke rs
including adequate lighting, grab bars, proper footwear, and
removal of fall hazards such as throw rugs. Home safety
eb oo e b oo
evaluations can prove invaluable in reducing fall risk (for
b o o
e/e
more information on falls and surgical management after
e / m e / the operation, see chapters 1.11 Sarcopenia, malnutrition,

m
/ /t . t .
frailty, and falls and 1.8 Postoperative surgical management).
//
ps: ps:
Providers should minimize the use of medications that
htt htt 81
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
1.10 O steoporosis
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
c ontribute to confusion, dizziness, hypotension, or fatigue, eral hours of levothyroxine, fluoroquinolones, phenytoin,
t . m e/e
s: / / / /
ps:
and they should also assess for visual impairments. Physical angiotensin-converting enzyme inhibitors, and bisphospho-
http htt
and occupational therapists can play critical roles in address- nates, which can interfere with its absorption. Vitamin D is
ing existing balance and gait abnormalities and cognitive available as ergocalciferol (D2), which is commonly given
impairments, as well as in instructing patients in regular at a dosage of 50,000 IU orally weekly for 8 weeks, followed
weight-bearing and muscle-strengthening exercises. While by 50,000 IU every 2–4 weeks. Alternatively, patients can
hip protectors, which provide padding around the hips to take cholecalciferol (D3) 1,000-2,000 IU orally once daily.
e rs
minimize the impact from a fall, were in common use in
recent decades, a metaanalysis in 2006 showed that their
er s
The goal of vitamin D supplementation is a serum 25-hy-
droxyvitamin D level at or above 29.6 ng/mL (74 nmol/L).
b o ok efficacy is limited in the community and uncertain in insti-
bo
tutional settings; moreover, poor fit and skin irritation led ok b o o
e/ e to poor compliance by many patients [22].
e/ e 9 Pharmacological treatment of osteoporosis
e/e
: // t .m
Patients with or at risk for accelerated bone loss should be
: /
Varying recommendations exist about which patients should
/ t .m
tps
educated on the importance of adequate calcium and vita-
ht
min D intake. In addition to its many other physiological
functions, calcium is required for adequate bone mineraliza- ht tps
receive pharmacological treatment for decreased BMD. Ac-
cording to the NOF, postmenopausal women and men aged
50 years and older should be treated if:
tion. In older adults, serum calcium decreases, intestinal
absorption of calcium decreases, and urinary calcium excre- • They have a clinical or radiographic hip or vertebral
tion increases. Vitamin D increases serum calcium by in- fracture, regardless of DEXA findings.
e r s
creasing intestinal absorption and renal reabsorption of
e r s
• They have a T-score equal to or less than -2.5 at the
ook ok o
calcium as well as resorption of calcium from bone. In hip, femoral neck or lumbar spine.
e b older adults, the production of inactive vitamin D in the

e b o • They have a T-score between -1.0 and -2.5 and a
b o
e / e/
skin decreases, as does renal conversion of vitamin D to its
m
active form, thereby leading to secondary hyperparathyroid-
t .
10-year probability of hip fracture of at least 3% or a
10-year probability of a major fragility fracture of at
t . m e/e
/ /
ism and subsequent hypocalcemia and bone resorption. least 20% as assessed by the WHO Fracture Risk
/ /
htt ps:
Studies have shown that calcium carbonate 600 mg twice
daily reduces the incidence of clinical fracture as compared
Assessment (FRAX) tool [27].
htt ps:
Life expectancy is likely necessary to accrue enough phar-
to placebo in patients who are at least 80% compliant; but macological effect from osteoporosis therapy to make the
despite minimal adverse effects, compliance can be as low benefits worth the risks. Canadian endorsed guidelines
as 43% [23]. Vitamin D supplementation alone has not been suggest a minimum life expectancy of 1 year to consider
e rs
shown to be effective in decreasing fracture rates, although
r s
pharmacological treatment [13].
e
b o ok it can yield improvements in BMD [24]. However, the com-
o
bination of calcium and vitamin D3 daily does appear both
b ok
Developed after analysis of population-based cohorts from
b o o
e/ e / e
to reduce bone loss and to decrease the risk of both hip and
e
other nonvertebral fractures among older women as com-
North America, Europe, Asia, and Australia, FRAX consid-
ers factors including age, gender, race, height and weight,
e /e
pared to placebo [25, 26].
://t . m /
fracture history, certain comorbidities, and medication and
: / t . m
t t p s tps
substance use, along with femoral neck BMD, to calculate
ht
Based on these findings, it is recommended that patients at the 10-year risk of hip or major fragility fractures. FRAX
h
risk for bone loss consume 1,200 mg of calcium daily, along
with vitamin D 800-1,000 international units (IUs) daily.
does not use spine BMD as this value can be falsely elevat-
ed in the presence of spinal osteoarthritis. The tool is vali-
Calcium supplements may be suggested for patients who dated only for postmenopausal women and men 50 years
cannot get enough calcium from dietary sources. Available of age and older. It also lacks validity in patients already
k e rs
calcium formulations include calcium carbonate and cal-
cium citrate. The former is less expensive and must be tak-
ke rs
taking antiresorptive therapy and therefore cannot be used
to determine the need for ongoing treatment.
eb oo en with meals, while the latter is more expensive but may
e b oo b o o
e/e
be taken at any time. Both formulations cause constipation Some experts suggest initiating antiresorptive therapy in
e / e /
and abdominal upset. For optimal absorption, a single dose
m
any patients, particularly women, taking or anticipated to
m
/ /t .
of supplemental calcium should not exceed 500 mg elemen- take glucocorticoids for longer than 3 months at doses ex-
// t .
ps: ps:
tal calcium, and calcium should not be given within sev- ceeding the equivalent of prednisolone 7.5 mg daily given
82
htt htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m
the strong negative effect of these agents on bone quality. e /
t
Oral bisphosphonates are associated with both poor gastro-
. m e/e
s: / / / /
ps:
In addition, some clinicians start therapy in patients with intestinal absorption and upper gastrointestinal side effects,
http htt
borderline bone mass and elevated markers of bone resorp- including dysphagia, esophageal reflux, and esophageal
tion, but the utility of these markers is not well established. inflammation. These medications must be taken on an
Multiple pharmacological classes have been approved by empty stomach with a full glass of water; in addition, patients
the US Food and Drug Administration (FDA) for the treat- must wait 30–60 minutes before reclining or consuming
ment of osteoporosis and are summarized in Table 1.10-2. other beverages, medications, and food. Not surprisingly,
e rs
9.1 Bisphosphonates
e s
adherence to these agents is poor and can limit their effi-
r
cacy. Intravenous bisphosphonates are better tolerated,
b o ok Bisphosphonates are the mainstay of treatment for osteo-

porosis and osteopenia. They are potent antiresorptive agents
bo ok
though zoledronic acid can be associated with an infusion
reaction characterized by fever, headache, and arthralgia
b o o
e / e that bind to calcium hydroxyapatite in the bone mineral
e/ e and myalgia. Adequate hydration and premedication with
e/e
: // t .m
matrix and inhibit the activity of osteoclasts, thereby de-
creasing bone remodeling. Bisphosphonates actually incor-
: / / .m
acetaminophen reduce the risk of an infusion reaction, and
t
the reaction is less likely to occur with subsequent infusions.
tps
porate themselves into the bone matrix, and their effects
ht
therefore persist for years. Salient characteristics of the
various bisphosphonates are summarized in Table 1.10-3. ht tps
Bisphosphonates are contraindicated in patients with sig-
nificant renal impairment (typically defined as creatinine
clearance < 30 mL/min); this can be a limiting factor for
many frail older adults.
There have been reports in the literature of bisphosphonate-
ke r s
Class Example(s)
e r s
associated osteonecrosis of the jaw (ONJ), thought to result
b o o Bisphosphonates • Alendronate
• Risedronate
b o ok
from the long-term suppression of bone remodeling and
accumulation of microscopic damage to bone. Risk factors
b o o
e /e e/ e e/e
• Ibandronate
for this rare condition include the type and cumulative dose
• Zoledronic acid
Anabolic agent
/ t . m
Teriparatide (recombinant human parathyroid hormone)
/
of bisphosphonate; most cases occur in patients with mul-
/ /t .
tiple myeloma and other malignancies involving lytic bone m
ps: ps:
Monoclonal antibody Denosumab (human monoclonal antibody against RANK-L)
lesions who are receiving higher and more frequent doses
htt htt
Hormone-based treatments Estrogens, selective estrogen receptor modulators (SERMs)
of bisphosphonates than are used for the treatment of os-
Miscellaneous Calcitonin
teoporosis. Dental trauma and infection also seem to pre-
Table 1.10-2 Pharmacotherapeutical classes approved for the dispose patients to ONJ, and it is therefore suggested that
treatment of osteoporosis. patients receive ongoing routine dental care and undergo
e rs e r s
b o ok Drug name Dosing
o
Efficacy
b ok Indications
b o o
e/ e Alendronate 70 mg orally weekly
e / e
Reduces hip and vertebral fracture risk Prevention and treatment of:
• Postmenopausal osteoporosis
e /e
://t . m • Osteoporosis in men
/ t .
• Glucocorticoid-induced osteoporosis
: / m
Risedronate
t t p s
35 mg orally weekly Reduces hip and vertebral fracture risk
tps
Prevention and treatment of:
ht
Risendronate
h
150 mg orally monthly As above
• Osteoporosis in men
Ibandronate 150 mg orally monthly Reduces vertebral fracture risk Prevention and treatment of postmenopausal osteoporosis
Ibandronate 3 mg intravenously every 3 months Increases BMD, but no effect on fracture risk Treatment of postmenopausal osteoporosis
kers kers
Zoledronic acid 5 mg intravenously yearly Reduces hip and vertebral fracture risk Prevention (when given every 2 years) and treatment of:
b o o b o o • Osteoporosis in men
b o o
e /e t . m e/e Prevention of new clinical fractures in men and women with
recent fragility hip fracture
t .m e/e
/ / //
ps: ps:
Table 1.10-3 Bisphosphonate characteristics.
htt htt 83
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
1.10 O steoporosis
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
any necessary dental surgery or treatment of oral infections 9.2 Teriparatide and Abaloparatide
t . m e/e
s: / / / /
ps:
prior to initiation of a bisphosphonate, if at all possible. Treat- Parathyroid hormone has a net resorptive effect on bone when
http htt
ment of ONJ involves pain management, infection control, given continuously and a net anabolic effect when given in-
debridement of necrotic tissue, and frequent cessation of termittently. Teriparatide is a recombinant human PTH that,
bisphosphonate therapy. Because ONJ is a complication when dosed at 20 µg subcutaneously daily, is an agent ap-
rarely seen in patients taking bisphosphonates for osteopo- proved for the treatment of osteoporosis that stimulates bone
rosis, concern over its occurrence should not preclude the formation rather than limiting bone resorption. The mechanism
e s
initiation of these agents if otherwise indicated. Significant-
r
ly higher rates of ONJ are reported in patients receiving
er s
of action of teriparatide involves the induction of cytokines
including insulin growth factor 1, transforming growth factor
b o ok frequent bisphosphonate dosing for malignancies [28].
bo ok
B, and RANK-L, as well as the inhibition of sclerostin, result-
ing in the activation of bone-building osteoblasts. The ana-
b o o
e/ e Bisphosphonates have also been associated with atypical
e/ e bolic effect of teriparatide begins within 1 month of initiation
e/e
: // t .m
femoral fractures, defined as low-trauma fractures of the
midfemoral diaphysis leading to a prodrome of vague thigh
and peaks at 6–9 months. The agent increases vertebral,
: / /
femoral, and total body BMD and decreases the risk of botht .m
tps
discomfort and weakness (see chapter 3.18 Atypical frac-
ht
tures). Again, oversuppression of bone remodeling may al-
low the accumulation of microscopic cracks in bone that ht tps
vertebral and nonvertebral fractures [33]. It is approved for
postmenopausal women and men with osteoporosis and high
fracture risk and for patients intolerant of bisphosphonates.
eventually coalesce into clinically apparent injury. Studies Teriparatide is generally well tolerated, with potential adverse
have shown that while the relative risk of atypical femoral effects including orthostatic hypotension, transient hypercal-
fractures does increase in patients taking bisphosphonates, cemia, nausea, and leg cramps. In animal models, teriparatide
e r s
the absolute risk remains very small [29–31]. Nevertheless,
e r s
was shown to increase the risk of osteosarcoma. Therefore,
ook ok o
in patients found to have this type of fracture, bisphospho- although there have been no reports of malignancy in humans
e b nate therapy should be discontinued.

e b o who receive lower effective doses than the laboratory animals
b o
e / m e/
The risk of both ONJ and atypical femoral fracture, though
t .
did, the agent is labeled as being contraindicated in patients
t . m
with Paget’s disease, a history of skeletal radiation, and un- e/e
/ /
small in both cases, appears to increase with the duration
/ /
explained elevations in serum alkaline phosphatase. Teripa-
ps:
of bisphosphonate use. This observation, coupled with the
htt
long half-life of bisphosphonates, has introduced uncer-
tainty about the optimal duration of bisphosphonate ther- htt ps:
ratide is administered for 2 years, after which, one study sug-
gests, patients should transition to bisphosphonate therapy in
order to maintain the achieved gains in BMD [34]. Abalopara-
apy. In a 2006 study, women who took alendronate for 5 tide is a newer injectable analogue of PTH-related peptide. It
years, then were randomized to the drug for another 5 years, is a daily subcutaneous administered drug with a pre-metered
had higher BMD and a lower risk of vertebral fractures than pen. Early data suggest similar performance in early study [35].
e rs
women randomized to placebo for the second 5 years. There
e r s
b o ok was no difference in the incidence of nonvertebral fractures
b o
[32]. Other studies have also shown inconsistent results with ok
9.3 Denosumab
Denosumab is a fully human monoclonal antibody directed
b o o
e/ e / e
regards to BMD and fracture prevention benefits after 5
e
years of therapy. Various groups have therefore suggested
against RANK-L. This cytokine mediates the formation, func-
tion, and survival of osteoclasts (Fig 1.10-1); blockage of the
e /e
://t . m
a risk-stratified approach to ongoing treatment with bisphos- interaction between RANK and RANK-L inhibits osteoclast-
: / / t . m
t t p s
phonates: patients at low risk for fracture could consider a
tps
mediated bone resorption. Denosumab has been shown to
ht
“drug holiday” after 3–5 years, while higher risk patients increase BMD at the spine and to decrease the risk of both
h
should continue therapy for a longer duration with a short-
er holiday, perhaps with use of an alternative agent during
radiographic vertebral fractures and clinical hip and nonver-
tebral fractures [36]. Administered as a 60 mg subcutaneous
the holiday. In either case, patients should be reassessed injections every 6 months, it is approved for the treatment
within 1–3 years of cessation of therapy and a bisphospho- of osteoporosis in postmenopausal women and men at high
k e rs
nate resumed if BMD decreases or if fracture occurs. Cur-
rently, few data exist on the specific utility of markers of
ke rs
risk of fracture, as well as for the treatment of bone loss in
women and men receiving hormonal therapies for breast
eb oo bone turnover for optimizing treatment duration.
e b oo
and prostate cancer, respectively. The most common adverse
b o o
e/e
effects include hypocalcemia, rash, cellulitis, and flatulence.
e / m e / As with bisphosphonates, denosumab has been rarely as-

m
/ /t . t
sociated with ONJ and atypical femoral fractures. The long-
// .
ps: ps:
term efficacy and safety of denosumab are unknown.
84
htt htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 9.4 Hormone-associated therapies
t . m e / 9.5 Calcitonin
t . m e/e
s: / / / /
ps:
Endogenous estrogens limit bone resorption through Endogenous calcitonin, secreted by the thyroid gland, plays
http htt
stimulation of the cytokine osteoprotegerin (Fig 1.10-1). a role in normal calcium homeostasis, guarding against hy-
Osteoprotegerin, a natural antagonist of RANK-L, blocks percalcemia by acting directly on osteoclasts to inhibit bone
the interaction of RANK with RANK-L, decreasing osteo- resorption. An intranasal salmon calcitonin formulation,
clast activation and thus bone resorption. As endogenous sprayed into alternating nostrils daily at a dose of 200 IU,
estrogen levels sharply decline at menopause, osteoclast has been shown to decrease the incidence of vertebral frac-
e rs
activation increases and leads to the accelerated bone loss
seen in postmenopausal women. The administration of
er s
tures. It has also been found to have a small analgesic effect
on vertebral compression fractures. It does not affect the
b o ok exogenous estrogens, with or without progesterone, has
bo
been shown to slightly reduce the risk of hip and vertebral ok
risk of hip or other nonvertebral fracture. Intranasal calci-
tonin has few immediate side effects other than rhinitis, but
b o o
e/ e e/ e
fractures. However, estrogens confer an increased risk of studies have suggested an increased risk of unspecified ma-
e/e
: // t .m
stroke, thromboembolic disease, coronary artery disease,
and breast cancer; and these risks outweigh the bone ben-
: / / .m
lignancy with this agent. Calcitonin is a third-line agent for
t
the treatment of osteoporosis given the availability of other
tps
efits. The FDA therefore recommends limiting the use of
ht
exogenous estrogen therapy for osteoporosis to women
with moderate to severe vasomotor symptoms, and only
medications with greater efficacy.
9.6 Other therapies ht tps

for short periods of time. Strontium ranelate is used in some European countries for
the treatment of osteoporosis. It has been shown to reduce
Historically, selective estrogen receptor modulators (SERMs) the risk of vertebral and nonvertebral fractures in postmeno-
e r s
provided another option for the treatment of osteoporosis
e r s
pausal women and, in a high-risk subgroup, to reduce the
ook ok o
in postmenopausal women, but may be falling out of favor. risk of hip fracture as well. Its mechanism is unclear, but it
e b b
These agents act as estrogen agonists in bone tissue, where
e o is theorized to incorporate into the crystalline structure of
b o
e / e/
they have an antiresorptive effect, and as estrogen antago-
m
nists in breast and uterine tissue, where they decrease the
t .
bone and enhance matrix mineralization. Strontium has
t . m
been associated with nausea, diarrhea, rash, and headache; e/e
/ /
risk of invasive breast cancer. They do not decrease the risk
/ /
and there have been reports of the drug reaction with eo-
htt ps:
of coronary artery disease and actually increase the risk of
thromboembolic disease and vasomotor symptoms. The most
commonly prescribed SERM, raloxifene, has been shown
tentially fatal.
htt ps:
sinophilia and systemic symptoms syndrome, which is po-
to decrease the risk of vertebral fractures, but not hip frac- Our increased understanding of the pathways involved in
tures. Some organizations are beginning to remove raloxi- bone metabolism and the pathophysiology of osteoporosis
fene from their guidelines, due to the poor risk/benefit ra- has led to the emergence of new targets for osteoporosis
e rs
tio for most patients [37]. Lasofoxifene is a third-generation
r s
treatment. Two targeted agents currently under study include
e
b o ok SERM currently under investigation for the treatment of
b o
osteoporosis. Studies have shown that this drug decreases ok
romosozumab and odanacatib. Romosozumab is a mono-
clonal antibody directed against sclerostin, an osteocyte-
b o o
e/ e / e
the risk of vertebral and nonvertebral fracture but not of
e
hip fracture; and it also decreases the risk of breast cancer,
derived protein that downregulates the bone-formative
e
effects of osteoblasts. A recent phase II study demonstrated/e
://t . m
stroke, and cardiovascular disease. However, there is a slight
/ t .
that romosozumab improves BMD by enhancing bone for-
: / m
t t p s
increase in overall mortality in patients taking lower-dose
tps
mation and decreasing bone resorption [38]. Odanacatib
ht
lasofoxifene rather than higher-dose lasofoxifene or pla- inhibits cathepsin K, an osteoclast-derived protease involved
h
cebo, and this finding is under further review. in collagen degradation. Early trials have indicated that
odanacatib increases spine and hip BMD [39]. Trials of frac-
Other hormone-associated therapies include combination ture risk reduction for both romosozumab and odanacatib
conjugated estrogen-SERM products. Conjugated estrogens/ are in process [40]. Several other new agents are currently
k e rs
bazedoxifene increases spine and hip BMD and reduces the
risk of both vertebral and hip fractures with a neutral effect
ke rs
in preclinical trials.
eb oo on breast and endometrial cancer risk. The combination
e b oo b o o
e/e
agents, like others containing estrogen, should be used for
e / m e /
the shortest possible duration and only after consideration
m
of estrogen-free alternatives.
/ /t . // t .
htt ps: htt ps:
85
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
1.10 O steoporosis
k e rs ke rs
e b oo e b oo b o o
e / 10
t . m
Rescreening, treatment monitoring, and follow-upe /
t .
adverse effects and difficulties in adhering to the prescribed
m e/e
s: / / / /
ps:
treatment regimen. They should have yearly height deter-
http htt
Although screening for osteoporosis is recommended for mination as an inexpensive screen for occult vertebral frac-
women 65 years of age or older, there are few data to guide tures, with follow-up imaging as indicated.
decisions about rescreening. In order to help clinicians de-
termine optimal testing intervals, a recent study investi- Many clinicians repeat BMD testing 2 years after the initia-
gated the rates of transition to osteoporosis for older wom- tion of therapy, sooner in patients with risk factors for on-
e s
en with normal BMD or osteopenia at initial assessment.
r
The investigators found that with rescreening intervals of
er s
going bone loss, such as long-term glucocorticoid therapy.
If at all possible, a follow-up DEXA should be performed on
b o ok 15 years for women with normal bone density or mild os-

teopenia, 5 years for women with moderate osteopenia, and
bo ok
the same DEXA scanner used to perform the initial screen,
as variations between scanners can cloud test results. While
b o o
e/ e 1 year for women with advanced osteopenia, less than 10%
e/ e an increase in BMD is the desired finding, particularly in
e/e
: // t .m
of the patients would develop osteoporosis [41]. patients taking anabolic therapies, a stable BMD may also
: / /
indicate the efficacy of therapy in the face of a tendency t .m
tps
In patients receiving treatment for osteoporosis, the need
ht
for ongoing therapy should be periodically reassessed to
optimize the balance between treatment benefits and bur- ht tps
towards ongoing bone loss. A decrease in BMD should prompt
concerns about inadequate calcium and/or vitamin D intake,
treatment nonadherence or failure, or a secondary cause of
dens. Some measures may be undertaken during routine bone loss, and appropriate investigation should be under-
office visits. Modifiable risk factors for bone loss, such as taken. Some clinicians follow markers of bone resorption:
tobacco and alcohol consumption and calcium and vitamin defined decreases in urine N-telopeptide and serum C-telo-
e r s
D intake should be addressed, as should factors involving
e r s
peptide at 6 months as compared to baseline indicate treat-
ook ok o
the risk of falls. Patients should receive ongoing education ment efficacy and compliance. However, these markers
e b about the nature and sequelae of bone loss, fall prevention

e b o should not be the sole factor in decisions regarding con-
b o
e /
t . m e/
strategies, diet, and exercise. Patients should be asked about tinuation, modification, or cessation of treatment.
t . m e/e
/ / / /
11 References
htt ps: htt ps:
1. Wright NC, Looker AC, Saag KG, et al. 6. Gallagher JC, Melton LJ, Riggs BL, et al. 12. Magaziner J, Simonsick EM,
The recent prevalence of osteoporosis Epidemiology of fractures of the Kashner TM, et al. Predictors of
and low bone mass in the United States proximal femur in Rochester, functional recovery one year following
based on bone mineral density at the Minnesota. Clin Orthop Relat Res. hospital discharge for hip fracture:
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e r s a prospective study. J Gerontol.
ok ok
Miner Res. 2014 Nov;29(11):2520–2526. 7. Cooper C, Campion G, Melton LJ 3rd. 1990 May;45(3):M101–M107.
b o
2. Office of the Surgeon General. Reports
of the Surgeon General. Bone Health
Hip fractures in the elderly: a world-
b o
wide projection. Osteoporos Int.
13. Papaioannou A, Santesso N, Morin SN,
et al. Recommendations for preventing
b o o
e/ e and Osteoporosis: A Report of the
Surgeon General. Rockville, MD: Office
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1992 Nov;2(6):285–289.
8. Kanis JA, Johnell O, De Laet C, et al.
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of the Surgeon General (US); 2004.
Available at: www.surgeongeneral.gov/
://t . m International variations in hip fracture

probabilities: implications for risk
14. Lyles KW, Colon-Emeric CS,
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Magaziner JS, et al. Zoledronic acid
: m
library/reports/index.
t t p
Accessed February 12, 2015.
s assessment. J Bone Miner Res.
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and clinical fractures and mortality
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h
3. Johnell O, Kanis J. Epidemiology of
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4. Cummings SR, Black DM, Nevitt MC,
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DH, et al. Incidence and economic
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ht
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associated with reduced mortality after
et al. Bone density at various sites Miner Res. 2007 Mar;22(3):465–475. hip fracture. Osteoporos Int.
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k e rs The Study of Osteoporotic Fractures

Research Group. Lancet.
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burden of fractures: today and in
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16. Xue D, Li F, Chen G, et al. Do
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oo oo o
1993 Jan 9;341(8837):72–75. 1997 Aug 18;103(2a):20S–25S; A meta-analysis of randomized
eb
5. Friedman SM, Mendelson DA. discussion 25S–26S.
e b
controlled trials. J Orthop Surg Res.
b o
e/e
Epidemiology of fragility fractures. Clin 11. Magaziner J, Hawkes W, Hebel JR, et al. 2014;9:45.
e / Geriatr Med. 2014 May;30(2):175–181.
m e /
m
/ /t . Med Sci. 2000 Sep;55(9):M498–M507.
// t .
htt ps: htt ps:
rs
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/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m
17. Li YT, Cai HF, Zhang ZL. Timing of the e /
25. Dawson-Hughes B, Harris SS, Krall EA,
. m
34. Black DM, Bilezikian JP, Ensrud KE,
t e/e
/ /
initiation of bisphosphonates after
:
et al. Effect of calcium and vitamin D
/ /
et al. One year of alendronate after one
s ps:
surgery for fracture healing: a supplementation on bone density year of parathyroid hormone (1-84) for
ht t p
systematic review and meta-analysis of
randomized controlled trials. Osteoporos
Int. 2015 Feb;26(2):431–441.
in men and women 65 years of age or
older. N Engl J Med.
1997 Sep 4;337(10):670–676.
htt
osteoporosis. N Engl J Med.
2005 Aug 11;353(6):555–565.
35. Miller PD, Hattersley G, Riis BJ, et al.
18. Cosman F, de Beur SJ, LeBoff MS, et al. 26. Chapuy MC, Arlot ME, Duboeuf F, et al. Effect of abaloparatide vs placebo on
Clinician’s Guide to Prevention and Vitamin D3 and calcium to prevent hip new vertebral fractures in
Treatment of Osteoporosis. Osteoporos fractures in the elderly women. N Engl postmenopausal women with
Int. 2014 Oct;25(10):2359–2381. J Med. 1992 Dec 3;327(23):1637–1642. osteoporosis: a randomized clinical trial.
e rs
19. Siddiqui NA, Shetty KR, Duthie EH Jr.
Osteoporosis in older men:
er s
27. Kanis JA. Fracture Risk Assessment
Tool (FRAX). Centre for Metabolic
JAMA. 2016 Aug 16;316(7):722–733.
36. Cummings SR, San Martin J,
b o ok discovering when and how to treat it.

Geriatrics. 1999 Sep;54(9):20–22,
bo ok
Bone Diseases. University of Sheffield,
UK. Available at: www.shef.ac.uk/
McClung MR, et al. Denosumab for
prevention of fractures in
b o o
e/ e 27–28, 30.
20. Kiebzak GM, Beinart GA, Perser K,
e/ e
FRAX. Accessed 2016.
28. Bamias A, Kastritis E, Bamia C, et al.
postmenopausal women with
e/e
.m .m
et al. Undertreatment of osteoporosis in Osteonecrosis of the jaw in cancer after 2009 Aug 20;361(8):756–765.
2002 Oct 28;162(19):2217–2222.

: // t
men with hip fracture. Arch Intern Med. treatment with bisphosphonates:
incidence and risk factors. J Clin Oncol.
: / / t
37. Qaseem A, Forciea MA, McLean RM,
et al. Treatment of low bone density or
tps tps
21. Feldstein A, Elmer PJ, Orwoll E, et al. 2005 Dec 1;23(34):8580–8587. osteoporosis to prevent fractures in
ht ht
Bone mineral density measurement 29. Black DM, Kelly MP, Genant HK, et al. men and women: a clinical practice
and treatment for osteoporosis in older Bisphosphonates and fractures of the guideline update from the American
individuals with fractures: a gap subtrochanteric or diaphyseal femur. College of Physicians. Ann Intern Med.
in evidence-based practice guideline N Engl J Med. 2010 May 2017 Jun 6;166(11):818–839.
implementation. Arch Intern Med. 13;362(19):1761–1771. 38. McClung MR, Grauer A, Boonen S, et al.
2003 Oct 13;163(18):2165–2172. 30. Schilcher J, Michaelsson K, Romosozumab in postmenopausal
e r s
22. Parker MJ, Gillespie WJ, Gillespie LD.
Effectiveness of hip protectors for
e r s
Aspenberg P. Bisphosphonate use and
atypical fractures of the femoral shaft.
women with low bone mineral density.
N Engl J Med.
ook ok
preventing hip fractures in elderly N Engl J Med. 2011 May 2014 Jan 30;370(5):412–420.
b
people: systematic review. BMJ.
2006 Mar 11;332(7541):571–574.
b o
5;364(18):1728–1737.
31. Schilcher J, Koeppen V, Aspenberg P,
39. Bone HG, McClung MR, Roux C, et al.
Odanacatib, a cathepsin-K inhibitor for
b o o
e / e 23. Prince RL, Devine A, Dhaliwal SS, et al.
Effects of calcium supplementation on
e/ e
et al. Risk of atypical femoral fracture
during and after bisphosphonate use.
osteoporosis: a two-year study in
postmenopausal women with low bone
e/e
t
clinical fracture and bone structure:
/ / . m Acta Orthop. 2015 Feb;86(1):100–107.

t .
density. J Bone Miner Res.
/ / m
ps: ps:
results of a 5-year, double-blind, 32. Black DM, Schwartz AV, Ensrud KE, 2010 May;25(5):937–947.
placebo-controlled trial in elderly et al. Effects of continuing or stopping 40. Bone HG, Dempster DW, Eisman JA,
htt htt
women. Arch Intern Med. alendronate after 5 years of treatment: et al. Odanacatib for the treatment of
2006 Apr 24;166(8):869–875. the Fracture Intervention Trial postmenopausal osteoporosis:
24. Lips P, Graafmans WC, Ooms ME, et al. Long-term Extension (FLEX): development history and design and
Vitamin D supplementation and a randomized trial. JAMA. participant characteristics of LOFT, the
fracture incidence in elderly persons. 2006 Dec 27;296(24):2927–2938. Long-Term Odanacatib Fracture Trial.
A randomized, placebo-controlled 33. Neer RM, Arnaud CD, Zanchetta JR, Osteoporos Int. 2015 Feb;26(2):699–712.
clinical trial. Ann Intern Med. et al. Effect of parathyroid hormone 41. Gourlay ML, Fine JP, Preisser JS, et al.
e rs 1996 Feb 15;124(4):400–406.

r s
(1–34) on fractures and bone mineral
e
Bone-density testing interval and
ok ok
density in postmenopausal women transition to osteoporosis in older
b o
with osteoporosis. N Engl J Med.
b o
2001 May 10;344(19):1434–1441.
women. N Engl J Med.
2012 Jan 19;366(3):225–233.
b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
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87
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htt ps: htt ps:
1.10 O steoporosis
k e rs ke rs
e b oo e boo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
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htt ps: htt ps:
Claudia M Gonzalez Suarez
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/
1.11 Sarcopenia, malnutrition, frailty,
/ / /
and falls htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e 2 Falls
e/e
: // t .m
Falls are common in older adults, occurring annually in 2.1 Risk factors and evaluation
: / / t .m
tps
more than 30% of community-dwelling adults aged 65 years
ht
and older, and half of those aged 85 years and older. Of
those falls, 50% are recurrent. Of the 10–40% of falls that ht tps
With advancing age, the normal adult gait changes to a
hesitant, broad-based, small stepped gait, often with a
stooped posture, diminished arm swing and en bloc turns
result in injury, 20% will require medical attention, and [4]. Disturbances of gait not only indicate the risk of falls but
10% will result in serious harm, including hip or other frac- may herald or reflect serious underlying ill health [5]. The
ture, head injury or serious soft-tissue injury. Inability to pattern of shortened step length and slowing of gait is par-
e r s
rise without help, experienced by 50% of older persons
e r s
ticularly noticeable in individuals who have fallen repeat-
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after at least one fall, may result in dehydration, pressure edly and is sometimes called the “post-fall syndrome”, which
e b ulcers, and rhabdomyolysis. Falls are associated with re-

e b o is related to fear of further falling [6].
b o
e / e/
stricted mobility, reduced ability to carry out daily activities,
m
and an increased risk of long-term institutional care. In
t . t . m
Since falls in older adults are usually the result of multiple e/e
/ /
addition to their physical toll, falls have psychosocial impli-
: / /
conditions and circumstances, falls are classified as a geri-
h t p s
cations, including anxiety, depression, and social isolation [1].
t
Few falls have a single etiology; the majority of falls are a htt ps:
atric syndrome rather than a discrete disease. The ability to
transfer and walk safely depends on coordination among
sensory (eg, vision, vestibular, proprioception), central and
product of patient and environmental risk factors. Intrinsic peripheral nervous, cardiopulmonary, musculoskeletal, and
physical and cognitive changes related to aging decrease other systems. Falls that occur during usual daily activities
functional reserve and predispose older patients to falling. generally result from impairments in one or more systems,
e rs
Sarcopenia, frailty and malnutrition are three interrelated
r s
such as occurs in frailty [7].
e
b o ok conditions to help identify and intervene in patients at risk
o
for falls and fragility fractures [1]. Sarcopenia refers to the
b ok
Common risk factors for falls include previous falls, age > 75
b o o
e/ e / e
age-related loss of muscle mass and function. Frailty refers
e
to the inherent vulnerability of older or comorbid persons
years, cognitive and visual impairment, arthritis, depression,
and the use of four or more medications (ie, polypharmacy),
e /e
://t . m
to physiological stress [2]. Malnutrition is common and po-
/ t .
particularly antihypertensive and psychiatric medications.
: / m
t t p s
tentially treatable in many older adults [3]. This chapter gives
tps
The risk increases with increasing number of factors, from
ht
an overview of these conditions, as well as strategies to 8% with no risk factors to 78% among those with four or
h
evaluate fall risk and to prevent falls. more risk factors [8].
A more comprehensive list of risk factors can be found in

Table 1.11-1.
k e rs ke rs
All patients should be asked about a history of falls, the
eb oo e b oo
specific circumstances of the falls, and any associated in-
b o o
e/e
jury. Focused questions regarding dizziness, lightheadedness,
e / m e / weight loss, symptoms of neuropathy, gait instability and

m
/ /t . t .
medication changes are necessary for adequate assessment
//
ps: ps:
for previous and future falls. Checking vision, postural blood
htt htt 89
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rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m
pressure and a general neurological exam are appropriate e / The more detailed performance-oriented mobility assessment
t . m e/e
s: / / / /
ps:
for most patients who report falls [10]. (POMA) involves assessing the quality of transfer, balance,
http htt
and gait maneuvers used during daily activities and takes
Osteoporosis is an important consideration when assessing about 5–10 minutes to complete [14]. The POMA is not ap-
someone at risk for falls and fractures. This population is at propriate for highly functional patients or patients with a
greater risk of serious injuries related to falls; diagnostic tools single disabling condition. It includes observing transfer and
like the Fracture Risk Assessment (FRAX) of the World Health balance maneuvers such as getting up from a chair, perform-
e s
Organization, as well as radiographic tools like bone densi-
r
tometry using dual-energy x-ray absorptiometry or calca-
er s
ing side-by-side 1-leg and tandem stands (5–10 seconds each),
turning in circle, and sitting down. In addition to the evalu-
b o ok neal quantitative ultrasound are useful methods to assess

osteoporosis and fracture risk. If osteoporosis is diagnosed,
bo ok
ation of gait during a 3-meter walk, gait initiation, heel-toe
sequencing, step length, height, symmetry, path deviation,
b o o
e/ e management should be instituted including pharmacological
e/ e walk stance, steadiness on turning, arm swing, as well as
e/e
: // t .m
and nonpharmacological interventions. Osteoporosis is
further described in chapter 1.10 Osteoporosis.
neck, trunk, hip, and knee flexion are also assessed. These
: / / t .m
results can not only assess the risk of falling but also deter-
2.2
ht tps
Balance and gait evaluation
There are simple office-based assessments that can help
tps
mine if there are balance and gait impairments that need
ht
intervention as well as assess the presence of neurological,
musculoskeletal or other relevant disorders.
evaluate gait and predict falls. The Timed Up and Go (TUG)
test is the most frequently recommended screening test for 2.3 Prevention strategies
mobility and entails having the patient get up from a chair, Trials of fall prevention strategies have shown that approx-
e r s
walk 3 meters (about 10 feet), turn and return to the chair,
e r s
imately 30% of falls can be prevented. Of those, several
ook ok o
and sit down [11]. Any abnormality in movement suggests healthcare-based strategies have been shown to reduce the
e b balance or gait impairment and increased risk of falling, re-

e b o
rate of falling; however, their implementation may be prob-
b o
e / quiring further assessment and suggest a likely need for treat-
m
ment. Clear TUG completion times that indicate increased
t . e/ lematic, as clinicians tend to be more experienced at manag-
ing discrete diseases than at managing multifactorial condi-
t . m e/e
/ /
fall risk have not been definitively established, although cut tions [15, 16].
/ /
htt ps:
points at 12 and 13.5 seconds have been suggested [12, 13].
htt ps:
Key domains of fall prevention typically include physical
strengthening, medical evaluation and treatment, medica-
tion adjustment, environmental modification and education
Domain Factors
[10]. Key strategies for most patients include the following:
History • History of falls
• Visual impairment
e rs • Reported balance impairment or gait difficulties

r s
• Review and modify risk factors related to the patient’s
e
ok ok
• Cognitive impairment
falls. Modifiable risk factors include correcting vision,
b o
• Age
b o reducing environmental hazards and obstacles, and edu-

b o o
e/ e Medications
medications
e e
• Number of medications, ie, use of more than four
/ cation about using walking aids correctly.

• All patients should undergo a medication review to iden-
e /e
• Medications by class:
://t
– Sedatives and hypnotics
. m
– Neuroleptics and antipsychotics
/ t .
tify any medication-induced contributors to falls, includ-
: / m
t t p s
– Nonsteroidal antiinflammatory drugs
tps
ing cardiovascular medications that may lead to ortho-
ht
– Antidepressants static hypotension, and neuropsychiatric medications that
Functional status
h – Benzodiazepines
• Impairments in ADLs and IADLs
may alter balance, awareness, or cognition.
• Vitamin D assessment for all patients and replacement
Physical examination • Gait and balance impairment for deficient patients.
• Orthostatic hypotension
• A history of one fall and no other balance or gait distur-
• Poor vision
k e rs
Home hazards • Lack of bathroom grab bars
• Dim lighting
k rs
bances should be followed by participation in an exercise
e
program that includes balance and strength training.
b o o • Slippery or uneven services

• Improper use of mobility aids
b ooExamples of these programs can include physical thera-
b o o
e/ e e /e py, tai chi, or other programs.
• Two or more falls, and/or balance or gait difficulties should
e/e
/t . m
Table 1.11-1 Risk factors for falls in older adults [9].
Abbreviations: ADLs, activities of daily living; IADLs, instrumental
/ // t .m
be followed by a detailed assessment and specialized phys-
ps: ps:
activities of daily living. iotherapy.
90
htt htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e
Formal fall prevention programs can be divided into three
/ 3 Sarcopenia
t . m e/e
s: / / / /
ps:
main categories:
http htt
Sarcopenia is defined as the loss of muscle mass, function,
• Single programs including one intervention compo- and efficiency. Aging is associated with sarcopenia and in-
nent, ie, supervised exercises creased body fat, resulting from intrinsic metabolic chang-
• Multicomponent programs including two or more es and reduction in physical activity. Weight loss is a poor-
intervention components, ie, exercises and environ- ly sensitive indicator of sarcopenia, as increasing fat
e rs mental modifications
• Multifactorial programs including two or more custom-
er s
deposition can mask concurrent muscle loss [3].
b o ok ized interventions for each participant targeted at

patient-specific risk factors
bo ok
At a microscopic level, sarcopenic muscle is characterized
by a reduction in type II motor units and an associated loss
b o o
e / e e/ e of alpha motor neurons from the spinal cord. The contrac-
e/e
: / .m
A recent metaanalysis found that single interventions failed
/ t
to show a beneficial effect on fall-related outcomes in the
: / / t .m
tile and mitochondrial protein synthesis rates of muscle are
reduced with advancing age, resulting in loss of muscle mass
tps
nursing home population, since they are most often physi-
ht
cally frail and the fall is frequently of a multifactorial nature
[17]. Single programs targeted at more functionally intact ht tps
and strength. As muscle mass decreases, there is also a less-
ened capacity for the mobilization of amino acids from
muscle proteolysis for protein synthesis in vital organs and
older adults may be more successful. for immune processes. Physical inactivity leads to acceler-
ated rates of muscle loss and can produce a cycle of falls, ie,
Interventions, particularly those with strength and balance increased fear of falling, reduced activity, muscle loss and
e r straining, can successfully increase muscle strength and func-

e r s
increased falls [3, 23, 24].
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tional abilities. Avoiding iatrogenic harm related to excessive
e b hospitalization, testing and polypharmacy is important when

e b o 3.1 Evaluation
b o
e / frailty is recognized [18–20].
t . m e/ Sarcopenia is identified by the presence of two of the fol-
t . m
lowing criteria: low muscle mass, low muscle strength, and e/e
/ /
Vitamin D levels fall with aging and low levels are associ-
/ /
low physical performance [25]. While low muscle mass and
ps:
ated with sarcopenia, falls, hip fracture, disability, and mor-
htt
tality. When levels are low, vitamin D replacement can
reverse some functional deterioration, providing support htt ps:
strength can be evaluated in the research setting using var-
ious imaging techniques and dynamic strength testing, most
practical testing focuses on physical performance. The most
for modest daily vitamin D supplementation [21]. A meta- commonly used office tests include usual gait speed and the
analysis found positive effects of vitamin D supplementation short physical performance battery (SPPB). Slow gait speed
on muscle strength, gait and balance suggesting that vitamin is currently the simplest screen for sarcopenia, with a cutoff
e rs
D supplementation of 800–1,000 international units (IUs)
r s
point of 0.8 m/s over a 4–6-m course as the threshold for
e
b o ok daily was associated with improvements of muscle strength
b o
and balance [22]. Vitamin D reduces the number of falls in ok
poor performance [25]. The SPPB is a more time-intensive
assessment, involving repeated chair stands, balance testing
b o o
e/ e / e
those who are deficient, and the combination of calcium
e
and vitamin D for older patients in long-term care can reduce
and gait speed measurements [26]. Sarcopenia is only typi-
e /
cally quantified in research settings, using handgrip strengthe
fractures.
://t . m / t .
(so-called handgrip dynamometer) or knee extension
: / m
t t p s tps
strength (so-called isokinetic dynamometer).
ht
Other than vitamin D, few pharmacological agents have
h
been investigated to improve muscle strength, balance and
falls, including angiotensin-converting enzyme inhibitors,
3.2 Pathophysiology
Inactivity is one of the most prominent contributors to sar-
testosterone, and insulin-like growth factors (IGFs); none copenia. Muscle contraction during exercise causes the
of these has emerged as safe and effective for fall prevention release of muscle growth factors (IGF and mechano growth
k e rs
at this time.
ke rs
factor [MGF]) activating satellite cells, protein synthesis
and muscle regeneration among other processes, all of which
eb oo e b oo
are decreased with aging. Nutritional deficiencies or
b o o
e/e
insufficiencies also play a major role in the development
e / m e / of sarcopenia, as it is postulated that to maintain muscle

m
/ /t . t .
mass an older adult requires at least 1.2 g of protein per
//
ps: ps:
kilogram of body weight per day.
htt htt 91
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m
Hormonal mediators such as testosterone also decline and e / 4 Frailty
t . m e/e
s: / / / /
ps:
contribute to the decline in muscle mass and to a lesser
http htt
extent the decline in strength. This decline is more pro- Frailty refers to the general vulnerability of older or highly
nounced in females. Sarcopenia is also associated with comorbid adults to physiological stress. It is related to the
elevated proinflammatory cytokines that also negatively diminution of several interrelated physiological systems,
impact muscle mass and function. beyond the expected gradual decrease in reserve that is seen
with aging. This process results in the subsequent depletion
e s
The major contributors to sarcopenia are delineated in
r
Table 1.11-2.
er s
of homeostatic reserve and vulnerability to disproportionate
health complications after minor stressors [2].
b o ok 3.3 Treatment
bo ok
Although frailty is not a specific disease, the frailty pheno-
b o o
e/ e There are no standard or clearly safe drug treatments for
e/ e type can be defined, measured and serves as one of the
e/e
: // t .m
sarcopenia. Current standard of care is focused on exercise
and nutrition. Exercise can promote muscle anabolism, and
strongest and most useful factors in identifying fragility
: / /
fracture patients at risk for surgical complications, periop- t .m
ht tps
this effect can become more pronounced with detailed train-
ing [1]. Even in very old individuals, resistance exercise has
been reported to increase muscle mass and strength [24].
nosis [30-33].
ht tps
erative morbidity and mortality, and poor functional prog-
Frailty is often clinically defined by the presence of three or

Testosterone and other anabolic steroids such as nandrolone more of the following: unintentional weight loss, self-re-
have been shown to increase muscle mass and in higher ported exhaustion, weakness, slow walking speed, and low
e r s
doses muscle strength but can produce significant increase
e r s
physical activity. See Table 1.11-3 for formal criteria extract-
ook ok o
in cardiovascular risk [27]. ed from the Cardiovascular Health Study [34].
e b e b o b o
e / Enobosarm is a potent oral selective androgen receptor mol-
m
ecule with tissue selectivity, still undergoing active study
t . e/ Simpler criteria (Table1.11-4) have been validated for falls
and osteoporotic fractures as well, and are very easy to in-
t . m e/e
/ /
for both sarcopenia and osteoporosis treatment [28]. As such,
/ /
tegrate into clinical physician or nursing practice. Frailty is
htt
ments of physical function and power.ps:
it has been shown to improve lean body mass and measure-
outcomes [30, 31, 36].
htt ps:
increasingly predictive of falls, mortality and poor surgical
Other therapies such as myostatin antibodies have been

developed and are still undergoing research, since they have
shown to have no significant effect on muscle gain [29].
e rs e r s
b o ok b o ok b o o
e/ e Domain Contributor
e / e Characteristic Measure
e /e
Environmental Malnutrition
://t . m Weight loss

/ t .
Self-reported loss of more than 4.5 kg in prior year
: / m
s tps
Decreased physical activity Recorded loss of >5% of body weight in prior year
Vascular
h t t p
Decreased capillary blood flow
Peripheral vascular disease
Exhaustion
Low-energy expenditure
ht
3–4 days per week or most of the time
Lowest quintile for gender
Endocrine Insulin resistance Men < 383 kcal/week
Decrease of hormones with anabolic properties Women < 270 kcal/week
(ie, testosterone, dehydroepiandrosterone, IGF 1, Slow gait speed Lowest quintile for time to walk 4.57 m, adjusted for gender
growth hormone) and height
kers kers
Immunologic Increased proinflammatory cytokines (ie, IL-6, TNF-α) Weak grip strength Lowest quintile for grip strength, stratified by gender and
body mass index
b o o Genetic
Neurogenic
Mitocondrial abnormalities
Motor end plate degeneration
b o o
Table 1.11-3 Frailty phenotype—Fried criteria derive from the
b o o
e /e e/e e/e
Peripheral neuropathy Cardiovascular Health Study [34].
/t
Table 1.11-2 Major contributors to sarcopenia.
/ . m // t .m
ps: ps:
Abbreviations: IGF, insulin-like growth factor; IL, interleukin.
92
htt htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Clinically important aspects of frailty include [2]:
t . m e / 5 Malnutrition
t . m e/e
s: / / / /
ps:
• High prevalence in older adults, where 10–25%
http htt
of persons aged 65 years and 30–45% of those aged Inadequate nutritional intake and malabsorption are com-
85 years and older are estimated to be frail [37] mon findings in hip fracture patients and associated with
• Highly associated with sarcopenia, exercise intoler- delirium, susceptibility to infection, poor recovery and mor-
ance, frequent falls, immobility, and incontinence tality [40–42]. Alterations in taste, smell, mental status, de-
• Poor response to standard medical and functional pression, physical incapacity, dysphagia, medication side
e rs therapies
• Increased risk of functional decline and mortality
er s
effects, chronic disease, and relative financial poverty are
all contributors to the development of malnutrition [43].
b o ok Although frailty is generally irreversible, exercise, protein-

bo ok
Monitoring for weight loss in the community and particu-
b o o
e/ e calorie supplementation, vitamin D, and reduction of poly-
e/ e larly in the long-term care setting is the most common mea-
e/e
: / .m
pharmacy may be able to slow its progression or delay com-
/ t
plications [38, 39]. As noted previously, it is highly valuable
: / / t .m
sure of quickly identifying those who may be at risk for
nutritional insufficiency. There are several validated screen-
tps
in identifying patients with short life expectancies, poor
ht
prognosis for recovery, and poor responses to many tradi-
tional therapies. ht tps
ing tools, including the simplified nutritional appetite ques-
tionnaire, the geriatric nutritional risk index, the Mini-
Nutritional Assessment (MNA), or its 6-item version
MNA-Short Form which can distinguish malnutrition from
4.1 Pathophysiology nutritional risk and normal nutritional status. Nutritional
Aging can be explained by the lifelong accumulation of mo- and swallowing assessments should be part of all fragility
e r s
lecular and cellular damage that is usually regulated by
e r s
fracture programs.
ook ok o
complex maintenance and repair network. There seem to
e b be multiple organ systems that are closely interrelated in

e b o
5.1 Nutritional strategies
b o
e / the development of frailty: the central nervous system, en-
m
docrine system, immune system, and skeletal muscle, medi-
t . e/ There is no high-quality evidence of improved outcomes to
t . m
support specific nutritional supplementation strategies in e/e
/ /
ated by intrinsic and extrinsic factors, such as nutritional
/ /
hip fracture populations [44]. Current practice is to provide
ps:
status. Frailty results from and contributes to impairments
htt
in all of these areas. In 2009, Fried et al [34] used twelve
measures to assess for cumulative dysfunction in aging htt ps:
high protein, nutrient dense oral nutrition when able [45,
46], as well as to provide adequate calcium and vitamin D
supplementation. Oral nutrition supplements seem to be of
women, reporting a nonlinear relation between the number some value in preventing pressure ulcers in patients after
of abnormal systems and frailty, independent of age and hip fracture in the hospital and postacute care settings [47].
comorbidity. Abnormal results in three or more systems However, these studies are small and further investigation
e rs
were a strong predictor of frailty, supporting the idea that
r s
is required. Routine iron administration for the treatment
e
b o ok there is an aggregate crucial level beyond which frailty be-
comes evident.
b o ok
of anemia has not been shown to be beneficial [48] and can
be complicated by side effects, eg, dyspepsia, constipation.
b o o
e/ e e / e Postoperative identification of oropharyngeal dysphagia is
e /e
://t . m / t .
common; many patients likely have preexisting swallowing
: / m
t t p s tps
dysfunction and even small amounts of functional decline
ht
and precipitate inability to manage adequate swallowing
h from nutritional and respiratory standpoints. Invasive forms
of nutritional supplementation, ie, nasogastric tube feeding,
Criteria Points* are not recommended, as they place older adults at risk for
5% weight loss over 1 year 1 delirium as well as infectious complications, ie, aspiration
kers rs
Inability to do five chair stands without using arms 1 pneumonia. Parenteral nutrition carries risk and expense
o
Feeling low energy 1
ke
as well.
b o Table 1.11-4 Simple frailty screening tool, adapted from Ensrud et al

b oo b o o
e /e e e/e
Nutritional support and supplementation is an important
[35].
*Points: 2–3 = frail
m e / component of functional optimization in older adults in the
m
1 = prefrail
/ /t . // t .
postacute setting. Therapeutic diets (eg, low fat or calorie
ps: ps:
0 = robust restricted) should generally be avoided in the long-term care
htt htt 93
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rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m
population [15]. In a 2009 systematic review, Milne and his e /
t
The American Geriatrics Society advocates for clinicians to
. m e/e
s: / / / /
ps:
colleagues [16] found 62 trials with more than 10,000 older avoid using prescription appetite stimulants or high-calorie
http htt
adults at risk of malnutrition, who demonstrated a significant ONS for treatment of anorexia or cachexia in older adults,
increase in weight of 2.2% with oral nutrition supplements and it encourages healthcare providers to instead optimize
(ONSs); however, the study failed to find mortality benefit social supports, provide feeding assistance and clarify patient
or functional improvement in the treatment group. In an- goals and expectations, particularly in patients with demen-
other study of community-dwelling women [49], the com- tia [50, 51]. Oral nutrition supplements may be of limited
e s
bination of supplemental protein and exercise improved
r
muscle mass and strength, and walking speed.
er s
benefit in specific subgroups, such as those with specific
nutrient deficiencies, recently hospitalized patients, and
b o ok bo ok
patients recovering from fracture.
b o o
e/ e e/ e e/e
6 References
: // t .m : / / t .m
ht tps
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ook ok o
3. Hebuterne X, Bermon S, Schneider SM. review and meta-analysis. BMC Geriatr. of sarcopenia. Clin Geriatr Med.
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e
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oo oo o
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11. Podsiadlo D, Richardson S. The timed
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21. Rondanelli M, Faliva M, 31. Kistler EA, Nicholas JA, Kates SL, et al.
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mobility for frail elderly persons. J Am
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Monteferrario F, et al. Novel insights on
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Geriatr Soc. 1991 Feb;39(2):142–148.
/ elderly. Biomed Res Int.
//
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e b oo e b oo b o o
e / 32. Rolland Y, Abellan van Kan G,
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39. Turner G, Clegg A. Best practice
. m
45. Roberts KC, Brox WT, Jevsevar DS, et al.
t e/e
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Benetos A, et al. Frailty, osteoporosis
:
guidelines for the management of
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and hip fracture: causes, consequences frailty: a British Geriatrics Society, elderly. J Am Acad Orthop Surg.
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Which frailty measure is a good 40. Koren-Hakim T, Weiss A, Hershkovitz A, hip fracture-related complications. Clin
predictor of early post-operative et al. The relationship between Orthop Relat Res. 2006 Oct;451:212–217.
complications in elderly hip fracture nutritional status of hip fracture 47. Houwing RH, Rozendaal M, Wouters-
patients? Arch Orthop Trauma Surg. operated elderly patients and their Wesseling W, et al. A randomised,
e rs 2016 May;136(5):639–647.
34. Fried LP, Tangen CM, Walston J, et al.
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functioning, comorbidity and outcome.
Clin Nutr. 2012 Dec;31(6):917–921.
double-blind assessment of the
effect of nutritional supplementation
b o ok Frailty in older adults: evidence for a

phenotype. J Gerontol A Biol Sci Med Sci.
bo ok
41. Bell JJ, Bauer JD, Capra S, et al.
Multidisciplinary, multi-modal
on the prevention of pressure ulcers
in hip-fracture patients. Clin Nutr.
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e/ e 2001 Mar;56(3):M146–M156.
35. Ensrud KE, Ewing SK, Taylor BC, et al.
e/ e
nutritional care in acute hip fracture
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2003 Aug;22(4):401–405.
48. Parker MJ. Iron supplementation for
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.m .m
Comparison of 2 frailty indexes for intervention. Clin Nutr. anemia after hip fracture surgery: a
: // t
prediction of falls, disability, fractures,
and death in older women. Arch Intern
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42. Juliebo V, Bjoro K, Krogseth M, et al.
: / / t
randomized trial of 300 patients. J Bone
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Med. 2008 Feb 25;168(4):382–389. Risk factors for preoperative and 49. Kim HK, Suzuki T, Saito K, et al. Effects
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36. Makary MA, Segev DL, Pronovost PJ, postoperative delirium in elderly of exercise and amino acid
et al. Frailty as a predictor of surgical patients with hip fracture. J Am Geriatr supplementation on body composition
outcomes in older patients. J Am Coll Soc. 2009 Aug;57(8):1354–1361. and physical function in community-
Surg. 2010 Jun;210(6):901–908. 43. Bell CL, Tamura BK, Masaki KH, et al. dwelling elderly Japanese sarcopenic
37. Ferrucci L, Guralnik JM, Studenski S, Prevalence and measures of nutritional women: a randomized controlled trial.
et al. Designing randomized, controlled compromise among nursing home J Am Geriatr Soc. 2012 Jan;60(1):16–23.
e r s trials aimed at preventing or delaying

functional decline and disability in frail,
e r
index, malnutrition, and feeding
s
patients: weight loss, low body mass 50. Hanson LC, Ersek M, Gilliam R, et al.
Oral feeding options for people with
ook ok
older persons: a consensus report. J Am dependency, a systematic review of the dementia: a systematic review. J Am
b
Geriatr Soc. 2004 Apr;52(4):625–634.
38. Regional Health Council. Frailty in
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literature. J Am Med Dir Assoc.
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Geriatr Soc. 2011 Mar;59(3):463–472.
51. American Geriatrics Society.
b o o
e / e elderly people. Florence (Italy): Regione
Toscana, Consiglio Sanitario Regionale;
e/ e
44. Avenell A, Smith TO, Curtain JP, et al.
Nutritional supplementation for hip
Ten Things Clinicians and Patients
Should Question. Available at:
e/e
t
2013. Available at: www.guideline.gov/
/ / . m fracture aftercare in older people.

t . m
www.choosingwisely.org/wp-content/
/ /
ps: ps:
summaries/summary/47484. Cochrane Database Syst Rev. uploads/2015/02/AGS-Choosing-
Accessed December 2017. 2016 Nov 30(11):CD001880. Wisely-List.pdf
htt htt
Accessed January 22, 2017.
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
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t . m e /
t .m e/e
/ / //
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95
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htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
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t . m e /
t . m e/e
/ / / /
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e rs er s
b o ok bo ok b o o
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: // t .m : / / t .m
ht tps ht tps
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t . m e/ t . m e/e
/ / / /
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e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
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k e rs ke rs
eb oo e boo b o o
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/ / //
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k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
1.12 Pain management / / / /
htt ps:
htt ps:
e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e 1.3 Negative effects of poor pain control
e/e
: // t .m
Uncontrolled pain is a common contributor to poor outcomes
: / / t .m
Regardless of the underlying cause, uncontrolled pain has
negative effects on the physiology and clinical outcomes in
tps
in both medical and surgical settings. Treatment of acute,
ht
chronic and perioperative pain in older adults with hip
fractures has been recognized as inadequate [1–3]. Pain ht tps
older adults, especially in the inpatient setting. Pain is a con-
tributor to tachycardia and myocardial oxygen consumption
[3]. Poor pain control in hip fracture patients has been shown
management is particularly complicated in older adults due to lead to increased rates of postoperative delirium, increased
to the significant physiological and cognitive vulnerabilities length of stay and poor participation in therapy [3]. Uncontrolled
of this population. In light of the many factors necessary pain delays postoperative ambulation and time to recovery.
e r sto achieve safe and adequate pain control, a thoughtful and

e r s
Decreased rates of delirium and early ambulation have been
ook ok o
thorough approach is required to appropriately treat pain shown to reduce length of stay and postoperative complications
e b in the perioperative period [3–5].

e b o including pneumonia [11]. While there is a paucity of evidence
b o
e / 1.1 Prevalence of preexisting pain
t . m e/ about the impact of specific pain regimens on hip fracture
m
outcomes [12], improved pain control is suspected to lead to
t . e/e
/ /
Estimates of chronic pain range from 20% to 46% in
/ /
less morbidity in hip fracture patients postoperatively [10].
ps:
community-dwelling older adults and from 28% to 73%
htt
in older adults living in residential care facilities or nursing
homes [6]. The prevalence of daily pain tends to increase
1.4
htt ps:
Unique pain pathophysiology in older adults
The neurophysiological mechanism of pain in older adults
with age with as many as 75% of adults older than 75 years has been shown to be substantially altered when compared
reporting pain [6, 9]. The prevalence appears to be higher to the pathways in younger adults. Neurochemical and elec-
in women [6]. trophysiological aspects of nociceptive pain pathways change
e rs e r s
as a person ages [4]. There is a known age-related loss in
b o ok 1.2 Recognition
b o
Older adults with cognitive impairment are a specific high- ok
several relevant neurotransmitters including serotonin,
gamma-aminobutyric acid as well as in opioid receptors,
b o o
e/ e / e
risk group for poor pain control, due both to inadequate
e
recognition and a tendency to undertreatment [6]. Identifi-
and a decrease in the function of the descending inhibitory
pain pathway. A slight increase in pain threshold, or a re-
e /e
://t . m
cation of pain is particularly challenging in the perioperative
/ t .
duced sensitivity to mild pain, has been demonstrated in
: / m
t t p s
and postoperative period when delirium and medical insta-
tps
older adults, particularly to thermal stimuli [13].
ht
bility complicate the clinical assessment.
h
Reasons for underrecognition and undertreatment of pain
From a treatment perspective, frail older adults typically
have reduced capacities for drug absorption, distribution and
in older adults include difficulties in assessment, particu- metabolism, and a higher risk for drug toxicity [14]. There is
larly in patients with dementia, fear of side effects and also evidence to suggest that the physiological response to
k e rs
overdose, and general provider uncertainty regarding the
response to opioids in a highly complex and comorbid
ke rs
pain may be blunted in older adults with dementia [15].
eb oo population.
e b oo
Table 1.12-1 [16] summarizes the many physiological and phar-
b o o
e/e
macokinetic changes that are common in older adults. These
e / e
A reluctance to use standing orders for analgesics in hip
m / factors are the basis for the unique issues with pain assess-
m
/ /t .
fracture patients after surgery illustrates this issue [10].
t .
ment, management, and expected response to therapy in
//
ps: ps:
older adults [15].
htt htt 97
rs
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/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 1.5 Types of pain
t . m e / • Neuropathic pain is caused by irritation or inflammation
t . m e/e
s: / / / /
ps:
While the specific nature and intensity of pain is subjective, of nerve fibers and/or neurons, and is usually described
http htt
clinically meaningful categories exist. Pain can be usefully as burning, tingling or numbness. It is usually localized
characterized as acute or chronic, and further divided into easily but may have a radiating component that follows
different pathophysiological subtypes [17]: the path of the nerve itself. This can also be seen in hip
fracture patients postoperatively if nerve fibers were dis-
• Acute pain is characterized by an abrupt onset, linked to turbed during the fracture or the procedure or by post-
e rs a specific insult and only lasts for a relatively short pe-

riod of time.
er s
operative edema and inflammation. Neuropathic pain
may have a variable or inadequate response to typical
b o ok • Chronic pain persists for more than 3–6 months and is

characterized by the ongoing pain in the absence of spe-
bo ok
pain medications, including antiinflammatory analgesics
or opioids. Nontraditional pain medications like anticon-
b o o
e/ e cifically identified stimuli. Lower socioeconomic status,
e/ e vulsants and antidepressants may be more effective for
e/e
: // t .m
inactivity, chronic illness, and lack of social support are
some of the factors that have been associated with the
neuropathic pain.
: / /
• The third subtype of pain is a mixed type with features t .m
ht tps
development of chronic pain in older adults [17].
There are three different pathophysiological subtypes of ht tps

of both nociceptive and neuropathic pain; this typically
requires multiple different modalities to treat adequate-
ly. One example of this mixed type is a vertebral fracture
pain: nociceptive, neuropathic and mixed [4]: with nerve impingement resulting in both somatic and
neuropathic components [4, 16, 18].
• Nociceptive pain is due to the activation of sensory recep-
e r s tors by noxious stimuli, and can be further divided into

e r s
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either somatic or visceral pain. Somatic pain tends to 2 Pain assessment
e b originate in the skin, muscle or bone and is often easily

e b o b o
e / localized. Pain related to an acute hip fracture is typi-
m
cally a nociceptive, somatic type of pain. Visceral pain is
t . e/ While pain assessment can be difficult in any patient popu-
t . m
lation, it can be particularly challenging in the fragility frac- e/e
/ /
a referred pain originating from an internal organ such
/
ture patient due to the high prevalence of cognitive and
/
ps:
as the heart, lungs or gastrointestinal (GI) tract. Usually
htt
visceral pain is relatively difficult to localize and is de-
scribed as aching, dull or vague. htt ps:
communication impairments. The most common and valid
methods for pain assessment include patient self-report,
visual rating scales, and behavioral pain assessment tools
for patients unable to effectively communicate.
e rs e r s
b o ok Changes in older adults
b
Clinical effect
o ok b o o
e/ e Gastrointestinal Decrease in GI transit time
e / e
More prolonged effect of
e /e
absorption Bowel more sensitive to opioid
dysmotility
Altered gastric pH (usually from
m
sustained release pain medications
://t .
Increased risk of side effects such
as constipation
: / / t . m
p s
other medications)
t t
Variable absorption of medications
tps
Drug distribution
h
Decrease in lean body
mass and increase in lipid
distribution
Could lead to longer drug half-life
and increased risk of drug side
effects
ht
Drug metabolism Decreased oxidation of Increased drug half-life and
medications in the liver increased risk of drug side effects
rs rs
Drug excretion Glomerular filtration rate Decreased rate of excretion of
k e decreases with age drug

Increased risk of accumulation of
ke
eb oo toxic metabolites
e b oo b o o
e / Table 1.12-1 Pharmacological changes in older adults. Adapted
t . m
from: American Geriatrics Society Panel on Pharmacological
e /
t .m e/e
/
Management of Persistent Pain in Older Persons [16].
/ //
ps: ps:
Abbreviation: GI, gastrointestinal.
98
htt htt
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rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
Pain is one of the major obstacles to good surgical and func- 2.2 Cognitively impaired patients
t . m e/e
s: / / / /
ps:
tional outcomes, and is typically present in all but the most The assessment of pain in a nonverbal or severely cogni-
http htt
minor of orthopedic trauma. Accurate assessment requires tively impaired patient can present a dilemma for clinicians
a thoughtful and methodical approach based on staff obser- and nurses. In order to obtain an accurate assessment, clini-
vation, physical exam, and the use of validated pain assess- cian and staff observation of nonverbal indicators is neces-
ment tools. Improved perioperative pain control is a cor- sary. The American Geriatrics Society (AGS) recommends
nerstone of delirium prevention, preservation of function the evaluation of six behavioral domains including facial
e rs
and avoidance of complications [3, 10, 11].
er s
expressions, verbalizations/vocalizations, body movements,
changes in interpersonal interactions, changes in activity
b o ok 2.1 Self-report
Self-report is the primary method in pain assessment for
bo ok
patterns, and changes in mental status [16].
b o o
e / e e/ e
older adults. This should be attempted first; if the patient is A number of behavioral pain assessment tools have been
e/e
: // t .m
unable to respond appropriately, then other clinical indica-
tors of pain should be sought. Autonomic symptoms such
validated for use in older adults with severe cognitive im-
pairment [20]. These include the Pain Assessment in Ad-
: / / t .m
tps
as diaphoresis, hypertension and tachycardia can sometimes
ht
suggest a high likelihood of pain. The following scales are
commonly used for pain assessment: ht tps
vanced Dementia scale [8], which consists of five items
that aid in the interpretation of nonverbal pain as seen in
Table 1.12-2.
• The numerical rating scale (NRS) is a verbally obtained Other validated scales include the Abbey pain scale and the
numerical pain scale ranging from 0 to 10 (0 is considered pain assessment checklist for seniors with limited ability to
e r s no pain and 10 is considered the most severe pain imag-

e r s
communicate [20, 21]. All of these can be used to assess and
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inable); patients are asked to ascribe a number to their track acute pain as well as measure the effectiveness of the
e b pain from this continuum. The NRS is the most common

e b o treatment.
b o
e / report [19].
t . e/
and most valid pain scale in older adults capable of self-
m t . m e/e
/ /
• The Visual Analog Scale is a related tool that prompts a
/ /
htt ps:
patient to indicate a pain rating on a printed line between
two extremes of no pain (0) and excruciating pain (10).
This has been shown to be less effective in older adults htt ps:
and has a higher error rate [20].
• The Verbal Descriptor Scale (VDS) has also been vali-
dated in older adults and consists of verbal indicators (eg,
e rs mild, moderate, severe) to quantify the intensity of a

e r s
b o ok patient’s pain. The VDS is preferred by older adults and
o
has been demonstrated to be effective in moderate and
b ok
Breathing
0
Normal
1
Occasional labored
2
Noisy labored breathing
b o o
e/ e severe dementia [19].
e / e
• Other self-report options include the Faces Pain Scale,
(independent of
vocalization)
breathing Long period of
hyperventilation
e /e
://t . m
commonly used in children but has also been validated Negative
vocalization
None Occasional moan or
groan
: / / t . m
Loud moaning or groaning
Crying
t s
in older adults [21]. It requires the patient to identify the
t p Facial expression Smiling Sad

tps Facial grimacing
ht
facial expression which best indicates the pain they are
nonverbal.
h
experiencing. This can be helpful in older adults who are
Body language
No expression
Relaxed
Frightened
Frowning
Tense Rigid
Distressed pacing Fists clenched
Fidgety Knees pulled up
All of these tools have limitations including inability to Pulling or pushing away
k e rs
describe pain location, problems with identifying dynamic
pain with activity, and inaccuracies with monitoring the
ke rs
Consolability No need to
console
Distracted
Reassured by voice
Unable to console, distract
or reassure
b o o response to the treatment of chronic pain.

b oo or touch
b o o
e/ e e /e Table 1.12-2 Pain assessment in advanced dementia (adapted from
e/e
/ /t . m the Pain Assessment in Advanced Dementia scale).
A possible interpretation of the scores is:
// t .m
ps: ps:
1–3 = mild pain; 4–6 = moderate pain; > 6 = severe pain
htt htt 99
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/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 3 Treatment
t . m e /
t
• Ice applied before and after physical therapy can reduce
. m e/e
s: / / / /
ps:
inflammation and lead to reductions in pain. Care should
http htt
As previously described, there are physiological changes be taken not to injure the skin by overexposure.
that occur in older adults that can affect the efficacy and • Other therapies such as massage therapy, acupuncture/
tolerance of pain medications and limit the effectiveness of acupressure, and use of transcutaneous electrical nerve
nonstandardized pain management strategies in older adults. stimulation (TENS) units have also helped in the manage-
Using a standardized and predictable approach can signifi- ment of postoperative pain in selected hip fracture pa-
e s
cantly reduce adverse effects while improving pain control
r
[4, 6, 15, 16]. This is especially true in postoperative patients
er s
tients. Limited data suggests TENS units can accelerate
recovery in range of movement and lead to a reduction
b o ok when blood loss, dehydration, and changes in mental status

can lead to uncertainty regarding appropriate pharmaco-
bo ok
in pain after hip surgery [23]. Acupressure has also been
shown to reduce pain in hip fracture patients preopera-
b o o
e/ e logical and nonpharmacological treatment.
e/ e tively [24]. These interventions are safe and can comple-
e/e
3.1 General principles
: // t .m ment the pharmacological management of pain and lead
: / /
to lower medication dosing and reduced adverse effects.t .m
tps
The first principle is “start low and go slow” as recommend-
ht
ed by the AGS. This refers to using the lowest dose possible
when starting a medication in an older adult and titrating ht tps
• Traction is not typically used in high-performing fracture
centers due to risks of skin injury and delirium in this
population [25].
up slowly until the desired effect is achieved. In light of the
reduced metabolic capabilities of older adults, this principle Nonpharmacological interventions are recommended by
is useful when starting any medication, and similarly im- the American Academy of Orthopaedic Surgeons [5] to treat
e r s
portant to the development of standardized treatment.
e r s
perioperative and postoperative pain after hip fracture in
ook ok o
older adults, supporting the multidisciplinary and multi-
e b A second principle is to maximize the use of nonpharma-

e b o modal approach necessary to treat pain in some older adults
b o
e / cological modalities to treat pain. The third one is to be
t . m
attentive for common adverse effects of (and other) medica- e/ effectively.
t . m e/e
/ /
tions, allowing for early recognition and adjustment to 3.3 Pharmacological interventions
/ /
prevent further morbidity [14, 15].
3.2 htt ps:

Nonpharmacological interventions htt ps:
Pharmacological agents, including opioids and acetaminophen,
are necessary for pain control in virtually all hip fracture pa-
tients during both the preoperative and postoperative phases:
Nonpharmacological interventions, eg, early surgery, early
mobilization, positioning, and ice have an excellent benefit • For patients without liver disease or other contraindica-
to risk ratio, and should be a consistent part of pain control tions, most current protocols utilize immediate use of
e rs
strategies in both the pre- and postoperative setting:
r s
scheduled dose acetaminophen and scheduled doses of
e
b o ok • Early mobilization and physical therapy are likely to con-
b o ok
opioids or as needed (eg, morphine, oxycodone, hydro-
morphone).
b o o
e/ e tribute to adequate pain control and lead to reductions
e / e
in overall mortality, reduced length of stay, and physical
• Nonsteroidal antiinflammatory medications (eg, ibupro-
fen, naproxen sodium, ketorolac) are avoided in the peri-
e /e
://t . m
disability [22]. A delay in ambulation postoperatively pro-
/ t
operative phase due to cardiovascular, renal, and cogni-
: / . m
t t p s
motes postoperative delirium and pneumonia as well as tive effects.
tps
ht
prolonged pain [11]. • Combination medications (eg, acetaminophen plus opi-
h oid) typically fail to allow appropriate dosing of the in-
dividual components.
kers rs
Usual starting doses*
o
Morphine immediate release 2.5–5 mg by mouth every 3–4 hours as needed
ke
oo o
(low potency) 2–4 mg intravenously every 3–4 hours as needed
b o Oxycodone immediate release

b
2.5–5 mg by mouth every 3–4 hours as needed
Table 1.12-3 Usual starting doses for acute pain in opioid naïve
older adults.
b o
e /e /e e/e
(moderate potency) No intravenous formulation available
Hydromorphone
m e
1–2 mg by mouth every 3–4 hours as needed
t .
* Please note that the initial starting does recommended for older
m
adults (> 65 years old) are approximately half the starting dose
t .
(high potency)
/
0.25–0.5 mg intravenously every 2–3 hours as
/ /
for younger opioid naïve adults. Intravenous preparations are more
/
ps: ps:
needed
potent compared to a similar dose in an oral preparation.
100
htt htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e
• Specific dosing and monitoring recommendations can be
/ Opioid side effects
t . m e/e
s: / / / /
ps:
found through the AOTrauma Orthogeriatrics Pain smart- Opioids have multiple side effects that need to be identified,
http htt
phone app [25], as well as the American College of Sur- treated, and prevented when possible (Table 1.12-4) [7, 28].
geons’ National Surgical Quality Improvement Program/
AGS best practice guidelines for preoperative assessment One of the most common and serious side effects of opioid
of the geriatric surgical patient [26]. medications is constipation, mostly through a direct effect
on gut motility, with contributions from decreased oral in-
e s
3.3.1 Opioids
r
Opioid preparations are often necessary to provide optimal
er s
take, hydration and immobility. Since constipation is already
a common issue in the older adult population, a constipation
b o ok pain relief in the perioperative setting for geriatric patients,
bo
and can be used safely. Medical and surgical clinicians should ok
protocol for all patients is typically warranted. Scheduled
doses of bowel stimulants (eg, sennosides) and an osmotic
b o o
e/ e e/ e
acquire familiarity with common issues related to adequate laxative (eg, polyethylene glycol or lactulose), in addition
e/e
tions:
: // t .m
dosing, side effects and toxicities of specific opioid prepara- to early ambulation and physical therapy, can limit consti-
: /
pation. Once a bowel movement is achieved, the regimen
/ t .m
ht tps
Opioid preparation, dose, and route considerations
Oral opioid administration offers a longer duration of action, ht tps
can be reduced if needed. For patients who develop severe
opioid-induced constipation resistant to multiple therapies,
a µ-opioid-receptor antagonist such as methylnaltrexone
but also a longer time to onset (up to 1 hour). Using paren- may be indicated but should only be used in consultation
teral medications in older adults requires clinician attention with a geriatrician or GI specialist.
to avoid excessive sedation, nausea, or delirium. Different
e r s
opioids have different potencies and careful selection is im-
e r s
Nausea and vomiting can be a side effect of opioid therapy
ook ok o
portant (Table 1.12-3). Sustained release formulations are although this is not commonly seen with low-dose regimens
e b b
usually not necessary in older adults for whom the half-life
e o and typically resolves after the first few days of therapy.
b o
e / e/
of short-acting opioids is typically prolonged. For younger
m
patients with normal renal function, sustained release prep-
t .
Managing constipation, lowering doses, switching opioids
or treatment with antiemetics is usually effective [29].
t . m e/e
/ /
arations may be helpful to meet more significant opioid
/ /
ps:
requirements, and reduce the need for frequent additional
htt
doses. Transdermal fentanyl is generally not appropriate in
the acute setting due to prolonged onset/peak (12–24 hours) htt ps:
Respiratory depression is perhaps the most feared side effect
of opioid therapy. It is typically seen with high doses and/or
rapid dose titration. The risk may also be increased in older
and offset (12–24 hours), and it can be difficult to calculate adults with previous respiratory pathology or who are taking
rescue/breakthrough doses. Parenteral fentanyl may be use- concurrent sedating medications. Sedation almost always
ful but because of short duration and potency, it is often occurs prior to clinically significant respiratory depression so
e rs
limited to monitored settings such as operating room, post-
r s
careful monitoring can help identify at-risk patients.
e
b o ok anesthesia care unit, and intensive care unit.
b o

ok b o o
e/ e Long-term opioid therapy
e / e
Patients on long-term opioid therapy are likely to require
e /e
://t . m
modestly increased opioid dosing for perioperative pain con-
Opioid side effect Treatment
: / / t . m
t t s
trol. Acute reductions in routine home doses may precipitate
p Mild to moderate constipation
tps
Early ambulation
ht
opioid withdrawal. One option for patients with significant
h
opioid tolerance due to long-term therapy includes continu-
ing the long-acting home regimen, and ordering 10–30% of Severe constipation
Scheduled sennoside and polyethylene glycol
or lactulose
Bisacodyl suppository
this total dose as a short-acting equivalent every 2–3 hours (no bowel movement in > 4 days) Enema
Methyl naltrexone (as last resort and in
as needed for breakthrough pain. Patients may need a 25– consultation with geriatrician)
k e rs
50% increase in baseline long-term regimen in the periop-
erative period. We recommend titrating doses based on pain
e rs
Nausea and vomiting
k
Treat constipation
Antiemetics
b o o assessment and side effect monitoring. Medical or pain spe-

b oo Lower opioid dose
Opioid rotation
b o o
e/ e long-term opioid therapy may be appropriate [27].
e /e
cialist consultation for the pain management of patients on
Delirium Ensure adequate treatment of pain
e/e
/ /t . m Consider opioid rotation
// t .m
ps: ps:
Table 1.12-4 Opioid side effects and treatment strategies.
htt htt 101
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
Naloxone is an opioid antagonist used to reverse respira-
t
sparing benefits in the short term. See chapter 1.3 Principles
. m e/e
s: / / / /
ps:
tory depression. However, it can precipitate a pain crisis and of orthogeriatric anesthesia for more details.
http htt
lead to worsening delirium in a postoperative patient. Nal-
oxone should only be used if significant respiratory depres- 3.3.3 Postoperative pain control
sion (< 6 breaths per minute) or worsening hypoxia is pres- After surgical fixation, IV opioids are usually not required,
ent. Usually, appropriate dose reduction is sufficient to and the risks of continued administration like excessive se-
prevent any life-threatening respiratory depression and the dation and short duration can outweigh the benefits. Rou-
e s
use of an opioid antagonist should rarely be needed. Nal-
r
oxone also has a significant side effect profile particularly
er s
tine acetaminophen and low-dose oral opioids are gener-
ally safe and effective, along with nonpharmacological
b o ok in the older adult [30].

bo ok
methods including extremity positioning, ice and mobiliza-
tion (Table 1.12-5).
b o o
e/ e e/ e
Concerns for opioid-induced delirium or cognitive impair-
e/e
: // t .m
ment can be confused with delirium caused by poorly con-
trolled pain [10]. In general, it can be assumed that almost
Acetaminophen (650–1,000 mg three times per day) is
: / / t .m
typically the first line oral agent chosen due to its low inci-
s tps
http
all hip fracture patients will require opioids for adequate dence of side effects.
pain control, even if they are unable to communicate this
need. Uncontrolled pain is likely to precipitate delirium, and
appropriate pain treatment has been demonstrated to reduce
ht
Combination medications of acetaminophen with an opioid
increase the hazard of inadvertent acetaminophen overdose,
the incidence of delirium in hip fracture cohorts [10]. Trials and otherwise limit the ability to titrate opioid doses. There
of small doses of opioids are often necessary to distinguish are no GI or renal side effects described with the use of
e r s
these causes. Synthetic opioids (eg, oxycodone, hydromor-
e r s
acetaminophen in older adults. In addition to routine
ook ok o
phone) may lead to less delirium than morphine [31, 32]. acetaminophen, a low-dose, moderate potency opioid should
e b e b o be available for moderate to severe pain (ie, oxycodone

b o
e / 3.3.2 Preoperative pain control
m e/
In the preoperative period, modest doses of intravenous (IV)
t .
2.5–5 mg every 3 hours as needed). If this dosing is inade-
quate, then a dose increase of 25–50% is usually appropri-
t . m e/e
/ /
opioids (eg, morphine sulfate 2–4 mg every 1–2 hours as ate while monitoring for any new adverse effects.
/ /
tive pain relief. ps:
needed) are typically necessary to achieve rapid and effec-
htt htt ps:

Cognitively impaired persons frequently have difficulty with
pain assessment and inability to request pain medications.
Using protocols and order sets facilitates safe initial dosing
and can promote more clinician familiarity with medication
effectiveness and toxicities. See chapter 2.7 Protocol and
e rs
order set development for more information on protocols
e r s
ok ok
Clinical setting Dosing and strategies
and order set development.
b o b o Preoperative dosing:
Frail older adult
Acetaminophen:
650–1,000 mg orally three times per day
b o o
e/ e e / e
Acute femoral nerve blockade is another excellent option to
improve pain control and to achieve a reduction in opioid
Chronic kidney disease Routinely scheduled
Morphine sulfate:
e /e
://t . m
needs; this has been best studied in the emergency depart-
t .
2–4 mg intravenously every 2 hours as needed
OR
: / / m
t t p s
ment setting [33, 34]. Nerve blocks are most appropriate in Hydromorphone:
tps
ht
the preoperative setting, as postoperative nerve blocks can 0.25–0.5 mg intravenously every 2 hours as needed
h
limit mobility. Nerve blockade has been shown to reduce
the risk of delirium, presumably through improved pain
Postoperative dosing:
Frail older adult
Chronic kidney disease
Acetaminophen:
650–1,000 mg orally three times per day, routinely
scheduled
control and reduced opioid use [12]. Peripheral nerve blocks Oxycodone:
include fascia iliaca blockade and femoral nerve blockade 2.5–5 mg orally every 3 hours as needed
rs rs
OR
with local anesthetic. Fascia iliaca blockade may be performed
k e by nonanesthesia personnel; femoral nerve blockade typi-

ke Hydromorphone:
1–2 mg orally every 3 hours as needed
eb oo cally involves consulting an anesthesiologist and the use of
e b oo
Other situations More robust patients may need higher dosing to achieve
b o o
e/e
ultrasound-guided technology. Preoperative femoral nerve adequate pain control
e / e /
block can also provide some degree of postoperative pain
m
For patients unable to report pain adequately, schedule
doses of opiates may be necessary
m
t .
control. All of these techniques complement the use of
/ / // t .
ps: ps:
systemic pain medications and can provide some opioid- Table 1.12-5 Pain medication dosing guidelines.
102
htt htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e
Scheduled analgesic medications, with instructions to hold
/
t . m
• Tramadol is a combined opioid agonist and serotonin/ e/e
s: / / / /
ps:
for excessive sedation, are necessary in these situations where norepinephrine reuptake inhibitor with a significant side
http htt
inadequately controlled pain is suspected. It is also appropri- effect profile including delirium, nausea, headaches, sweat-
ate to schedule analgesic medications prior to situational ing and tremors. It is not tolerated by up to one-third of
pain episodes such as a dressing changing or prior to phys- patients due to these adverse effects [27]. One study im-
ical therapy, and may improve participation in therapy- plicated its use as a risk factor for new hip fracture [36].
reduced pain afterwards. • Meperidine use has largely fallen out of favor due to
e rs
3.3.4 Problematic medications
er s
severe delirium, especially in older adults, and numerous
other toxic effects [10].
b o ok • Nonsteroidal antiinflammatory drugs (NSAIDs) are con-

bo ok
• Muscle relaxants (eg, cyclobenzaprine, benzodiazepines)
have a poor side effect profile in older adults.
b o o
e/ e e/ e
traindicated in patients with known chronic kidney disease, • Gabapentin, pregabalin, and duloxetine all have signifi-
e/e
: // t .m
cerebrovascular disease, bleeding disorders, congestive
heart failure, or heart disease, and carry significantly
: / / .m
cant risks for delirium and medication interactions dur-
t
ing the dynamic perioperative period. In general, they
ht tps
increased risk of adverse effects including GI bleeding,
myocardial ischemia, heart failure and delirium. Nonste-
roidal antiinflammatory drugs are also listed on the AGS ht
3.3.5 Patient controlled analgesia
tps
should not be initiated for standard hip fracture pain.
Beers Criteria for medications to avoid in older adults [35]. Patient-controlled analgesia (PCA) is problematic for cog-
• Cyclooxygenase 2 (COX-2) inhibitors such as celecoxib nitively impaired patients, and carries the disadvantage of
purport to have less GI effects, but have the same renal restricting mobility. It is typically not appropriate for use in
e r s toxicities and are usually avoided in the dynamic postop-

e r s
most older FFPs. It is important to consider consultation
ook ok o
erative period. Some COX-2 inhibitors have been withdrawn with geriatrics and/or a pain management specialist when
e b from the market due to associated cardiovascular events.

e b o using a PCA in an older patient, since intense monitoring
b o
e / • Proton pump inhibitors (PPIs) can be prescribed con-
t . m e/
comitantly with NSAIDs to provide a GI protective effect,
of side effects and attenuated dosing may be needed.
t . m e/e
/ /
but PPIs have their own risks (eg, Clostridium dificile infec-
/ /
htt ps:
tion, osteoporosis, pneumonia) and do not mitigate the
renal and cardiovascular toxicities of NSAIDs or COX-2
inhibitors. htt ps:
e rs
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e r s
o ok ok o
/ebo o
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e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
1.13 Polypharmacy / / / /
htt ps:
htt ps:
e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e 2 Unique prescribing issues for older adults
e/e
: // t .m
Long medication lists are a typical feature of fragility fracture
: / / t .m
There are a number of issues that make current disease
ht tps
patients (FFPs) for many reasons. The presence of multiple
comorbidities, advances in disease-specific drug treatment,
increased diagnostic testing and changing thresholds for ht
• Lack of valid clinical trials:
tps
specific prescribing guidelines problematic for older adults:
treatment have contributed to significant increases in the The vast majority of clinical trials of pharmacological
number of medications prescribed for older adults. The ma- interventions are not validated in older or highly
jority of older adults take more than five prescribed medica- comorbid populations, making risks and benefits
e r s
tions [1] and 40% of nursing home residents use nine or
e r s
uncertain, even for many standard medications.
ook ok o
more medications each day [2]. The potential benefits of • Lower dose thresholds for toxicity:
e b b o
these medications are often offset by risks related to interac-
e
Age- and disease-related changes in drug absorption,
b o
e / e/
tions and toxicities in frail older patients. Adverse drug
m
reactions due to common medications (ie, anticoagulants,
t .
distribution, metabolism and excretion can result in
t . m
lower thresholds for drug toxicity in older adults. e/e
/ /
antithrombotics, antidiabetic medications, and digoxin) • Limited lifespan:
/ /
ps:
account for a significant number of emergency hospitaliza-
htt
tions [3], and benzodiazepenes, antihistamines, and opioids
are often implicated in delirium [4]. htt ps:
Older adults may not have sufficient remaining
lifespan to realize the benefit of many standard chronic
disease-directed drug therapies, making potential
benefits unlikely.
Common postoperative complications related to polyphar-
macy include: Common drug side effects like delirium, constipation,
e rs e r s
anorexia and hypotension often complicate the periopera-
b o ok • Hypotension due to the combination of blood loss,

opiates and home antihypertensive agents
b o ok
tive and postsurgical course of orthogeriatric patients and
have a big impact on recovery and outcomes. These factors
b o o
e/ e / e
• Acute renal failure related to diuretics and angioten-
sin-converting enzyme inhibitors
e
should result in a general reluctance to routinely prescribe
many medications found in standard disease-specific guide-
e /e
://t . m
• Sedation and delirium due to interactions between
/ t . m
lines, and support the geriatric maxim to “start low, go slow”
: /
t t p s
postoperative pain medications and home medications
tps
whenever choosing medications and doses in this population.
ht
(eg, antidepressants, muscle relaxants, and psychiatric
medications) h
• Urinary retention and constipation due to opioids and 3 Definitions and challenges
anticholinergic agents
Polypharmacy can be defined in many ways:
k e rs
Addressing polypharmacy is fundamental to optimal short-
and long-term outcomes for orthogeriatric fracture patients.
ke rs
• Five or more medications [5]. This is the most common
eb oo Standardized medication reconciliation by appropriate
e b oodefinition but other studies use cut-offs as low as two

b o o
e/e
orthogeriatric team members at each transition of care is and as high as eleven.
e / e
the primary tool to reduce unnecessary and harmful medi-
m / • The use of one or more medications, herbal remedies, or
m
/ /t .
cations during hospitalization and at the time of discharge. supplements with potential interactions.
// t .
htt ps: htt ps:
105
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rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
1.13 Polypharmacy
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
• Inappropriate use of any specific medication in an older c linicians should verify that there are no other treatment
t . m e/e
s: / / / /
ps:
adult. Each medication should have a clear indication alternatives with significantly less side effects.
http htt
and be prescribed at the minimum effective dose. Short 2. Stop medications that are likely to interfere with post-
life expectancy, side effects, and goals of care can all im- operative recovery and rehabilitation, especially those
pact the appropriateness of specific medications for indi- that produce excessive sedation, hypotension, or delirium.
vidual patients. 3. Stop medications that have no obvious clinical indica-
tion, might produce significant side effects, or lead to
e rs
The risk of drug-related adverse events is higher as the num-
ber of medications increases, with nearly 20% of patients
er s
complications.
b o ok on eight or more medications likely to experience an adverse

drug event [6].
bo ok
With each of these steps, the clinician needs to consider the
risk for medication withdrawal, especially for those medica-
b o o
e / e e/ e tions for which there are known withdrawal syndromes,
e/e
: // t .m
Obtaining an accurate admission medication list for all
orthogeriatric patients is essential, but not the only step in
eg, benzodiazepines, opiates, some antidepressants, cloni-
dine, and beta-blockers. Rapid discontinuation of some of
: / / t .m
ht tps
managing medications in the hospital setting. Regardless of
the criteria, polypharmacy occurs as a result of a lack of
appropriate and thoughtful review of the patients’ medica- ht tps
these medications—most likely drugs with cardiovascular
and neurological indications—can cause adverse events [11].
tion regimen [7–9]. Many home medications may need to be Medication management needs to be coordinated by team
stopped or the dose reduced during the perioperative period. members with experience in perioperative and geriatric
medicine. Some common issues are summarized in Table 1.13‑2.
e r sIt can be challenging to correctly identify polypharmacy, as

e r s
ook ok o
most patients take medications consistent with disease-specific The STOPP/START criteria are the best studied single point of
e b b
clinical guidelines. Despite having appropriate indications,
e o care intervention aimed at modifying drug regimens [12]. These
b o
e / e/
individual patients can have side effects or toxicities that
m
make the risks of a particular medication or medication dose
t .
criteria use a structured and detailed approach to evaluating
patient and disease factors that should prompt appropriate
t . m e/e
/ /
excessive. The cumulative effect of medications can produce
/
prescribing. The benefits of applying these criteria have been
/
htt ps:
symptoms that sometimes are mistakenly attributed to other
etiologies or new medical problems. Acutely compromised
orthogeriatric patients can become vulnerable to previously
demonstrated up to 6 months after hospitalization.
htt
In addition, the STOPP/START criteria make appropriate
ps:
well-tolerated medications. For any significant sign or symp- suggestions for dosage selection, particular for older adults
toms, the clinician should always evaluate the patient’s with reduced renal function [12]. Patients with high degrees
current medication regimen as a potential contributor. of inappropriate prescribing as measured by STOPP/START
e rs e r s
criteria appear to be at higher risk for mortality after hip
b o ok 4 Strategies to safely reduce medications

b o ok
fracture [11]. These criteria are generally too cumbersome
to use in a busy clinical setting but do support the rationale
b o o
e/ e e / e
Despite the need to stop or reduce the dose of some long-
for more limited prescribing.
e /e
://t . m
term medications in the perioperative setting, specific
: / / t . m
t t p s
approaches to achieve this are not well studied or specified
tps
ht
[10]. Moreover, the few available studies are limited by b
eing
h
observational and short term. Strategy
Stop/reduce dose of medications
Example
Anticoagulants during the preoperative period
causing immediate harm or likely to Antihypertensive medications in hypotensive
We offer the following 3-step approach to evaluating and
delay surgery patients
modifying the medication regimen for FFP (Table 1.13-1).
rs rs
Stop/reduce dose of medications Diabetes medications in patients with poor intake
likely to interfere with postoperative Anticholinergic medications
k e 1. Stop medications that are likely to delay surgical repair

ke
recovery (eg, diphenhydramine, bladder antispasmodics)
eb oo or are expected to produce clinically significant side
e b oo Sedatives
b o o
e/e
effects in the perioperative period. Each prescribed Stop medications without clear Proton pump inhibitors in patients without recent
e / e /
medication should be reviewed to ensure that it is clin-
m
indications gastrointestinal bleeding
m
/ /t .
ically necessary at the time of surgery, and it is being Table 1.13-1 Stepwise approach to reducing polypharmacy in the
// t .
s:
prescribed at the most appropriate dose. Moreover, perioperative period.
ps:
106
http htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 5 Medication reconciliation
t . m e / Keys to success:
t . m e/e
s: / / / /
http
Medication reconciliation is the process used to verify and
intentionally adjust medications during transitions of care
htt ps:
• Standardizing the reconciliation process. It is helpful to
clearly define the team member responsible for medica-
either between settings (ie, inpatient admission or discharge) tion list verification. Setting the requirement that all
or providers (ie, from a specialist office to the primary care providers update the medication list may create oppor-
physician). tunities for error if there is inadequate time, training, or
e rs
The majority of admission order errors in the inpatient set-
er s
information for the provider to accomplish this task.
• Respecting medical record system capabilities from the
b o ok ting are associated with poor medication reconciliation [13].

The process of medication reconciliation is usually limited
bo ok
accepting and referring facilities to ensure that accurate
medication lists are received and processed between set-
b o o
e/ e by clinician time, availability of medical records, and the
e/ e tings.
e/e
: // t .m
literacy level of the patient and family members. Based on
previous studies, almost half of the patients have unintend-
: / / t .m
Although most facilities in different settings of care use elec-
list [11].
ht tps
ed medication discrepancies in their discharge medication
ht tps
tronic medical records, the systems may not be compatible.
Communication via paper forms is often still necessary. Ef-
forts should be made to improve the format of discharge
Patients at the highest risk for errors during medication documents in order to have a clear, readable medication list
reconciliation include older adults with multiple comor- that includes correct dosing, frequency and duration, par-
bidities, multiple medications, and cognitive impairment. ticularly for time-limited medications like antibiotics and
e r s e r s
some anticoagulants. In addition, specific attention must be
ook ok o
directed to identifying active medications not on the current
e b e b o electronic medication lists and confirming the actual fre-

b o
e /
t . m e/ quency of use by the patient, especially for “as needed”
t . m
medications. Any medication started during the surgical e/e
Medication Common
/ /
Strategies/special issues
/ /
admission should be highlighted and appropriate monitor-
ps: ps:
class/examples complications
ing should be specified if indicated. Medications with an “as
htt htt
Antihypertensives Excessive Stop/reduce dose of medications until the
hypotension in the patient demonstrates hypertension
needed” indication should be ordered only for clearly an-
setting of blood Beta-blocker and clonidine withdrawal can ticipated needs, placing emphasis on those to treat pain,
loss, anesthesia, and occur, may need to continue at reduced nausea, constipation, and dyspepsia.
opioids doses
Some antihypertensives also used for
arrhythmia control, may need to continue Additional communication points to consider include:
e rs drug
e r s
ok ok
Diabetes Hypoglycemia due to Hold oral agents; reduce long-acting insulins • For patients on thromboembolic prophylaxis, a clear stop
b o medications reduced oral intake

o
until patient demonstrates significant
hyperglycemia
b date should be specified in the discharge documents.
b o o
e/ e Anticoagulants Excessive bleeding
e / e
Hold until hemostasis is achieved
• Reconciling the dose of each medication is also important,
e /
particularly if patients are not taking the exact doses thate
. m
(see chapter 1.6 Anticoagulation in the
://t
perioperative setting)
: / / t .
were prescribed, or if doses have been reduced during m
Chronic opiates Sedation
t t p s Dose reduction may precipitate opiate the postoperative period.
tps
ht
Constipation withdrawal
• The final list of medications should be shared with all
h Often need to use increased doses for pain
control in the perioperative period
May need to limit other sedating medications
the providers that are going to care for the patient dur-
ing the postacute rehabilitation phase and also upon
and aggressively treat constipation
discharge back to the community. This typically includes
Anticholinergic Delirium Avoid the use of highly anticholinergic the rehabilitation facility or ward, the primary care and
rs rs
medications Constipation medications (eg, diphenhydramine,
antispasmodics for urinary incontinence) subspecialty physicians, and any involved nursing or
k e ke
home care agencies. Being on a shared medical record
oo oo o
Diuretics Hypotension Hold medications until hemodynamically
eb
Volume depletion stable
e b
has the potential to have the same medication list display
b o
e/e
Urine output may be limited until these are in all appropriate settings.
e / resumed
m e / • Patients and their families must receive appropriate and

m
/t .
Table 1.13-2 Common perioperative prescribing issues in the
/ // t .
sufficient counseling and education about the medications
ps: ps:
orthogeriatric patient. throughout the continuum of care. They should participate
htt htt 107
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rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
1.13 Polypharmacy
k e rs ke rs
e b oo e b oo b o o
e /
t . m e
in the maintenance of the medication list and should be
/ Even when using ordering systems with decision-support
t . m e/e
s: / / / /
ps:
empowered to provide feedback to providers regarding alerts that fire to the prescriber, there is likely an addi-
http htt
any changes in the dose or frequency of the medications tional benefit of pharmacist medication review [15]. When
as well as side effects [14]. electronic flagging is used by a pharmacist to identify po-
tentially inappropriate medications pharmacists are able to
rapidly screen for inappropriate prescribing and deliver
6 Pharmacist-based evaluation timely point-of-care interventions [16].
e rs
The addition of a pharmacist to the care team may c ontribute
er s
There is conflicting evidence of how long-term outcomes
b o ok to reductions in polypharmacy and improving the self-rat-

ed health of older adults. Some research has found that
bo ok
are influenced by such single point of care interventions [17,
18, 19]. In the postacute setting, the involvement of a clini-
b o o
e/ e patients who have their medications reviewed by a phar-
e/ e cal pharmacist to evaluate patients for polypharmacy shows
e/e
of stay.
: // t .m
macist have a lower hospitalization rate and shorter length similar reductions in the overall number of medications.
: / /
The cost effectiveness and long-term benefits of these in- t .m
ht tps terventions are still to be determined [19, 20].
ht tps
7 References
ke r s
1. Tinetti ME, Bogardus ST Jr, Agostini JV.
Potential pitfalls of disease-specific
k e r
9. Gleason KM, McDaniel MR, Feinglass J,
et al. Results of the Medications at
s 15. Zaal RJ, Jansen MM, Duisenberg-van
Essenberg M, et al. Identification of
b o o guidelines for patients with multiple

conditions. N Engl J Med.
o o
Transitions and Clinical Handoffs
b
(MATCH) study: an analysis of
drug-related problems by a clinical
pharmacist in addition to computerized
b o o
e /e e/e e/e
2004 Dec 30;351(27):2870–2874. medication reconciliation errors and alerts. Int J Clin Pharm.
2. Dwyer LL, Han B, Woodwell DA, et al. risk factors at hospital admission. J Gen 2013 Oct;35(5):753–762.
Polypharmacy in nursing home
/ / t . m Intern Med. 2010 May;25(5):441–447. 16. O’Sullivan D, O’Mahony D,
/ /t . m
ps: ps:
residents in the United States: results of 10. Schuling J, Gebben H, Veehof LJ, et al. O’Connor MN, et al. The impact of a
the 2004 National Nursing Home Deprescribing medication in very structured pharmacist intervention on
htt htt
Survey. Am J Geriatr Pharmacother. elderly patients with multimorbidity: the appropriateness of prescribing in
2010 Feb;8(1):63–72. the view of Dutch GPs. older hospitalized patients. Drugs Aging.
3. Budnitz DS, Lovegrove MC, Shehab N, A qualitative study. BMC Fam Pract. 2014 Jun;31(6):471–481.
et al. Emergency hospitalizations for 2012 Jul 09;13:56. 17. Crotty M, Rowett D, Spurling L, et al.
adverse drug events in older 11. Gosch M, Wortz M, Nicholas JA, et al. Does the addition of a pharmacist
Americans. N Engl J Med. Inappropriate prescribing as a transition coordinator improve
2011 Nov 24;365(21):2002–2012. predictor for long-term mortality after evidence-based medication
e rs
4. Clegg A, Young JB. Which medications hip fracture. Gerontology.
e r s management and health outcomes in
ok ok
to avoid in people at risk of delirium: 2014;60(2):114–122. older adults moving from the hospital
b o
a systematic review. Age Ageing.
2011 Jan;40(1):23–29.
12. Gallagher PF, O’Connor MN,
b o
O’Mahony D. Prevention of potentially
to a long-term care facility? Results of a
randomized, controlled trial.
b o o
e/ e 5. Wallace J, Paauw DS. Appropriate
prescribing and important drug
e / e
inappropriate prescribing for elderly
patients: a randomized controlled trial
Am J Geriatr Pharmacother.
2004 Dec;2(4):257–264.
e /e
interactions in older adults. Med Clin
North Am. 2015 Mar;99(2):295–310.
://t . m using STOPP/START criteria.

Clin Pharmacol Ther.
18. Chisholm-Burns MA, Kim Lee J,
/ / t .
Spivey CA, et al. US pharmacists’ effect
: m
t p s
6. Onder G, Petrovic M, Tangiisuran B,
et al. Development and validation of a
t
2011 Jun;89(6):845–854.
13. Wong JD, Bajcar JM, Wong GG, et al.
tps
as team members on patient care:
systematic review and meta-analyses.
h
score to assess risk of adverse drug
reactions among in-hospital patients
65 years or older: the GerontoNet ADR
risk score. Arch Intern Med.
Medication reconciliation at hospital
discharge: evaluating discrepancies.
Ann Pharmacother.
2008 Oct;42(10):1373–1379.
ht
Med Care. 2010 Oct;48(10):923–933.
19. Hughes CM, Lapane KL. Pharmacy
interventions on prescribing in nursing
homes: from evidence to practice. Ther
2010 Jul 12;170(13):1142–1148. 14. Commonwealth of Massachusetts, Adv Drug Saf. 2011 Jun;2(3):103–112.
7. Lee RD. Polypharmacy: a case report Board of Registration in Medicine. 20. Mueller SK, Sponsler KC, Kripalani S,
k e rs and new protocol for management.

J Am Board Fam Pract.
ke rs
Quality and Patient Safety Division.
Advisory Medication Reconciliation,
et al. Hospital-based medication
reconciliation practices: a systematic
b o o 1998 Mar–Apr;11(2):140–144.
8. Viktil KK, Blix HS, Moger TA, et al.
oo
January 2015. Available at: http://c.
ymcdn.com/sites/www.mashp.org/
b
review. Arch Intern Med.
2012 Jul 23;172(14):1057–1069.
b o o
e/ e Polypharmacy as commonly defined is
an indicator of limited value in the
e /e
resource/resmgr/medication-
reconciliation-ja.pdf.
e/e
assessment of drug-related problems.
Br J Clin Pharmacol.
/ /t . m Accessed March 5, 2015.
// t .m
ps: ps:
2007 Feb;63(2):187–195.
108
htt htt
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/ / t . m // t . m
htt ps: htt ps:
Markus Gosch, Katrin Singler
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
1.14 Delirium / / / /
htt ps:
htt ps:
e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e • As with delirium, dementia also strongly correlates with
e/e
: // t .m
The two most important cognitive issues affecting h
ospitalized
: / / t .m
age. Starting at age 65 years, the risk of developing de-
mentia doubles every 5 years. By age 85 years and older,
tps
older adults are delirium and dementia, impacting areas
ht
such as memory, awareness, perception, reasoning, and
judgment. ht tps
between 25% and 50% of persons will exhibit signs of
Alzheimer’s disease, the most common type of dementia.
Dementia is a particularly strong risk factor for delirium.
• Globally, 24 million people have dementia today and this
While these two disturbances in cognition have overlapping prevalence is likely to double every 20 years to 42 million
causes, clinical findings and management, they should be by 2020, and 81 million by 2040.
e r s
understood as distinct conditions that warrant unique
e r s
• Of those with dementia, 60% live in developing countries,
ook ok o
approaches to evaluation and treatment. The history, time with the number expected to rise to 71% by 2040 [5].
e b b o
course, and progression of these deficits allow clinicians to
e
• The increasing prevalence of dementia is mainly due to
b o
e / e/
distinguish between delirium and dementia. Delirium is an
m
acute medical condition that develops quickly, waxes and
t .
increased life expectancy and the increasing proportion
of older adults in modern society.
t . m e/e
/ /
wanes, and has the potential to resolve. Dementia is a pro-
/ /
ps:
gressive and irreversible loss of cognition. This chapter fo-
htt
cuses on summarizing the impact of delirium on patient
outcomes and identifying optimal prevention, diagnostic
3 Definitions
htt ps:
and treatment strategies. 3.1 Delirium
Delirium is an acute and fluctuating disturbance in cognition
characterized by inattention.
e rs
2 Prevalence in older adults
e r s
b o ok There is a high prevalence of delirium and dementia in
b o ok
In the Diagnostic and Statistical Manual of Mental Disorders
(DSM-V) [6], delirium is defined by the following criteria:
b o o
e/ e older adults, particularly during hospitalization:
e / e e
A A disturbance in attention (ie, reduced ability to direct,/e
://t . m
• Among older adults in healthcare settings, delirium is
/ t . m
focus, sustain, and shift attention) and awareness (ie,
: /
t t p s
common, occurring in 10–34% of those living in long-
tps
reduced orientation to the environment)
ht
term care facilities, 30% of those in emergency depart- B The disturbance develops over a short period of time
h
ments, and 10–42% during a hospital stay [1, 2, 3].
• Delirium complicates 17–61% of major surgical proce-
(usually hours to a few days), represents a change from
baseline attention and awareness, and tends to fluctuate
dures and occurs in 25–83% of patients at the end of life in severity during the course of a day
[1, 4]. This huge range reported in the literature may be C An additional disturbance in a second cognitive domain
k e rs explained by historical difficulties in accurately diagnos-

ing delirium as well as by the use of other descriptive
ke rs
(eg, memory deficit, disorientation, language, visuospatial
ability, or perception)
eb oo terms, eg, acute brain failure, acute confusional state,
e b oo b o o
e/e
acute organic brain syndrome, cerebral insufficiency, The disturbances in criteria A and C are not better explained
e / e /
encephalopathy, postoperative psychosis, or toxic psy-
m
by another preexisting, established, or evolving neurocog-
m
chosis.
/ /t . t .
nitive disorder. There is evidence from the history, physical
//
ps: ps:
examination, or laboratory findings that the disturbance is
htt htt 109
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rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
1.14 Delirium
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
a direct physiological consequence of another environmen- 4 Delirium
t . m e/e
s: / / / /
ps:
tal or medical condition, substance intoxication or with-
http htt
drawal (ie, due to drug abuse or to medication). Delirium during hospitalization of FFPs has an enormous
impact on the patient outcomes and is an independent risk
Delirium can be clinically subclassified as hyperactive (ie, factor for many complications including:
marked by agitation), hypoactive (ie, marked by lethargy
and sedation), or mixed [7]. • Increased length of hospitalization
e rs
3.2 Dementia
e s
• Increase in functional impairment
r
• Complications including urinary incontinence,
b o ok Unlike delirium, dementia represents a progressive and
bo
irreversible loss in cognitive function. Current DSM criteria ok
falls and pressure ulcers
• Increase in admission to nursing homes [1, 9]
b o o
e / e e/ e
include memory impairment, but also emphasize deteriora- • Increased mortality (as much as fivefold) [9]
e/e
: // t .m
tion in other cognitive domains like speech or language
ability. Dementia, also called major neurocognitive disorder,
• Significant cognitive impairment in > 50%,
:
and impairment may persist for more than one year [9]
/ / t .m
tps
is defined by the following [6]:
ht
• Evidence of substantial decline in one or more cognitive ht tps
Only one third of hospitalized older adults fully recover
from delirium [1]. Delirium is likely a marker of overall
domains (ie, attention, awareness, memory, language, frailty, an indicator of clinical instability, and a contributor
visuospatial ability, and perception), and a decline in to poor long-term function. Delirium is always a medical
neurocognitive performance (ie, two or more standard emergency, and requires a prompt diagnostic process and
e r s deviations below appropriate norms on formal testing or

e r s
initiation of therapy.
ook ok o
equivalent clinical evaluation)
e b b o
• The cognitive deficits are sufficient to interfere with in-
e
4.1 Pathogenesis
b o
e / dependence
m e/
• The cognitive deficits do not occur exclusively in the con-
t .
Delirium is typically due to multiple causal mechanisms.
Several interacting biological factors result in disruption of
t . m e/e
text of delirium
/ / /
the neuronal networks of the brain, leading to acute cogni-
/
ps:
• The cognitive deficits are not primarily attributable to
htt
another mental disorder (eg, major depressive disorder,
and schizophrenia) htt ps:
tive dysfunction. Current evidence suggests that neuroin-
flammatory processes, changes in balances of neurotrans-
mitters, physiological stressors, metabolic derangements as
well as electrolyte disorders and genetic factors contribute
According to the DSM-V criteria, individuals with major to the development of delirium [9].
neurocognitive disorder exhibit cognitive deficits that in-
e rs
terfere with independence. Persons with mild neurocogni-
r s
Many neurotransmitters are implicated, but cholinergic de-
e
b o ok tive disorder may retain the ability to be independent.
b o ok
ficiency and/or dopaminergic excess are of special impor-
tance. These systems are often influenced by drugs known
b o o
e/ e / e
Typical assessment tools for dementia are of limited use in
e
the acutely hospitalized fragility fracture patient (FFP), as
to interfere with synaptic transmission and cause delirium.
Cytokines, such as interleukin-1 (IL-1), IL-2, IL-6, tumor
e /e
://t . m
these assessments are only valid when patients are at their
/
necrosis factor-α (TNF-α) and interferon, influence the per-
: / t . m
t t p s
baseline cognitive function. Abnormalities in dementia test-
tps
meability of the blood-brain barrier and disturb the process
ht
ing like the Mini-Mental Status Exam, Montreal Cognitive of neurotransmission. In addition, systemic inflammatory
h
Assessment, or clock drawing tests can also be found in
delirious patients. Information gained from patient history,
processes including trauma, hypoxia and surgery result in
an increase of cytokine levels, causing activation of the mi-
such as the progressive inability to manage home medica- croglia and increasing the risk for delirium [9].
tions or finances, may be of more use in identifying patients
kers rs
with previously undiagnosed dementia [8]. 4.2 Risk factors
o ke
Delirium typically results from acute stressors in a vulner-
b o b oo
able patient. Identifying high-risk patients and common
b o o
e /e e e/e
triggers are an essential workflow for optimal care of ortho-
m e / geriatric patients. A standardized workup for the diagnosis

m
/ /t . and management of delirium should be integrated in an
// t .
ps: ps:
orthogeriatric comanagement model.
110
htt htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t .
Patients with dementia are at particularly high risk for the
m e / • Infections
t . m e/e
s: / / / /
ps:
development of delirium. This group should be identified • Metabolic derangements, eg, hypogylcemia,
http htt
as soon as possible and receive all available nonpharmaco- hyponatremia, hypoxia, fever
logical prevention measures for delirium. • Systemic organ failure, eg, heart failure, renal failure
• Urinary obstruction and constipation
Common patient-related risk factors for delirium: • Physical restraints and tethers, eg, telemetry,
intravenous lines, and urinary catheters
e rs
•
•
Preexisting dementia
Previous delirium
er s
• Impaired perception of the environment,
eg, missing glasses and hearing aids
b o ok •
•
Older age
Severe comorbidities and polypharmacy
bo ok
• Withdrawal of benzodiazepines or alcohol
b o o
e/ e • Visual and/or hearing impairment
e/ e 4.4 Diagnosis
e/e
• Major fractures, eg, hip fracture
: // t .m : / / .m
Delirium may be the first sign of critical medical decompen-
t
sation in older patients. Since drug treatment of delirium is
ht tps
Because of the high prevalence of risk factors and the high
incidence of delirium [4], all older patients should be man-
aged as high-risk patients. One proposed risk assessment ht tps
potentially harmful, it is very important to detect and reverse
underlying medical causes as soon as possible.
tool is described in Table 1.14-1. 4.4.1 Clinical presentation

Up to 70% of delirium is unrecognized by clinicians [9], in
4.3 Common etiologies part due to the variability of clinical manifestations of a
e r s
Many common hospital treatments and minor complications delirium.
e r s
ook ok o
are triggers for the development of delirium. These are es-
e b sential to recognize and manage, and include:

e b o Patients with a hyperactive state of delirium are often eas-
b o
e / • Poorly controlled pain
t . m e/ ily recognized, as these patients show increased psychomo-
t . m
tor activity, agitation, aggression, mood lability, and, in some e/e
/ /
• Medication effects, eg, toxicity, withdrawal, and cases, hallucinations and delusions.
/ /
anesthesia
htt ps: htt ps:

On the other hand, it can be difficult to detect a patient in
hypoactive delirium. This form is characterized by decreased
psychomotor activity, with the presence of lethargy and
Predisposing risk factors for delirium Points drowsiness, apathy, and confusion.
e rs
Delirium during previous hospitalization
Dementia
5
5
e r s
Conversation with the patient may elicit memory difficul-
b o ok Clock drawing (displaying 10 past 11):

• Small mistakes 1
b o ok
ties, disorientation, or speech that is tangential, disorganized,
or incoherent. The clinician should be aware of superfi-
b o o
e/ e • Big mistakes, unrecognizable or no attempt
e /2
e cially appropriate conversation that follows social norms
e
but is poor in content. It is important that the clinicians are /e
Age:
• 70–85 years
://t . m 1
: / / t . m
sensitive to the patient’s flow of thoughts and do not a ttribute
• > 85 years
t t p s 1
tps
tangential or disorganized speech to age, dementia, or fatigue.
h
Impaired hearing, ie, patient is not able to hear speech
Impaired vision, ie, vision less than 40%
Problems in activities of daily living:
1
1 ht
A focused clinical examination, targeted laboratory tests,
and occasionally intracranial imaging are necessary for all
patients with new symptoms of delirium. If no easily
• Domestic help or help with meal preparation 0.5
reversible causes are identified and nonpharmacological
rs rs
• Help with physical care 0.5
methods of control are insufficient, pharmacological symp-
o k e Use of heroin, methadone or morphine 2
ke
tom control may be necessary to prevent harm or to allow
oo o
Daily consumption of four or more units of alcohol 2
eb o Total score
e b
evaluation and treatment. There are limited data to guide
b o
e/e
treatment. Delirium is still managed empirically and there
e/ m
Table 1.14-1 Risk model for delirium according to Vochteloo et
t . e / is no evidence in the literature to support change to current

practice at this time.
t .m
/
al [10]. Patients with a score of 5 or more are considered high-risk
/ //
ps: ps:
patients.
htt htt 111
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
1.14 Delirium
k e rs ke rs
e b oo e b oo b o o
e / 4.4.2 Confusion Assessment Method
t . m e / Early surgery and proactive geriatric management are cru-
t . m e/e
s: / / / /
ps:
Standardized tools help to accurately diagnose delirium. cial. The following preventive measures can be taken in
http htt
They can be easily and quickly administered. The Confusion clinical practice:
Assessment Method (CAM) is a widely used delirium screen-
ing instrument based on DSM-III-R criteria [11]. A diagnosis • Early volume and electrolyte repletion
of delirium requires according to the CAM the presence of • Adequate pain therapy
item 1 and 2 plus either 3a or 3b: • Medication review:
e rs
1. Acute onset and fluctuating course (required)
er s
–– Avoidance of anticholinergic (eg, diphenhydramine)
and sedative medications, particularly new intro-
b o ok –– Is there evidence of an acute change in mental

status from the patient‘s baseline?
bo ok
duction of benzodiazepines
–– Avoidance of acute medication or substance
b o o
e/ e e/ e
–– Did the abnormal behavior fluctuate during the day? withdrawal, eg, continuation of long-term opiate or
e/e
2. Inattention (required)
: // t .m
–– Did the patient have difficulty focusing attention,
benzodiazepine therapy, management of alcohol
withdrawal
: / / t .m
tps
being easily distractible or having difficulty keeping
ht
track of what was being said?
3a. Disorganized thinking
• Early mobilization
ht
• Avoidance of physical restraints and/or tethers
• Routine evaluation for urinary retention and constipa-
tps
–– Was the patient’s thinking disorganized or tion
incoherent, such as rambling or irrelevant • Environmental modification and nonpharmacological
conversation, unclear or illogical flow of ideas, or sleeping aids for patient with insomnia
e r s unpredictable switching from subject to subject?

e r s
• Orientation protocol and cognitive stimulation for
ook ok o
3b. Altered level of consciousness? patients with cognitive impairment
e b –– Any condition other than alert, eg, vigilant,

e b o • Monitoring high-risk patients with validated scoring
b o
e / lethargic, drowsy, comatose.
t . m e/ tools, like the DOSS or CAM
t . m e/e
/ /
4.4.3 Delirium Observation Screening Scale
/ /
ps:
The Delirium Observation Screening Scale (DOSS) (Table
htt
1.14-2) is a validated surveillance tool that can be performed
by the nursing staff throughout the day [12]. In addition to DOSS criteria htt ps:
Never Sometimes
identifying delirium, the DOSS is also useful to describe the Dozes off during conversation or activities 0 1
course of a delirium over time. In clinical practice it can be
Is easily distracted by stimuli from the environment 0 1
used like a pain score. The DOSS includes 13 items and the
e rs
final score is calculated from the three scores per day and
e r s
Maintains attention to conversation or action 1 0
b o ok divided by 3. If the final score is 3 or higher, delirium is

likely present.
b o ok
Does not finish question or answer 0 1
b o o
e/ e 4.5 Delirium prevention
e / e Gives answer that do not fit the question 0 1
e /e
://t . m
It is important to maximize nonpharmacological attempts
Reacts slowly to instructions 0
: / / t .
1
m
ttps tps
to prevent or minimize delirium by all healthcare providers, Thinks they are somewhere else 0 1
ht
since treatment strategies are less effective and more harm-
h
ful than preventive measures.
Knows which part of the day it is
Remembers recent events

1
1
0
Prevention is based upon four principles: Is picking, disorderly, restless 0 1
rs rs
Pulls intravenous tubing, feeding tubes, catheters etc 0 1
• Avoid triggers and worsening factors
k e • Identify and treat possible causes

ke
Is easily or suddenly emotional 0 1
eb oo • Start mobilization and rehabilitation early in a support-
e b oo
Sees/hears things which are not there 0 1
b o o
e/e
ive environment to avoid further physical and cogni-
e / tive decline
m e / Table 1.14-2 Delirium Observation Screening Scale [12]. Patients
m
: / /t .
• Prevent/control potentially injurious behavior with a score of 5 or more are considered high-risk patients.
// t .
s ps:
Abbreviation: DOSS, Delirium Observation Screening Scale.
h t t p htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m
For most FFPs, pharmacological prevention using haloper- e / reactions to benzodiazepines, including w
orsening confusion,
t . m e/e
s: / / / /
ps:
didol, atypical neuroleptics or rivastigmine is not recom- and this class of medication should generally be avoided.
http htt
mended, with only one study suggesting that the use of low
dose haloperidol or atypical neuroleptics preoperatively may After initiation of therapy, pharmacological delirium treat-
reduce the length and severity of delirium. ment should be reviewed for discontinuation as soon as
possible. Improvement can be suggested by repeat clinical
Specific pharmacological prevention for some individual examinations and use of the validated tools noted earlier,
e s
high-risk patients can be considered, after risks and benefits
r
have been carefully considered [13].
er s
eg, DOSS. Consultation with geriatric or psychiatric teams
may be necessary for complicated or high-risk cases.
b o ok 4.6 Delirium treatment

bo ok b o o
e/ e There are no large placebo-controlled randomized trials that
e/ e Medication Dosage Comment
e/e
: // .m
recommend the use of antipsychotics to treat hyperactive
t
delirium. If nonpharmacological measures fail to keep the
Haloperidol 0.25–0.5 mg oral or
intramuscular every 6 hours
/ t .m
• Increase in side effects > 3 mg/d
: /
• Avoid in patients with Parkinson’s
s tps
http
agitated patient and the treating staff safe, both the Amer- as needed disease
ht
• Toxicity: QTc prolongation, sedation,
ican Geriatrics Society [14] and the National Institute for extrapyramidal side effects
Health and Care Excellence guidelines [15] state that the Risperidone 0.25–1 mg repeated every • Toxicity: QTc prolongation, sedation,
prescription of a low dose of any antipsychotic drug for a 12 hours as needed extrapyramidal side effects
short period may be considered (Table 1.14-3). Quetiapine 12.5–25 mg every 8 hours • Can be used in Parkinson´s disease
as needed • Toxicity: QTc prolongation, sedation,
e r s
No adequately controlled trials support the use of benzodiaz-
e r s extrapyramidal side effects
ook ok
Olanzapine 2.5 mg to 5 mg every • Toxicity: QTc prolongation, sedation,
b
epines in the treatment of most cases of delirium, with excep-
tions for delirium clearly linked to alcohol withdrawal or ben-
b o 12 hours as needed extrapyramidal side effects
b o o
e / e zodiazepine withdrawal. Many older adults have paradoxical
e/ e Table 1.14-3 Pharmacological treatment for delirium [16].
e/e
/ / t . m / /t . m
5 References
htt ps: htt ps:
1. Inouye SK. Delirium in older 7. Fong TG, Tulebaev SR, Inouye SK. 12. Schuurmans MJ, Shortridge-
persons. N Engl J Med. Delirium in elderly adults: diagnosis, Baggett LM, Duursma SA. The Delirium
2006 Mar 16;354(11):1157–1165. prevention and treatment. Nat Rev Observation Screening Scale:
2. de Lange E, Verhaak PF, van der Meer K. Neurol. 2009 Apr;5(4):210–220. a screening instrument for delirium.
e rs Prevalence, presentation and prognosis 8. Cromwell DA, Eagar K, Poulos RG.
e r s Res Theory Nurs Pract.
ok ok
of delirium in older people in the The performance of instrumental 2003 Spring;17(1):31–50.
b o
population, at home and in long term
care: a review. Int J Geriatr Psychiatry.
activities of daily living scale in
b o
screening for cognitive impairment in
13. Gosch M, Nicholas JA. Pharmacologic
prevention of postoperative delirium.
b o o
e/ e 2013 Feb;28(2):127–134.
3. Siddiqi N, House AO, Holmes JD.
e / eelderly community residents. J Clin
Epidemiol. 2003 Feb;56(2):131–137.
Z Gerontol Geriatr.
2014 Feb;47(2):105–109.
e /e
Occurrence and outcome of delirium in
medical in-patients: a systematic
://t . m9. Inouye SK, Westendorp RG,

Saczynski JS. Delirium in
/ / t .
14. American Geriatrics Society Expert
Panel on Postoperative Delirium in
: m
2006 Jul;35(4):350–364.
t t p s
literature review. Age Ageing. elderly people. Lancet.
2014 Mar 8;383(9920):911–922.
tps
Older Adults. Postoperative delirium in
older adults: best practice statement
h
4. Marcantonio ER. Postoperative
delirium: a 76-year-old woman with
delirium following surgery. JAMA.
2012 Jul 4;308(1):73–81.
10. Vochteloo AJ, Moerman S,
van der Burg BL, et al. Delirium risk
screening and haloperidol prophylaxis
program in hip fracture patients is a
ht
from the American Geriatrics Society.
J Am Coll Surg.
2015 Feb;220(2):136–148.e1.
15. Young J, Murthy L, Westby M, et al.
5. Ferri CP, Prince M, Brayne C, et al. helpful tool in identifying high-risk Diagnosis, prevention, and
Global prevalence of dementia: patients, but does not reduce the management of delirium: summary
k e rs a Delphi consensus study. Lancet.

2005 Dec 17;366(9503):2112–2117. 2011 Aug 11;11:39.
ke rs
incidence of delirium. BMC Geriatr. of NICE guidance. BMJ.
2010 Jul 28;341:c3704.
oo oo o
6. American Psychiatric Association, ed. 11. Wei LA, Fearing MA, Sternberg EJ, et al. 16. Fruhwald T, Weissenberger-Leduc M,
eb
Diagnostic and statistical manual of mental The Confusion Assessment Method:
e b
Jagsch C, et al. Delir: eine
b o
e/e
disorders. 5th ed. Arlington: American a systematic review of current usage. interdisziplinäre Herausforderung
e / Psychiatric Association; 2013.
m e /
J Am Geriatr Soc.
2008 May;56(5):823–830.
[Delirium: an interdisciplinary
m
challenge]. Z Gerontol Geriatr.
/ /t . / t .
2014 Jul;47(5):425–438; quiz 439–440.
/
ps: ps:
German.
htt htt 113
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
1.14 Delirium
k e rs ke rs
e b oo e boo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e boo b o o
/ / e/e
e
Section
p s: / / t . m 2 e
ps: / / t . m
htt htt
rs
Improving r s
the
system of care
ok e o k e o
eb o e bo eb o
e/ t .m e /
t .m e /
s : // s : / /
http http
e r s e r s
e /
t . me/ t . m e/e
/ / / /
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t .m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
e rs e rs
e b oo Section 2
k
e b oo k
b o o
e / Improving the system
t . m e / of care
t . m e/e
: / / / /
h t t p s
htt ps:
e rs 2.1 Models of orthogeriatric care

er s 117
b o ok o
2.2 Overcoming barriers to implementation of a care model
b ok b o o
e / e Stephen L Kates
e/ e 129
e/e
2.3 Clinical practice guidelines
: // t .m
Stephen L Kates, Michael Blauth 133
: / / t .m
ht tps
2.4 Elements of an orthogeriatric comanaged program
Carl Neuerburg, Christian Kammerlander 137 ht tps
2.5 Adapting facilities to fragility fracture patients
Edgar Mayr 145
e r s 2.6 Orthogeriatric team—principles, roles, and responsibilities
e r s
ook ok
Markus Gosch, Michael Blauth 151
b 2.7 Protocol and order set development

b o b o o
e / e Stephen L Kates, Joseph A Nicholas
e/ e 157
e/e
t . m
2.8 Fracture liaison service and improving treatment rates for osteoporosis
/ / / /t . m
ps: ps:
Paul J Mitchell 165
htt
2.9 Use of registry data to improve care
Colin Currie 173 htt
2.10 Lean business principles
Stephen L Kates, Andrew J Pugely 181
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t .m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
116
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
2.1 Models of orthogeriatric care
/ / / /
htt ps:
htt ps:
e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e On the other hand, these metaanalyses emphasize the lim-
e/e
: // t .m
The growing awareness of the consequences of hip and
: / / t .m
itations of available studies and the need for well-designed
RCTs with standardized end points, complete reporting, and
ht tps
other fragility fractures, the expected rise in the total num-
ber of osteoporotic fractures worldwide, and improvements
in surgical techniques have led to the development and ht tps
inclusion of functional outcomes [6, 7].
This chapter provides a brief description of the models im-

implementation of alternative models of care for the acute plemented in the last 20 years, describes their potential
and postacute management of older adults with fractures benefits on short-term and long-term outcomes, defines the
[1–5]. strengths and limitations of these models, highlights the
e r s e r s
areas of uncertainty, and considers the future of orthogeri-
ook ok o
These services seek to achieve the following major goals: atric care.
e b e b o b o
e / •
•
Improve functional and clinical outcomes
Minimize in-hospital complications
t . me/ 2
m
ariables involved in the implementation of
V
t . e/e
• Streamline hospital care
: / / orthogeriatric care models
/ /
•
•
Promote early discharge
h t t p s
Reduce direct and indirect healthcare costs 2.1
htt ps:
Which patients should be targeted?
Theoretically, all older adults presenting with hip or other
The main features that distinguish these innovative models disabling fragility fractures (eg, ankle) should be managed
of care from the traditional ones are: within an orthogeriatric service unit. Randomized controlled
trials and before-after observational studies include primar-
e rs
• A multidisciplinary and interprofessional team of
r s
ily hip fracture patients older than 65 or 70 years [4, 5]. In
e
b o ok healthcare professionals that share responsibilities for
the patient
b o ok
some cases, it has been proposed to include subjects older
than 70 years presenting with relevant comorbidities and
b o o
e/ e / e
• The organization of an orthogeriatric service unit [4, 5]
e
any patients older than 80 years. Indeed, the characteristics
of the patients eligible for an orthogeriatric service unit
e /e
://t . m
It is not possible to define the single best model of care for
/ t .
should be based also on the available resources, since the
: / m
t t p s
fragility fracture patients (FFPs) based on evidence. How-
tps
setting of a given criterion may significantly influence the
ht
ever, randomized controlled trials (RCTs) and before-after volume of patients.
h
observational studies have demonstrated superior outcomes
for organized, sophisticated multidisciplinary programs when There are no established criteria from the available literature,
compared to the traditional models [4–8]. and, due to the small number of RCTs, cost-effectiveness
analyses are lacking. Moreover, the baseline characteristics
k e rs
A number of reviews and two metaanalyses support these
conclusions, demonstrating a trend toward better short-term
ke rs
of hip fracture patients are of limited benefit in identifying
subjects at greatest risk of adverse outcomes, given the high
eb oo and long-term outcomes with the more recent models based
e b oo
degree of frailty in almost all FFPs. Therefore, we believe
b o o
e/e
on geriatric orthopedic comanagement [4–9]. In particular, that orthogeriatric services should make an effort to include
e / e /
the results of two metaanalyses demonstrate that most mod-
m
all older adults with hip or other disabling fractures by op-
m
/ /t .
els are able to reduce length of hospital stay (LOS), time to timizing the resources available.
// t .
ps: ps:
surgery, and, in some but not all studies, mortality [6, 7].
htt htt 117
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
Section 2 Improving the system of care
k e rs ke rs
e b oo e b oo b o o
e / 2.2
t
Responsibility and leadership—who is in charge?
. m e / • In both the traditional model (Fig 2.1-1a) and the routine
t . m e/e
s: / / / /
ps:
The multidisciplinary approach is now the gold standard in geriatric consultation model (Fig 2.1-1b), the primary re-
http htt
the care of older adults presenting with hip or other osteo- sponsibility for oversight and coordination lies with the
porotic fractures. The basic multidisciplinary team of these orthopedic surgical staff.
orthogeriatric models includes an orthopedic surgeon, a • The comanaged care model is characterized by the co-
geriatrician or internist, an anesthesiologist during the peri- management of the fracture patient by the geriatrician
operative phase, and other healthcare providers, such as a and the orthopedic surgeon, with shared responsibility
e s
physiotherapist, clinical nurse, nutritionist, and a social
r
worker, during the acute and postacute phases [4]. Direct
er s
and leadership from admission to discharge (Fig 2.1-1c).
• Finally, geriatrician leadership distinguishes the third
b o ok communication, scheduled meetings, and written orders

are the usual way to share information and communicate
bo ok
model, usually referred to as the geriatric-led model
(Fig 2.1-1d–e).
b o o
e/ e between team members, even if, in some cases, a skilled
e/ e e/e
: //
of care and fostering communications between profession- .m
care manager takes on the role of coordinating the pathway
t 2.3 Time to surgery
:
Recent data and metaanalyses support the beneficial effect
/ / t .m
s tps
http
als [4, 10]. of early surgery in the management of older adults present-
The main difference between the variety of orthogeriatric

models concerns which professional discipline retains the
ht
ing with hip fractures [4, 5, 11]. Indeed, there is no clear
definition of early surgery, since, in the various studies, it
has been defined as “within 24 hours”, “within 48 hours”
primary responsibility for the management of the patients or even “as soon as medical conditions are stable” [4, 5, 11].
throughout the care pathway (Fig 2.1-1) [4, 5]: Although the meaning of “early surgery” is debatable, guide-
e r s e r s
lines suggest that medically stable patients should undergo
ook ok o
surgery as soon as possible, while unstable ones should be
e b e b o quickly optimized to avoid detrimental delays [5, 11].

b o
e /
t . m e/ t . m e/e
/ / / /
Traditional model
htt
Consulting physicians
ps: Geriatric consultation model
htt ps:
Orthogeriatric comanagement model
Anesthes. Anesthes.
Orthopedic-geriatric
Anesthes.
leadership
e rs Orthopedic surgeon leadership Orthopedic surgeon leadership
e r s
ok ok
Geriatrician Geriatrician
b o
a b
b o
c
b o o
e/ e Orthopedic unit
e / e Orthopedic unit Orthopedic unit—Orthogeriatric unit
e /e
Geriatric-led model
://t . m Geriatric-led model
: / / t . m
t t p s tps
ht
Anesthes.
h
Geriatric leadership
Preoperative
phase Geriatric leadership
Orthopedic surgeon Orthopedic surgeon
k e rs
d
Orthopedic unit—Orthogeriatric unit
e
DEU-ICU
ke rsGeriatric unit
eb oo b oo
Fig 2.1-1a–e Models of orthogeriatric care for the management of the older adults presenting with hip fracture. The models distinguish
e b o o
/ / e/e
themselves by the team of different healthcare professionals that retain the responsibility for managing the patients throughout the care
e t . e
pathway. The setting of the care is described at the bottom of each figure.
m t .m
/
Abbreviations: Anesthes, anesthesiologist; DEU-ICU, Department of Emergency Unit-Intensive Care Unit.
/ //
htt ps: htt ps:
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / The recognition of hip fracture as an urgent scenario requir-
t . m e /
t . m
In general, there is an inverse relationship between LOS e/e
s: / / / /
ps:
ing early surgery has significantly impacted the organization and rate of transfer to rehabilitation services in the com-
http htt
and implementation of the orthogeriatric models. In an munity (Fig 2.1-2):
ideal model, the patient may be transferred directly to the
operating room from the emergency department and admit- • Models characterized by short LOS require the support
ted to a hospital ward only after surgical repair. The feasibil- of postdischarge rehabilitation services, with the ability
ity of this approach has been tested in a study undertaken to take care of the patients undergoing early discharge,
e s
at the Pitié-Salpêtrière Hospital in Paris, where the FFPs,
r
following a fast-track procedure, are quickly repaired and
er s
and community rehabilitation. In the US, where the LOS
for hip fracture has decreased dramatically over the last
b o ok are postoperatively admitted to a dedicated geriatric unit

within 1–2 days from their arrival in the emergency depart-
bo ok
20 years to a national average of 6.3 days [13, 14], patients
are usually discharged on the third postoperative day if
b o o
e/ e ment (Fig 2.1-1e) [12]. Although at least in part still theo-
e/ e they are clinically stable and able to transfer from bed to
e/e
retical, it is highly probable that this approach will signifi-
cantly affect the development of orthogeriatric models in
: // t .m : / / .m
a chair with assistance. In these circumstances, more than
t
70% of hip fracture patients should be transferred to
the near future.
In conclusion, early surgery appears to produce potential ht tps ht tps

inpatient rehabilitation or community skilled nursing
facilities (SNFs) to continue rehabilitation. A similar pic-
ture has been observed in other countries where the LOS
advantages in the management of older adults with hip is less than 1 week [12, 15, 16].
fractures, without significant risks for the patients, and it is • The opposite scenario is typically represented by the UK
the most ethical and humane approach to deal with FFPs. system, where patients complete functional recovery dur-
e r sTherefore, all orthogeriatric models should clearly support

e r s
ing the hospital stay [17–20]. Although decreasing in recent
ook ok o
this goal, addressing underlying problems and identifying years, the mean LOS in the UK remains more than 20 days,
e b solutions through intensive teamwork involving physicians

e b o as less than 30% of hip fracture patients are discharged
b o
e / and hospital management staff.
t . m e/ to rehabilitation facilities [18, 19].
t . m
• In between these two scenarios are most European (and e/e
2.4 ength of hospital stay, early and late
L
/ / / /
some other) countries with LOS between 10 and 15 days
rehabilitation
In many countries, orthogeriatric models of care have also
been influenced by the need to reduce acute hospital stay htt ps: htt ps:
[21–31]. In the European models, the rehabilitation is usu-
ally broken down into two phases, ie, early rehabilitation
that occurs during hospital stay and late rehabilitation
and promote early discharge, and by the availability of re- that takes place after discharge.
habilitation facilities in the community. Even when strate-
gies to reduce the LOS are implemented, LOS is largely The rehabilitation program and discharge planning should
e rs
dependent on the features of the local healthcare system
r s
be the result of a comprehensive evaluation involving the
e
b o ok and often related to local organizational factors [4].
b o ok
different members of the orthogeriatric team. To optimize
use of resources, the orthogeriatric team should also decide
b o o
e/ e e / e which patients are most likely to benefit from using reha-
bilitation.
e /e
100
://t . m : / / t . m
Rate of patients transferred to rehab services, %
USA
t t p s tps
ht
USA
80 NL
h
USA
AUS
F
E
60
AUS
CDN
DK I
kers rs
IRL
40 Fig 2.1-2 Inverse relationship between length of hospital stay and
o
NL CDN
AUS
ke
rate of transfer to rehabilitation services in the community examined
oo o
B
/eb o 20
UK
e b
by different published studies.
Abbreviations: d, days; rehab, rehabilitation;
b o
/ e/e
IL
e 0
0 5 10 15
t . m 20 e
25 30
AUS, Australia [16, 27, 28]; B, Belgium [23]; CDN, Canada [25, 26];
t m
DK, Denmark [31]; E, Spain [21]; F, France [12]; I, Italy [29, 30];
.
s: / / //
IL, Israel [20]; IRL, Ireland [22]; NL, the Netherlands [15, 24];
ps:
Length of acute hospital stay, d UK, United Kingdom [18, 19]; USA, United States of America [13, 14].
http htt 119
rs rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 2.5 Case volumes
t . m e / 3 Models of orthogeriatric care
t . m e/e
s: / / / /
ps:
A positive relationship between case volume and improved
http htt
outcomes has been shown for a wide range of surgical pro- 3.1 General considerations
cedures across a variety of specialties [4]. In particular, Innovative models of care for the management of FFPs have
higher surgeon and hospital procedure volumes have been been developed and implemented over the past 30 years,
associated with lower mortality rates, fewer complications, with the first RCT comparing a traditional model with an
and shorter LOS [4]. A minimum of 100 cases per year has orthopedic geriatric inpatient service published by Gilchrist
e rs
been suggested to develop sufficient expertise in managing
FFPs and to adopt an efficient orthogeriatric model of care
er s
et al in 1988 [35].
b o ok [4, 32]. There are no studies to clearly define a precise min-

imum caseload.
bo ok
High-level evidence establishing superiority of any specific
model is still limited. Ideally, several features of these in-
b o o
e / e e/ e novative models of care would be compared and clarified
e/e
: / .m
In the case of hip fractures, current literature [4, 32–34] offers
/ t
conflicting results about the optimum number of cases re-
by head-to-head RCTs. One example where this approach
would be helpful concerns the creation of an emergency
: / / t .m
ht tps
quired to implement a successful fragility fracture program.
Some additional considerations include:
ht tps
department “fast track” for FFPs. While the evaluation and
optimization of patients within the emergency department
by the emergency staff or multispecialty team can reduce
• Even if a precise minimum number of cases needed to time to surgery, and, theoretically, improve in-hospital out-
implement a service for the management of FFPs cannot comes, this has not been demonstrated. Without clear evi-
be defined, low-volume hospitals are at risk for suboptimal dence of benefit, it can be difficult to justify the costs of staff
e r s outcomes.
e r s
reorganization and changes in workload and workflow.
ook ok o
• Both the acute care ward volume and the rehabilitation
e b unit volume may be relevant.

e b o 3.2 Traditional model
b o
e /
t . m e/
• The concentration of orthogeriatric services in high-vol-
ume hospitals may have significant implications in the
In the traditional model, the key elements are:
t . m e/e
/ /
(re)distribution of resources, (re)organization of health- • The patient is managed on a general orthopedic ward.
/ /
htt ps:
care, and costs in developed countries.
htt ps:
• The orthopedic service holds primary responsibility for
inpatient plan of care while nonsurgical concerns and
complications are dealt with by consultative medical ser-
vices upon request (Fig 2.1-1a) [4, 5, 8].
• The medical physician is only involved when requested
by the orthopedic service.
e rs e r s
• Early rehabilitation typically takes place on the orthopedic
b o ok b o
ward.
ok
• The patient is discharged directly home, to an SNF, or to
b o o
e/ e e / e a rehabilitation facility, without strong emphasis on con-
tinuity of care and careful handoffs.
e /e
://t . m : / / t . m
t t p s tps
While several lines of evidence have demonstrated that this
ht
approach is appropriate for younger adults presenting with
h a simple traumatic fracture, it is not adequate for the man-
agement of the complex needs of FFPs [1–5]. As a result,
several care models involving collaboration between ortho-
pedic surgeon and geriatrician have been developed [4, 5].
k e rs ke rs
The first models introduced were simple variations of the
traditional model. They were characterized by routine input
eb oo e b oo
from a specific consultant team of different professionals,
b o o
e/e
with the overall responsibility of the care remaining with
e / m e / the orthopedic surgical staff.

m
/ /t . // t .
htt ps: htt ps:
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
Over the years these models evolved and were replaced by
t . m
The implementation of a geriatric consultant team on the e/e
s: / / / /
ps:
multidisciplinary and coordinated approaches that have been orthopedic ward seems to add some benefits to the tradi-
http htt
demonstrated to be more effective to meet patients’ complex tional model of care, but only when the consultant team is
needs. These experiences have been designated with differ- involved early in the process of care. These benefits are
ent names, such as orthogeriatric units (OGUs), comanaged probably related to an earlier identification of common is-
geriatric fracture centers, or geriatric hip fracture clinical sues and complications compared to the traditional model
pathways, which in most cases distinguish unique models [8]. However, the absence of an active, integrated, and co-
e s
in terms of setting and organization. The common goals of
r
most of these models were to define a multidisciplinary team
er s
ordinated interdisciplinary care can increase the risk of de-
lays or errors, produce a detrimental fragmentation of care,
b o ok dedicated to the surgical and medical care of FFPs, to pro-

mote rapid management of the comorbid medical conditions,
bo ok
and compromise an early and adequate discharge [4, 8].
b o o
e/ e e/ e
early surgical repair, mobilization and rehabilitation, coor- 3.4 Orthogeriatric comanaged care
e/e
: // t .m
dinated discharge planning, and continuity of care [4].
: / / .m
This is probably the most sophisticated and complex model
t
implemented for the management of older adults with frac-
tps
Although a variety of experiences have been described,
ht
nontraditional services can be summarized by the following
models (Fig 2.1-1b–e). ht tps
tures. The geriatric fracture center developed at the Univer-
sity of Rochester (New York) is the reference model of the
orthogeriatric comanaged care [14, 32], and it has been ad-
opted by many other hospitals, mainly in North America and
3.3 Geriatric consultant in the orthopedic ward Europe [3, 15, 17, 22, 24, 31, 36–42]. This model has evolved over
The geriatric consultant in the orthopedic ward model is the the last 10–15 years with gradual improvements over time.
e r s
simplest model [4, 5, 8].
e r s
ook ok o
Its key elements are:
e b The key elements are:

e b o b o
e / m
• The patient is managed on the orthopedic ward.
t . e/ • The patient is managed on the orthopedic ward or ortho-
geriatric unit.
t . m e/e
/ /
• The overall responsibility of the care is under the
/ /
• Co-ownership—the orthogeriatric team shares respon-
orthopedic surgical staff.
htt ps:
• A geriatric consultant is involved either preoperatively
or postoperatively. htt ps:
sibility and leadership from admission to discharge [4, 8].
• An interdisciplinary team including several healthcare
professionals skilled in the care of FFPs supports this co-
• A multidisciplinary team holds regular rounds to develop direction, working in close and integrated collaboration.
and monitor treatment plans of all FFPs on the ward. Al- • Standardized patient-centered, protocol-driven treat-
though many relevant clinical services may participate, ments and pathways are implemented.
e rs these are typically not coordinated or integrated, and do

r s
• Geriatrician and surgeon visit the patient daily, write their
e
b o ok not clearly impact the overall plan of care.
• Prevention and management of common problems and
b o ok
own orders, and communicate frequently, sharing their
opinions and choices with the other members of the in-
b o o
e/ e / e
complications are based on the individual choices of the
surgeon or geriatric consultant.
e
terdisciplinary team. This approach reduces the risk of
delays, inappropriate variations in care, and iatrogenic
e /e
://t . m / t . m
errors, and it promotes clinical coordination. Even tradi-
: /
t t p s
This model and closely related variations have been inves-
tps
tionally surgical issues like evaluation of surgical fitness,
ht
tigated with the largest amount of studies including RCTs. timing of procedure, and preoperative planning are usu-
h
Interpretation of the results of these trials is limited by the
huge heterogeneity in design and outcomes, the small sam-
ally shared and discussed between both the medical and
surgical service to optimize the management of the patients.
ple sizes, and the absence of long-term follow-up [4–7].
The beneficial effects on short-term and long-term func-
k e rs
Significantly improved outcomes compared to usual care
could not be demonstrated when the consultant team’s con-
ke rs
tional and clinical outcomes of this innovative model have
been illustrated in a number of well-designed before-after
eb oo tribution started postoperatively [4]. Slightly better results
e b oo
observational studies and RCTs, in their reviews, and meta-
b o o
e/e
were reported with involvement of the geriatric consultant analyses [4–7, 43]. Table 2.1-1 and Table 2.1-2 describe most
e / e
team at the time of admission and in models with daily
m / relevant studies published in the last 15 years. Trials are
m
/ /t .
medical visits [4]. This approach reduced the LOS and the
t .
heterogeneous in terms of design, duration of follow-up,
//
ps: ps:
number of medical complications. and outcomes considered.
htt htt 121
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / In most of the studies, the implementation of a comanaged
t . m e / In conclusion, the orthogeriatric comanaged care service
t . m e/e
s: / / / /
ps:
care model for FFPs demonstrates a clinically significant represents a valuable and more effective alternative to the
http htt
reduction in both short-term and long-term adverse events. traditional approach to inpatient management of FFPs. Un-
Compared to the traditional model, the comanaged care fortunately, there are no published head-to-head RCTs
model has been shown to improve many short-term out- comparing this model with the geriatric consultant in the
comes, including length of stay, time to surgery, in-hospital orthopedic ward service. The fully implemented model re-
complications, and in-hospital mortality. Specifically, three quires considerable effort, consistent administrative support,
e s
of five studies demonstrated a significant decrease in the
r
incidence of in-hospital complications [14, 37, 41], and four
er s
strong physician leadership, and a commitment to continu-
ous quality improvement. Given the relevant resources
b o ok well-designed trials reported a significant reduction of in-

hospital mortality [3, 15, 40, 41].
bo ok
needed to implement an orthogeriatric comanaged care
model, additional studies are warranted for a better under-
b o o
e/ e e/ e standing of its impact on long-term functional outcomes,
e/e
: // t .m
Few long-term trials have been published (Table 2.1-2), with
inconsistent and sometimes skewed results. In these studies,
to evaluate its cost-effectiveness, and whether this service
is translatable and applicable to any hospital organization
: / / t .m
tps
this model has been shown to increase long-term survival,
ht
and possibly improve functional recovery compared to the
traditional model. For example, in three studies (ie, one
and framework [4].
3.5 ht tps
eriatric-led fracture service with orthopedic
G
RCT and two before-after trials), the 1-year survival rates consultant
were about 10% higher in the orthogeriatric comanaged The key elements of this model are:
care group than in the controls [3, 22, 41]. Vidan et al [41]
e r salso reported, after adjustment for confounding variables,

e r s
• The geriatric ward is under the leadership of the geriatri-
ook ok o
a 45% lower probability of death or major complications, cian [4, 5, 43]. Usually, the FFP is admitted directly from
e b and a significantly greater functional recovery at 3 months.

e b o the emergency department, evaluated and prepared for
b o
e /
t . m e/ surgery in the geriatric ward, transferred to the operating
room, and then returned to the geriatric ward.
t . m e/e
/ / / /
htt ps:
Khan et al Khasraghi Friedman Gonzalez- Folbert et al Biber et al htt
Zeltzer et al
ps:
Bhattacharyya Flikweert
[36] et al [37] et al [14] Montalvo [24] [39] [40] et al [17] et al [15]
et al [38]
Study design Before-after Before-after Retrospective Randomized- Before-after Before-after Retrospective Before-after Before-after
e rs prospective prospective cohorts controlled

r s
prospective
e
retrospective multicenter prospective prospective
ok ok
Country United United States United States Spain Netherlands Germany Australia United Kingdom Netherlands
b o Number of Intervention
Kingdom
208 273
b o 193 101 140 114 4,575 249 256
b o o
e/ e patients Control 537 237
e / e 121 123 90 169 5,026 274
e
145
/e
Mean age, y Intervention
Control
82
81
://t . m
80
80
85*
82
85
87
81
82
82
82
84
84
://t.
83
83
m78
80
In-hospital Intervention
t t p s 11.1 NA 1.6 5.9 5.0 4.4
t t p
6.5*
s 8.4 2.0*
mortality, %
Length of stay
[mean days
Control
h
Intervention
10.4
27 (23)
NA
6 (NR)*
2.5
5 (3)* 12 (4)*
6.5 8.9
11 (7–18)
5.9
14 (7)* h
30 (23)*
8.1 12.4
20 (NR)
5.5
7 (6–10)*
Control 26 (26) 8 (NR) 8 (6) 18 (8) 12 (6–20) 17 (10) 29 (30) 25 (NR) 11 (7–16)
(SD or IQR)]
Time to surgery Intervention NA 1.1 (NR)* 1.0 (0.7)* 5 (3–6)* NR 2.1 (1.8)* 1.8 (2.7) NR NR
kers kers
[mean days Control NA 1.9 (NR) 1.6 (2.7) 6 (5–9) NR 3.1 (4.6) 1.7 (13.2) NR NR
(SD or IQR)]
b o o In-hospital
complications, %
Intervention
Control
NA
NA
36*
51
31*
46
b o o NA
NA
NR
NR
NA
NA
NA
NA
NA
NA
51
49
b o o
e /e m e /e
Table 2.1-1 Studies evaluating the in-hospital beneficial effects of a comanaged care service in the management of hip fractures in older adults.
m e/e
t . t .
s:// /
Abbreviations: IQR, interquartile range; NA, not assessed; NR, data assessed but not reported; SD, standard deviation.
* Significant difference between intervention and control.
ps: /
122
http htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t .
• The geriatrician, as the primary attending physician for
m e /
t . m
The first geriatric-led fracture service with an orthopedic e/e
s: / / / /
ps:
all patients from hospital admission to discharge, plays a consultant dedicated to older adults presenting with hip
http htt
central role. He/she evaluates the patient on admission fractures was implemented at the Sheba Hospital in Tel Aviv
and during the in-hospital stay, coordinates the timing in 1999 [20, 44, 45]. This experience was unique since the
of surgery, procedures, diagnostics, treatments, and tran- patient was cared for throughout the acute and postacute
sition/discharge planning. rehabilitative phases in the same setting, with an overall
• The geriatrician, orthopedic surgeon, and anesthesiologist high LOS. In the most recent experiences, the geriatric-led
e rs manage the patients together in the perioperative phase.

In the postoperative phase, the orthopedic surgeon is a
er s
fracture service was restricted to the acute phase, followed
by an early transfer to a community SNF for further reha-
b o ok consulting physician who follows the patients until com-

plete wound healing.
bo ok
bilitation, with the attention focused on reducing the time
to surgery and LOS [12, 46–48].
b o o
e/ e • An interdisciplinary team, including different healthcare
e/ e e/e
in the care of the patients.
: // t .m
professionals, is integrated in the service and participates
: / / .m
Actually, the relevant difference in the organization of the
t
postacute phase seems to be attributable to the organization
s tps
http
• Standardized orders and protocols are implemented. of the healthcare system in the country where the program
On the basis of the clinical/rehabilitative pathway following

these preoperative and perioperative phases, different ex-
ht
is adopted, to the resources available, and to the main objec-
tives of the program. For example, in the Sheba model all
the care takes place in the same setting with the same in-
periences have been described [4]. tensity of care [20, 44, 45]. This is a strong point, producing
e r s e r s
e b ook Vidan et al [41]
e b o
Barone et al [3]
ok Cogan† et al [22] Gregersen et al [31] Watne et al [42]
b o o
/ / e/e
Study design Randomized Before-after Before-after Before-after Randomized
e . m e
controlled prospective retrospective retrospective controlled
. m
://t /t
Country Spain Italy Ireland Denmark Norway
Number of patients
p s
Intervention 155 272 98 233
ps: / 163
Mean age, y
h t t
Control
Intervention
Control
164
81
83
252
84
84
103
82*
75
htt
262
83
82
166
84
85
In-hospital mortality, % Intervention 0.6* 4.8* 8.2 7.7 3.7
Control 5.5 9.9 20.4 6.1 1.8
k e rs
3- or 4-month mortality, % Intervention
Control
NR
NR
NR
NR
k e r s NR
NR
16.3
14.9
17.2
14.5
b o o 12-month mortality, % Intervention 18.9
b o o
25.0* 33.7 NA 28.2
b o o
e/e /e /e
Control 25.6 35.3 44.6 NA 25.9
3- or 4-month readmission, % Intervention
. me NA NA NA 12.9
.
17.4
m e
://t / t
Control NA NA NA 12.2 17.4
: /
ttps tps
Length of stay Intervention 16 (5) 21 (11) 30 (NR) 13 (NR)* 11 (8–15)*
[mean days (SD or IQR)]
ht
Control 18 (8) 21 (13) 23 (NR) 15 (NR) 8 (5–11)
Time to surgery
[mean days (SD or IQR)] hIntervention
Control
3.2 (1.8)
3.3 (2.2)
NA
NA
1.9 (0.9)
1.9 (1.9)
0.9 (0.8)*
0.7 (1.0)
1.1 (0.7–1.8)
1.0 (0.7–1.6)
In-hospital complications, % Intervention 45* NA NA NA 44
Control 62 NA NA NA 46
kers kers
Functional status recovery Intervention 57* NA NA NA NA
3 month, % Control 44 NA NA NA NA
b o o b o o
Table 2.1-2 Studies evaluating the short- and long-term beneficial effects of a comanaged care service in the management of hip fractures in
b o o
e /e older adults.
m e/e
Abbreviations: IQR, interquartile range; NA, not assessed; NR, data assessed but not reported; SD, standard deviation.
t . t .m e/e
/
/ //
ps: ps:
†
The authors did not report the statistical significance in the between-groups comparisons.
htt htt 123
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m
continuous geriatric supervision for the prevention of com- e / However, none of the trials published to date report a sig-
t . m e/e
s: / / / /
ps:
mon geriatric syndromes, and reducing the detrimental ef- nificant beneficial effect on short- and long-term mortality.
http htt
fects of fragmentation of care. On the other hand, it seems Interestingly, Miura et al [46] demonstrated a significant
that this model design may be not acceptable (in terms of reduction in the direct and indirect costs when the geriatric
costs and resources) for the healthcare systems of most Eu- leadership was implemented only for the acute phase and
ropean countries or in the US, where the trend in the last followed by early discharge.
10 years has been to separate the settings of the acute and
k e rs intermediate care to appropriately use available resources

and reduce costs.
er s
In conclusion, on the basis of the few papers published, a
geriatric-led fracture service with orthopedic consultant ap-
o o o ok
proach seems feasible, applicable, and efficacious in terms
o o
e/eb b b
depicts relevant studies designed to evaluate the of functional outcomes when the overall care takes place
Table 2.1-3
geriatric-led fracture service [12, 45–49]. In contrast to the
e/ e in the same setting with the same intensity of care. The
e/e
: // t .m
wealth of data published for the other models described,
information regarding the efficacy of the geriatric-led fracture
beneficial effects of models in which the geriatric leadership
: / /
is limited to the acute phase still need to be established, in t .m
ht tps
service is relatively limited. The model originally proposed
by Adunsky et al [44] has been shown in one study to improve
long-term functional outcomes and in other studies to reduce
in many health systems.
ht tps
light of the common separation of acute and postacute care
time to surgery and hospital stay compared to the tradi-

tional orthopedic-centered approach [12, 45–49].
e r s e r s
e/e
Stenvall et al [49] Miura et al [46] Adunsky et al [45] Della Rocca et al Boddaert et al Gupta [48]
e / m e/ [47] [12]
m
Study design
: / / t
Randomized
. Before-after† Retrospective Before-after Prospective
/ /t . Before-after†
ps:
controlled prospective cohort retrospective cohorts prospective
Country
t p s Sweden United States Israel United States France United Kingdom

Number of patients
Mean age, y
h t
Intervention
Control
Intervention
102
97
82
91
72
80
847
2,267
82*
115
82
31 htt 203
131
86
259
235
81
Control 82 81 81 82 85 82
In-hospital mortality, % Intervention 5.9 NA 1.9 4.3 3.0 NA
e rs Control 7.2 NA
e r s
3.0 9.7 7.6 NA
b o ok Long-term mortality, % Intervention

Control
15.7
18.6
b o
NA
NA ok 14.8
17.3
31.3
45.2
14.3
23.7
NA
NA
b o o
e/ e Length of stay [mean Intervention
e /
30 (18)*
e 5 (1)* 32 (20)* 7 (NR)* 11 (8–16)* 15 (NR)*
e /e
days (SD or IQR)]
Time to surgery [mean

Control
Intervention
://t . m
40 (41)
1.0 (0.7)
6 (2)
NA
25 (31)
3.0 (2.9)*
10 (NR)
1.2 (NR)
13 (10–20)
: /
0.9 (0.5–1.4)
/ t . 19 (NR)
NA m
days (SD or IQR)] Control
t t p s 1.0 (0.6) NA 2.9 (6.5) 1.5 (NR)
tps
1.0 (0.6–1.7) NA
Discharge to
preadmission place of
residence, %
h
Intervention
Control
84
76
NA
NA
NA
NA
NA
NA ht NR
NR
NA
NA
In-hospital Intervention NA NA NA NA NR NA
complications, % Control NA NA NA NA NR NA
kers kers
Functional status (ADLs) Intervention 58* NA NA NA NA NA
recovery 12 months , % Control 36 NA NA NA NA NA
b o o b o o
Table 2.1-3 Studies assessing the beneficial effects of a geriatric-led model with orthopedic consultant in the management of hip fractures in
b o o
e /e older adults.
m e/e
Abbreviations: ADLs, activities of daily living; IQR, interquartile range; NA, not assessed; NR, data assessed but not reported; SD, standard deviation.
t . t .m e/e
/
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†
Control: retrospective chart review.
124
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Early supported discharge and postacute care e /
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Since their implementation, these units have produced bet- e/e
s: / / / /
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ter short-term and long-term outcomes than those from
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4.1 General considerations traditional rehabilitation units [49, 53–57]. A number of well-
The concept of using forms of skilled and dedicated postacute designed trials have demonstrated significant reduction in
care like a geriatric orthopedic rehabilitation unit and early LOS in the rehabilitation setting, greater recovery of func-
home-based care for FFPs was originally introduced in the tional status, lower risk of institutionalization, and higher
United States and more recently also adopted in the United rates of survival compared to those treated in the tradition-
e s
Kingdom and other European countries [4, 18]. These strat-
r
egies were implemented primarily to improve functional
er s
al rehabilitation ward. Finally, it should be emphasized that
this rehabilitation approach was also demonstrated to be
b o ok recovery by offering dedicated services skilled in the reha-
b
bilitation of older adults presenting with hip fractures, ino ok
successful in patients with moderate to severe dementia [56].
b o o
e/ e e/ e
contradistinction to traditional inpatient rehabilitation [2, 4, 4.3 Home-based rehabilitation
e/e
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5, 50]. They also offered the opportunity to reduce acute
hospital stay and promote early discharge in FFPs while
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Early discharge and home-based rehabilitation (HBR) ap-
t
proaches after hip fracture have been developed since 1986
tps
maintaining an acceptable quality of care and short-term
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and long-term outcomes. Geriatric orthopedic rehabilitation
units and home-based supported discharge represent the ht tps
in Europe, Australia, and North America [4]. The implemen-
tation of this alternative to traditional inpatient rehabilita-
tion requires adequate community resources and the pres-
more consistently implemented approaches to achieve these ence of home rehabilitation and community nursing
goals [2, 4, 50–54]. services in the patient’s healthcare district [4].
e r s
Since they focus on only a part of the overall care, these
e r s
Patients potentially suitable for early discharge to home are
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innovative rehabilitation schemes should be considered as usually those living at home with relatives or with other types
e b possible postacute transitions that could be used in tandem

e b o of social support and are medically fit enough to be discharged
b o
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with any of the aforementioned models, rather than as a
m
standalone and comprehensive model of care [4]. Indeed,
t .
to an outpatient setting, ie, clinically stable without relevant
t . m
acute illness [2, 4]. Patient and relatives should be assessed on e/e
/ /
the implementation of these services without including a
/ /
admission for suitability, informed about the service, and
expected outcomes.
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specific orthogeriatric acute model may not produce the
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agreeable to this discharge plan. In some experiences, a trained
geriatric nurse, a physiotherapist, or an occupational therapist
visits the patient’s home before discharge to evaluate the home
4.2 Geriatric orthopedic rehabilitation units for suitability and identify any necessary equipment. Then,
The geriatric orthopedic rehabilitation unit (GORU) is a soon after surgery, the patient is transferred directly home for
variation of the traditional geriatric rehabilitation unit, rehabilitation. An interdisciplinary team, including a geriatri-
e rs
fully dedicated to the care and rehabilitation of older adults
r s
cian and a geriatric nurse, is usually involved in the care of
e
b o ok presenting with a fracture. In general, the transition to a
b o
GORU may follow the admission to one of the services pre- ok
the older adult in collaboration with the general practitioner.
b o o
e/ e / e
viously described. Once the orthopedic surgeon, the geri-
e
atrician, or the orthogeriatric team judges that the patient
A number of RCTs and prospective observational studies
have evaluated the potential benefits of HBR [2, 4, 50, 52,
e /e
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is fit to be moved to a rehabilitation ward, he/she is rapidly
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57–61]. Published studies demonstrate that HBR services in
: / m
transferred to a GORU [4].
t t p s tps
older adults after hip fracture are feasible, safe, and effective
ht
producing comparable results in terms of functional out-
h
The presence of an interdisciplinary team skilled in the care
of older adults distinguishes this service from other reha-
comes and reduced LOS to traditional rehabilitation pro-
grams. These results were also confirmed in patients with
bilitation programs. The orthopedic specialist is not rou- prefracture cognitive decline or disability [2, 50].
tinely present but advises the team on demand. The health-
k e rs
care providers of the interdisciplinary team hold weekly or
more frequent meetings to evaluate progress and problems
ke rs
eb oo arising during the rehabilitation. The specific contents, fre-
e b oo b o o
e/e
quency, duration, and intensity of the training or rehabili-
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125
rs
rs 26.07.18 10:26
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k e rs ke rs
e b oo e b oo b o o
e / 5 References
t . m e /
t . m e/e
/ / / /
htt ps:
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ht
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outcome, mortality,
ke
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t .m
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patients: the advantage of a
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team approach to hip fracture 45. Adunsky A, Lerner-Geva L, Blumstein T, care after fractures of the proximal
management. J Surg Orthop Adv. et al. Improved survival of hip fracture femur in elderly women:
2005 Spring;14(1):27–31. patients treated within a a randomised clinical trial. BMJ.
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model of care that improves efficiency
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39. Biber R, Singler K,
Curschmann-Horter M, et al.
: // t economic outcomes. J Am Geriatr Soc.
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Randomised, clinically controlled trial
of intensive geriatric rehabilitation in
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Arch Orthop Trauma Surg. study. Geriatr Orthop Surg Rehabil. Systematic review of hip fracture
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58. Crotty M, Whitehead CH, Gray S, et al.
ook ok
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b
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Efficacy of a comprehensive geriatric
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cognitive function in patients with hip Rehabilitation after hip fracture in comparison of home versus
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(Oslo Orthogeriatric Trial). BMC Med. Soc. 2007 Aug;55(8):1309–1310. with hip fracture. Clin Rehabil. 2002
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ok ok
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et al. Home-based multicomponent
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://t . m
52. Hollingworth W, Todd C, Parker M,
et al. Cost analysis of early discharge
1999 Aug;80(8):916–922.
: / / t . m
t t p s after hip fracture. BMJ.
1993 Oct 09;307(6909):903–906.
tps
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Stephen L Kates
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e b oo e b oo b o o
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t . m e /
t . m e/e
/
2.2 Overcoming barriers to implementation
/ / /
of a care model htt ps: htt ps:
Stephen L Kates
e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e organized care and experience more adverse events and
e/e
: // t .m
Over the past several years, a great deal of literature has been
longer LOSs as a result.
: / / t .m
tps
published about the benefits of starting and using an enhanced
ht
care model for fragility fracture patients (FFPs). Many care
models have been described in the literature [1, 2], four of
3 Institutional barriers
ht tps
which are presented in chapter 2.1 Models of orthogeriatric There are certainly many potential barriers that exist from
care. The benefits of such models include improved quality an institutional standpoint.
of patient care, shorter length of hospital stay (LOS), fewer
e r s
adverse events during and after the hospital stay, improved 3.1
e r s
Other priorities
ook ok o
collegiality among healthcare providers, and reduced costs One of the more common barriers includes capacity of the
e b of care [3–7].
e b o hospital or institutional leadership team because of the range
b o
e / m e/
Despite these reported benefits, most hospitals have not yet
t .
of tasks allocated to the team members. In this situation, there
t . m
are often more pressing matters that present themselves to e/e
/ /
adopted a comanaged care model. Many possible reasons
/ /
the institutional leadership [8]. These include regulatory and
ps:
exist for not implementing such a program. This chapter
htt
covers some of these barriers to the implementation of an
organized geriatric fracture program. htt ps:
payment changes, local, state, and national dictums, space
concerns, recruitment of physician concerns, and potential
penalties, or punitive measures facing the hospital externally.
3.2 Other clinical service lines

2 I f an organized program is better, why doesn’t Additionally, there are numerous other diagnoses and pro-
e rs everyone want one?

r s
grams competing for the attention of hospital leadership,
e
b o ok o
In some centers, physicians and institutional team members
b ok
many of which are perceived as more commercially attrac-
tive. Fragility fractures do not usually make it to that level
b o o
e/ e / e
may be of the opinion that their usual care model is accept-
e
able and performing adequately. Although there has been
of significant attention from hospital administration. It is
the job of the physician leaders to elevate the importance
e /e
://t . m
a universal emphasis on the reduction of LOS, few hospitals
/ t . m
of the FFP to the hospital leadership to get it into the queue
: /
t t p s
have made the direct association between a standardized
tps
of projects needing to be accomplished.
ht
geriatric fracture care program, reduced LOS, and improved
h
quality of care. Additionally, there are a number of surgeons
and physicians who believe no one else needs to tell them
3.3 Overcrowded emergency department
Other common barriers to implementation include over-
how to take better care of their FFPs. Some perceive the crowded emergency departments which often hinder the
model as too hard to implement [8]. Other centers suffer FFP from being treated efficiently. More pressing matters,
k e rs
from a lack of physician leadership, resulting in failure to
implement such a model of care [8]. In some centers, there
ke rs
such as acute high-energy or penetrating-trauma patients,
take on higher priority for the emergency department staff
eb oo are major institutional barriers to implementing a program
e b oo
[9]. Also, patients using the emergency department for com-
b o o
e/e
[8]. Additionally, many other issues have been described mon, often nonurgent medical problems clog up the emer-
e / e
that interfere with the implementation of an organized,
m / gency department, preventing the FFP from being seen
m
/ /t .
standardized, and comanaged geriatric fracture program
t .
promptly and receiving the appropriate attention [9].
//
ps: ps:
(Table 2.2-1). In such cases, the patients suffer from a lack of
htt htt 129
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 3.4 Overcrowded floors
t . m e / surgical leadership are required to help the administrative
t . m e/e
s: / / / /
ps:
Once seen in the emergency department, bed capacity of team understand the importance of early surgery for this pa-
http htt
the hospital becomes a major issue. Oftentimes, hospitals tient group. The hospital without any operating room capac-
are full to capacity, preventing the FFP from being admitted ity remaining will often decline to institute an organized fra-
in a timely manner. In which case, the patient may be gility fracture program because they will be fearful of success.
boarded in the emergency department for a prolonged pe-
riod, in some cases with a LOS measured in days. 3.6 Minimum caseload
e rs
3.5 Lack of operating room capacity
e s
Another institutional problem relates to the number of pa-
r
tients seen. There have been a few published estimates of
b o ok Operating room capacity also represents a significant issue for

the FFP [8]. If the operating room is full to capacity, more
bo ok
patient volumes needed to implement a successful fragility
fracture program. These range from 49 to 159 patients [10].
b o o
e / e pressing acute cases will be treated first, relegating the FFP to
e/ e Published work suggests the average number of patients
e/e
: // t .m
the end of the queue. Here again, appropriate medical and seen yearly should be 100 or greater for an organized pro-
gram to be worthwhile [5].
: / / t .m
Barrier
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Countermeasure
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Personnel needed for implementation
Program leadership • Select committed: • Can be selected by:
– Surgeon – Department
– Medical leaders – Chairman
– Peers
e r s e r s – Hospital
ook ok
– Administration
b
Hospital administration
– Patient satisfaction
b o
• Engage, educate, and persuade, with an emphasis on expected improvements in: • Program champions with departmental
support
b o o
e / e – Cost reduction
– Hospital prestige
e/ e e/e
Skeptical surgeons
/ t . m
• Education to explain the problem
/
• Surgeon champion
/ /t . m
s: ps:
• Review data
http
• Emphasize physician benefits including improved patient outcomes and ease of care
Regulatory • Education
• Collaboration with other centers
• Business planning that documents outcomes/costs
htt
• Program champions
Technical implementation • Read published literature • Program leaders

• Visit a successful center • Hospital administration
• Attend a course and/or webinars
e rs • Engage a consultant if needed
e r s
ok ok
Bed capacity • Collect data on LOS • Program leaders with hospital administrators
b o o
• Examine ways to shorten LOS and recognition that a 50% reduction in LOS doubles the bed capacity
of the unit
b b o o
e/ e Operating room capacity
e / e
• Look for designated time for geriatric fracture cases • Surgeon leader
e /e
://t m
• Emphasize need for early surgery to improve outcomes and reduce LOS
.
• Sometimes requires negotiation and helping the operating room personnel to learn how to shorten
: / / t . m
t t p s
turnaround times
tps
ht
Anesthesia buy-in • Select an anesthesia champion to educate and lead colleagues to a collaborative and collegial • Program leaders
Cardiac clearance h approach to caring for geriatric fracture patients

• This is a problem of tradition and lack of education. It can be ameliorated with education and trust-
building of the medical and anesthesia colleagues
• Hospital administration
• Medical, anesthesia, and surgical champions
• Published literature clearly documents when an echocardiogram is required and when to consult a
cardiologist
kers kers
Need a case manager • A case manager can be a nurse, physician’s assistant, or nurse practitioner • Administration with program leader input
• This is an important position for a busy program
b o o b o o
• Designating an experienced, respected individual already employed by the hospital is a good strategy
• The hospital administration will need to accept the cost in return for cost savings realized by the
b o o
e /e e/e e/e
program with time
countermeasures to overcome them [8].

/ /t . m
Table 2.2-1 Barriers to the implementation of an organized, standardized, and comanaged geriatric fracture program, as well as
// t .m
ps: ps:
Abbreviation: LOS, length of hospital stay.
130
htt htt
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rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
Stephen L Kates
k e rs ke rs
e b oo e b oo b o o
e / 3.7 Costs and effectiveness
t . m e /
t . m
care team. It is a long-term commitment that must be con- e/e
s: / / / /
ps:
An additional institutional concern is based on the cost of sidered carefully when choosing leaders.
http htt
running such a program, particularly if the savings are not
realized until future years. Support costs can run from min- Individual medical and surgical physicians may not agree
imal to significantly more than USD 150,000 depending on with the program and may in fact strongly wish to continue
whether or not a consulting firm is used to implement the their traditional approach to care (ie, usual care). A combi-
program or if new employees are hired. If a program requires nation of education and persuasion with good communica-
e s
employees to be hired, costs will obviously be ongoing and
r
higher than if existing employees can be used. Likewise, if
er s
tion is required here. The program leaders should recognize
that about 70% of the physicians and surgeons must agree
b o ok existing space and other resources can be used, costs will

be considerably lower for both implementation and the on-
bo ok
to participate in the program and comply with policies to get
it successfully started. Once running, the outcome data are
b o o
e/ e e/ e
going operation of an organized standardized fragility frac- frequently persuasive to stubborn providers to show them
e/e
ture program.
: // t .m : / / t .m
the new program is better. For undermining or recalcitrant
providers, replacement may be necessary if all else fails.
tps
Finally, institutional administration leadership expects such
ht
a program to be both cost-effective and the outcomes to be
measurable. Both cost-effectiveness and outcomes are mea- 5 Regulatory barriers ht tps
surable, but this requires work and ongoing attention to
these metrics. Creation of a monthly scorecard to be reviewed In most locales, some forms of regulatory barriers exist to
by the hospital administration officials is one good method implementing a fragility fracture program. These may be
e r s
for management of cost and outcomes.
e r s
relatively simple or more complex.
e b ook e b o 5.1 ok
Hospital board approval
b o o
e / 4 Provider barriers
t . m e/ Hospital board approval is commonly required and can be
t . m
a barrier if the program is not presented to them in the e/e
/ /
Published literature has identified a number of provider
/ /
proper manner. The program should be presented by the
ps:
barriers to implementing a standardized fragility fracture
htt
program [8]. These include lack of surgeon or medical cham-
pions, lack of a case manager, anesthesia department prob- htt ps:
surgeon champion to the board emphasizing the quality,
safety, and economic benefits of the program and include
an abbreviated business plan overview. This presentation
lems, and difficulty obtaining cardiology clearance in a should last 7–10 minutes in most cases and will likely be
timely manner [8]. successful if presented well.
e rs
4.1 Surgical and medical leadership 5.2
r s
Regional and/or provincial barriers
e
b o ok Surgical and medical leadership of the program represents
b o
an essential element for success of any organized standard- ok
In some systems, changing the care model will require re-
gional and/or provincial approval. Again, a focus on the
b o o
e/ e / e
ized orthogeriatric fracture program [5]. The leaders should
e
agree to work together and have a collegial relationship
quality and safety aspects of the program along with poten-
e
tial cost savings should be emphasized. The regional system/e
://t . m
with one another. It is also important to engage the anes-
/ t . m
data should be included in such a presentation to demonstrate
: /
t t p s
thesiologists by finding a suitable committed leader to help
tps
the economic aspects of the program to the regional au-
ht
with implementation and ongoing operation of the program. thorities. It may also need to include consensus from other
h
Regular and ongoing communication between the indi-
vidual physician leaders is essential to proactively identify
regional centers or a plan to scale the program regionally
in order to be successful. The Canadian province of On-
new problems and to ensure the representation and support tario has successfully implemented an improved care system
of the care team members. Communication forums can in- in this manner.
k e rs
clude regular team meetings, routine review of processes
and outcomes, and reinforcement of best-practice efforts. 5.3
ke rs
National approval barriers
eb oo In addition, as members of the extended care team change
e b oo
National approval barriers are considerably greater. Few
b o o
e/e
over time, basic educational efforts about orthogeriatric care nations have successfully changed the hip fracture care
e / e /
are always needed. The leaders should have departmental
m
model. The UK is an excellent example of consensus build-
m
/ /t .
support, administration support, and be respected by the
t .
ing, governmental lobbying, and outstanding leadership
//
htt ps: htt ps:
131
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e
from surgeons, physicians, and thought leaders to success-
/ mon issue of tradition, ie, “we have always done it this way
t . m e/e
s: / / / /
ps:
fully implement the Best Practice Tariff nationally in the and it works.” Likewise, the care team may not understand
http htt
National Health Service. The program has shown reduced that providing the care in an organized manner is actually
mortality rates at 30 days along with a high level of compli- better. Education of the team is an effective countermeasure.
ance by hospitals. This program required a committed group Education can include reading literature, attending lectures
of champions from across the nation to achieve this success and programs by visiting professors, site visits to successful
that now serves as a model for other diagnoses in the UK. programs, and attending face-to-face educational events
e s
There are analogous efforts in the US to reward systems
r
with organized fracture programs [11, 12].
er s
such as a regional AO orthogeriatric course. It is essential
here to show that a better quality of care is actually easier
b o ok bo ok
once the model has been implemented.
b o o
e/ e 6 Cultural barriers
e/ e 6.2 Patient-related cultural barriers
e/e
: // t .m
Cultural barriers are many and are difficult to change. As
It is important to educate patients and families about a new
: /
system and emphasize the safety and quality benefits. Con-
/ t .m
forms.
ht tps
with the regulatory barriers, cultural ones come in many
ht tps
sistent messaging from a committed care team is essential
here. Because care is delivered locally, local education efforts
should extend into the local community to educate pri-
6.1 Traditions and attitudes mary care physicians, nursing home staff, and groups of
Local cultural barriers consist of traditions and attitudes senior citizens about the new care model to achieve buy-in
toward care held by the care provider team. There is a com- and understanding of the program goals.
e r s e r s
e / 7 References
t . m e/ t . m e/e
/ /
1. Giusti A, Barone A, Razzano M, et al. 5. Kates SL, Mendelson DA, Friedman SM.
/ /
10. Clement RC, Ahn J, Mehta S, et al.
ps: ps:
Optimal setting and care organization Co-managed care for fragility hip Economic viability of geriatric hip
htt htt
in the management of older adults with fractures (Rochester model). Osteoporos fracture centers. Orthopedics.
hip fracture. Eur J Phys Rehabil Med. Int. 2010 Dec;21(Suppl 4):S621–S625. 2013 Dec;36(12):e1509–e1514.
2011 Jun;47(2):281–296. 6. Della Rocca GJ, Moylan KC, Crist BD, 11. Neuburger J, Currie C, Wakeman R,
2. Grigoryan KV, Javedan H, Rudolph JL. et al. Comanagement of geriatric et al. The impact of a national
Orthogeriatric care models and patients with hip fractures: clinician-led audit initiative on care
outcomes in hip fracture patients: a retrospective, controlled, cohort and mortality after hip fracture in
a systematic review and meta-analysis. study. Geriatr Orthop Surg Rehabil. England: an external evaluation using
e rs J Orthop Trauma.
2014 Mar;28(3):e49–e55.
2013 Mar;4(1):10–15.
e r s
time trends in non-audit data. Med Care.
2015 Aug;53(8):686–691.
b o ok 3. Friedman SM, Mendelson DA,

Bingham KW, et al. Impact of a
b o ok
The value of an organized fracture
program for the elderly: early results.
12. Johansen A, Boulton C, Hertz K, et al.
The National Hip Fracture Database
b o o
e/ e comanaged Geriatric Fracture Center
on short-term hip fracture outcomes.
e / e
J Orthop Trauma.
2011 Apr;25(4):233–237.
(NHFD)—using a national clinical
audit to raise standards of nursing care.
e /e
Arch Intern Med.
2009 Oct 12;169(18):1712–1717.
://t
4. Friedman SM, Mendelson DA, Kates SL, . m8. Kates SL, O’Malley N, Friedman SM,
et al. Barriers to implementation of an
organized geriatric fracture program.
Int J Orthop Trauma Nurs.
2017 Aug;26:3–6.
: / / t . m
p s
et al. Geriatric co-management of
t t
tps
ht
proximal femur fractures: total quality 2012 Mar;3(1):8–16.
h
management and protocol-driven care
9. Rashid A, Brooks TR, Bessman E, et al.
Factors associated with emergency
department length of stay for patients
2008 Jul;56(7):1349–1356. with hip fracture. Geriatr Orthop Surg
Rehabil. 2013 Sep;4(3):78–83.
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
Stephen L Kates, Michael Blauth
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
2.3 Clinical practice guidelines / / / /
htt ps:
htt ps:
e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e vanced diagnostic imaging, timing of surgery, postoperative
e/e
: // t .m
Clinical practice guidelines (CPGs) are designed to inform prac-
weight-bearing status, medical comanagement, management
: / / t .m
of femoral neck and trochanteric fractures, and postfracture
tps
tice, and offer guidance and direction on clinical care. Clinical
ht
practice guidelines are typically evidence-based and construct-
ed by a workgroup of interested physicians. Most CPGs are ht tps
osteoporosis management. For a more comprehensive list,
see Table 2.3-1. Review of this table shows considerable com-
monality exists in topics covered and similar recommendations
supported by governments or medical societies with endorse- as well [1–3]. The reassuring aspect of comparing CPGs from
ment from other stakeholders. A CPG helps to set care standards
that physicians and surgeons can use to guide their patient
e r scare practices. Typically, CPGs on orthogeriatric comanagement

e r s
Recommendation AAOS NICE ANZHFR
ook ok o
will cover the time period from hospital admission to comple-
e b tion of healing including secondary fracture prevention.

e b o MRI for undisplaced fracture   
b o
e/e
Pain management   
e / m e/
Clinical practice guidelines are not designed to specifically
Early assessment 
m

/ / t .
dictate care but serve as a framework for care. Individual
Early surgery  
/ /t . 
ps: ps:
Early weight bearing  
physicians should consider the recommendations and the
htt htt
strength of these recommendations when providing care to Multidisciplinary care model   
specific patients. Clinical practice guidelines, when done well, Presurgical optimization  
can highlight evidence-based best practices and also point Anesthetic choice   
out gaps in knowledge that will require future study to an- Surgical team composition  
swer. They also serve as a convenient reference for evidence Displaced femoral neck fracture
e rs
on specific aspects of care for medical and surgical providers.
e r s
Physical therapy






b o ok b o ok
Delirium avoidance
Falls assessment
 
b o o
e/ e 2 ommonality of national clinical practice
C
guidelines
e / e Early discharge

 
e /e
://t . m Nursing home involvement 
: / / t . 
m
s
Many national guidelines exist for the care of hip fractures but
t t p
Nondisplaced femoral neck fracture  
tps
ht
not as many exist for osteoporotic fractures in general. Among Implant for trochanteric fracture   
h
these national CPGs, several will be discussed in this chapter,
including the American Academy of Orthopaedic Surgeons
Anticoagulation postsurgery
Transfusion threshold


No clear advice No clear advice
(AAOS) CPG, the National Institute for Health and Care Excel- Nutrition   
lence (NICE) guidelines, and the Australian and New Zealand Osteoporosis assessment  
kers rs
Hip Fracture Registry (ANZHFR) guidelines [1–3]. These three Osteoporosis treatment
o
sets of CPGs are among the finest created and often serve as
ke  
/eb o templates for future efforts in other countries and regions.
e b oo
Table 2.3-1 Commonality of recommendations of clinical practice
guidelines for hip fracture care.
b o o
e t . e
significant amount of commonality and the recommendations
/
Since all these guidelines are evidence-based, they contain a
m
Abbreviations: AAOS, American Academy of Orthopaedic Surgeons;
ANZHFR, Australian and New Zealand Hip Fracture Registry;
t .m e/e
/ / /
MRI, magnetic resonance imaging; NICE, National Institute for Health
/
ps: ps:
made are similar. Specific topics covered include use of ad- and Care Excellence.
htt htt 133
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
different regions is the general agreement on evidence-based The following steps have proven to be key success factors
t . m e/e
s: / / / /
ps:
best practices that are most useful for hip fracture patients. in the local adoption of CPGs:
http htt
This international agreement is based on existing literature,
which covers the most important aspects of care for the hip 1. Creating awareness: The first step is making clinicians
fracture patient. There are no guidelines offered for osteo- and care providers aware of the publication of the guide-
porosis-related fractures or fragility fractures in general; all lines and the evidence basis used to create these docu-
the existing guidelines are concerned specifically with hip ments. It should not be assumed that all clinicians are
e s
fractures. However, there are two well-written monographs
r
on fragility fractures that offer guidance, the BOA/BGS Blue
er s
aware of the guidelines or of their content, and it may
require repeated efforts on the hospital level to make
b o ok Book [4, 5] and the A Guide to Improving the Care of Fragility

Fractures by Mears et al [6]. The national guidelines have
bo ok
clinicians aware of their publication and content. Com-
munication with care providers is an essential element
b o o
e/ e e/
clearly focused on hip fracture due to its prevalence ande for local implementation. Repeated communication and
e/e
comes.
: // t .m
high societal costs combined with frequent suboptimal out- repeated review of new guidelines should be strongly
: / /
considered by hospital and physician leadership to informt .m
3 ht tps
Local adaptation and implementation
clinicians of their content.
ht tps
2. Meetings: Well-organized meetings with team members
help to convey information, build trust, and enhance
mutual understanding. The meetings should result in
Once CPGs have been published by a national organization written and agreed upon local guidelines that address all
or society, the stepwise adaptation and implementation of steps in the treatment of fragility fracture patients (FFPs).
e r s
these guidelines to the local or hospital setting becomes
e r s
3. Internal communication systems: Guidelines should be
ook ok o
important. In some cases, hospitals will adopt the national made readily available, for example via the hospital or
e b b
CPGs to be their local guidelines and set these as a standard
e o department intranet. Local guidelines should be studied
b o
e / of care.
t . m e/ and their important messages and recommendations

should be incorporated into order sets, care plans, and
t . m e/e
/ /
Creating consensus, and publishing and communicating surgical tactics and approaches (Table 2.3-2).
/ /
ps:
local guidelines with all stakeholders in the process is the
htt
most important step in implementing optimal orthogeriat-
ric fracture care. Often, national guidelines are not detailed. htt ps:
4. Monitoring and supervision: Adherence to the guidelines
must be monitored, especially after implementation. A
practical way to do so is the discussion of cases while
Local guidelines can be explicit including the choice and doing rounds or in morbidity and mortality meetings.
dosage of drugs in specific situations. Particularly, when adverse events occur in the care of a
FFP, the specific deviations in practice should be identi-
e rs
In large institutions, typically university departments, core
e r s
b o ok team members like orthopedic trauma surgeons, geriatri-
b o
cians, anesthetists, and staff nurses can be complemented ok b o o
e/ e / e
by local specialists like a cardiologist, microbiologist, and
e
specialist for anticoagulation and thrombosis prophylaxis.
CPG recommendation
Osteoporosis assessment
Standard order
• Admission order
e /e
://t . m
These specialists can give input on specific topics, strength-
• Vitamin D level
/ / t .
• Intact parathyroid hormone level
: m
s
en the significance and power of the local guidelines and
t t p tps
• Thyroid-stimulating hormone level
ht
• Ionized calcium level
help to avoid disagreement during implementation. The
h
treatment team in smaller institutions may simply adopt the
recommendations of those local guidelines.
Blood transfusion
Anticoagulation
• Do not transfuse patient unless the hemoglobin level
is < 8 grams
• Enoxaparin 40 mg SQ daily
Nutrition • High-calorie, low-bulk dental soft diet
Consensus guidelines are a strong tool to implement best
rs rs
Delirium avoidance • Be certain the patient retains and uses glasses
practices standard in hospitals with many different “players”.
k e Since CPGs are typically based on best available evidence,

ke and hearing aids
• Do not restrain patient
eb oo their adoption is expected to benefit the majority of patients
e b oo • Avoid use of diphenhydramine, meperidine,

and H2 blockers
b o o
e/e
[1–3].
e / m e / Osteoporosis treatment • Vitamin D3, 2,000 international units daily
m
/ /t . Table 2.3-2 Examples of order sets matching CPGs.
// t .
s: ps:
Abbreviations: CPG, clinical practice guidelines; SQ, subcutaneous.
134
http htt
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rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
fied and it should be determined if these are also devia-
t
• Admission under the joint care of a consultant
. m e/e
s: / / / /
ps:
tions from national guidelines, and if this variation was geriatrician and a consultant orthopedic surgeon
http htt
appropriate. Educational efforts for the care team should • Application of a standard assessment protocol agreed
focus on adherence to these guidelines in most cases un- upon by geriatric medicine, orthopedic surgery and
less there is a strong clinical reason not to. In such cases, anesthesia
the physician should be encouraged to carefully document • Assessment by a geriatrician in the preoperative
reasons for not adhering to the local guidelines. period, within 72 hours of admission
e s
5. Outcome measurement: Measurement of guideline ad-
r herence linked to outcomes is a reasonable approach to
er s
• Postoperative geriatrician-directed multiprofessional
rehabilitation team
b o ok determining if guidelines are actually being used by treat-
b
ing physicians. One helpful approach is to provide a “doto ok
• Fracture prevention assessments (falls and bone health)
b o o
e/ e e/ e
plot” of adherence and identify and inform specific phy- 4.2 Certification
e/e
: // t .m
sician outliers. This will help the physician understand
their actual adherence to the guidelines in relation to
: / / .m
In Germany, so-called centers for fragility fractures can be
t
certified by the Academy of the German Trauma Association
tps
their peers. Because physicians are typically competitive
ht
individuals, the underperforming physician will have a
strong incentive to improve their performance. Such un- ht tps
[9]. The requirements aim to foster an orthogeriatric inter-
disciplinary approach and to improve the quality of care
and results documented in the national hip fracture registry.
derperforming individuals should have education and In order to become certified, a long list of items that are in
counseling offered to them by departmental leaders on concordance with national and international guidelines need
how they can improve results. The collection of a small to be audited. This process creates positive competition be-
e r s amount of key data to monitor the outcome of FFPs is

e r s
tween providers. Reimbursement can be significantly in-
ook ok o
an appropriate quality control in countries without na- creased if the ambitious requirements for a diagnosis-relat-
e b b o
tional hip fracture registry. If done regularly, trends and
e
ed group dedicated to orthogeriatric management are
b o
e / patterns can identify issues related to outcomes.
t . m e/ fulfilled.
t . m e/e
/ / 4.3 Indicators used by the government
/ /
4 Nationwide initiatives
htt ps:
Some nations with CPGs are developing process measures htt ps:
In the Netherlands, evidence-based guidelines made by
practicing professionals serve as a basis for indicators used
by the government [10]. This set of parameters must be re-
for guideline adherence and the impact of guideline devia- corded by each hospital yearly and includes a pain score,
tion. These so-called process measures are often obtained time to surgery within 24 hours, reoperation rate within 60
from claims data or from national hip fracture registry data. days, pressure ulcers, nutritional status, and delirium. The
e rs
A powerful approach to change physician behavior is to
r s
parameters change over time.
e
b o ok modify reimbursement according to the level of adherence
o
to guidelines and participation in registries for benchmark-
b ok
The healthcare inspectorate may visit places with suboptimal
b o o
e/ e ing.
e / e performance, come up with a list of corrective actions, and
may even initiate legal action if required.
e /e
4.1 The Best Practice Tariff
://t . m : / / t . m
t t p s
The British Best Practice Tariff was developed for osteopo-
tps
The National Hip Fracture Database in the UK is designed
ht
rotic hip fractures to encourage two key clinical character- by professionals. It is a web-based audit of hip fracture treat-
h
istics of best practice: prompt surgery and appropriate in-
volvement of geriatric medicine [7, 8]. The key clinical
ment and prevention. Similar to the British Best Practice
Tariff, departments get a bonus if the patient is operated
characteristics of best practice were chosen by a group of within 36 hours, care is taken by trauma and geriatric pro-
clinicians and service managers chaired by the National fessionals, if there is an agreement on protocols of standard
k e rs
Clinical Director for trauma care. The following best prac-
tices focused on FFPs aged 60 years and older:
ke rs
care by surgeon, geriatrician and anesthetist, if there is pre-
and perioperative assessment by geriatricians, if the geriatri-
eb oo e b oo
cians take the lead in multidisciplinary revalidation, and if
b o o
e/e
• Time to surgery within 36 hours from arrival in an secondary fracture and falls prevention is addressed [8].
e / emergency department, or time of diagnosis if an

m e / m
inpatient, to the start of anesthesia
/ /t . // t .
htt ps: htt ps:
135
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 5
t . m
Periodic reassessment and revision of guidelines e /
t . m e/e
/ / / /
htt ps:
Because CPGs are based on the best available evidence on
a specific topic, best practices can be expected to change
htt ps:
with time as new or better evidence becomes available. It
is probably wise to revisit CPGs every 3–5 years to be sure
that they are still consistent with best available evidence on
e s
the topic [3]. The task of reevaluating and revising CPGs
r
should be undertaken by an expert group of physicians and
er s
b o ok surgeons assembled by the national group sponsoring the
guidelines [1]. In some cases, this group will be governmen-
bo ok b o o
e/ e e/
tal, whereas in other cases the group will be the medical or e e/e
: // t .m
surgical specialty society. Because tremendous effort and
rigid methodology is used to prepare CPGs, practicing phy-
: / / t .m
ht tps
sicians and surgeons should closely study CPG recommen-
dations and try to adopt them in their clinical practice.
ht tps
6 References
e r s e r s
ook ok o
1. American Academy of Orthopaedic 4. British Orthopaedic Association and 8. Khan SK, Weusten A, Bonczek S, et al.
e b
Surgeons (AAOS). Management of hip
e b o
British Geriatrics Society. The care of The Best Practice Tariff helps improve
b o
e/e
fractures in the elderly. Available at: patients with fragility fracture. management of neck of femur fractures:
e / www.aaos.org/Research/guidelines/
HipFxSummaryofRecommendations.
m e/
Available at: www.nhfd.co.uk.
Published 2007. Accessed 2018.
a completed audit loop. Br J Hosp Med
m
(Lond). 2013 Nov;74(11):644–647.
pdf. Published 2014. Accessed 2017.
/ / t . 5. Marsh D, Curry C, Brown P, et al. The
/ /t .
9. Krause U, Jung K. Geriatric Fracture
ps: ps:
2. Australian and New Zealand Hip Care of Patients with Fragility Fracture: Centre (German Trauma Society):
Fracture Registry (ANZHFR). Australian British Orthopaedic Society Available guidelines and certification to improve
htt htt
and New Zealand Guideline for Hip at: www.bgs.org.uk. Published 2007. geriatric trauma care. Innovative Surg
Fracture Care: Improving Outcomes in Accessed 2017. Sci. 2016;1(2):79–85.
Hip Fracture Management of Adults. 6. Mears SC, Kates SL. A guide to 10. Zielinski SM, Meeuwis MA,
Available at: www.anzhfr.org/ improving the care of patients Heetveld MJ, et al. Adherence to a
guidelines-and-standards. Published with fragility fractures, edition 2. femoral neck fracture treatment
2014. Accessed 2017. Geriatr Orthop Surg Rehabil. guideline. Int Orthop. 2013
e rs
3. National Institue for Health and Care
Excellence (NICE). Hip fracture: the
2015 Jun;6(2):58–120.
r s
7. Khan SK, Shirley MD, Glennie C, et al.
e
Jul;37(7):1327–1334.
ok ok
management of hip fracture in adults. Achieving best practice tariff may not
b o Clinical guideline [CG124]. Available at:

https://www.nice.org.uk/guidance/
o
reflect improved survival after hip
b
fracture treatment. Clin Interv Aging.
b o o
e/ e cg124. Published 2014. Accessed 2017.
e / e2014;9:2097–2102.
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://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
2.4 Elements of an orthogeriatric
/ / / /
comanaged program htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e In order to ensure these elements, certain principles must
e/e
: // t .m
In light of the historically poor perioperative outcomes in
be applied:
: / / t .m
tps
fragility fracture patients (FFPs) [1–3], unique interdisciplin-
ht
ary team approaches in the treatment of these patients have
been implemented to reduce peri- and postoperative com- ht tps
• Interdisciplinary teamwork and co-ownership: Patients
should be treated in a coordinated manner and without
conflicts among orthopedic, geriatric, and anesthesio-
plications. Orthogeriatric models of care were developed in logical teams.
England in the late 1950s and are now widely accepted [4]. • Interdisciplinary communication including team meet-
Geriatricians are specialized in addressing comorbidities, ings.
e r s
ensuring optimal medical management for older multimor-
e r s
• Goal setting: Based on protocols and guidelines, patient-
ook ok o
bid individuals, and can help to improve the outcomes of specific short-term and medium-term treatment goals
e b older patients with fragility fractures [3]. These interdisci-

e b o must be set and revised according to the dynamic status
b o
e / plinary approaches have been described in various terms
m
including orthogeriatric management, comprehensive ge-
t . e/ and functional potential of each patient. Diagnostic and
t . m
therapeutic interventions must be aligned with those e/e
/ /
riatric care, or comanagement [5, 6]. The implementation of
/ /
goals. Consented goal setting is an excellent technique
ps:
a successful orthogeriatric comanagement model of care
htt
varies from one hospital to another, but some key elements
have to be considered. htt ps:
to get all clinicians and family members on the same page
and to ease interprofessional and interdisciplinary com-
munication.
Key elements of the comanaged care model, adapted from These elements require a lot of additional resources, thus
Lisk and Yeong [7], are: the importance of the individual elements have to be further
e rs e r
discussed.
s
b o ok • Prompt admission to orthopedic care
• Rapid and comprehensive medical, surgical, and
b o ok b o o
e/ e anesthesiologic assessment
• Minimal delay to surgery
e / e e /e
://t . m
• Accurate and well-performed surgery (single-shot
: / / t . m
surgery)
t t p s tps
ht
• Prompt mobilization and rehabilitation
h
• Early supported discharge and ongoing community
rehabilitation
• Secondary prevention, addressing bone protection and
falls assessment
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
137
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 2 Key elements of comanaged care
t . m e / 2.3 Single-shot surgery
t . m e/e
s: / / / /
ps:
Adapted surgical techniques respecting the low bone qual-
http htt
2.1 apid comprehensive medical, surgical, and
R ity, bleeding issues, and reduced reserves in the soft tissues
anesthesiologic assessment are required (see chapter 1.2 Principles of orthogeriatric
Up to a quarter of patients with hip fractures have a preex- surgical care). Revision surgeries must be avoided because
isting cardiovascular disease, and some patients already have they usually lead to significant deterioration.
subclinical infections prior to their fracture [8, 9]. The post-
k e rs operative course is often marked by an increased incidence

of chest infections due to the combination of pain, immobil-
2.4
er s
Prompt mobilization
Immobilization of FFPs can be associated with various med-
o o ity and reduced ability to cough [7].

o ok
ical complications such as pressure ulcers, venous throm-
o o
e/eb b b
boembolism, wound and systemic infections, loss of muscle
e/ e
The following correctable comorbidities should be identified mass and muscle strength, or demineralization of bone that
e/e
: // t .m
and addressed immediately in order not to delay surgery
[10] (see chapter 1.4 Preoperative risk assessment and pre-
deteriorates during postoperative recovery. Postoperative
: / /
mortality is known to be associated with the extent of post- t .m
paration):
• Anemia ht tps ht tps

operative mobilization. This was shown for patients suffer-
ing from femoral periprosthetic fractures (Fig 2.4-2) [16].
• Anticoagulation The importance of targeting the vulnerability of these pa-

• Volume depletion tients at an early stage to prevent functional decline in the
• Electrolyte imbalance long run was also illustrated in the Trondheim Hip Fracture
e r s
• Uncontrolled diabetes
e r s
Trial [17]. Geriatric trauma patients were investigated in a
ook ok o
• Uncontrolled heart failure randomized controlled trial comparing comprehensive ge-
e b • Correctable cardiac arrhythmia or ischemia

e b o riatric care (CGC) to conventional orthopedic care. In this
b o
e / •
•
Acute chest infection
m
Exacerbation of chronic chest conditions
t . e/ study, participants who received CGC had significantly
higher gait speed, less asymmetry, better gait control, and
t . m e/e
/ / /
more efficient gait patterns. Furthermore, the CGC partici-
/
htt ps:
Data on the power of rapid comprehensive assessment still
remain weak. It is recommended that an interdisciplinary
prioritization of orthogeriatric trauma patients should start
mobility at 4 and 12 months.
htt ps:
pants were more often able to walk and reported better
in the emergency department and the postoperative care In conclusion, prompt mobilization remains an essential
unit should be informed as soon as possible to allocate ca- element for the treatment of orthogeriatric patients (see
pacities. chapter 1.8 Postoperative surgical management).
e rs e r s
b o ok 2.2 Minimal delay to surgery
b o
There is growing emphasis on the benefits of minimizing
2.5
ok Early multidisciplinary rehabilitation
In orthogeriatric patients, it is of particular importance to
b o o
e/ e / e
surgical delay for orthogeriatric hip fracture patients [11]. It
e
has been shown that a prolonged time to surgery is a risk
start rehabilitation immediately after surgery to prevent a
loss of self-care and independence. Especially in patients
e /e
://t . m
factor for delirium, whereas delirium was found to be as- with high degrees of comorbidity, frailty and polypharma-
: / / t . m
t t p s
sociated with a poor functional outcome and increased mor-
tps
cy, a multidisciplinary rehabilitation process is an important
ht
tality [12, 13]. factor leading to optimal outcomes and a successful surgical
h
However, there are still authors querying the necessity of
procedure [18]. To determine the most appropriate reha-
bilitation program, the individual’s baseline health status
early surgery. Lizaur-Utrilla et al [14] stated recently that should be assessed. The assessment of prefracture mobility,
delaying surgery up to 4 days was not associated with high- cognition, depression, fall risk, nutritional status, inconti-
k e rs
er morbidity or mortality rates. The authors recommended
concentrating more on preoperative optimization with suf-
ke rs
nence, and visual function are of importance to plan the
optimal rehabilitation program [19]. Interdisciplinary reha-
eb oo ficient medical treatment rather than being bound by a uni-
e b oo
bilitation programs are known to have the best outcomes
b o o
e/e
versal timing of surgery [14]. in terms of quality of life, reduced readmission rates, depres-
e / m e / sion and fall prevention, highlighting the importance of

m
/ /t .
The majority of studies consistently show that early surgery early multidisciplinary rehabilitation [20].
// t .
ps: ps:
has a strong impact on reducing patient’s mortality (Fig 2.4-1).
138
htt htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Timeframe and
t . m e / Favors Favors
t . m e/e
s: / / early surgery
/ /
delayed surgery
ps:
study Early surgery, n Delayed surgery, n RR (95% CI)
http htt
Short-term
Davie et al 105 95 0.66 (0.28–1.56)
Harries et al 40 40 1.00 (0.21–4.71)
Parker et al* 290 178 0.68 (0.28–1.65)
Smektala et al 139 22 0.79 (0.19–3.33)
k e rs Moran et al*
Rae et al*
982
137
1,372
85
0.98 (0.75–1.28)
0.62 (0.24–1.59)
er s
o o Overall 1,693 1,792 0.90 (0.71–1.13)
o ok o o
e/eb b b
Medium-term
Davis et al* 45 185
e/ e
0.80 (0.43–1.50)
e/e
Mullen et al†
Dorotka et al
8
158
: // t .m 52
24
2.17 (1.42–3.31)
0.42 (0.21–0.84)
: / / t .m
s tps
http
Orosz et al 398 780 0.70 (0.50–0.97)
Overall
Long-term
609 1,041 0.87 (0.44–1.72)
ht
Zuckerman et al‡ 267 100 0.58 (0.35–0.99)
Beringer et al 133 70 0.54 (0.39–0.75)
ke r sElliott et al 169 1,611 0.35 (0.21–0.59)
e r s
ok
Doruk et al§ 38 27 0.36 (0.14–0.92)
b o o Siegmeth et al* 3,454 174
o
0.50 (0.34–0.74)
b b o o
e /e e e/e
Smektala et al 609 1,629 0.90 (0.71–1.15)
Overall 4,670
t
3,673
. m e/
0.55 (0.40–0.75)
t . m
/ / 0.1 0.2 0.5 1.0 2
/ / 5 40
ps: ps:
RR, 95% CI
htt htt
Fig 2.4-1 Stratified analysis by time of death adapted from Simunovic et al [15]. Forrest plot of unadjusted relative risks for the effect
of early compared with delayed surgery for hip fractures on all-cause mortality assessed in hospital or at 30 days (short-term), at
3–6 months (medium-term) or at 1 year (long-term) (random-effects model based on inverse variance method). Studies used a cut-off
for delay of 24 hours, except as indicated otherwise.
Abbreviations: CI, confidence interval; n, number of patients included in the study group analyzed by the authors; RR, relative risk.
*Study used a cut-off of 48 hours for delay.
e rs
†
Data based on patients who had medical illness in combination with hip fracture.
e r s
ok ok
‡
Study used a cut-off of 72 hours for delay.
b o §
Study used a cut-off of 5 days for delay.
b o b o o
e/ e Survival functions
e / e e /e
1.0
://t . m Group
ORIF
: / / t . m
t t p s Nail
tps
ht
ORIF censored
0.8
h ORIF censored
Cum Survival
0.6
rs rs
0.4
k e ke
eb oo 0.2
e b oo Fig 2.4-2 Kaplan-Meier survival analysis for total

mortality adapted from Langenhan et al [16] in
b o o
e / 0.0
t . m e / patients being treated with either open reduction and
t .m
internal fixation (ORIF) or a modular prosthesis nail.
e/e
0 20 40 60
s: / / 80 100 120
//
Patients in the ORIF group underwent a prolonged
ps:
Mortality, months period of partial or non-weight bearing.
http htt 139
rs rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 2.6
t .
arly supported discharge and ongoing
E
m e / 3 Cost of care
t . m e/e
s: / / / /
ps:
community rehabilitation
http htt
Planning patients’ rehabilitation should start as early as pos- At first glance, the comprehensive orthogeriatric model ap-
sible, ideally on the day of admission to the hospital. Coop- pears to require a lot of additional resources. Cost-utility
eration with rehabilitation facilities and specialists with analyses integrating epidemiological and economic aspects
expertise in the care of older adults, including departments for hip fracture patients treated within a comprehensive
for acute geriatrics, represent a proven approach to ensure orthogeriatric model of care, as compared with the standard
e s
early and safe discharge of patients [21]. Rehabilitation
r
within the hospital has the advantage of continuity of care.
er s
of care model, are of interest. In hip fracture patients it has
been shown that a comprehensive orthogeriatric care mo-
b o ok When being discharged home, early supported discharge

should also ensure as much home care as possible.
bo ok
dality is more cost-effective, as it provides additional qual-
ity-adjusted life years (QALYs) while using fewer resources
b o o
e/ e e/ e compared with standard care [25].
e/e
2.7
: //
protection and falls assessment.m
econdary prevention, combining bone
S
t : /
Another prospective randomized controlled trial compared
/ t .m
tps
In a double-blind, placebo-controlled trial, treatment with
ht
zoledronic acid compared with placebo reduced the risk of
morphometric vertebral fractures by 70% during a 3-year ht tps
the effectiveness of comprehensive geriatric care in a dedi-
cated geriatric ward with usual orthopedic care and sup-
ported the above findings (Table 2.4-1). The staffing ratios of
period. These findings strengthen the need of secondary medical professionals used in this study is listed in T able 2.4-2.
fracture prevention [22]. However, in women eligible for
the treatment of osteoporosis in Germany, only 23% of
e r s
them received appropriate treatment [23]. The implementa-
e r s
ook ok o
tion of a fracture liaison service (FLS) that provides a stan-
e b dardized identification and treatment of osteoporosis to

e b o b o
e / e/
orthogeriatric patients has proven to be an effective approach
m
for secondary fracture prevention (see also chapter 2.8 Frac-
t . t . m e/e
/ /
ture liaison service and improving treatment rates for oste-
/ /
htt ps:
oporosis). In one trial, the FLS produced a 30% reduction
for any fracture and a 40% reduction for major refractures
compared to a standard approach hospital, whereas only 20 htt ps:
patients needed to be treated to prevent one new fracture
over 3 years [24]. The impact of comprehensive geriatric care
on the patients’ mobility and subsequent fall prevention is
e rs
also important for secondary fracture prevention.
e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Comprehensive
t
Orthopedic
. m Difference e /
t . m e/e
/ / / /
ps: ps:
geriatric care care (n = 198)
(n = 198)
htt htt
Mean (SD) Mean (SD) Estimate P value
(95% Cl)
Index stay* 11,868 9,537 2,331 < .0001
(4,185) (4,393) (1,483 to 3,178)
Hospital costs 7,745 11,022 -3,277 .07
after discharge* (15,006) (20,119) (-6,784 to 230)
e rs
Rehabilitation 8,105 9,633 -1,529 .14
er s
ok ok
stay* (9,076) (11,125) (-3,535 to 477)
b o Nursing home 14,874 18,798 -3,923
bo
.22
b o o
e / e stay*
Other primary
(30,153)
11,741
(32,959)
10,496
(-10,164 to 2,318)
1,246
e/ e.40
e/e
health and care
services*
(15,128)
: // t .m
(14,498) (-1,683 to 4,173)
: / / t .m
tps tps
Total cost* 54,332 59,486 -5,154 .22
ht ht
(38,048) (44,301) (-13,311 to 3,007)
Table 2.4-1 Overall costs per patient in a comprehensive geriatric

care model compared to conventional orthopedic care. Adapted from
Prestmo et al [26].
Abbreviations: Cl, confidence interval; SD, standard deviation.
e r s* Costs are in euros for 2010.
e r s
e/e
Comprehensive geriatric care Orthopedic care
e / Department • Department of Geriatrics
m e/ • Department of Orthopedic Surgery
m
/ / t .
• Clinic of Internal Medicine
/ /t .
• Clinic of Orthopedics and Rheumatology
ps: ps:
Facilities* • Geriatric ward: • Orthopedic trauma ward:
– Five 1-bed rooms organized in a group together reserved – 1-, 2-, or 4-bed rooms in a 19-bed ward before,
htt htt
for patients with hip fractures within a 15-bed ward or single rooms in a 24-bed ward after relocation
– Mixed orthopedic trauma patient population
Team members, number per bed †:
• Geriatricians 0.13 No geriatrician in this setting
• Registered nurses, licensed practical nurses 1.67 1.48
• Physiotherapists 0.13 0.09 (0.07 after relocation)
e rs
• Occupational therapists
• Orthopedic surgeons
0.13
No geriatrician in this setting
e r s None
0.11 (0.08 after relocation)
b o ok Treatment
o
assessment and care focusing on:
b ok
• Structured, systematic interdisciplinary comprehensive geriatric Following routines of Department of Orthopedic Surgery
b o o
e/ e e / e
– Somatic health (comorbidity management, review of drug regimens,
pain, nutrition, elimination, hydration, osteoporosis, and prevention
e /e
://t m
of falls)
.
– Mental health (depression, delirium)
: / / t . m
t t p s – Function (mobility, PADL, and IADL)
– Social situation
tps
h • Early discharge planning
• Early mobilization and initiation of rehabilitation
Table 2.4-2 Supply of medical professionals and management in the comprehensive geriatric assessment and care and the orthopedic care
ht
groups. Adapted from Prestmo et al [26].
Abbreviations: IADL, instrumental activity of daily living; PADL, personal activity of daily living.
k e rs
*Orthopedic care was relocated to a new hospital building after 219 of 397 patients were recruited.
†
Separate teams with no collaboration.
ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
141
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 4
t
Standard care pathways, protocols, and order sets
. m e / 5 Data collection
t . m e/e
s: / / / /
http
The implementation of standard treatment approaches is a
crucial part of the treatment of FFPs to ensure routine use
htt ps:
There are a variety of outcome parameters to assess the ef-
fectiveness of an orthogeriatric service. Specific parameters
of best practice in the areas of osteoporotic fracture repair, including the time to surgery, length of hospitalization, and
anticoagulant management, treatment of comorbidities, and 1-year mortality are easily comparable measures to monitor
early mobilization (see chapter 2.3 Clinical practice a system’s effectiveness (Table 2.4-3) As stated above, in pa-
e s
guidelines). In the National Institute for Health and Care
r
Excellence guideline, a standardized pathway for the treat-
er s
tients with a hip fracture, longer preoperative waiting times
increase the risk of medical complications due to immobil-
b o ok ment of hip fractures in orthogeriatric patients has been

proposed (Fig 2.4-3).
bo ok
ity [3]. Thus, patients should undergo surgery as soon as
possible. Similarly, the length of hospitalization is an im-
b o o
e/ e e/ e portant parameter, as it can be associated with development
e/e
: // t .m
In a prospective study of orthogeriatric patients that suffered
from a hip fracture, Ogilvie-Harris et al [27] observed sig-
of complications and there is a direct correlation with costs
[28].
: / / t .m
tps
nificantly improved outcomes for those patients treated with
ht
standardized medical and nursing protocols. See chapter 2.7
Protocol and order set development for concepts and issues ht tps
Ideally, the goal of optimal fracture care is the restoration
of the patients’ function, with the lowest mortality possible.
regarding standardizing care. To measure these parameters, appropriate geriatric assess-
ment scores can be useful. Functional outcome and activi-
ties of daily living (ADLs) can be assessed with the Barthel
e r s e r s
Index that is used to measure performance in basic ADLs
ook ok o
Person aged 18 years or older
by scaling the presence or absence of fecal or urinary incon-
e b
with hip fracture undergoing
e b o tinence, the help needed with grooming, toilet use, feeding,

b o
e/e
surgery
e / m e/ transfers (eg, from chair to bed), walking, dressing, climbing

stairs, and bathing. For each question there are two to four
m
/ / t . /
ordinal responses with a fixed count that are summed up.
/t .
ps: ps:
Identify and treat correctable
Operating room staffing
comorbidities The maximum of 100 points implies that the patient is in-
htt
Preoperative pain relief
htt
dependent in his basic ADLs. This score was found to be a
reliable outcome parameter for FFPs [29, 30].
Another frequently used index to assess ADLs is the Katz

score. It analyzes the patient’s performance in six functions
e rs Anesthesia
r s
using yes or no questions to evaluate their performance
e
b o ok b o ok
while bathing, dressing, toileting, transferring, feeding, and
being continent. A score of 6 indicates full function, 4 mod-
b o o
e/ e Surgery
e / e erate impairment, and 2 or less describes a relevant impair-

ment of the patient’s ADLs. The Functional Independence
e /e
://t . m /
Measure uses similar items to evaluate motor and cognitive
: / t . m
t t p s
Postoperative pain relief
tps
performance and is frequently used to describe the ADLs of
ht
the patient at discharge. Another simple tool to evaluate
h
Mobilization and physiotherapy
mobility is the Parker Mobility Score. The Timed Up and Go
test is another commonly used mobility score known to be
a valid and reliable tool to assess patient mobility [31]. As-
sessment of geriatric function is addressed in greater detail
k e rs ke rs
in chapters 1.4 Preoperative risk assessment and preparati-
on and 1.11 Sarcopenia, malnutrition, frailty, and falls.
eb oo Early supported discharge Intermediate care
e b oo b o o
e / m
Fig 2.4-3 Pathway proposed in the National Institute for Health and
t . e /
t .m e/e
/
Care Excellence guideline for the treatment of hip fractures in fragility
/ //
ps: ps:
fracture patients.
142
htt htt
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rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m
Furthermore, perioperative and postoperative complications e /
t . m
Further parameters to assess quality are the readmission e/e
s: / / / /
ps:
must be evaluated. Common complications of patients hav- rate, analysis of the quality of life, pain (see chapter 1.12
http htt
ing suffered fragility fracture are cardiac, cerebral, throm- Pain management), and patient satisfaction.
boembolic, and pulmonary complications such as renal
failure, urinary tract infection, delirium, pressure ulcers, Given the high financial burden of osteoporosis-related frac-
gastrointestinal complications, adverse drug reactions, and tures with estimated annual costs of EUR 31.7 billion (about
subsequent fractures. The main surgical problems are surgi- USD 33.6 billion in 2017) in Europe [32], cost-effectiveness
e rs
cal site infection and other surgical complications such as
catastrophic failures [28].
er s
remains another tool to evaluate a program’s effectiveness.
b o ok bo ok b o o
e/ e e/ e e/e
Outcome parameter Assessment tool
: // t .m Admission* Discharge† 30 days 90 days
: / / t .m1 year
Mortality Mortality rate (%)
s X
tps
X
http ht
Length of stay Midnight census method X
Time to surgery Time from admission until arrival in operating X
room (h)
Complications: Complication rate (%) using the complication
list
• Medical X X
ke r s
• Surgical
k
X
e r s X X
b o o Readmission: Readmission rate (%) using the complication

list
b o o b o o
e /e e/e e/e
• Medical X X
• Surgical
Mobility • Parker Mobility Score
: / / t . m X
X X
X
/ /t . m X
X
ttps ps:
• Timed Up and Go test X X
htt
Quality of life EQ-5D X X X
Pain
Satisfaction
hVerbal rating scale
No appropriate tool available
X‡ X X
ADLs Barthel Index X X X X

Falls No appropriate tool available
e rs
Medication use:
e r s
b o ok • Inappropirate
• Osteoporosis
• Adverse drug reaction with complications
• Medication list
b o X ok X
X
X
X X
b o o
e/ e Place of residence Living situation list
e / e X X X
e /e
Costs
://t m
Percentage of expected national costs
.
X
: / / t . m
t p s tps
Table 2.4-3 Overview of the relevant outcome parameters, assessment tools, and their follow-up to monitor system’s effectiveness [28].
Abbreviations: ADLs, activities of daily living; EQ-5D, EuroQoL-5 dimension (questionnaire to assess quality of life); h, hour.
t
†
‡
h
* Assessment of prefracture status.
Discharge from the acute hospital.
Two days postoperative.
ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
143
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 6 References
t . m e /
t . m e/e
/ / / /
1. Friedman SM, Mendelson DA,
htt ps:
comanaged Geriatric Fracture Center
on short-term hip fracture outcomes.
12. Juliebo V, Bjoro K, Krogseth M, et al.
Risk factors for preoperative and
postoperative delirium in elderly
patients with hip fracture. J Am Geriatr
ps:
22. Black DM, Delmas PD, Eastell R, et al.
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2. Kammerlander C, Gosch M, Frequency, risk factors, and prognosis Goal-directed treatment of osteoporosis
e rs Kammerlander-Knauer U, et al.
Long-term functional outcome in
er s
of prolonged delirium in elderly
patients after hip fracture surgery.
in Europe. Osteoporos Int.
2014 Nov;25(11):2533–2543.
ok ok
geriatric hip fracture patients. Clin Orthop Relat Res. 24. Nakayama A, Major G, Holliday E, et al.
b o Arch Orthop Trauma Surg.

2011 Oct;131(10):1435–1444.
bo
2011 Sep;469(9):2612–2620.
14. Lizaur-Utrilla A, Martinez-Mendez D,
Evidence of effectiveness of a fracture
liaison service to reduce the
b o o
e/ e 3. Kammerlander C, Roth T, Friedman SM,
et al. Ortho-geriatric service—a
e/ e
Collados-Maestre I, et al. Early surgery
within 2 days for hip fracture is not
re-fracture rate. Osteoporos Int.
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e/e
models. Osteoporos Int.
: / t .m
literature review comparing different
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reliable as healthcare quality indicator.
Injury. 2016 Jul;47(7):1530–1535.
: / / t
A cost-utility analysis of a.m
25. Ginsberg G, Adunsky A, Rasooly I.
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4. Hempsall VJ, Robertson DR, et al. Effect of early surgery after hip hip fracture patients, compared with
Campbell MJ, et al. Orthopaedic fracture on mortality and standard of care treatment. Hip Int.
geriatric care—is it effective? A complications: systematic review 2013 Nov–Dec;23(6):570–575.
prospective population-based and meta-analysis. CMAJ. 26. Prestmo A, Hagen G, Sletvold O, et al.
comparison of outcome in fractured 2010 Oct 19;182(15):1609–1616. Comprehensive geriatric care for
neck of femur. J R Coll Physicians Lond. 16. Langenhan R, Trobisch P, Ricart P, et al. patients with hip fractures:
1990 Jan;24(1):47–50. Aggressive surgical treatment of a prospective, randomised,
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5. Kammerlander C, Gosch M, Blauth M,
r s
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e
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b
Center: an orthogeriatric co-
management model. Z Gerontol Geriatr.
reduction and internal fixation versus
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a modular prosthesis nail. J Orthop
27. Ogilvie-Harris DJ, Botsford DJ,
Hawker RW. Elderly patients with hip
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6. Prestmo A, Saltvedt I, Helbostad JL,
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17. Thingstad P, Taraldsen K, Saltvedt I,
fractures: improved outcome with the
use of care maps with high-quality
e/e
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et al. Who benefits from orthogeriatric
t m et al. The long-term effect of

comprehensive geriatric care on gait
/ /t . m
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hip-fracture trial. BMC Geriatr. after hip fracture: the Trondheim Hip 28. Liem IS, Kammerlander C, Suhm N,
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7. Lisk R, Yeong K. Reducing mortality controlled trial. Osteoporos Int. outcome parameters for the evaluation
from hip fractures: a systematic quality 2016 Mar;27(3):933–942. of orthogeriatric co-management for
improvement programme. 18. Pils K, Muller W, Likar R, et al. hip fractures. Injury.
BMJ Qual Improv Rep. 2014;3(1). Rehabilitation nach Hüftfraktur 2013 Nov;44(11):1403–1412.
8. Cameron ID, Chen JS, March LM, et al. [Rehabilitation after hip fracture]. 29. Bryant DM, Sanders DW, Coles CP, et al.
Hip fracture causes excess mortality Wien Med Wochenschr. Selection of outcome measures for
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19. Givens JL, Sanft TB, Marcantonio ER.
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Trauma. 2009 Jul;23(6):434–441.
b o ok people: a prospective 5-year study.

J Bone Miner Res.
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the combined effects of depressive
30. Kammerlander C, Riedmuller P,
Gosch M, et al. Functional outcome
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9. Roche JJ, Wenn RT, Sahota O, et al.
e / e
symptoms, cognitive impairment,
and delirium. J Am Geriatr Soc.
and mortality in geriatric distal femoral
fractures. Injury.
e /e
Effect of comorbidities and
postoperative complications on
://t
mortality after hip fracture in elderly . m 2008 Jun;56(6):1075–1079.
20. Huusko TM, Karppi P, Avikainen V, et al.
Intensive geriatric rehabilitation of hip
2012 Jul;43(7):1096–1101.
: / / t .
31. Hutchings L, Fox R, Chesser T. Proximal
femoral fractures in the elderly:
m
t t p s
people: prospective observational fracture patients: a randomized,
tps
how are we measuring outcome? Injury.
ht
cohort study. BMJ. controlled trial. Acta Orthop Scand. 2011 Nov;42(11):1205–1213.
h
2005 Dec 10;331(7529):1374.
10. National Clinical Guideline Centre. The
Management of Hip Fracture in Adults.
2002 Aug;73(4):425–431.
21. Friedman SM, Mendelson DA, Kates SL,
32. Kanis JA, Johnell O. Requirements for
DXA for the management of
osteoporosis in Europe. Osteoporos Int.
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books/NBK83014. Accessed 2018. management and protocol-driven care
rs rs
11. Khan SK, Jameson SS, Avery PJ, et al. result in better outcomes for a frail
k e Does the timing of presentation of neck

of femur fractures affect the outcome of
k
2008 Jul;56(7):1349–1356.
e
eb oo surgical intervention. Eur J Emerg Med.

2013 Jun;20(3):178–181.
e b oo b o o
e /
t . m e /
t .m e/e
/ / //
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rs
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htt ps: htt ps:
Edgar Mayr
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/
2.5 Adapting facilities to fragility
/ / /
fracture patients htt ps: htt ps:
Edgar Mayr
e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e It is necessary to provide the appropriate patient rooms,
e/e
: // t .m
With future demographic changes, an increasingly large
: / / t .m
therapy rooms, and bathroom facilities. These must be
accessible without obstacles and offer enough space and
tps
number of geriatric fracture patients are expected. As an
ht
example, the total number of 80- to 100-year old patients
with a proximal femoral fracture will more than double by
sonal hygiene.
ht tps
safety, ie, handrails to help the patients with their per-
• A therapy room located on the ward helps to avoid patient

2050 [1]. Notably, these injuries carry a 1-year mortality rate transportation, which is both time-consuming, costly in
of up to 30%. Furthermore, many of these patients are threat- terms of manpower, and provocative for the onset of a
ened by the loss of their independence and about 50% require delirium by changing the familiar environment.
e r s
nursing care or general support within the first year [2].
e r s
e b ook b
Specialized centers for geriatric fracture care nicely address
e o 3 okGeneral measures
b o o
e / e/
some of the problems associated with the treatment of fra-
m
gility fracture patients (FFPs). Two approaches can be dif-
t . t . m
As with children, older adults have unique needs and re- e/e
ferentiated:
: / / / /
quirements, which need to be met by specialized facilities.
h t t p s
• The “ward round model” or “network model” has the
patients being treated on a standard trauma ward with
ps:
The creation of a completely new special geriatric fracture
htt
ward will in many cases not be feasible, but is also not man-
datory. Many existing structural factors can be modified to
additional regularly scheduled ward rounds by a geriatri- meet these special requirements at an economically justifi-
cian to address the specific geriatric problems. able cost and effort.
• The “ward model” or “comanaged program” on the oth-
e rs er hand has FFPs treated on a specialized ward, whereby

r s
Typical examples are:
e
b o ok the specialization also concerns its construction. Ward
o
rounds are made by a trauma surgeon as well as a geri-
b • ok
Wards
b o o
e/ e atrician resulting in comanaged care [3].
e / e •
•
Walls and colors
Common rooms
e /e
://t . m • Patient rooms and beds
: / / t . m
2 Rationale for adaptation
t t p s • Common areas
tps
ht
• Washrooms and bathroom facilities
h
Older patients often have an altered cognitive status as well
as physical condition. Their health and well-being are at
• Therapy rooms
risk as an inpatient and therefore require special caution: On a specialized geriatric trauma ward, these measures will
prove extremely valuable and may be indispensable.
k e rs
• The healing process is complicated for older adults [4, 5].
Patients on a geriatric fracture ward should therefore be
ke rs
eb oo protected from harm. The patient’s unsteady gait must
e b oo b o o
e/e
be considered [6].
e / m e
• Facilities should be designed to avoid the development / m
t .
of delirium; nursing interventions to enhance patients’
/ / // t .
ps: ps:
activity and early mobilization are helpful in this regard [7].
htt htt 145
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 3.1 Inpatient ward
t . m e / • Good lighting is also important to prevent tripping and
t . m e/e
s: / / / /
ps:
Suitable wards are essential (Fig 2.5-1, Fig 2.5-2): assist with reduced visual acuity. Contrasting colors on
http htt
the walls, such as pictures, can aid patient’s orientation
• Usually a hospital’s hallways are sufficiently wide but are and motivation by, for instance, defining an area to be
often used for the storage of carts with bandaging mate- covered in mobilization. A visible scaling along the floor
rials, food, wheelchairs, material for ward rounds, etc. can also be helpful.
This creates a lot of obstacles that hinder the mobilization • Floors that reduce tripping have proper visual character-
e rs of the patient. Such hallway clutter should be avoided.

• The hallways of a geriatric fracture ward should not only
er s
istics for aging eyes and reduction of doorway thresholds.
• Mobile telemetry units can be retrofitted to nearly any
b o ok allow for patient transport, but also for gait training and
exercise. For these reasons, the halls need to be free of
bo ok
ward without difficulty.
b o o
e/ e e/ e
barriers and obstacles, steps, thresholds, or tripping hazards. 3.2 Walls and colors
e/e
: // t .m
Furthermore they should offer solid handrails and benches
to sit down and recover from strenuous practice. Seating
Suitable wall equipment and colors are important (Fig 2.5-3):
: / / t .m
ht tps
for intermittent recovery breaks enhances mobility.
ht tps
• The color scheme of the ward can also be designed to
meet the needs of older adults. Smooth, pastel shades are
both calming and mood-lifting. Sufficient contrast be-
tween walls, floors, and doors allow good orientation
even with impaired eyesight. Differing colors of doors
and walls can be used to illustrate the covered distance.
e r s e r s
• For the patient’s optimal mobilization, the hallways should
ook ok o
be equipped with a sufficient amount of handlebars or
e b e b o handrails. Fold-out seating offers possibilities for breaks,

b o
e /
t . m e/ and they do not obstruct when in a hinged position. Both
increase the ability of older adults to ambulate.
t . m e/e
/ / / /
htt ps: htt ps:
e rs
Fig 2.5-1 The hallway on a regular ward is dark, monotonous, and
e r s
ok ok
full of obstacles.
b o b o b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
Fig 2.5-2 The hallway on a geriatric trauma ward has abundant
light, contrasting colors and is free of obstacles to assure good
Fig 2.5-3 Staircase with handrails on both sides to assure secure
mobilization of the patient.
t .m e/e
/ / //
ps: ps:
mobilization of patients.
146
htt htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
Edgar Mayr
k e rs ke rs
e b oo e b oo b o o
e / 3.3 Patient room
t . m e /
t . m
on the one hand, but designed to make it resemble a e/e
s: / / / /
ps:
hospital as little as possible on the other (Fig 2.5-4). It
http htt
• A large clock and calendar help to maintain orientation. should offer the patient a comforting atmosphere in a
Adequate lighting and a night light are necessary. Large familiar environment.
windows provide daylight, which is mood lifting and • As a rule we find 2-bed rooms to be a reasonable size, as
maintains a circadian rhythm. it offers needed space and a conversational partner, but
• The patient should be allowed to personalize his or her still does not create a noisy or disturbing environment.
k e rs room by, for example, putting up pictures of his or her

family and relatives. This helps to maintain family rec-
•
er s
Certain patients, such as those that are difficult to mobi-
lize, or are delirious, will benefit from single patient rooms.
o o ognition and links positive memories and associations to

o ok
In these few cases, the extra space is needed to provide
o o
e/eb b b
the room. the required nursing care including aids, ie, for mobiliza-
• Room changes throughout the stay should be avoided. A
e/ e tion (Fig 2.5-5).
e/e
: // t .m
patient room needs to be spacious and functional enough •
: / / .m
As an aid to avoid falls, especially with delirious patients,
t
low-to-floor beds with adjustable height have proved to
s tps
http
be very valuable (Fig 2.5-6). The low height level reduces
ht
risk of falls without having to restrain the patient to the
bed. Evidence shows that this sort of bed should be avail-
able for about 30% of the patients [8].
• Other equipment should include a bedside locker of
proper height and a mobile bed, since the patient may
e r s e r s
need to be transferred to another bed or a wheelchair for
ook ok o
transport within the hospital.
e b e b o b o
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
e rs e r s
ok ok
Fig 2.5-4 Patient room with mobile mirror ball unit providing visual,
b o
acoustic, and olfactory stimulus.
b o b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e / m e /
Fig 2.5-5 Patient room with required auxiliary material and assistive
t . t .m
Fig 2.5-6 Patient room with height-adjustable low-floor bed. e/e
: / /
devices for patients with difficult mobilization. Almost the entire
//
s ps:
room is occupied.
h t t p htt 147
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 3.4 Common areas
t . m e / • A common room has the additional advantage that pa-
t . m e/e
s: / / / /
ps:
A room for common activities is another important element tients with delirium can be taken care of much more
http htt
(Fig 2.5-7): easily and with fewer staff, as they are together in a group
instead of their own rooms.
• A common room suitable to the patients of a geriatric
trauma ward can be simply designed. When put to prop- 3.5 Washrooms and bathrooms
er use, this space can be used not just as a meeting place, Bathrooms should be appropriately equipped (Fig 2.5-8,
e rs but also as an extensive therapy concept.

• Simple measures can help to address many issues for an
Fig 2.5-9):
er s
b o ok older patient. Repeated transfers every day from the
patient room to the common space, for instance, offer
bo ok
• Easy access without obstacles is essential for older adults.
• Seating in the shower is also important.
b o o
e / e mobility of the patient.
e/ e • Handlebars, which should always be installed on both
e/e
: // t .m
• Dining in the company of other patients and sitting at a
table rather than dining in bed may increase the patient’s
sides since one side of the patient may be impaired due
to his or her injury, are also needed in the shower.
: / / t .m
ht tps
appetite and counter malnourishment.
• The predetermined day’s structure can be a prophylactic
measure against the development of delirium. ht tps
• Shared parlor games and activities not only provide
amusement but are also helpful with cognitive activation.
• Overall, the patient is engaged in a normal day structure
e r s and their independence is strengthened [3].

e r s
ook ok o
• The furnishing of such a common room includes suitable
e b tables and diverse seating opportunities ranging from a

e b o b o
e / large TV set, possibly equipped with headphones, an
t . e/
couch to a specialized chair for mobilization, a sufficiently
m t . m e/e
/ /
overall ambience with recognizable objects, ie, bus stop
/ /
htt ps:
sign to prevent patients from leaving the ward, old piano,
old posters, toys. With help from volunteers an alternat-
ing program with parlor games, singalongs, or pottery htt ps:
can be offered.
Fig 2.5-8 Patient bathroom
e rs e r s with barrier-free access to the

shower and handlebars with
b o ok b o ok fold-out seating.
b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e / Fig 2.5-7 Common room with patients having lunch together.
t . m e /
The open and friendly design with old movie posters offers great
Fig 2.5-9 Patient bathroom free of obstacles, equipped with plenty
t
of handlebars and enough room for the patient, a nurse, and an
.m e/e
/ / //
ps: ps:
recognition value. A calendar and clock offer temporal orientation. occupational therapist, along with auxiliary material.
148
htt htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
Edgar Mayr
k e rs ke rs
e b oo e b oo b o o
e /
t . m
• Enough space for the patient plus an additional nursee / 4 Delirium prevention
t . m e/e
s: / / / /
ps:
and occupational therapist with assistive equipment
http htt
should be available to allow autonomous personal hygiene Prevention of delirium is a multimodal exercise. Many non-
with corresponding practice. pharmacological concepts are important [9]. In this context
environmental factors in wards play a major role and should
3.6 Therapy room not be underestimated. They can promote but also coun-
A spacious therapy room is an essential element: teract delirium as follows:
e rs
• All necessary equipment is available (Fig 2.5-10).
er s
• A friendly and colorful but soothing wall design can have
b o ok • It offers sufficient open space to permit group therapy

sessions (Fig 2.5-11).
bo ok
a prophylactic effect.
• Large windows and good lighting promote the mainte-
b o o
e/ e e/ e nance of a circadian rhythm.
e/e
: // t .m : / / t .m
• The same applies to patient activation, meals, games, or
music, and watching TV during daytime in a common
ht tps ht tps
room [6]. This room should, just like the patient rooms,
be designed in a considerate way concerning the patient’s
age by creating points with recognition value, such as
old movie posters or an old piano (Fig 2.5-7).
• The patient rooms should, if possible, be personalized
during and throughout the stay by, for example, decorat-
e r s e r s
ing them with family pictures. Switching rooms during
ook ok o
one stay on the ward must be avoided.
e b e b o• Frequent changes of environment can also be reduced

b o
e /
t . m e/ with a therapy room on the ward by reducing the num-
t . m
ber of required transports and changes of location, there- e/e
/ / by reducing the likelihood of delirium.
/ /
htt ps: htt ps:
See chapter 1.14 Delirium for a more thorough discussion.
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e / material and training devices.
t . m e /
Fig 2.5-10 Therapy room on the ward with necessary auxiliary Fig 2.5-11 Therapy room on the ward with enough space for group
sessions.
t .m e/e
/ / //
htt ps: htt ps:
149
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 5 References
t . m e /
t . m e/e
/ / / /
htt ps:
1. Lohmann R, Haid K, Stockle U, et al.
Epidemiologie und Perspektiven der
Alterstraumatologie [Epidemiology
and perspectives in traumatology of
3. Werther SFJ, Mayr E. Interdisziplinäres
Management im Zentrum für
geriatrische Traumatologie.
[Interdisciplinary management at the
ps:
6. Gillespie LD, Robertson MC,
htt
Gillespie WJ, et al. Interventions for
preventing falls in older people living
in the community. Cochrane Database
the elderly]. Unfallchirurg. center for geriatric traumatology]. Syst Rev. 2012 Sep 12(9):CD007146.
2007 Jun;110(6):553–560; Orthopäd Unfallchirur. 7. Holroyd-Leduc JM, Khandwala F,
quiz 561–552. German. 2014;9(05):387–406. German. Sink KM. How can delirium best be
e rs
2. Muller-Mai CM, Schulze Raestrup US,
Kostuj T, et al. Einjahresverläufe nch
er s
4. Bellelli G, Mazzola P, Morandi A, et al.
Duration of postoperative delirium
prevented and managed in older
patients in hospital? Can med Assoc J.
ok ok
proximalen Femurfracturen. is an independent predictor of 6-month 2010 Mar 23;182(5):465–470.
b o Poststationäre Analyse von Letalität

und Pflegestufen durch Kassendaten.
o
mortality in older adults after hip
b
fracture. J Am Geriatr Soc.
8. Tzeng HM, Yin CY, Anderson A, et al.
Nursing staff’s awareness of keeping
b o o
e/ e [One-year outcomes for proximal
femoral fractures: Posthospital analysis
e/ e
2014 Jul;62(7):1335–1340.
5. Marcantonio ER, Flacker JM,
beds in the lowest position to prevent
falls and fall injuries in an adult acute
e/e
of mortality and care levels based on
: //
health insurance data]. Unfallchirurg.
t .m Michaels M, et al. Delirium is
independently associated with poor
: / / t .m
surgical inpatient care setting. Medsurg
Nurs. 2012 Sep-Oct;21(5):271–274.
tps tps
2015 Sep;118(9):780–794. German. functional recovery after hip fracture. 9. Tabet N, Howard R. Non-
ht ht
J Am Geriatr Soc. pharmacological interventions in the
2000 Jun;48(6):618–624. prevention of delirium. Age Ageing.
2009 Jul;38(4):374–379.
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
Markus Gosch, Michael Blauth
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/
2.6 Orthogeriatric team—principles, roles,
/ / /
htt
and responsibilities ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e A systematic approach helps to manage this information
e/e
: // t .m
Fragility fracture patients (FFPs) are medically complex and
: / / t .m
and to detect underlying cognitive, functional, medical, and
social problems that are likely to impact outcomes and effect
tps
typically present with more than a single medical problem.
ht
While some of these problems are apparent, others may
remain unrecognized and lead to complications and adverse ht tps
prognosis. For the team to work effectively, it is essential to
clearly define the orthogeriatric team and the roles of each
member. This chapter is written based on the academic and
outcomes. Because of this typical complexity, systematic clinical experience of a mature orthogeriatric team using
efforts are necessary to routinely obtain detailed patient- the principles of orthogeriatric comanagement (see chapters
specific clinical information and to set patient-specific goals. 2.1 Models of orthogeriatric care and 2.4 Elements of an
e r sThis approach requires a coordinated team of health profes-

e r s
orthogeriatric comanaged program) [1].
ook ok o
sionals, each of whom is focused on specific aspects of care
e b (Fig 2.6-1).
e b o b o
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m b
: / / t . m
t t p s tps
h ht
k e rs
a c
ke rs d
b o o b oo
Fig 2.6-1a–d An 88-year-old woman was admitted to the emergency department following a fall on the way to the bathroom. The x-rays
of her left hip showed a femoral neck fracture (a–b). Her body weight was 46 kg. Nine months before, a kyphoplasty was performed after
b o o
e / e e /e
a fracture of the first lumbar vertebra (c–d). She had many comorbidities, including osteoporosis, heart failure, hypertension, depression,
mild cognitive impairment, and urinary incontinence, and was taking 10 different drugs daily. Additionally, she had difficulty swallowing her
e/e
/t . m / t .m
medication and sometimes her food. To that point, she had been living alone and independently and had received help from her neighbors.
/ /
ps: ps:
She had to climb the stairs to enter her second-floor apartment. Her son worked in another town and was not able to come to the hospital.
htt htt 151
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/ / t . m // t . m
htt ps: htt ps:
2.6 Orthogeriatric team—principles, roles, and responsibilities
k e rs ke rs
e b oo e boo b o o
e / 2 The comorbidity construct
t . m e / • Finally, the complexity of patients’ conditions result from
t . m e/e
s: / / / /
ps:
their nonhealth-related individual attributes (eg, person-
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The comorbidity construct (Fig 2.6-2) is a useful tool to get ality, social supports, and financial supports).
a better overview of the complexity that needs to be ad-
dressed for most FFPs [2]. This approach should help illustrate By using this systematic framework in the rather simple
the necessary components and goals of the orthogeriatric example described in Fig 2.6-1, the team is more likely to
team. identify the relevant medical and social problems and better
e rs
Usually, the index disease (ie, fragility fracture) leads to
er s
address those conditions that are likely to impact recovery
from fracture repair and attainment of the highest level of
b o ok hospital admission. In order to prioritize the treatment goals,

it is worthwhile to identify and define additional important
bo ok
function (Fig 2.6-3). When applying the comorbidity construct
to this specific example, it becomes clear that:
b o o
e/ e conditions:
e/ e e/e
• Comorbidities are medical conditions that are strongly
: // t .m • The index disease for hospital admission is the hip fracture.
• A contributing comorbidity is osteoporosis. There is a
: / / t .m
s tps
http
interrelated with the index disease and the outcomes of strong relationship between the fracture and osteoporo-
interest. When treating the index disease, you have to
include the comorbidities in the treatment plan for an
optimal outcome.
ht
sis. When treating FFPs, you should initiate osteoporosis
care. Otherwise, you will miss an opportunity; probably
the most important in terms of secondary fracture pre-
• Multimorbidity refers to the total burden of other dis- vention, and your case management will be at risk to fail.
eases in a patient. These may play a general role in out- • Other potentially important comorbidities are heart fail-
e r s comes, but may not be modifiable, or need to be specifi-

e r s
ure, hypertension, and depression. Their impact on short-
ook ok o
cally addressed during the hospitalization. term recovery is not entirely clear and may be influenced
e b • Interestingly, the impact of the chronological age is not

e b o by the severity of each disease and other individual fac-
b o
e / as significant. The biological age of patients and the es-
m
timated life expectancy are more relevant for the outcome.
t . e/ tors. The team must evaluate which medical conditions
might have an impact on the outcome of the patient and
t . m e/e
/ /
• Fragility fractures are mainly a result of a low-energy need to be included in the team’s treatment plans.
/ /
ps:
trauma, eg, a fall from standing height. In older patients,
htt
intrinsic factors are a major contributor in terms of falls.
Besides comorbidities, health-related individual attributes
• Gender aspects should also be considered. Usually, male
htt
patients have worse outcomes than female patients. So-
cial environments are not comparable.
ps:
must be taken into consideration. Health-related attributes • The correlation of increased age and mortality is mainly
are existing or developing functional disabilities and ge- the result of the higher prevalence of disease and func-
riatric syndromes (eg, frailty, gait instability, cognitive tional disabilities with increasing age. For highly func-
e rs impairment, urinary incontinence). They all contribute

r s
tional and healthy adults, the correlation between age
e
b o ok to the overall morbidity burden.
b o ok
and mortality is not strong [3].
b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
Disease 1 (index)
h Disease 2 Disease n Hip fracture
ht
Osteoporosis Heart failure
Hypertension
Depression
Comorbidity (index of diseases) Multimorbidity Comorbidity (of index diseases) Multimorbidity
kers kers
Gender Age Life expectancy Female 88 years Limited
b o o Morbidity burden
Other health-related individual attributes
boo
Immobility, malnutrition, cognitive impairment, pain, polypharmacy, dysphagia
Morbidity burden
b o o
e /e Patients’ complex medical conditions
t . m e /
Nonhealth-related individual attributese Lives alone, independently, low income, one son, has to use stairs
Patients’ complex medical conditions
t .m e/e
s: / / //
ps:
Fig 2.6-2 Comorbidity construct according to Valderas et al [2]. Fig 2.6-3 Comorbidity construct applied to Fig 2.6-1.
152
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/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
• In terms of goal setting, life expectancy should be esti- 4 Team members and roles
t . m e/e
s: / / / /
ps:
mated. Functional and robust older adults may still have
http htt
a remarkably long life expectancy. In the example case, For FFPs, a team approach is essential to attain success. A
the life expectancy was limited, but not so much as to frequently asked question concerns leadership. The coman-
preclude fracture repair and an attempt at rehabilitation agement paradigm is based on shared leadership from all
(see chapter 1.5 Prognosis and goals of care). core team members (ie, surgeons, anesthesiologists, and
• Different functional disabilities such as immobility, mal- geriatricians) and decisions are made collaboratively [4].
e rs nutrition, cognitive impairment, pain, polypharmacy,

and dysphagia may be present. These health-related in-
er s
Leadership is not regulated by hierarchical structure but by
medical qualification. Based on the knowledge and the ex-
b o ok dividual attributes can have more impact on the outcome

than the index diagnosis and should be specifically and
bo ok
pertise in the involved disciplines, leadership changes depend
on the clinical situation. In addition to providing leadership,
b o o
e/ e systematically addressed by the team.
e/ e each team member has a specific role within the team.
e/e
: // t .m
• Finally, morbidity burden not only reflects the diagnosis
but also the functional disabilities of a patient.
: / / t .m
All team members play their role at different phases of the
tps
• Based on a holistic approach, the orthogeriatric team also
ht
has to assess for nonhealth-related individual attributes
including the social environment. The social network is ht tps
treatment and even in different facilities. Depending on
local resources and practices, they may have different roles
and responsibilities to those suggested below. But they all
not only extremely important for discharge planning but must agree on the basic principles of treatment according
also for reduction of readmissions and secondary fracture to the guidelines, and they all must feel responsible with a
prevention. sense of co-ownership of the patient. This obviously requires
e r s e r s
regular communication and meetings around specific patient
ook ok o
issues as well as system concerns.
e b 3 Goal setting
e b o b o
e / m e/
After having collected all information by using the comor-
t .
4.1 Orthopedic trauma surgeon
t . m
The orthopedic trauma surgeon has specific roles and tasks e/e
/ /
bidity construct, the process of goal setting starts. This pro- when seeing an FFP. He/she:
/ /
ps:
cess should be based on the following principles:
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• Ensure the goal you set is specific, clear, and attainable. patient. htt ps:
• Is often the first member of the core team to evaluate the
• The goal should be measurable, ie, if you cannot measure • Obtains the history of the patient including the mecha-
it, you cannot manage it. nism of injury. In some settings, the surgeon decides if
• A goal needs to be attractive and acceptable to the patient, an older patient requires admission to a geriatric-based
e rs family, and team.

r s
unit, based on age, comorbidities, and fracture details.
e
b o ok • The timeline should be considered by setting short-term
b o
as well as long-term goals. Usually, the long-term goal is ok
• Starts the interdisciplinary process by contacting the
geriatrician and anesthesiologist if a surgery is planned.
b o o
e/ e / e
the expected outcome in several weeks, ie, “to live inde-
e
pendently” or “to walk without using a walking aid”. In
• Initiates the diagnostic workup regarding injuries, makes
diagnoses, and classifies fracture(s).
e /e
://t . m
order to achieve the long-term goal, it is necessary to
/ t . m
• Activates standard preoperative order sets and protocols.
: /
t t p s
meet different short-term goals for each problem, like
tps
• Takes part in the process of goal setting in cooperation
ht
walking with a roller after the first week or removing the with the geriatrician and anesthesiologist.
h
urine catheter within 2 or 3 days after surgery. The goals
may be changed due to medical complications or if patients
• Plans and performs surgery, typically determining the
optimal technique to promote full weight bearing during
were to become unwilling or unable to continue or if the immediate postoperative period.
they progress more slowly or quickly than expected. • Cares for anticoagulation management preoperatively
k e rs
Goal setting should be integrated into the regular team
ke rs
and postoperatively in cooperation with the geriatrician
and the anesthesiologist. Especially among patients re-
eb oo meetings.
e b ooceiving chronic anticoagulation, these team members

b o o
e/e
should weigh risks and benefits for each patient.
e / m e / • Initiates and reviews pain management, starting on eval-

m
/ /t . t .
uation and including local anesthesia, enteral and paren-
//
ps: ps:
teral drug treatment, and nonpharmacological measures.
htt htt 153
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rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / • Plans perioperative antibiotic management.
t . m e / drug treatment for every patient. Geriatricians must look
t . m e/e
s: / / / /
ps:
• Supervises wound healing and the control of wound in- for fall risk factors and work out a specific treatment plan
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fections [5]. to reduce the risk of subsequent falls and fractures.
4.2 Geriatrician or medical leader 4.3 Anesthesiologist

The geriatrician or medical leader takes part in the interdis- The anesthesiologist is an essential team member that is
ciplinary ward rounds and team meetings, evaluates treat- closely involved in the decision to operate and the manage-
e rs
ment progress, and adjusts treatments and goals together
with the other team members. She/he:
er s
ment of fracture pain. He/she:
b o ok • Should be involved as soon as possible, ideally in the

b ok
• Should be involved as soon as possible.
o
• Is often responsible for the procedure to achieve acute
b o o
e / e emergency department.
e/ e pain relief in the emergency department, eg, local anes-
e/e
: // t .m
• Performs a physical examination, particularly focused on
the cardiopulmonary and neurological status. Collects
thetic nerve blocks.
: /
• Evaluates patient fitness for surgery together with med-
/ t .m
tps
medical history, especially comorbidities and medication.
ht
Basic assessment tools, like prefracture functional scores
(eg, Parker Mobility Score) or cognitive assessments (eg,
strategies for each patient.
ht
• Helps to determine the timing of surgery.
tps
ical and surgical teams. Identifies additional optimization
Confusion Assessment Method or Mini-Cog tests) should • Determines the perioperative anesthesia plan and antici-
be part of the clinical examinations. Standard orders and pates postanesthesia recovery needs (eg, postanesthesia
protocols should have already been initiated, but the care unit [PACU] or intensive care unit [ICU] recovery).
e r s medical team is responsible for any nonstandard tests or

e r s
• Is responsible for the immediate postoperative care of the
ook ok o
consultations. patient, eg, PACU or ICU.
e b • Has, if surgery is required, the most important task to

e b o
• Benefits from cooperation between surgeons and geriatri-
b o
e / exclude conditions (eg, uncontrolled heart failure) that
t . m e/
could result in surgical delay. In these rare cases the core
cians.
t . m e/e
/ /
team has to set a clear goal for the optimization and a 4.4 Orthopedic staff nurse
/ /
time line.
htt ps:
• Optimizes the patient for surgical repair, focused on pre-
operative fluid support, hemodynamic stability, and acute htt ps:
The orthopedic nurse spends a great deal of time and effort
taking care of the FFP and communicating with the family.
She/he:
pain management.
• Identifies patient-specific goals of care, and surrogate • Spends the most time with the patients. Therefore, the
decision makers and advanced directives in the event of nursing staff play a major role in the interprofessional
e rs cardiac arrest or need for cardiopulmonary resuscitation.

r s
team and in the treatment process.
e
b o ok • Is in charge of medical treatment postoperatively, par-
b o
ticularly of the comorbidities, and supervises prevention ok
• Provides essential care such as pain assessment, medication
administration, vital sign tracking, wound care, and com-
b o o
e/ e / e
and treatment of complications (eg, delirium, pneumonia,
heart failure, and renal insufficiency).
e
munication of patient status with medical and surgical teams.
• Focuses on prevention of falls, pressure ulcers, malnutri-
e /e
://t . m
• Is primarily responsible for medication management and tion, delirium, and infections.
: / / t . m
t t p s
avoidance of polypharmacy. Usually, FFPs are medically
tps
• Assesses and encourages nutritional intake and any fac-
ht
complex patients in an unstable situation. Many chron- tors that may impair optimal oral nutrition (eg, dyspha-
h
ic medications can be dangerous during this dynamic
situation, and a high level of prescribing expertise is
gia, nausea, consistency, and taste).
• Ensures that sensory aides (eg, glasses and hearing aids)
needed. Potentially inappropriate medications should be are present and working.
avoided. Some medications issues, like anticoagulants, • Implements specific tools to assess pain, delirium, and
k e rs antibiotics, or pain medications, should be discussed by

the interdisciplinary team.
ke rs
fluid and nutrition management.
• Manages incontinence and catheters. Urinary retention
eb oo • Is primarily responsible for initiating secondary fracture
e b ooshould be excluded using ultrasound. If urinary incon-

b o o
e/e
prevention. Osteoporosis and fall assessment have to be tinence occurs, it has to be documented and included in
e / completed. Geriatricians should evaluate for metabolic

m e / the treatment process.
m
t .
bone disease, ensure adequate calcium intake and vitamin
/ / • Encourages patients in activities of daily living (ADLs).
// t .
ps: ps:
D supplementation, and consider specific osteoporosis
154
htt htt
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/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
• As a specialized orthopedic nurse, they are involved in 4.7 Speech therapist
t . m e/e
s: / / / /
ps:
secondary fracture prevention. They choose the appropri- The speech pathologist has an essential and unique role in
http htt
ate walking aid, and counsel their patients and relatives care of the FFP. He/she:
about osteoporosis and fall risk factors [6].
• Is involved in discharge management together with social • Provides treatment, support, and care for older adults
workers. that have difficulties with eating, drinking, and swallow-
ing. Pneumonia is a frequent complication after surgery
k e rs 4.5 Physiotherapist
The physiotherapist is closely involved with the FFP and their
er s
with aspiration being a common cause. Postoperative
swallowing disturbances are frequent in older adults. In
o o rehabilitation and physical function assessment. He/she:

o ok
confused patients, sedation during or after anesthesia
o o
e/eb b b
aggravates the risk for aspiration.
e/
• Implements and adjusts a physiotherapy plan for FFPs. e • Helps to confirm the risk of aspiration and is able to treat
e/e
: // t .m
• Prepares patients for transfer to the next setting (ie, re-
habilitation facility, nursing home, or home).
:
be integrated in the treatment process.
/ / .m
them successfully. An assessment of swallowing should
t
sources to assist with ADLs.tps
• Obtains details regarding home setting and home re-
ht
• Helps to encourage development and facilitates recovery,
4.8 Medical social worker
ht tps
The involvement of the medical social worker should ide-
adjusting for common geriatric issues like gait instability, ally begin at hospital admission [4]. She/he:
orthostatic hypotension, dyspnea, and delirium.
• Identifies obstacles to mobility (eg, pain with activity and • Stays in contact with the relatives, nursing homes, and
ke r s
room clutter) and is extremely important for mobilization
e r s
rehabilitation centers.
b o o and specific exercises as well as for checking further func-

tional problems.
b o ok
• Evaluates home environment and social support of the
patients.
b o o
e /e aids.
t . e/ e
• Trains patients and family in the proper use of walking
m
• Is extremely important in terms of goal setting and
discharge planning.
t . m e/e
/ /
• Trains patients how to use stairs safely.
/ /
htt ps:
• Provides feedback to the team regarding functional lim-
its, pain, or other obstacles to recovery.
4.9 Dietitian or nutritionist
htt ps:
Many older adults suffer from poor nutrition. As a result,
the involvement of a dietician or nutritionist is important.
4.6 Occupational therapist Malnutrition is common among older FFPs for many reasons.
The occupational therapist is focused on the patient’s return Supplementation of protein improves the outcome of these
to independence with ADLs. She/he: patients and is able to prevent sarcopenia. See chapter 1.11
e rs e r s
Sarcopenia, malnutrition, frailty, and falls for more discus-
b o ok • Addresses the needs of rehabilitation, disability, and par-

ticipation.
b o ok
sion on malnutrition. The dietitian:
b o o
e/ e / e
• Practices activities like eating, bathing, or toileting. Ac-
e
tivities of daily living are very important for independence.
• Assesses patients for presence of malnutrition.
• Creates a dietary plan that maximizes nutritional intake
e /e
://t . m
• Assists the team in determining a safe discharge plan.
: / / t .
of protein, calories, water, and micronutrients. m
s
• Teaches ADLs, the use of walking aids, and special devices.
t t p tps
• If food intake is insufficient, the dietitian can develop a
ht
• Should also be involved in the treatment of delirium. special food plan.
h
Occupational therapy is charged with evaluating patient
cognition, as it relates to home safety and ability to be
• Can be helpful in the management of swallowing distur-
bances.
independent. They have different options to work with
confused patients and to help them to recover earlier 4.10 Care coordinator or case manager
kers rs
from delirium. Environmental stimuli may help to reduce A care coordinator or case manager can help to manage an
o
the risk of delirium.
ke
optimal treatment process, organize team meetings, and
b o b oo
stays in contact with general practitioners, nursing homes,
b o o
e /e e e/e
and rehabilitation centers. This role is often filled by a non-
m e / clinical nurse or a social worker dedicated to overall unit

m
/ /t . efficiency.
// t .
htt ps: htt ps:
155
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/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
ps: ps:
4.11 Pharmacist 4.13 Emergency physicians and emergency team
htt htt
Polypharmacy is a widespread problem among older FFPs The role of the emergency physicians and the emergency
[7]. Drug-drug interactions and adverse drug reactions are team depends on the local situation and structure of the
strongly associated with the number of drugs. A pharmacist: hospital. Based on their expertise, they can assume some
responsibilities from trauma surgeons, anesthesiologists,
• Or pharmacy assistant can verify the accuracy of home and geriatricians.
e rs medication lists, identify appropriate drug dosing for frail

older adults, and assist with the education of patients around
er s
The treatment process starts at the location of accident, es-
b o ok specific medication issues (eg, anticoagulant teaching).

• Can be involved as a part of ward rounds or in team
bo ok
pecially pain treatment and delirium prevention. The emer-
gency team collects all available information including
b o o
e/ e meetings.
e/ e medications, medical reports, and patient’s advanced direc-
e/e
: // t .m
• Advises the geriatrician, trauma surgeon, and nursing
staff on prescribing and administration, with a focus on
tives. The team typically focuses on initiating standard pro-
: / / t
tocols and order sets focused on diagnostic workup, restora- .m
ht tps
avoiding adverse drug reactions.
• Can ensure that the discharge medication list is accurate.
4.14 ht
Cardiologist or other specialists
tps
tion of intravascular volume, and acute pain control.
4.12 Psychiatrist The majority of FFPs can be managed without further sub-
Delirium is the most frequent complication. Usually, a well- specialty consultation, and consultation does carry the risk
trained orthogeriatric team is able to care for patients suf- of inappropriate surgical delay or delay in initiation of re-
e r s
fering from delirium. However, in severe cases of delirium,
e r s
habilitation [8]. Occasionally, patients will require consulta-
ook ok o
a psychiatrist may need to be involved. tion for new medical complications or complex chronic
e b e b o disease. The primary team should incorporate subspecialty

b o
e / Depression and fear of falling are other frequent symptoms.
m
Older FFPs frequently fear losing their autonomy. The hos-
t . e/ advice along with other goals to limit polypharmacy and
adapt medical treatment to life expectancy and goals of care.
t . m e/e
/ /
pital stay is a source of psychological stress for these patients.
/ /
htt ps:
The indication for antidepressants should be evaluated by
the psychiatrist. Particularly regarding secondary fracture htt ps:
prevention, antidepressants have a negative effect on risk
of falls and bone quality. Therefore, the risks and benefits
of treatment should be considered.
e rs e r s
b o ok 5 References
b o ok b o o
e/ e 1. Gosch M, Hoffmann-Weltin Y, Roth T,
e / e
4. Friedman SM, Mendelson DA, Kates SL, 7. Harstedt M, Rogmark C, Sutton R, et al.
e /e
et al. Orthogeriatric co-management
improves the outcome of long-term
://t . m et al. Geriatric co-management of
proximal femur fractures: total quality
t .
Polypharmacy and adverse outcomes
: / /
after hip fracture surgery. J Orthop Surg m
t t p s
care residents with fragility fractures. management and protocol-driven care
tps
Res. 2016 Nov 24;11(1):151.
ht
Arch Orthop Trauma Surg. result in better outcomes for a frail 8. Kates SL, Mendelson DA, Friedman SM.
h
2016 Oct;136(10):1403–1409.
2. Valderas JM, Starfield B, Sibbald B,
et al. Defining comorbidity:
2008 Jul;56(7):1349–1356.
5. Mears SC, Kates SL. A guide to
Co-managed care for fragility hip
fractures (Rochester model). Osteoporos
Int. 2010 Dec;21(Suppl 4):S621–S625.
implications for understanding health improving the care of patients with
and health services. Ann Fam Med. fragility fractures, edition 2.
2009 Jul–Aug;7(4):357–363. Geriatr Orthop Surg Rehabil.
k e rs
3. Keeler E, Guralnik JM, Tian H, et al.
The impact of functional status
2015 Jun;6(2):58–120.
ke rs
6. Bunta AD, Edwards BJ, Macaulay WB Jr,
oo oo o
on life expectancy in older persons. et al. Own the bone, a system-based
eb J Gerontol A Biol Sci Med Sci.

b
intervention, improves osteoporosis
e b o
/ / e/e
2010 Jul;65(7):727–733. care after fragility fractures. J Bone
e t . m e
Joint Surg Am. 2016 Dec 21;98(24):e109.
t .m
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
Stephen L Kates, Joseph A Nicholas
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/
2.7 Protocol and order set development
/ / /
htt ps:
htt ps:
e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e • When all patients are managed using standard protocols
e/e
: // t .m
High-performing geriatric fracture centers report the insti-
: / / t .m
and order sets, outcomes can be better assessed and com-
pared. When an order or pathway is changed, it is con-
tps
tution of protocols and order sets as one of the major tools
ht
to improve outcomes. These attempts at standardization of
care are often focused on many different members of the ht tps
siderably easier to assess the effects of the change.
• An unspoken benefit of standard protocols and order sets
is that all members of the care team come to accept them
care team, including providers, nursing, ancillary services, as being the norm, and recognize potentially harmful
and administrative staff responsible for arranging safe and deviations. When there is a variation from the norm, the
timely surgery. team members will question why, often avoiding harm
e r s e r s
or an adverse event. Use of standard order sets offers the
ook ok o
Standardization of care is an essential part of providing op- opportunity for significant cost savings by reducing the
e b b o
timal care for fragility fracture patients (FFPs). Order sets,
e
use of “physician preference” medications and other
b o
e / e/
protocols, and care plans are tools that can help organize
m
safe and efficient care, and avoid errors due to inappropri-
t .
variations. This results in measurable cost savings and
t . m
offers the opportunity to avoid medication errors. e/e
/ /
ate variation. These tools are the centerpiece of fracture
/ /
in harm. ps:
programs that yield significant gains in safety and reductions
htt 3
htt ps:
Development of a standard care pathway
This chapter will discuss the rationale for increased stan- The essential steps in developing a standard pathway are:
dardization of care, as well as issues to consider in the de-
velopment, adoption, and maintenance of these tools. • To reach a clinical and administrative consensus that the
e rs e r s
pathway and order sets are needed to improve patient
b o ok 2 hy are standard protocols and order sets

W
b o ok
care. The benefits of standardizing pathways should be
carefully explained to members of the care team. One
b o o
e/ e needed?
e / e benefit of the implementation of electronic health records
is that it becomes much simpler to have standard order
e /e
://t . m
The primary concept is to create a standard work flow for
/ t . m
sets. Once an order set is created for a specific diagnosis,
: /
t t p s
a specific diagnosis. The concept of standard work is ubiq-
tps
it becomes the easier path for physicians to follow.
ht
uitous in industry dating back to the early 20th century in • To obtain buy-in from all team members affected by the
h
the automotive industry [1]. Standard order sets offer a lot
of benefits, as the following list and Table 2.7-1 show:
protocols and order sets. This is best accomplished by
meeting as a team and requesting the assistance of a rep-
resentative from each discipline involved in care of the
• They may help to reduce unnecessary variations [2–6]. patients with the diagnosis.
k e rs This avoids what is referred to as “inappropriate creativ-

ity” by the physician when writing orders and devising
ke rs
• Use of an older order set or an order set from a success-
ful program is a good starting place. Each order should
eb oo treatment plans.
e b oobe examined in detail and discussed with the entire team

b o o
e/e
• They ensure that patient care follows a predetermined to improve it. It should be understood that such order
e / e /
pathway that has been shown to be effective and hope-
m
sets will need to be revisited and upgraded over time to
m
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fully is based on evidence-based best practices [7].
t .
improve outcomes and to adapt them to the availability
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of new medical evidence.
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Emergency department
Benefit
• Rapid admission
t . m e / Example
• Emergency department order set
Team members
• Surgeon
t . m e/e
s: / / / /
ps:
order sets • Avoid unnecessary tests and x-rays • Medical doctor
• Nurses
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• Pharmacist
• Emergency physician
Admission orders • Optimize patient • Admission order set for hip fractures • Surgeon
• Appropriate tests • Geriatrician
• Avoid bad medications • Nurses
• Pharmacist
e rs er s • Social worker
• Therapists
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• Mid-level providers
b o Postoperative orders • Streamlined postoperative care
bo • Postoperative hip fracture order set • Surgeon
b o o
e / e • Appropriate medications ordered
• Avoid unnecessary tests
e/ e • Geriatrician
• Nurses
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• Early discharge • Pharmacist
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• Avoid delirium • Social worker
: / / t
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• Therapists
Consultation form
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• Standard assessment for preoperative patient
• Risk stratification
• Avoid unnecessary consultations
• Preoperative geriatric fracture consultation form
ht
• Geriatrician
• Surgeon
• Anesthesiologist
Surgical choices • Develop decision tree based on radiographic • Hip fracture poster to hang in surgical area • Surgeon champion
pattern for evidence-based correct hip fracture
s s
fixation
e r • Goal is stable fixation that allows immediate
e r
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weight bearing
b
Metabolic bone • Standardized assessment for osteoporosis, primary
o
• Set of orders, including vitamin D level, PTH level,
b
• Surgeon and medical physicians
b o o
e / e workup
Transfer protocol
or secondary
e
• Standard method for streamlined acceptance of
/ e TSH level, calcium
• Transfer protocol and poster
• Surgeon
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transfers from other facilities
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Direct admission
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• Standard method for streamlined acceptance of
direct admission to the orthopedic floor from
other facilities
• Direct admission protocol
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• Surgeon
• Medical physician
Nursing care • Plan that follows each step of the standard order • Nursing care map • Surgeon
sets • Medical physician
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Discharge process
• Everyone is on the same page
• Early hospital discharge
e r s
• Standardized social work assessment done prior to
• Nursing leaders
• Social worker
b o ok Consent forms
b o
• Preprinted procedure-specific consent forms ok
surgery after admission
• Expedite consent process with legible complete
• Surgeon and medical champion
• Surgeon champion
b o o
e/ e e / e form
• Avoid liability issues
e /e
Outcomes report
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• Collect standard outcome measures for hip
fracture patients
• Monitor program performance
t .
• Surgeon and medical champions
: / /
• Hospital administration m
Comorbidity scoring
t p s
• Score patients with a standard score that predicts
t
• Helps to risk-stratify patients
tps
• Surgeon and medical champion
h outcomes
Table 2.7-1: Areas to address in a standardized program.

• For outcomes, and understand patient
comorbidity severity
ht
• Hospital quality department and
information technology personnel
Abbreviations: PTH, parathyroid hormone; TSH, thyroid-stimulating hormone.
k e rs ke rs
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• For team members to compromise on some of the spe-e /
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electronic or paper product should be piloted with the e/e
s: / / / /
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cific aspects (eg, specific medications and dosages) se- team members who will use these tools; this can help
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lected for the order set in order to produce a straightfor- identify content or formatting issues that may impair
ward, concise, and safe pathway. safety and efficiency.
• Be periodically revisited by the team, especially if a prob-
lem is identified upon review of quality management
4 reation or adaptation of standard order sets for
C data.
e rs fragility fracture patient care
er s
• Offer the opportunity to help physicians comply with
hospital, local, and governmental regulations for care
b o ok Order sets should:
bo ok
provision. Such regulatory mandates should be built into
an order set. For example, it may be required to docu-
b o o
e / e e/ e
• Help the physician to follow clinical practice guidelines ment the patient’s preferences for resuscitation in the
e/e
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when caring for their patients, as these are becoming
more prevalent for FFPs. Two examples would be use of
: / / .m
event of respiratory or cardiac arrest. The standard order
t
set can include a mandatory order where the physician
ht tps
prophylactic anticoagulation in the perioperative period
and obtaining a mini-metabolic bone workup as part of
the admission order set. The physician has only to sign
documents the resuscitation status.
ht tps
Once an order set has been created and agreed to by the
the order if this order has been defaulted in the order set. team, it should be reviewed and approved by the hospitals
• Default to the best available evidence and serve as a tem- order set committee to be certain it is in full compliance
plate for individual patient care plans; they should also with all hospital policies and procedures as well as nation-
e r s offer an opportunity for variation if clinically indicated.

e r s
al requirements. At that point, the order set will be given
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• Be patient centered, meaning that they can be adapted to the electronic medical record team to create a usable
e b b
to the individual patient’s needs. For example, most pa-
e o electronic document. For centers still using paper medical
b o
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tients with a hip fracture typically should not be managed
m
with a knee brace following surgery. However, in certain
t .
records, at this stage it would be sent to the printer to be
printed.
t . m e/e
/ /
instances, it may be necessary to utilize a knee brace and
/ /
set for knee brace. ps:
therefore an unchecked box would be placed in the order
htt
• Indicate that a particular medication or treatment is htt ps:
After creation of the new order set, it is essential to make
sure that the nursing care map matches the order sets step
by step. Typically, the medical and surgical program leaders
known to be harmful and should not be used in a patient meet with nursing leaders caring for the patients to be cer-
group to which it is specifically harmful. That may include tain that the nursing care map matches the order sets.
use of medications such as meperidine, diphenhydramine,
e rs or H2 receptor blockers for older adults [8]. These are all

e r s
b o ok known to be problematic in older FFPs and should be
avoided in essentially all cases.
b o
5
ok tandardized protocols for accepting patients
S
transferred from another facility
b o o
e/ e / e
• Encourage specific treatment or protocols that are known
e
to be helpful, such as the retention of eye glasses and An organized orthogeriatric program will tend to attract
e /e
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hearing aids throughout the hospital stay [6, 9]. This helps
/ t .
medically complex patients from smaller or less experienced
: / m
t t p s
to avoid the complication of delirium yet these aids are
tps
hospitals for transfer. This, in fact, is a service to the patient
ht
often taken away from the older patient upon hospital and the transferring center and should be considered as
admission. h
• Reach a practical compromise when there is a question
such. It is important for the receiving orthogeriatric fracture
program to have a standardized and organized method for
on a specific area and lack of agreement. accepting such transfers that include the following steps:
• Be based on a comprehensive literature search or con-
kers rs
sultation with experts in the field as indicated if there is • It is helpful if the transferring center can transfer the
o
considerable uncertainty on a specific area. There are
ke
patient with one telephone call explaining the need for
b o many unanswered questions remaining in the field of

b oothe transfer and other particular important medical and
b o o
e /e e e/e
osteoporotic fracture management. social information.
m e /
• Not be too long or cumbersome to effectively use. A com- • Electronic transfer of x-rays and other data may help
m
/ /t .
plicated or exhaustive order set may not result in stan-
t .
with the assessment of the patient in question from the
//
ps: ps:
dardized and efficient care for most patients. The final receiving center.
htt htt 159
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e b oo e b oo b o o
e /
t . m e
• When the patient is transferred, it is helpful to use a
/ • Development of a written protocol is extremely helpful.
t . m e/e
s: / / / /
ps:
transfer envelope in which to place all pertinent medical All members of the team need to know about the receiv-
http htt
information. On the front of the transfer envelope, there ing protocol. Patients should be accepted if at all possible,
should be a checklist that helps the transferring team and their care should be streamlined and facilitated at
provide all necessary information to facilitate care at the the receiving center. Transfers are best received during
receiving center. daylight hours when the team is present to assess the
patient in a timely manner after admission. Use of a trans-
e rs er s
fer protocol and transfer envelope is recommended for
both the transferring center and the receiving center.
b o ok bo ok
Examples can be found in Fig 2.7-1 and Fig 2.7-2.
b o o
e/ e e/ e e/e
: // t .m : /
Geriatric Fracture Center at Highland Hospital/ t .m
t t p s t tp s
h Transfer Process
for Regional Hospitals
h
Regional Hospital determines patient will benefit from care for
PLEASE TRANSFER:
geriatric fracture at Highland Hospital
e r s e r s • Highland affiliated patients

• Patient/family requests
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Medical assessment to determine medical stability for direct
b
admission
b o
CONSIDER TRANSFER FOR ANY
GERIATRIC FRACTURES OF:
• Long Bones
b o o
e / e e/ e
Additional assessment & pain management as needed to insure
comfort & stability
• Hip
• Knee
e/e
/ / t . m • Ankle
• Pelvis
/ /t . m
ps: ps:
Patient determined appropriate for direct admission to Geriatric • Periprosthetic fractures
Fracture Center at Highland Hospital on Orthopaedics Service
htt htt
EXCEPTIONS:
• Medically unstable
Regional Hospital representative calls Strong Health Transfer • Appropriate for outpatient care
Center and provides: • Not surgical candidate
• Demographics (face sheet) • Major trauma (transfer to Strong
• Diagnosis Memorial Hospital)
• Insurance information
k e rs e r s
Transfer Center notifies Highland Orthopaedics Attending of
k
On-Call Orthopaedics Attending
b oo boo o
potential admission after confirming bed availability with
On-Call Geriatrics Attending
Highland Admitting
b o
e/e t e / e
Highland Hospital Orthopaedics Attending accepts patient,
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notifies Resident, & PCP or Geriatrics Attending for consult
Highland Hospital Admitting Officer
t . m e /e
s : / / : / /
tps
Highland Hospital Admitting Office:
h t t p • obtains pre-certification as needed

• assigns appropriate bed
• notifies Patient Unit and Admitting Officer
• notifies Regional Hospital to transfer patient ht
Required Documents
(Use Highland Hospital Transfer Envelope)
•
•
Lab Results
Radiographs
• EKG
Regional Hospital arranges for ambulance transport with all • All recent notes
required documents. • Most Recent H&P
• Medication Record
k e rs ke rs
Ambulance transfers patient directly to patient unit
• Advanced Directives
(MOLST, DNR, Proxy, etc.)
b o o b oo
Orthopaedics & Geriatrics: evaluation & management
• Nursing Transfer Form
b o o
e / e e /e e/e
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ps: ps:
Fig 2.7-1 Example of a transfer protocol.
160
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/ / / /
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Facility Transfer Packet
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Transport to Highland Hospital
e r s Unit/Room if assigned:
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Patient Name
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Transportation Vendor
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t . m t . m
/ / / /
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Sending Facility Phone #
Contact Person Name

ps: htt ps:
Relationship: Spouse Child Guardian Healthcare Agent Friend Other
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Please Include or Attach the following:
b o Face or Cover Sheet: Contact & Insurance Information
b o b o o
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Adcance Directives (MOLSR, DNR, Proxy, Living Will)
.
Last Medical & Nursing Progress Notes (Last 3 Days)
: / / t . m
p s
Recent Rehabilitation Notes (PT, OT, SLP)
t t tps
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Recent Consultation Notes
X-ray Reports (or Films if Available)
Most Recent Lab Results & EKG
ht
Nursing Summary for Hospital Transfer
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Up-to-date Medication Administration Record (MAR)
k e Appropriate Patient Belongings (to be sent)

ke
eb oo Immunization/Screening Records
e b oo Fig 2.7-2 Example of a transfer envelope.

b o o
e/e
Problem List
e / m e / The checklist on the front of the envelope
m
enables the transferring team to assemble all
PACKET ASSEMBLED BY
/ /t . // t .
the needed data to facilitate the transfer. This
ps: ps:
helps avoid wasting time and errors.
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k e rs ke rs
e b oo e b oo b o o
e / 6
t . m
tandard consultation form to document and
S e /
t . m e/e
s: / / / /
suggest wording indicating to other providers that a high-
ps:
prevent case cancellation risk procedure is still appropriate for highly comorbid or
http htt
frail patients. The standard consultation form should not
The standard consultation form in the medical record helps recommend the type of anesthetic to be used, nor should it
the medical consultant accurately document the results of specify intraoperative management by the anesthesiologist
the patient’s history and physical examination. The forms unless there is a critical piece of information that needs to
should be designed to fit the physician’s workflow in docu- be shared, for instance, a critical aortic stenosis.
e s
menting their findings and assessment. Using a standardized
r
consultation form as a template, documentation is improved
er s
Another benefit of a standard consultation form is appropri-
b o ok and is readily searchable by members of the care team. This
bo
avoids a loss of sometimes difficult to gather but important ok
ate hospital and team documentation of the patient’s pre-
operative status. Very few to no liability cases will result
b o o
e/ e information specifically in demented patients.
e/ e from outstanding documentation. Care needs to be taken
e/e
: // t .m
Standardized consultation forms ease and speed up the treat-
to avoid excessive amounts of imported or highly detailed
: /
documentation; key clinical communication should be con-
/ t .m
ht tps
ment progress. They may be used in the emergency depart-
ment and for daily ward rounds. If possible they should be
integrated in the electronic chart of the patient to be read-
ie, the beginning or the end.
ht tps
solidated in a consistent and easy to find section of the notes,
ily available for all team members.

7 evelopment of standard protocols for
D
Early surgery for the optimized patient has shown to be assessment and risk stratification
e r s
beneficial in the care of geriatric fracture patients [10, 11].
e r s
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The frequent concern of surgeons is that the patient’s surgery It is frequently beneficial that the patient is risk-stratified
e b will be canceled for reasons that they deem inappropriate.

e b o into a category of low risk, intermediate risk, high risk, or
b o
e / e/
Case cancellation is often the result of poor communication
m
or poor documentation in the preoperative notes by the
t .
extremely high risk [3]. This risk assessment helps the an-
esthesiologist and the team members to understand the
t . m e/e
/ / / /
patient’s true surgical risk. It also helps the medical consul-
ps: ps:
surgeon and medical physician. When an anesthesiologist
reviews the medical record, they look for a legible and com- tant to appropriately document whether the patient is op-
htt
prehensive medical assessment of the patient. A short note
stating “cleared for surgery” is meaningless and not helpful
to the anesthesiologist. What is beneficial is a comprehensive
htt
timized for surgery and their level of risk [2, 6]. Some peri-
operative risk assessment tools (eg, Revised Cardiac Risk
Index) can help anchor risk estimates to those from the
history and physical review of the past medical history, literature, but all team members should recognize that risk
medications, allergies, family history, social history, preop- estimation is less accurate in frail older adults (see chapter
e rs
erative functional status, and response to prior surgery. Ad-
r s
1.4 Preoperative risk assessment and preparation for further
e
b o ok ditionally, the patient needs to be medically optimized,
b o
fluid resuscitated, and truly ready for surgery. This status ok
discussion of these issues).
b o o
e/ e / e
should be clearly documented in the preoperative medical
assessment.
e
Typically in the perioperative period, the anesthesiologist
will assign an American Society of Anesthesiologists (ASA)
e /e
://t . m score to the patient. The ASA score has been shown to ac-
: / / t . m
s
Other areas that standardized consultation forms can pro-
t t p tps
curately correlate with patient outcomes [12]. Recently, a
ht
mote include attention to goals of care, such as resuscitation mini-frailty index has been developed, which also helps to
h
status and also patient decision regarding resuscitation dur-
ing surgery, healthcare proxy designation, and advanced
predict short-term adverse events that can occur in the peri-
operative period [13]. Risk stratification supports the ortho-
directives in the event of a poor outcome. These consultation pedic surgeon in the determination of surgical or nonsurgi-
forms can also display standardized care plan recommenda- cal treatment for fractures without a clearly superior standard
k e rs
tions for predictable issues like venous thromboembolism
prophylaxis, delirium prevention, disposition needs, and
ke rs
of care, typically after fractures of the upper extremity.
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
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e b oo e b oo b o o
e / 8
t
Standardization of discharge processes
. m e / 9
t . m
eriodic reassessment and revision of standard
P e/e
s: / / / /
ps:
protocols in order sets
http htt
Geriatric fractures, especially hip fracture, create the high-
est risk for hospital readmission at 30 and 90 days among Orthogeriatric programs should typically collect data and
orthopedic patients [14]. Although there are multiple causes look at the results over time [6]. Graphing the results over
of readmission and no obvious way to avoid all of them [15], time will visually demonstrate variation in some of the mea-
appropriate discharge documentation including all needed sured parameters. If there is a negative progression in out-
e s
information to appropriately care for the patient should be
r
provided to the receiving facility (eg, nursing home) at the
er s
comes or metrics or a serious adverse event occurs, the
reasons for this should be sought and corrected. This may
b o ok time of hospital discharge.
bo ok
require reassessment of the treatment protocol or order sets.
Sometimes the change in the order sets reflects a change in
b o o
e/ e e/ e
Standardizing the discharge process is a way to improve the what is best practice. Other times, changes in the order set
e/e
: // t .m
packaging of the patient at the time of discharge to reduce
errors and complications. A thoughtful and well-document-
: / / .m
will be needed to meet hospital or regulatory requirements.
t
As time progresses, it is certain that all order sets will need
tps
ed handoff to the receiving providers will help to reduce
ht
medical errors and readmissions. It is important to recognize
that many patients will be discharged to a facility that has ht tps
to be revisited and appropriately amended to benefit the
patient and the system. When such changes are needed, it
is extremely important to include care team members at the
no prior medical knowledge of the patient; discharge docu- table when decisions are made. That way each representa-
mentation that contains a clear summary of the patient’s tive of the discipline can report their recent changes to their
prefracture medical history, medications, functional status coworkers and help them understand the need to make
e r s
and goals of care are essential to minimizing readmissions
e r s
changes. In this manner, care can improve with time.
ook ok o
for lapses in care.
e b e b o Order set improvements will be needed more commonly

b o
e / e/
Placement of appropriate documentation in a large envelope
m
with a checklist on the front is one useful strategy to nice-
t .
soon after implementation and, as time passes, the changes
t . m
required will become less frequent. Nonetheless, as science e/e
/ /
ly package the patient for discharge (Fig 2.7-2). Included in
/ /
and medical evidence improves, changes will be needed to
this package should be:
htt ps:
• The most recent medication list
benefit the patients.
htt ps:
• The most recent history, physical examination,
and discharge summary
• Necessary orders
e rs
• Name and contact information for care providers at the
e r s
b o ok hospital
• Date of next recommended follow-up visit
b o ok b o o
e/ e / e
• Any specifics such as laboratory workup or wound care
e e /e
://t . m
Careful documentation and creation of an appropriate pack-
: / / t . m
t t p s
age upon discharge reduces errors and improves the qual-
tps
ht
ity of the patient handoff. It is well-known that most errors
h
occur at the time of a handoff to another provider [16].
k e rs ke rs
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t . m e /
t .m e/e
/ / //
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163
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rs 26.07.18 10:26
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htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 10 References
t . m e /
t . m e/e
/ / / /
htt ps:
1. Womack JP, Jones DT, Roos D. The
Machine That Changed the World. New
York: Simon&Schuster; 1990.
7. Neuman MD, Archan S, Karlawish JH,
et al. The relationship between
short-term mortality and quality
of care for hip fracture: a meta-analysis
ps:
12. Michel JP, Klopfenstein C, Hoffmeyer P,
htt
et al. Hip fracture surgery: is the
pre-operative American Society of
Anesthesiologists (ASA) score a
Co-managed care for fragility hip of clinical pathways for hip fracture. predictor of functional outcome? Aging
fractures (Rochester model). Osteoporos J Am Geriatr Soc. Clin Exp Res. 2002 Oct;14(5):389–394.
Int. 2010 Dec;21(Suppl 4):S621–S625. 2009 Nov;57(11):2046–2054. 13. Kistler EA, Nicholas JA, Kates SL, et al.
e rs
3. Friedman SM, Mendelson DA, Kates SL,
8. Fick DM, Semla TP. 2012 American
er s
Geriatrics Society Beers Criteria:
Frailty and short-term outcomes
in patients with hip fracture.
ok ok
proximal femur fractures: total quality new year, new criteria, new Geriatr Orthop Surg Rehabil.
b o management and protocol-driven care

bo
perspective. J Am Geriatr Soc.
2012 Apr;60(4):614–615.
2015 Sep;6(3):209–214.
14. Goodman DC, Fisher ES, Chang C-H,
b o o
e/ e patient population. J Am Geriatr Soc.
2008 Jul;56(7):1349–1356.
e/ e
9. Inouye SK. Delirium after hip fracture:
to be or not to be? J Am Geriatr Soc.
et al. After Hospitalization: a Dartmouth
Atlas Report on Post-Acute Care for
e/e
4. Friedman SM, Mendelson DA,
:
// t .m 2001 May;49(5):678–679.
10. Bottle A, Aylin P. Mortality associated
: / / t .m
Medicare Beneficiaries. Hanover, NH: The
Dartmouth Institute for Health Policy
tps tps
comanaged Geriatric Fracture Center with delay in operation after hip and Clinical Practice. 2011;28.
ht ht
on short-term hip fracture outcomes. fracture: observational study. BMJ. 15. Kates SL, Behrend C, Mendelson DA,
Arch Intern Med. 2006 Apr 22;332(7547):947–951. et al. Hospital readmission after hip
2009 Oct 12;169(18):1712–1717. 11. Moran CG, Wenn RT, Sikand M, et al. fracture. Arch Orthop Trauma Surg.
5. Kates SL. Lean business model and Early mortality after hip fracture: 2015 Mar;135(3):329–337.
implementation of a geriatric fracture is delay before surgery important? 16. Starmer AJ, Spector ND, Srivastava R,
center. Clin Geriatr Med. J Bone Joint Surg Am. et al. Changes in medical errors
2014 May;30(2):191–205. 2005 Mar;87(3):483–489. after implementation of a handoff
e r s
6. Mears SC, Kates SL. A guide to
e r s program. N Engl J Med.
ook ok
improving the care of patients 2014 Nov 06;371(19):1803–1812.
b
with fragility fractures, edition 2.
b o b o o
e / e 2015 Jun;6(2):58–120.
e/ e e/e
/ / t . m / /t . m
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e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
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t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:26
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htt ps: htt ps:
Paul J Mitchell
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/
2.8 Fracture liaison service and improving
/ / /
htt ps:
treatment rates for osteoporosis htt ps:
Paul J Mitchell
e rs er s
b o ok bo ok b o o
e/ e 1 What is a fracture liaison service?
e/ e other organizations [6, 9, 21, 22] endorse secondary fracture
e/e
: // t .m
The fracture liaison service (FLS) was developed in response
prevention as a requirement for men too.
: / / t .m
tps
to a pervasive and persistent postfracture care gap evident
ht
among fragility fracture patients (FFPs) throughout the world
[1]. The majority of people aged 50 years and older who ht tps
A broad array of pharmacological interventions has been
demonstrated to reduce future fracture risk for individuals
who have suffered a fragility fracture [23]. Given that these
present with a fragility fracture do not receive the osteopo- treatments have been available for 20 years, why are they
rosis assessment and management as advocated in clinical not routinely being targeted to individuals at high risk of
guidelines [2–7]. Furthermore, interventions intended to suffering further fractures? This question has been consid-
e r s
identify and mitigate risk factors for falls are often not a
e r s
ered by investigators from several countries [2, 3]. A study
ook ok o
standard component of postfracture care. The secondary that evaluated the practice of orthopedic surgeons and gen-
e b fracture prevention care gap and the role that FLS can play
e b o eral practitioners (GPs) in the UK provided an insight into
b o
e / to reduce it have been highlighted by international and
national campaigns, including:
t . m e/ why this apparent breakdown in chronic disease manage-
t . m
ment is occurring [24]. Surgeons and GPs were asked about e/e
/ / / /
their routine clinical practice when confronted with three
htt
the Fracture Campaign [1, 7, 8] ps:
• International Osteoporosis Foundation’s (IOF) Capture
• Osteoporosis Canada’s Make the FIRST break the LAST

clinical scenarios:
htt ps:
• A 55-year-old woman with a low-trauma Colles wrist
with Fracture Liaison Services [9] fracture
• Osteoporosis New Zealand’s Bone Care 2020 [10] • A 60-year-old women with a vertebral wedge fracture
• Falls and Fractures Alliance in England [11] • A 70-year-old woman with a low-trauma femoral neck
e rs
• National Bone Health Alliance in the United States
r
fracture
e s
b o ok [12–14]
b o ok
Both groups agreed in principle that FFPs should be inves-
b o o
e/ e / e
The rationale for prioritizing secondary fracture prevention
e
stems from epidemiological observations that about half of
tigated for osteoporosis, ie, 81% of surgeons and 96% of
e
GPs. However, as indicated in Fig 2.8-1, in most scenarios /e
://t . m
all hip fracture patients break another bone before they
/ t . m
both surgeons and GPs would not take direct responsibility
: /
t t p s
fracture their hip [15–18]. Among postmenopausal women,
tps
to do so themselves. This study mirrors the findings of sys-
ht
estimates suggest that one-sixth will have suffered a fragil- tematic reviews that considered barriers to secondary frac-
h
ity fracture at any relevant skeletal site (ie, generally exclud-
ing fractures of the skull, fingers, and toes) [5]. Taken to-
ture prevention in clinical practice. There is a tendency for
orthopedic surgeons and primary care providers to rely upon
gether, among women aged 50 years and older, these data one another to implement secondary fracture prevention,
suggest that half of all future cases of hip fracture will em- resulting in its omission for the majority of FFPs. The frac-
k e rs
anate from the one-sixth of the population who have suf-
fered a prior fragility fracture. Older men account for 30%
ke rs
ture liaison service was developed to overcome the lack of
clarity regarding clinical ownership of secondary prevention
eb oo of the world’s hip fractures. Information on the prevalence
e b oo
efforts, and to eliminate the care gap.
b o o
e/e
of prior fracture history is not broadly available. However,
e / e
several studies suggest that 30–59% of men who have suf-
m / The fracture liaison service is a program designed to ensure
m
/ /t .
fered a hip fracture had previously broken another bone
t .
that all FFPs above a specific age receive secondary preven-
//
ps: ps:
[15, 16, 18]. The IOF [8, 19], the Endocrine Society [20], and tive care. This program includes both osteoporosis assessment
htt htt 165
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m
and treatment, and where appropriate, an intervention to e / The place of an FLS in a systematic approach to hip fracture
t . m e/e
s: / / / /
ps:
reduce the risk of falls. A critical component of an FLS is care and prevention is illustrated in Fig 2.8-2, which describes
http htt
personnel dedicated to identifying, investigating, and initi- the approach being taken in New Zealand [10]. This approach
ating secondary preventive care for fracture patients. While was based on previous experience from the UK [27], which
this FLS coordinator is often a nurse practitioner or registered has also been adopted in Australia [28], Canada [9], and the
nurse, some FLS have employed physicians in training or United States [14], and internationally by IOF [1]. The FLS
allied healthcare professionals to fulfil this role. An FLS will can be configured to provide secondary preventive care for
e s
adhere to protocols of care agreed with all relevant local
r
hospital specialists, primary care providers, and health sys-
er s
all FFPs. In institutions with established orthopedic-geriat-
ric comanagement services, which usually manage osteo-
b o ok tem administrators.
bo ok
porosis and fall risks for hip fracture patients, the FLS can
serve the nonhip FFPs, which usually represents 80–85%
b o o
e/ e The scope of an FLS may vary, depending on the case mix
e/ e of the fragility fracture case load [25, 26].
e/e
: // t .m
of fracture patients presenting to the particular hospital or
health system. The FLS may manage all FFPs, just those The process of planning for an FLS, considerations during
: / / t .m
tps
admitted as inpatients to a hospital, or just those managed
ht
in the outpatient setting. The operational structure of an
FLS will be influenced by local orthopedic service configu- ht tps
implementation, and results achieved from well-established,
high-performing FLS will be discussed in the next topics of
this chapter.
rations, particularly the presence or absence of orthopedic-
geriatric comanagement services for FFPs also known as
geriatric fracture centers or orthogeriatrics services [25, 26].
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
ps: ps:
Maximize cost-
htt htt
effectiveness by Hip
stepwise delivery fracture
patients
%
Non-hip fragility
100 fracture patients
e rs
90
e r s Individuals at high risk

of 1st fragility fracture or
other injurious falls
ok ok
80
o o
/ebo o
Older people
e/ e b 70
60
e e /e b
50
://t . m / / t .
professional standards of care monitored by a new NZ Hip Fracture Registry
: m
Objective 1: Improve outcomes and quality of care after hip fractures by delivering ANZ
40
t t p s tps
ht
Objective 2: Respond to the first fracture to prevent the second through universal
30
20 h access to Fracture Liason Services in every District Health Board in New Zealand
Objective 3: GPs to satisfy fracture risk within their practice population using Fracture
10
Risk Assessment tools supported by local access to axial bone densitometry
0
kers rs
Ortho GP Ortho GP Ortho GP Objective 4: Consistent delivery of public health messages on preserving physical
o
Wrist Vertebral Hip
e
activity, healthy lifestyles and reducing environmental hazards
k
b o Fig 2.8-1 The proportion of orthopedic surgeons and general
b oo
Fig 2.8-2 Fracture liaison service in the context of a systematic
b o o
e /e t . m e /e
practitioners who would routinely assess the fracture patient and/or
initiate osteoporosis treatment, or would refer the fracture patient to
approach to hip fracture care and prevention for New Zealand
(reproduced with kind permission of Osteoporosis New Zealand) [10].
t .m e/e
a local osteoporosis clinic [24].
/ / Abbreviations: ANZ, Australian and New Zealand; GP, general
//
ps: ps:
Abbreviations: GP, general practitioner; Ortho, orthopedic surgeon. practitioner.
166
htt htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
Paul J Mitchell
k e rs ke rs
e b oo e b oo b o o
e / 2 Planning
t . m e /
t .
• Relevant specialist nurses, physiotherapists, and other
m e/e
s: / / / /
ps:
allied healthcare professionals
http htt
All successful FLS programs have required an individual to • Information technology (IT) professionals responsible
champion the case for FLS implementation within their for development and/or installation of an FLS database
institution or health system. This person is often formally • Hospital and primary care pharmacy or medicines
or informally designated as the “lead clinician for osteopo- management representatives
rosis” in his/her place of work. In the hospital setting, the • Hospital administration and/or business planning
e s
FLS champion may be an endocrinologist, rheumatologist,
r
geriatrician, or orthopedic surgeon. Some FLS programs
er s
group representatives
• Local primary care-based service commissioning group
b o ok have been established in primary care, where the FLS cham-

pion is a GP (ie, a family physician) with a special interest
bo ok
representatives
• Local primary care practice representatives
b o o
e/ e in osteoporosis or musculoskeletal disease [29]. A selection
e/ e • Local public health authority representatives
e/e
: // t .m
of useful resources to support champions embarking upon
their FLS development efforts is available in topic 5 of this 2.2 Needs assessment
: / / t .m
ht tps
chapter. The key steps in planning for an FLS that a physi-
cian champion should consider are illustrated in Fig 2.8-3.
ht tps
Numerous published audits of secondary fracture prevention
have reported, in the absence of a systematic approach, that
most FFPs do not receive guideline-based care [7]. To illus-
2.1 Stakeholders trate that a need exists for development of a new FLS, an
The care of FFPs involves a broad group of health profes- audit is likely necessary to quantify the local care gap. Anal-
sionals and administrative staff. The champion’s first task ysis of the following key performance indicators over a
e r s
is to identify which individuals should become members of
e r s
1–3-month period would provide an adequate overview of
ook ok o
a multidisciplinary stakeholder group that will guide and postfracture care at baseline:
e b enable development of the FLS. This group is likely to in-

e b o b o
e / clude:
t . m e/ • How many women and men aged 50 years and older
t . m
presented to the hospital or health system with a fragil- e/e
• The FLS champion
/ / / /
ity fracture, which resulted from a fall from standing
fracture surgery ps:

• Orthopedic surgeons with an interest in hip or fragility
htt
• Geriatricians, orthogeriatricians, hospitalists, or
or outpatients?
htt ps:
height or less, and who were managed either as inpatients
• Of these, what percentage received an osteoporosis as-

internists working in orthopedic-geriatric comanage- sessment? This question needs to be answered for two
ment services groups, ie, those that were assessed with bone mineral
• A radiologist and/or nuclear medicine specialist density (BMD) measurement by axial dual-energy x-ray
e rs e r s
absorptiometry (DEXA) scan and those assessed without
b o ok b o ok
a DEXA scan.
b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
Establish multidisciplinary
stakeholder group
h Quantify postfracture care gap
at baseline
Design FLS processes with
stakeholder group
ht
kers rs
Develop FLS protocols with all
o ke stakeholders
b o b oo b o o
e /e t . m e /
Develop fully costed FLS
e Develop FLS documentation
Fig 2.8-3 Key steps in planning
t .m
for a fracture liaison service.
e/e
Engage health system funders
s: / / //
Abbreviation: FLS, fracture
ps:
business plan and communication standards
liaison service.
http htt 167
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m
• What percentage received an assessment of fall risk fac- e /
t
The potential sources of savings that will be relevant to the
. m e/e
s: / / / /
ps:
tors, either delivered by an appropriately skilled clinician funder(s) of the FLS business plan will depend upon the
http htt
within an FLS or by referral to a local falls service, or reimbursement system for healthcare in the particular coun-
equivalent, operating independently of an FLS? try. In a health and social care system with unified budgets,
• Of these, what percentage received lifestyle advice relat- reductions in direct costs for acute fracture care and hospi-
ing to osteoporosis, including diet and activity? What tal admissions, reductions in postdischarge fracture-related
percentage received specific medication for osteoporosis, visits to primary care providers, and avoidance of admissions
e rs and what percentage received advice and/or intervention

to mitigate fall risk for identified risk factors?
er s
to centrally funded nursing homes will all contribute to
offset the cost of implementing the FLS. In a different en-
b o ok The processes for identification, investigation, and initiation

bo ok
vironment, the United States for example, reimbursement
for providers of healthcare can be higher for those organiza-
b o o
e/ e of secondary preventive care need to be designed by the
e/ e tions that achieve higher quality ratings for postfracture
e/e
: // t .m
stakeholder group. It can be more efficient to establish a
subgroup to define draft processes, documentation, and
care (eg, Medicare Advantage’s Five-Star Quality Rating
:
System). The business plan must clearly articulate why
/ / t .m
tps
communication mechanisms that can be reviewed and
ht
amended by the entire stakeholder group membership. Key
considerations will include: ht tps
implementation of FLS is in the funder’s interest. Early en-
gagement with representatives of the hospital, the health
system administration, and/or the business planning group,
by inviting a representative to join the multidisciplinary
• Defining the initial scope of the FLS, eg, inpatients and/ stakeholder group, should ensure that the preparatory work
or outpatients, patients aged 50 years and older or 65 years and comprehensive business plan is presented in a fashion
e r s and older
e r s
most likely to meet with success.
ook ok o
• Determining how existing IT systems can aid identifica-
e b tion of fracture patients, and facilitate ordering of inves-

e b o In 2013, the IOF published a best practice framework (BPF),
b o
e / tigations and communication with local primary care
providers
t . m e/ which provides globally endorsed standards of care for FLS
[8]. Given the variation in structure of healthcare systems
t . m e/e
/ /
• Considering the impact of FLS on capacity of local bone
/ /
throughout the world, the IOF consulted with leading experts
densitometry services
2.3 Business plan htt ps: htt ps:

from many countries who had established FLS in their lo-
calities and undertaken beta testing to ensure that the stan-
dards were internationally relevant and fit for purpose. The
Development of a formal business plan for the new FLS is BPF sets an international benchmark for FLS, which defines
a critical step in the development of a service. Fracture li- essential and aspirational elements of service delivery. For
aison service business plan templates are available in Can- those in the early stages of FLS development, the BPF clear-
e rs
ada [9], New Zealand [30], and the United States [14] (see
r s
ly shows what a high-performing FLS would actually de-
e
b o ok topic 5 in this chapter). As the costs related to FLS imple-
b o
mentation will vary between and within countries, the fol- ok
liver. To expedite sharing of best practice between centers,
the IOF developed a process for best practice recognition,
b o o
e/ e / e
lowing list provides an illustration of the sources of costs
that will generally apply:
e
which can result in FLS featuring on the “map of best prac-
tice” [7]. The map provides an opportunity for those under-
e /e
://t . m taking FLS development to learn from the experience of
: / / t . m
t t p s
• Fracture liaison service coordinator salary
tps
colleagues elsewhere who have successfully established a
ht
• Fracture liaison service lead clinician offering one service.
session per week h
• Administrative support
• Bone density scans
• Drug treatment
k e rs
• Fracture liaison service database and IT costs
• Patient literature
ke rs
eb oo • Printing of reports and questionnaires
e b oo b o o
e/e
• Postage
e / • Office costs
m e / m
/ /t . // t .
htt ps: htt ps:
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
Paul J Mitchell
k e rs ke rs
e b oo e b oo b o o
e / 3 Implementation
t . m e / 4 Result and impact of fracture liaison services
t . m e/e
s: / / / /
http
Once funding has been identified to establish an FLS, staff
recruited, and the service has been launched to the local
htt ps:
A growing number of FLS programs have published articles
describing aspects of the development of their service and
medical community, ongoing evaluation of FLS performance process of care outcomes, while a comparatively small num-
is required. The key steps in such a process are illustrated ber of publications have described impacts on secondary
in Fig 2.8-4. fracture rates and health economic aspects.
e rs
Plan-Do-Study-Act methodology has been successfully ap- 4.1
er s
Process of care outcomes
b o ok plied to support continuous improvement of FLS perfor-

mance [31]. Aspects of service delivery that will benefit from
bo ok
To date, there has been a lack of standardized reporting of
outcomes from FLS. In an attempt to determine how the
b o o
e / e close monitoring include:
e/ e organization of an FLS impacts on process of care outcomes,
e/e
: // t .m
• Patient identification—knowledge of the proportion of
Ganda et al [32] undertook a systematic review and meta-
: / / t .m
analysis. This study established a classification system for
tps
all FFPs presenting to the hospital or health system that
ht
are receiving care from the FLS is essential. This data may
be available from hospital IT systems for patients admit- ht tps
FLS, relating to the intensity of service provision, based on
the premise that FLS can identify, investigate, and initiate
(hence 3i) interventions for FFPs:
ted as inpatients. However, robust mechanisms must be
in place to ensure a basic level of information is also • Type A models undertake identification, investigation,
known about patients managed only in the outpatient and initiation (ie, 3i model).
e r s setting.
e r s
• Type B models undertake identification and investigation,
ook ok o
• Communication with patients—ongoing assessment but leave initiation to the primary care provider (ie, 2i
e b should be undertaken of the effectiveness of information

e b o model).
b o
e / relating to lifestyle advice and treatment recommenda-
tions.
t . m e/ • Type C models undertake just identification, whereby
t . m
the primary care provider is alerted that the fracture has e/e
/ /
• Communications with primary care—in systems where
/ /
occurred and further assessment should be conducted
ps:
primary care providers take responsibility for manage-
htt
ment of chronic diseases, the effectiveness of all aspects
of FLS-initiated communications with primary care should
(ie, 1i model).
htt ps:
• Type D models only provide education on osteoporosis
to the patient and do not alert the primary care provider
be scrutinized. or recommend investigation (ie, zero i model).
• Interaction with hospital specialists—FLS care must be
delivered in a patient-centered manner, keeping in mind The findings of the metaanalysis in relation to the process
e rs that patients may find interactions with multiple health-

r s
outcomes of BMD testing and initiation of osteoporosis treat-
e
b o ok care professionals bewildering. The FLS must work seam-
lessly with orthopedic doctors and nursing staff and, for
b o ok
ment are shown in Fig 2.8-5. Clearly, type A (3i) and type B
(2i) models outperform the less intensive type C (1i) and
b o o
e/ e / e
patients admitted to hospital, with colleagues in geriatric
medicine.
e
type D (zero i) models.
e /e
://t . m : / / t . m
t t p s tps
h ht
kers rs
Implement initial FLS model Collect data on key Quantify impact of FLS on the
o
of care performance metrics
ke care gap
b o b oo b o o
e /e Implement changes and
t . m e /
Refine FLS design and
e Analyze barriers to optimal FLS
Fig 2.8-4 Key steps in fracture
m
liaison service implementation.
t . e/e
s: / / //
Abbreviation: FLS, fracture
ps:
monitor performance processes to improve performance
liaison service.
http htt 169
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 4.2 Impact on secondary fractures
t . m e / In Germany, Niedhart et al [36] described a significant re-
t . m e/e
s: / / / /
ps:
Studies to evaluate the impact of FLS on secondary fracture duction of osteoporosis fracture-related hospitalization rate
http htt
rates can be challenging to undertake. The presence of na- due to an intensified, multimodal treatment in the integrat-
tional clinical guidelines that recommend or mandate that ed healthcare network Osteoporosis North Rhine. A retro-
FFPs should undergo osteoporosis assessment, and be initi- spective cross-sectional analysis was performed using routine
ated on treatment where appropriate, can eliminate the data from the regional public health insurer for the years
appropriateness of a control group that are denied access to 2007–2010. Patients were included if they were 50–89 years
e s
care by the FLS. Two approaches have been taken to estab-
r
lish contemporaneous control groups to enable evaluation
er s
old, had a diagnosis of osteoporosis, and at least three pre-
scriptions of osteoporosis-specific medication. Data were
b o ok of the impact of FLS on fracture rates.
bo ok
analyzed separately for integrated and regular healthcare.
Of the 22,040 patients identified, 3,173 were participants in
b o o
e/ e Dutch investigators evaluated subsequent nonvertebral frac-
e/ e the integrated healthcare group (IV). The hospitalization rate
e/e
ture experience and mortality for patients managed by their
own hospital-based FLS as compared to the experience of
: // t .m for hip fractures was significantly lower in the IV group, ie,
: / /
5.93 per 1,000 patient-years versus 22.96 per 1,000 patient- t .m
tps
patients managed at another hospital that lacked an FLS
ht
[33]. The risk for subsequent nonvertebral fractures and
mortality were analyzed and adjusted for age, gender, and ht tps
years (-74%, P < .05). Also the hospitalization rate of all
other osteoporosis-related fractures was reduced by 73% to
46.92 per 1,000 patient-years versus 172.88 per 1,000 patient-
baseline fracture location. Over 2 years of follow-up, patients years (P < .05).
managed at the FLS hospital had a 56% reduction in non-
vertebral fracture incidence and 35% lower mortality com- 4.3 Cost-effectiveness evaluations
e r s
pared to those managed at the hospital without an FLS.
k e r s
A number of formal cost-effectiveness analyses of FLS have
b o o In Australia, two groups of investigators based in New South

b o ok
been published from several countries.
b o o
e /e Wales compared the fracture experience of patients man-
aged by their own FLS with that of patients who chose not
t . m e/ e 4.3.1 Australia
A Markov model [37] was developed, which incorporated
t . m e/e
be managed by their FLS [34, 35]. Over 4 years the FLS based
: / / / /
fracture probabilities and resource utilization data obtained
in Sydney observed an 80% (P < .01) difference between
h t t p
nonvertebral fracture rates between the FLS group (4.1%)
s
and the control group (19.7%). Over 2 years the FLS based htt
4.2 of this chapter [34]. Findings included that: ps:
directly from study of the FLS in Sydney mentioned in topic
in Newcastle observed similar differences in fracture inci- • A mean improvement in discounted quality-adjusted life
dence between the FLS group (5.1%) and the control group expectancy per patient of 0.089 quality-adjusted life years
(16.4%) [35]. (QALYs) was gained.
e rs e r s
• There was a partial offset of the higher costs of the FLS
b o ok b o ok
by a decrease in subsequent fractures, which lead to an
overall discounted cost increase of AUD 1,486 per patient
b o o
e/ e 100
e / e over the 10-year simulation period.

• The incremental costs per QALY gained (ie, incremental
e /e
90
80
://t . m cost-effectiveness ratio) were AUD 17,291, which is well

: / / t . m
s tps
% of fracture patients
70 below the Australian accepted maximum of AUD 50,000

60
50
h t t p to pay for one QALY gained.
ht
40
4.3.2 Canada
30
A 1-year decision-analysis model was developed to evaluate
20
10
the FLS at St Michael’s Hospital in Toronto [38]. Findings
k e rs 0
Type A – 3i Type B – 2i Type C – 1i Type D – 0 i
ke rs
included the following:
eb oo e b oo
• A hospital that hired an FLS coordinator managing 500
b o o
e/e
BMD Testing Osteoporosis treatment patients with fragility fractures annually could reduce
e / m
Fig 2.8-5 Intensity of fracture liaison service model and process of
e / the number of subsequent hip fractures by 9% in the first
m
care outcomes [32].
/ /t . year.
// t .
ps: ps:
Abbreviation: BMD, bone mineral density.
170
htt htt
rs rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
Paul J Mitchell
k e rs ke rs
e b oo e b oo b o o
e /
t . m e
• A net hospital cost saving of CND 48,950 would be real-
/ 4.3.5 United States of America
t . m e/e
s: / / / /
ps:
ized (Canadian dollars in year 2004 values). A Markov model was developed to evaluate an FLS that
http htt
• Hiring an FLS coordinator would be a cost-saving measure provided postfracture osteoporosis care specifically for hip
even when the coordinator manages as few as 350 patients fracture patients [40]. The model considered remaining life-
annually. time fracture incidence (mean 8.6 years) and associated
costs for 10,000 men and women who had experienced an
4.3.3 Germany index hip fracture. Treatment delivered by a universal FLS
e s
Osteoporosis-related medication costs were doubled in the
r
integrated healthcare group (IV), while total medication
er s
for this population was compared to usual care. Implemen-
tation of the FLS was predicted to result in the following:
b o ok costs were lower in the IV group (EUR 1,438 versus EUR

1,702).
bo ok
• There would be 153 fewer fractures, ie, 109 hip,
b o o
e/ e e/ e 5 wrist, 21 spine, and 17 other fractures.
e/e
4.3.4 United Kingdom
: // t .m
A Markov model was developed, utilizing detailed audit
• Patients would gain 37.4 more QALYs.
: /
• The healthcare system would save USD 66,879
/ t .m
ht tps
data collected by the West Glasgow FLS [39]. The model
compared costs and outcomes for a hypothetical cohort of
1,000 FFPs, of whom 740 required treatment, managed by
compared with usual care.
ht tps
the FLS with usual care in the UK according to data from a 5 Useful resources
comprehensive national audit program. Considerably more
patients (n = 686) managed by the FLS received treatment The following online resources may prove useful to FLS
ke r s
as compared to those who received usual care (n = 193).
e r s
champions and multidisciplinary teams at the outset of FLS
b o o Findings included:
b o ok
development:
b o o
e /e • Assessments and osteoporosis treatments cost an addi-
m e/
tional £ 83,598 and £ 206,544, respectively, in the FLS.
t .
e • IOF Capture the Fracture Campaign website
www.capture-the-fracture.org [7]
t . m e/e
/ /
• The FLS prevented 18 fractures (including 11 hip
/ /
• Osteoporosis Canada’s Make the FIRST break the LAST
ps:
fractures), with an overall saving of £ 21,000.
htt
• Setup costs for widespread adoption of FLS across the
UK were estimated at £ 9.7 million.
with Fracture Liaison Services
htt ps:
www.osteoporosis.ca/fracture-liaison-service [9]
• NBHA Fracture Prevention CENTRAL website
www.FracturePreventionCENTRAL.org [14]
e rs e r s
b o ok 6 References
b o ok b o o
e/ e 1. Åkesson K, Mitchell PJ. Capture the
fracture: a global campaign to break
e / e
4. Cooper C, Mitchell P, Kanis JA.
Breaking the fragility fracture cycle.
8. Akesson K, Marsh D, Mitchell PJ, et al.
e
Capture the Fracture: a Best Practice
/e
the fragility fracture cycle. Nyon:
://t
International Osteoporosis Foundation;
2012. Available at: http://share. . m Osteoporos Int.
2011 Jul;22(7):2049–2050.
5. Marsh D, Akesson K, Beaton DE, et al.
Framework and global campaign to
Osteoporos Int.
: / / t . m
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t t p s
iofbonehealth.org/WOD/2012/report/ Coordinator-based systems for
tps
2013 Aug;24(8):2135–2152.
ht
WOD12-Report.pdf. Accessed 2017. secondary prevention in fragility 9. Osteoporosis Canada. Make the FIRST
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2. Elliot-Gibson V, Bogoch ER, Jamal SA,
et al. Practice patterns in the diagnosis
and treatment of osteoporosis after a
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6. Eisman JA, Bogoch ER, Dell R, et al.
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Osteoporos Int. 2004 Oct;15(10):767–778. fracture: ASBMR task force report on 10. O steoporosis New Zealand. Bone Care
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3. Giangregorio L, Papaioannou A, secondary fracture prevention. J Bone 2020: a systematic approach to hip
Cranney A, et al. Fragility fractures
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ke
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eb oo an international phenomenon.
Semin Arthritis Rheum.
e b oo
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osteoporosis.org.nz/wp-content/
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osteoporosis in postmenopausal
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innovative public-private partnership
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opportunity for intervention. Osteoporos
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health and social care. Available at:
[Significant reduction of osteoporosis
fracture-related hospitalisation rate due
ook ok
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17. McLellan A, Reid D, Forbes K, et al.
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results from the integrated healthcare
network osteoporosis North Rhine].
b o o
e / e Prevention of Osteoporotic Fractures in
Scotland (CEPS 99/03). Scotland: NHS
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Accessed 2017.
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et al. Prior fractures are common in Care for Osteoporotic Refracture Cost-effectiveness of the Concord
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30. Osteoporosis New Zealand. Fracture
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ok ok
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20. Watts NB, Adler RA, Bilezikian JP, et al.
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39. McLellan AR, Wolowacz SE,
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e/ e Society clinical practice guideline.
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Zimovetz EA, et al. Fracture liaison
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21. Papaioannou A, Morin S, Cheung AM,
://t . m31. Harrington JT, Barash HL, Day S, et al.

Redesigning the care of fragility
management of patients with
/ / t .
osteoporotic fracture: a cost-
: m
t t p s
et al. 2010 clinical practice guidelines
for the diagnosis and management of
fracture patients to improve
osteoporosis management: a health
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effectiveness evaluation based on data
collected over 8 years of service
h
osteoporosis in Canada: summary.
CMAJ. 2010 Nov 23;182(17):1864–1873.
22. National Osteoporosis Foundation.
Clinician’s guide to prevention and
care improvement project. Arthritis
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32. Ganda K, Puech M, Chen JS, et al.
Models of care for the secondary
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provision. Osteoporos Int.
2011 Jul;22(7):2083–2098.
40. Solomon DH, Patrick AR, Schousboe J,
et al. The potential economic benefits
treatment of osteoporosis. Washington: prevention of osteoporotic fractures: a of improved postfracture care:
2013. Available at: emri.tums.ac.ir/ systematic review and meta-analysis. a cost-effectiveness analysis of a
k e rs upfiles/158936855.pdf. Accessed 2017.
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Osteoporos Int. 2013 Feb;24(2):393–406. fracture liaison service in the US
health-care system. J Bone Miner Res.
oo oo o
2014 Jul;29(7):1667–1674.
eb e b b o
e /
t . m e /
t .m e/e
/ / //
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rs 26.07.18 10:26
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htt ps: htt ps:
Colin Currie
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/
/ / /
htt
Colin Currie
ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e Hip fracture is increasingly acknowledged as the tracer con-
e/e
: // t .m
This chapter discusses the importance and utility of registry
: / / t .m
dition for the rapidly growing challenge of osteoporotic
fracture care. As more orthopedic trauma units are able to
tps
data to improve the care of fragility fracture patients. It
ht
focuses upon hip fracture because, as the most common
serious fracture, it is the tracer condition for the current ht tps
deliver high-quality hip fracture care as a result of audit
participation, they now deploy the skills, expertise, and sys-
tems that can meet the care and rehabilitation needs of frail
pandemic of osteoporotic fractures, and because the evidence older adults with the full range of nonhip osteoporotic frac-
base for care is good and hip fracture registries are now well tures. This “halo effect” is a beneficial and welcome result
established. The chapter aims to help the reader understand of rising standards in hip fracture care.
e r s
the importance of registry participation and the use of reg-
e r s
ook ok o
istry data at the hospital, national, and international levels Large-scale hip fracture audits began with the Swedish Rik-
e b to drive improvements in the quality, effectiveness, and

e b o shoft register [2], launched in 1989. Generously supported
b o
e / cost-effectiveness of care.
t . m e/ by Rikshoft expertise and technology, both the Scottish Hip
t . m
Fracture Audit [3] and the multinational Standardized Audit e/e
/ / / /
of Hip Fracture in Europe (SAHFE) project [4] followed in
2
htt ps:
verview of registries for osteoporotic fracture
O
care and their current and future impact ps:
the 1990s. A third national audit, the UK National Hip Frac-
htt
ture Database (NHFD) [1], drew on Swedish and Scottish
experience and was developed from 2004 as a collaboration
Hip fracture is the most common serious osteoporotic frac- between the British Orthopaedic Association (BOA) and the
ture. It is well defined anatomically. Its presentation is acute British Geriatrics Society (BGS). The NHFD incorporated
and normally results in hospital admission. Hip fracture care continuously reported feedback technology derived from a
e rs
costs are high, and care quality and patient outcomes vary
r s
National Health Service (NHS) cardiac audit. This proved to
e
b o ok greatly. Hip fracture care is therefore an ideal subject for
b o
clinical audit and has been implemented at local, national, ok
be a considerable advance on the annual reports of the two
national audits cited above. The NHFD was launched in
b o o
e/ e / e
and international levels since the mid-1980s. Over time, an
e
audit has often helped to raise the quality of care [1]. /e
2007 alongside The Care of Patients with Fragility Fracture (ie,
the Blue Book), also a BOA/BGS collaboration, with the
e
://t . m / t .
NHFD monitoring compliance with the six consensus-derived
: / m
t t p s
In contrast, nonhip osteoporotic fractures are less well de-
tps
clinical standards for hip fracture care set out in the Blue
ht
fined, more variable in their presentation, and may, as in Book [5]. The following list shows the six standards moni-
h
the case of vertebral fractures, be clinically silent. The evi-
dence base for the care of such fractures is generally less
tored by NHFD. All patients:
robust than that for hip fracture. For these reasons, a large- 1. With hip fractures should be admitted to an acute
scale audit of nonhip osteoporotic fractures is challenging, orthopedic ward within 4 hours of presentation.
k e rs
and no such audits could be identified in a recent literature
search. For the purposes of this brief chapter, the focus is
ke rs
2. With hip fractures that are medically fit should have
surgery within 48 hours of admission, during normal
eb oo on hip fracture registries and hip fracture care; the terms
e b oo working hours.
b o o
e/e
audit, register, and registry are regarded as interchangeable. 3. With hip fractures should be assessed and cared for
e / m e / with a view to minimizing the risk of developing a

m
/ /t . pressure ulcer.
// t .
htt ps: htt ps:
173
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m
4. Presenting with fragility fractures should be managede / Clearly the nature of the gathered data greatly influences
t . m e/e
s: / / / /
ps:
on an orthopedic ward with routine access to ortho- the effectiveness of a hip fracture audit. In general, the data
http htt
geriatric medical support from the time of admission. must be sufficient in scope, volume, and quality to influence
5. Presenting with fragility fractures should be assessed behavior and improve care. In most audits, the data need
to determine their need for antiresorptive therapy to not, and will not, be of research quality, but it will serve its
prevent future osteoporotic fractures. main purpose of quantifying and improving clinical care.
6. Presenting with fragility fractures following a fall The work of gathering, recording, and uploading audit data
e rs should be offered multidisciplinary assessment and

intervention to prevent future falls.
er s
are a serious responsibility. Experience has shown that it is
risky to rely on its casual delegation to voluntary or con-
b o ok Since then, national hip fracture audits have been established

bo ok
scripted nursing staff or junior medical colleagues employed
for other duties. Recruiting, training, and supporting com-
b o o
e/ e e/ e
successively in Norway [6], Denmark [7], Ireland [8], and Aus- petent and committed audit staff is essential.
e/e
: // t .m
tralia and New Zealand [9]—all essentially Rikshoft-derived,
and incorporating datasets and clinical standards similar to
: / /
A supportive approach pays dividends, and advancing tech- t .m
tps
those used in the NHFD. In Germany, an extensive nation-
ht
al fragility fracture registry [10] includes key elements of hip
fracture audit data compatible with NHFD standards 1–6 [11]. ht tps
nology, eg, offering drop-down definitions of data items,
can contribute much. Regional data quality workshops,
bringing together audit staff from a number of hospitals,
have proved to be popular and effective in the case of the
The rise of such large-scale hip fracture audits, and of simi- NHFD. Working alone or in pairs in participating units can
lar local initiatives, can be seen as a rational response to the be isolating, and for such staff peer support, exchanging
e r s
aging of populations and the consequent pressures on or-
e r s
views and troubles, and learning and lunching together
ook ok o
thopedic services and healthcare delivery systems. In paral- serves to promote and maintain enthusiasm and to help
e b lel, commendable surgical and industry interest in an injury

e b o people wanting to do a good job to do it better. The involve-
b o
e / once regarded as burdensome has led to the development
m e/
of more reliable fixation methods and has also resulted in
t .
ment of such staff, alongside clinicians, managers, and cen-
t . m
tral audit staff, in the larger regional meetings described in e/e
/ /
the rise of collaborative care, with geriatricians and other
/ /
the following topics serve to recognize their essential con-
htt ps:
physicians becoming involved in nonsurgical aspects of the
care of frail older adults [12, 13]. Importantly, major recent
developments in information technology and internet com-
tribution to the wider effort.
htt ps:
Where nursing professionals are involved in data collection,
munication have made data collection, transfer, and analy- professional standards apply inasmuch as to willfully enter
sis all faster and cheaper, so that international collaboration false and misleading information about a patient could lead
has become easier and more cost-effective. Large-scale audits to a disciplinary process. Awareness of this might in itself
e rs
with high data quality and audit-based research with large
r s
deter such practice. In a few instances in the work of the
e
b o ok prospective observational series and case-mix-adjusted out-
b o
comes, for example in anesthetic care, [14] are now possible. ok
NHFD, suspiciously low 30-day death rates prompted sus-
picions of the possible omission of poor prognosis patients,
b o o
e/ e e / e
Another major factor in the rise of effective hip fracture
and these were checked by the use of nonaudit routine NHS
data, ie, the Hospital Episode Statistics data, which records
e /e
://t . m
audits has been the increasing availability of guidelines.
/
hospital admissions for hip fracture. Current NHFD advice
: / t . m
t t p s
These have taken various forms. An early example is United
tps
on data quality assurance recommends that service lead
ht
They Stand: Coordinating care for elderly patients with hip fracture clinicians check random monthly samples of records against
h
from 1995 [15]. The more formally evidence-based Scottish
Intercollegiate Guideline Network guideline [16] Prevention
data uploaded. Where sites have joint lead clinicians (eg, a
surgeon and a geriatrician), data quality and performance
and Management of hip fracture in older people followed in 2002 standards are higher.
and was updated in 2009. More recently, the UK National
kers rs
Institute for Health and Care Excellence followed with Hip Issues arise in some jurisdictions where individual patient
o
fracture: management (CG124) [17]. In the US, A Guide to Im-
ke
consent for inclusion in an audit is mandatory, and data
b o proving the Care of Patients with Fragility Fractures [18] covers

b oo
completeness suffers accordingly. When it is accepted that
b o o
e /e e e/e
both hip and nonhip fractures. Another recent US guideline a clinical audit is an integral part of good care, there are
adopted by the American Academy of Orthopaedic Surgeons
m e / fewer problems. The cost of gathering specific data for audit
m
/ /t .
Management of Hip Fractures in the Elderly focuses only on hip at around GBP 80 per case, a negligible sum when compared
// t .
ps: ps:
fracture care [19]. to the price of care (“if you think information is expensive,
174
htt htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
Colin Currie
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
try ignorance”), when routinely collected hospital data might
t . m
reports of multicenter audits seem to have relatively little e/e
s: / / / /
ps:
suffice, has been raised as an objection to free-standing au- impact on meaningful individual program improvement.
http htt
dits, although there is a broad counterview that the latter Units in the top percentiles may enjoy temporary satisfac-
form of data are not fit for audit purposes. These and other tion while those at the bottom of the league table may tem-
questions have been helpfully addressed by Martyn Parker per remorse with a vague intention, or a hope, that things
[20] in a guest editorial. In broader terms, and on the basis might improve in time for the next report.
of experience, single-payer healthcare systems offer a more
k e rs favorable environment for hip fracture audits than those

that are less developed, or developed but commercially frag-
er s
Conversely, regular feedback, ideally continuous, confers
on clinical teams the benefits of what production engineers
o o mented. If demographic and societal needs in coming decades

o ok
call statistical process control. At regular meetings clinical
o o
e/eb b b
dictate the development of hip fracture audits, the difficul- teams can look at their data and ask, for instance, what
e/
ties encountered in these varying environments must even- e happened the previous month that resulted in longer pre-
e/e
tually be addressed.
: // t .m : / / .m
operative delay: more cases, lack of operating room time,
t
poor management of operating room time, an unenthusi-
tps
Hip fracture audits are therefore now a mature web-based
ht
technology and an effective change agent, and also a platform
for both quality improvement [1], research collaboration [14], ht tps
astic anesthetist, or unnecessary preoperative investigations?
In this way local teams can use data to address local problems
and find local solutions. In effect they are empowered by
and for the development of patient-reported outcome mea- information, which produces a mindset different from that
sures [21]. Given the current predictions for the worldwide of an annual league-table.
rise in osteoporotic fractures, the status of hip fracture as its
e r s
tracer condition, and the halo effect of audit-driven improve-
e r s
A successful audit is likely to be supportive not only via
ook ok o
ments in hip fracture for other fragility fracture cases, the regular feedback, but by making available examples of good
e b potential international influence of hip fracture audits in

e b o practice, providing practical online support with a regu-
b o
e / e/
developed and less well-developed healthcare economies is
m
considerable. Over the next few decades standards of fragil-
t .
larly updated “key papers” literature library, model business
t . m
cases for funding, and even job descriptions for various au- e/e
/ /
ity fracture care could rise substantially, and audit-based
/ /
dit and clinical roles. A regular web-based newsletter featur-
htt ps:
research collaborations could drive forward evidence-based
care in a range of national and international settings.
htt ps:
ing relevant meetings and news from teams and from the
audit’s leadership will supplement the above measures in
creating a hip fracture audit community with the real sense
of itself and its purpose.
3 sing audits and feedback to improve patient
U
care and outcomes Meetings matter. Within a large national audit, regional
e rs e r s
meetings bring people together. Such meetings with 100 or
b o ok The purpose of hip fracture audits is to change behavior in
b o
ways that improve patient care and outcomes. Individual ok
more clinicians, audit staff, managers, and a program of
presentations, lunch, and coffee breaks can promote and
b o o
e/ e / e
audits vary greatly in scope, methods, and impact. Access
e
to the detailed information on hip fracture audits also var-
maintain enthusiasm. And they may have a competitive
edge too, and successive local presentations often reflect
e /e
://t . m
ies greatly, and clearly a great many local audit initiatives
/ t . m
this, adding to the enjoyment and effectiveness of the meet-
: /
t t p s
fail to surface in the literature. Audits may range from sin-
tps
ings. Of course there are other approaches quite different
ht
gle-hospital efforts that are transient or more enduring and from the above, such as an audit as a top-down bureau-
h
largely unreported to established national audits, currently
few in number, though with other national initiatives emerg-
cratic exercise, departmentally controlled, and lacking in
central clinical leadership, judgmental rather than support-
ing in Japan, the Netherlands, and Spain. Such audits can ive, and communicating only via annual reports. However,
document thousands of cases annually, deliver measurable they are less likely to create “a critical mass of enthusiasm
k e rs
improvements in care, and are now making substantial con-
tributions to the hip fracture literature.
ke rs
and expertise in hip fracture care” with a demonstrable and
sustained impact achieved by overall quality improvement
eb oo e b oo
and resulting in improved survival [1].
b o o
e/e
What matters most for any hip fracture audit is its impact
e / e
on care teams, which is best addressed in terms of hearts
m / An early and interesting example of a regional audit was
m
/ /t .
and minds. So it is worth considering audit characteristics
t .
carried out in East Anglia, England, in 1992 and repeated
//
ps: ps:
likely to achieve this. Reporting methods matter. Annual in 1997 [22]. The 1992 findings showed no significant dif-
htt htt 175
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rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
ferences in case-mix across the eight participating hospitals, 4 ospital-level use of audits—the impact of good
H
t . m e/e
s: / / / /
ps:
meaning that differences in outcome were likely to be at- practice on care quality and outcomes
http htt
tributable to variance in care. There were significant differ-
ences in 90-day mortality. Results showed that only around Together, audits, standards, and regular or continuous feed-
half of the survivors regained their prefracture physical back offer clinical teams actionable data to address barriers
function, with a marked decrease in physical function (for to good practice. When solving emergent problems requires
31%) being associated with postoperative complications. management support and/or additional resources, discussion
e s
Key measures for improvement identified for scrutiny in
r
the 1997 audit were processes likely to reduce postoperative
er s
with management is more likely to be rational, objective,
and productive than it would be in the absence of audit
b o ok complications and improve outcomes at 90 days.
bo ok
data. Perhaps the most productive use of audit data are in
prompting and monitoring changes in clinical care and/or
b o o
e/ e The 1997 findings showed reduced pneumonia, wound and
e/ e service structure.
e/e
: // t .m
hip joint infections, pressure sores, and fatal pulmonary
embolism. Two relevant interventions were more widely
: / /
The NHFD issues annual reports [24] aimed at a broad read- t .m
tps
applied, leading to a rise in thromboembolic prophylaxis
ht
from 45% to 81% and early mobilization from 56% to 70%.
However, 90-day functional outcomes and mortality were ht tps
ership that includes Department of Health officials, NHS
regional and local management, national press and media,
and participating hospitals. These reports include a section
unchanged. The 1997 population sample was older, but called Using Audit to Improve Care: Good Practice Examples, from
again there were no significant differences across the hos- which the following have been extracted:
pitals. In 1992, one hospital had impressively low mortal-
e r s
ity, but by 1997 this hospital “had lost its … preeminence,
e r s
• Northumbria Healthcare NHS Foundation Trust: Wansbeck
ook ok o
perhaps partly because of the improvement of some other General Hospital and North Tyneside General Hospital:
e b hospitals, but primarily because of failure to maintain and

e b o A quality improvement program for hip fracture care
b o
e / e/
improve its overall package of care … We therefore recom-
m
mend that hospitals continue to audit the care of patients
t .
began in October 2009. A multidisciplinary steering group
worked to improve care from admission to discharge.
t . m e/e
with hip fractures.” [22].
/ / / /
Pain control improved, with 79% of patients receiving a
htt ps:
National hip fracture audits remain few in number, and
where they exist, their relationships with their respective htt ps:
nerve block on admission. A total of 90% of patients now
undergo surgery within 36 hours. Of medically fit patients,
25% are mobilized on the day of surgery and 100% by
health departments will vary by context. Some audits may the following day. With the help of newly appointed
have developed with independent funding and subsequent- nutrition assistants, 81% received additional feeding. An
ly been recognized as innovative and effective and therefore information booklet on hip fracture is now provided for
e rs
meriting funding from national sources, as was the case with
r s
patients and caregivers. Feedback on care from patients
e
b o ok the UK NHFD. Others may have had to negotiate the com-
plexities of a federal system, together with predetermined
b o ok
and families is high, with monthly average scores con-
sistently above 9.3 of 10.
b o o
e/ e /
national processes and conditions for audit development,
e e
as was the case in Australia. In smaller nations, such as
• Salisbury NHS Foundation Trust: Salisbury District
Hospital:
e /e
://t . m
Scotland, Ireland, and New Zealand, tighter networks may
/
In 2010, with no orthogeriatrician, a noncollaborative
: / t . m
t t p s
make things easier. But once established, effective nation-
tps
approach, and long preoperative delays, Salisbury ranked
ht
wide clinically-led audits may find themselves in a position 98th out of 100 NHS England trusts in Best Practice Tar-
h
to influence policy. In this respect the UK NHFD was fortu-
nate, with various NHFD activists working within the White-
iff (BPT) achievement (see topic 5 in this chapter). A
change program introduced orthogeriatric and nurse
hall village where the profiles of hip fracture care and fragil- practitioner staffing, additional operating room capacity,
ity fractures generally rose quite markedly [23]. The political and active leadership shared by an orthopedic surgeon,
k e rs
element of hip fracture audit work should be openly recog-
nized, and is essential if the goal of influencing policy is to
ke rs
the lead anesthetist, and the consultant orthogeriatrician.
By 2012, 80% of patients reached orthopedic care with-
eb oo be achieved.
e b oo in 4 hours, 95% had a preoperative othogeriatric assess-

b o o
e/e
ment, 92% had surgery within 48 hours and 84% with-
e / m e / in 36 hours; pressure ulcer incidence fell from 5.4% to

m
/ /t . t
1.2%. Mortality fell from 10.1% to 8.4% and acute length
// .
ps: ps:
of stay from 27.6 days to 19.8 days. Best Practice Tariff
176
htt htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
Colin Currie
k e rs ke rs
e b oo e b oo b o o
e /
t . m e
attainment rose from 1.5% to 84.4%, with BPT income
/ 5
t . m
I ncentives for hospitals to improve care like the e/e
s: / / / /
ps:
of GBP 187,790 and efficiency savings of GBP 391,000 Best Practice Tariff
http htt
(calculated as 1,955 bed-days at GBP 200 per day). Im-
portantly, feedback from patients, relatives, and clinical In 1988, a US community hospital retrospective study [25]
staff was positive. assessed the impact on the care of hip fracture patients ad-
• St Peter’s Hospitals NHS Foundation Trust: St Peter’s Hos- mitted from home of a prospective payment system (PPS)
pital, Chertsey: introduced in 1983. Some 330 eligible cases were identified,
e rs In 2010, the trust invested in a 4-day efficiency, quality,

improvement, and productivity initiative on the hip frac-
er s
149 before the implementation of PPS, 189 thereafter. Mean
hospital stay fell from 21.9 days to 12.6 days following im-
b o ok ture pathway. Analysis of NHFD data showed that the
bo
longest delays occurred during or just after the weekend. ok
plementation. Other main findings gave serious cause for
concern. Maximum walking distance prior to discharge fell
b o o
e/ e e/ e
To address this, an all-day Saturday operating room list from 27 meters to 11 meters. The proportion of patients
e/e
: // t .m
was split into two half-day lists. As a result, 60% of pa-
tients underwent surgery within 24 hours and 80%
: / / .m
discharged to nursing homes rose from 38% to 60%, and
t
the proportion remaining in nursing homes a year later rose
tps
within 36 hours. Time to trauma ward admission was
ht
reduced by the introduction of a priority hip fracture
pager. Weekend physiotherapy and a hip fracture exer- ht tps
from 9% to 33% (P < .0001 for all values quoted). While
the aim of the PPS may have been to contain acute sector
costs, its overall impact on the quality and cost effectiveness
cise class improved mobilization rates within 24 hours of of subsequent patient care appeared adverse. Rehabilitation
surgery. Length of stay dropped from 25 days to 22 days, and return home were seriously affected, and the human
with considerable efficiency savings. Importantly, dis- and economic costs of one-third of the patients still in nurs-
e r s charge to original residence improved to 60% within

e r s
ing home care at 1 year are truly alarming, and illustrate
ook ok o
25 days compared with 44% within 30 days 2 years pre- the problems raised by a focus purely on acute care.
e b viously.
e b o b o
e / m e/
These initiatives have been described in some detail because
t .
A 2009 Israeli report [26] on a retrospective analysis of two
t . m
samples of patients (ie, total number of 10,620 patients from e/e
/ /
they illustrate a wide range of clinical and service improve-
/ /
1999–2006 and from seven hospitals participating in a trau-
ps:
ments that were locally driven, informed by baseline data,
htt
monitored by continuing feedback, and went beyond simple
compliance with the six clinical standards embodied in the htt ps:
ma registry) was carried out to assess the impact of a change
in 2004 that reduced significantly the diagnosis-related group
(DRG) tariff for patients undergoing surgery more than
NHFD audit. Patient-centered measures promoting improved 48 hours after admission. This data showed a 35% increase
pain control, weekend rehabilitation, and improved nutri- in the number of patients having surgery within 48 hours
tion are good in themselves but also contribute to overall and a 30% reduction in inpatient mortality for all operated
e rs
efficiency through quicker recovery, sometimes with sub- patients.
e r s
b o ok stantial savings. Patient and caregiver involvement, in the
o
form of leaflets and surveys, is unusual but admirable. Many
b ok
A 2013 report from Lazio, Italy, [27] retrospectively analyzed
b o o
e/ e / e
teams might hesitate but more should attempt it. And since
e
acute length of stay is less important for patients than get-
data on 12,433 hip fracture admissions from a variety of
e /e
local, teaching, religious, and private hospitals in the region.
://t . m
ting home as soon as possible, St Peter’s Hospital’s achieve-
/ t .
A 2009 change in DRG payment led to full reimbursement
: / m
t t p s
ment in discharging more patients straight home earlier is
tps
only for patients having surgery within 48 hours, with fur-
ht
patient-centered and probably cost-effective too, since re- ther reductions proportionate to longer preoperative delay.
h
habilitation costs can rise rapidly as a result of the unneces-
sary use of postacute hospital care.
A comparison of the years preceding and following this
change showed that the proportion of patients having sur-
gery within 48 hours rose from 11.7% to 22%. Some im-
Together, and importantly, the three local reports just men- provement was seen in all types of hospitals, with the great-
k e rs
tioned show that, in general, quality and cost are not in
conflict. “Looking after hip fracture patients well is cheaper
ke rs
est improvement in the private sector.
eb oo than looking after them badly” [5] is a simple message that
e b oo
These two studies have limitations, the former for its dura-
b o o
e/e
makes sense to clinicians, managers, health departments, tion, over which many non-DRG factors may have contrib-
e / e /
and politicians, and might itself be the best short argument
m
uted to mortality reduction, the latter in its relatively mod-
m
t .
for the wider implementation of effective hip fracture audits.
/ / // t .
est impact on serious baseline preoperative delay.
htt ps: htt ps:

177
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m
The UK NHFD, which has documented more than half a e /
t
grams focusing on key topics, such as the International Ge-
. m e/e
s: / / / /
ps:
million cases since its launch in 2007 and now captures over riatric Fracture Society CORE Certification initiative [30].
http htt
95% of eligible hip fractures, made hip fracture care an
obvious topic for the BPT when it was introduced by the Other more recent progress includes successful large-scale
English Department of Health in 2010. The standards set prospective observational audit-based research studies such
reflected those of the NHFD, with the early surgery target as the one by White et al [14] which observed 5-day and
tightened from 48 hours to 36 hours. The incentive was an 30-day case mix-adjusted mortality in 11,085 patients and
e s
incremental payment of GBP 445 (“differential”) over the
r
base tariff. The BPT base tariff remained constant, but the
er s
highlighted statistically significant increased mortality as-
sociated with intraoperative hypotension. This study now
b o ok differential increased relative to the base tariff from the

original GBP 445 to GBP 890 for 2011–2012 and further
bo ok
transcends the vast majority of previous hip fracture anes-
thesia reports that were small and/or selective, eg, in exclud-
b o o
e/ e e/ e
still thereafter. At the same time the base tariff was cut by ing patients with mental impairment, generally around
e/e
: // .m
a similar amount to put a “carrot and stick” incentive on
t
participants to improve. As intended, an increase in BPT
one-third of the hip fracture population.
: / / t .m
achievement occurred [15].
ht tps ht tps
In addition, one serious criticism of hip fracture audits,
namely that of the moral hazard arising from the fact that
they are self-reporting, has been addressed and its value as
6 rogress, challenges, and opportunities in hip
P a quality improvement initiative established [1]. This study
fracture audits used national nonaudit data and examined trends in early
surgery and mortality at 30 and 90 days and 1-year in a
e r s
In the year 2000, 1.6 million hip fractures occurred glob-
e r s
series of 471,590 patients admitted from 2003–2011, ie,
ook ok o
ally. Numbers will rise dramatically as a result of mass aging spanning 4 years before and following the NHFD’s launch
e b of the baby boomer generation in some populations, and

e b o in 2007. The 30-day mortality fell from 10.9% to 8.5% over
b o
e / e/
more dramatically in others such as Brazil, China, and India
m
where a first mass aging cohort will dominate the demog-
t .
the second 4-year period compared with a small reduction
from 11.5% to 10.9% over the first. The 2007–2011 decrease
t . m e/e
/ /
raphy for the coming decades [28]. Progress in hip fracture
/ /
in 90-day mortality was greater in absolute terms than the
ps:
audit and improvements in hip fracture care since 2000
htt
should give grounds for cautious optimism, not least that
over the next few decades, comparable further progress and htt ps:
decrease in 30-day mortality and similar in magnitude to
the decrease in 1-year mortality. This suggests that better
acute hip fracture care reduces mortality by minimizing the
improvements are still to come. collateral damage of poor care, and that this reduction is
maintained at 1 year. This is consistent with the evidence
The rise of collaborative care, with orthopedic surgeons and that between 17% and 32% of deaths after hip fracture are
e rs
orthogeriatricians working together, has greatly improved
r s
potentially avoidable [31].
e
b o ok the care and outcomes for hip fracture patients, who are
o
often the frailest and most vulnerable presenting to the acute
b ok
Unfortunately, acute care dominance is embedded in the
b o o
e/ e / e
healthcare sector. The care of their multiple comorbidities,
e
including cognitive impairment, has been transformed and
developed healthcare economies. This is reflected in the hip
fracture care with its focus on the first few weeks of care
e /e
://t . m
their outcomes much improved [13]. A recent NHFD-based
: / / t
and its failure to engage seriously with postacute care and
. m
s
study [29] showed that increased orthogeriatrician hours per
t t p tps
rehabilitation. There is no more costly and undesirable out-
ht
patient were associated with higher rates of prompt surgery, come of hip fracture care than avoidable permanent insti-
h
but were independently associated with lower 30-day mor-
tality. Such access to orthogeriatric care, however, is avail-
tutionalization, which can be a personal tragedy and often
an unjustifiable cost, however that cost is met [25].
able in few healthcare systems. In the UK, geriatricians and
orthopedic surgeons constitute the largest medical and sur- Postacute care varies greatly and generally reflects service
k e rs
gical specialties respectively, and the absence of fee-for-
service in trauma care makes collaborative care simple and
ke rs
structure and provision rather than the individual patient’s
needs and potential. Complexities around costs and respon-
eb oo cost-effective. In other contexts, where geriatricians are few
e b oo
sibilities, divisions between health and social care, and com-
b o o
e/e
or absent, other contributors who can offer geriatric medi- mercial interests present vast challenges to researchers. And,
e / e /
cal expertise, such as hospitalists, physician assistants, and
m
in contrast to technical advances in acute care such as those
m
t .
nurse specialists, might be identified and trained. These
/ / // t
in surgery and anesthetics, the findings from such research
.
ps: ps:
clinicians may benefit greatly from modular training pro- are, for similar reasons, not easily generalizable.
178
htt htt
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
Colin Currie
k e rs ke rs
e b oo e b oo b o o
e /
t . m e
Ideally, the development of community services that offer
/
t . m
The Hip Fracture Audit Database Implementation Group in e/e
s: / / / /
ps:
social services, nursing, and rehabilitation, and are capable the FFN worked, via an international expert group meeting
http htt
of dealing confidently and well with patients discharged on Skype, to use a consensus approach to develop a concise
directly home from acute care following early in-hospital and practical minimum common dataset (MCD) capturing
rehabilitation, would deliver on the mantra that “looking key elements of case-mix, care and outcomes in hip fracture
after hip fracture patients well is cheaper than looking after care [11]. This work was based on the much more extensive
them badly” [5], but such services are currently the excep- and largely Rikshoft-based datasets already in use in estab-
e s
tion. Sadly, care that is both bad and expensive is accepted
r
as the norm. There are no simple one-size-fits-all remedies,
er s
lished national audits, and was therefore compatible with
them for comparison purposes, but sufficiently user-friend-
b o ok but the combination of spiraling costs and patient discontent,

much more likely as the baby boomer generation ages, may
bo ok
ly for the purposes of start-up audits, and cost-effective where
resources were limited. Subsequently, a small-scale pilot
b o o
e/ e e/ e
serve to focus attention and lead to local or national initia- phase using the MCD has established the feasibility of in-
e/e
: // t .m
tives, such as the much-discussed merger of health and so-
cial care services in the UK context, which would make
: / / .m
ternational web-based hip fracture audit in collaboration
t
between five European centers (Barcelona, Spain; Celje,
tps
sense in both economic and human terms. Addressing these
ht
challenges requires a political response, ideally that of build-
ing a common agenda, with government and the professions ht tps
Slovenia; Lübeck, Germany; Msida, Malta; Stuttgart, Ger-
many) from which valuable lessons have been learned [11].
The pilot phase also allowed the MCD-based international
working on better and cheaper care, and better patient and comparison of data on case-mix, care, and early outcomes
caregiver satisfaction. from established audits, most recently those in Sweden, the
UK, Ireland, Australia and New Zealand.
e r s
In less developed healthcare economies, even greater chal-
e r s
ook ok o
lenges exist. The nations with the greatest challenges are In summary, hip fracture audits are already a mature tech-
e b also those least equipped to address them. But again, prog-

e b o nology that have established their effectiveness in improv-
b o
e / ress will depend on a broadly based political medium to
m e/
long-term clinical and political responses, most probably
t .
ing care and outcomes at a national level. Now, given the
t . m
status of hip fracture as the tracer condition for the looming e/e
/ /
with the establishment of pioneer initiatives in academic
/ /
pandemic of fragility fractures worldwide, the implementa-
htt ps:
settings and an outward diffusion of improving practice
compatible with the national context.
htt ps:
tion of effective hip fracture audits has the potential to play
an important part in responding to the clinical and organi-
zational challenges posed by that pandemic.
Such progress is a central goal of the Fragility Fracture Net-
work (FFN), an international nonprofit organization that One recent publication [33] has expressed support for the
brings together a broad international membership of activists, concept of international progress in extending the imple-
e rs
including orthopedic surgeons, geriatricians, nurses, and
r s
mentation of effective hip fracture audits, with dataset
e
b o ok other clinical disciplines, together with scientists with relevant
b o
interest. It seeks to promote the dissemination globally of ok
comparability offering a practical basis for collaboration in
mutual learning, and also bringing opportunities for col-
b o o
e/ e / e
the best multidisciplinary practice in preventing and manag-
e
ing fragility fractures, the promotion of research aimed at
laborative research, in the form of prospective observa-
tional studies or even RCTs. The challenge of the coming
e /e
://t . m
better treatment, and the generation of political priority for
/ t .
decades is great, but there are now at least some grounds
: / m
t t p s
fragility fracture care in all countries. With the status of hip
tps
for cautious optimism, and the outlines of a strategy for
ht
fracture as the tracer condition of the wider fragility fracture delivering on that optimism are now emerging.
h
epidemic, an FFN consensus strategic document The Future
of Hip Fracture Audit was developed over 2013–2015 [32].
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
179
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 7 References
t . m e /
t . m e/e
/ / / /
htt ps:
1. Neuburger J, Currie C, Wakeman R,
et al. The impact of a national
clinician-led audit initiative on care
and mortality after hip fracture in
12. Wakeman R, Sheard PD, Jenner GH.
Ortho-geriatric liaison—the missing
link? J Bone Joint Surg Br.
2004 Jul;86(5):636–638.
ps:
23. Oliver D. Development of services for
htt
older patients with falls and fractures
in England: successes, failures, lessons
and controversies. Arch Gerontol Geriatr.
England: an external evaluation using 13. Johansen A. The future of 2009 Dec;49 Suppl 2:S7–S12.
time trends in non-audit data. Med Care. orthogeriatrics. Age Ageing. 24. Royal College of Physicians. The
2015 Aug;53(8):686–691. 2010 Nov;39(6):664–665. National Hip Fracture Database.
e rs
2. Rikshöft. Swedish National Registry of
hip fracture patient care. Available at:
er s
14. White SM, Moppett IK, Griffiths R, et al.
Secondary analysis of outcomes after
Part of the Falls and Fragility Fracture
Audit Programme. Available at:
ok ok
rikshoft.se/about-rikshoft. Published 11,085 hip fracture operations from the www.nhfd.co.uk/docs/reports.
b o 2013. Accessed 2017.

3. Currie CT, Hutchison JD. Audit,
bo
prospective UK Anaesthesia Sprint
Audit of Practice (ASAP-2). Anaesthesia.
Accessed November 29, 2017.
25. Fitzgerald JF, Moore PS, Dittus RS.
b o o
e/ e guidelines and standards: clinical
governance for hip fracture care in
e/ e
2016 May;71(5):506–514.
15. United Kingdom National Audit
The care of elderly patients with hip
fracture. Changes since
e/e
Oct 15;27(18-19):1099–1105.
: / t .m
Scotland. Disabil Rehabil. 2005 Sep 30–
/
Commission. United They Stand:
Coordinating Care for Elderly Patients With
: / / t .m
implementation of the prospective
payment system. N Engl J Med.
tps tps
4. Parker M, Currie C, Mountain J, et al. Hip Fractures. London: HMSO; 1995. 1988 Nov 24;319(21):1392–1397.
ht ht
Standardised audit of hip fracture in 16. Scottish Intercollegiate Guidelines 26. Peleg K, Savitsky B, Yitzhak B, et al.
Europe (SAHFE). Hip International. Network (SIGN). Prevention and Different reimbursement influences
1998;8:11–18. Management of hip fracture in older surviving of hip fracture in elderly
5. British Orthopaedic Association and people. A national clinical guideline patients. Injury.
British Geriatrics Society. The care of (Guideline 56). Edinburgh: SIGN 2011 Feb;42(2):128–132.
patients with fragility fracture. Executive; 2002. Available at: www. 27. Colais P, Pinnarelli L, Fusco D, et al.
Available at: www.nhfd.co.uk. sif-fisioterapia.it/wp-content/ The impact of a pay-for-performance
e r s Published 2007. Accessed 2018. uploads/2014/12/Hip-Fracture-
e r s system on timing to hip fracture
ook ok
6. Gjertsen JE, Engesaeter LB, Furnes O, Management-Prevention- surgery: experience from the Lazio
b
et al. The Norwegian Hip Fracture
Register: experiences after the first
Scotland-2002.pdf. Accessed 2017.
b o
17. National Institute for Health and Care
Region (Italy). BMC Health Serv Res.
2013 Oct 7;13:393.
b o o
e / e 2 years and 15,576 reported operations.
Acta Orthop. 2008 Oct;79(5):583–593.
e/ e
Excellence (NICE). Hip fracture:
management. Clinical guideline
28. Cooper C, Campion G, Melton LJ 3rd.
Hip fractures in the elderly:
e/e
7. DrHoftebrud. Dansk Tværfagligt
/ /
Register for Hoftenære Lårbensbrud.
t . m [CG124]. Available at: www.nice.org.
uk/guidance/cg124. Published 2011. 1992 Nov;2(6):285–289.
/ /t . m
a world-wide projection. Osteoporos Int.
ps: ps:
National årsrapport 2016. Available at: Accessed 2017. 29. Neuburger J, Currie C, Wakeman R,
htt htt
https://www.sundhed.dk/content/ 18. Bukata SV, Digiovanni BF, Friedman SM, et al. Increased orthogeriatrician
cms/62/4662_hofte-fraktur_ et al. A guide to improving the involvement in hip fracture care and
årsrapport-2016.pdf. Published 2016. care of patients with fragility fractures. its impact on mortality in England.
Accessed 2017. Danish. Geriatr Orthop Surg Rehabil. Age Ageing. 2017 Mar 01;46(2):187–192.
8. National Office of Clinical Audit 2011 Jan;2(1):5–37. 30. Mears SC, Suk M, Cobbe F, et al.
(NOCA). Irish Hip Fracture Database 19. American Academy of Orthopaedic International Geriatric Fracture Society
National Report 2015. Available at: Surgeons (AAOS). Management of hip CORE Certification: turning knowledge
e rs https://www.noca.ie/irish-hip-
fracture-database. Published 2016. http://www.aaos.org/Research/
e r s
fractures in the elderly. Available at: into action. Geriatr Orthop Surg Rehabil.
2014 Sep;5(3):91–92.
b o ok Accessed 2017.
9. Australian and New Zealand Hip
guidelines/
b o ok
HipFxSummaryofRecommendations.
31. Kanis JA, Oden A, Johnell O, et al.
The components of excess mortality
b o o
e/ e Fracture Registry (ANZHFR).
Annual Report 2016. Available at:
e / e
pdf. Published 2014. Accessed 2017.
20. Parker MJ. Databases for hip fracture
after hip fracture. Bone.
2003 May;32(5):468–473.
e /e
www.anzhfr.org/reports.
10. AUC Geschäftsstelle Register und
://t . maudit. Acta Orthop.
2008 Oct;79(5):577–579.
21. Griffin XL, Parsons N, Achten J, et al.
32. Currie C, Mitchell P. The Future of Hip
: / / t .
Fracture Audit. A Draft Consensus
Statement. Available at: http://
m
Forschungskoordination.
t t p s Recovery of health-related quality of
tps
fragilityfracturenetwork.org/files/
ht
AltersTraumaRegister DGU. Available life in a United Kingdom hip fracture future_of_hip_fracture_audit_-_a_
h
at: www.alterstraumazentrum-dgu.de/
de/qualitaet_sicherheit/
alterstraumaregister_dgur.html.
population. The Warwick Hip Trauma
Evaluation—a prospective cohort study.
Bone Joint J. 2015 Mar;97-B(3):372–382.
consensus_statement.pdf. Published
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33. Saez-Lopez P, Branas F, Sanchez-
Published 2016. Accessed 2017. 22. Freeman C, Todd C, Camilleri-Ferrante C, Hernandez N, et al. Hip fracture
German. et al. Quality improvement for patients registries: utility, description, and
rs rs
11. Hip Fracture Audit Database (HFAD). with hip fracture: experience from a comparison. Osteoporos Int.
k e Minimum Core Dataset for hip fracture

audit. Available at: http://web1. 2002 Sep;11(3):239–245.
ke
multi-site audit. Qual Saf Health Care. 2017 Apr;28(4):1157–1166.
eb oo crownaudit.org/ffn/info.nsf.
Accessed 2017.
e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
Stephen L Kates, Andrew J Pugely
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
2.10 Lean business principles / / / /
htt ps:
htt ps:
e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e waste in the manufacturing process by prescribing standard
e/e
: // t .m
There are multiple clinical and health system models of care
: / / t .m
work and the use of recycled defective steel parts. Ford stan-
dardized the size of the boards composing the wooden ship-
tps
pertaining to orthogeriatric care. Guisti et al [1] described
ht
five distinct organizational models in their landmark paper
(see chapter 2.1 Models of orthogeriatric care for a sum- ht tps
ping crates including where the drill holes were made. When
emptied, the crates were disassembled at the factory and
became the floorboards of the Model T car. He actually re-
mary and discussion of these models). However, from a duced the price of the vehicle every year, passing on the
business model standpoint, there are only three models to realized savings to the customers.
discuss. These include “craft production”, semiorganized
e r s
care using “mass production” principles, and highly organized
e r s
However, about 25% of the cars would not start and run
ook ok o
care using “lean business principles”. These three business properly at the end of the assembly line and required re-
e b models derive from the automotive industry and can be

e b o working from the “craftsmen” he employed to correct the
b o
e / applied within a medical care context.
t . m e/ defects. Mass production quality control efforts often failed
t . m
to determine the true root cause of an error, thus the error e/e
/ /
With the use of lean business methods, considerable im-
/ /
was repeated over and over again. Despite its shortcomings,
ps:
provement in program outcomes can be achieved. The dual
htt
goals of quality improvement and cost saving are achievable
and more cost-effective care can be delivered [2]. Lean busi- htt ps:
mass production was a tremendous success and mass pro-
duction principles greatly increased output of all factories
employing the principles.
ness methods are a win for the institution, patients, and
healthcare teams. This chapter is designed to discuss the use 2.3 Lean production
of business modeling and its role in care improvement. Lean production began in postwar Japan with the Toyoda
e rs e r s
family, their engineer Taiichi Ohno, and Dr W Edwards Dem-
b o ok 2 Models from the automotive industry

b o ok
ing who was serving in MacArthur’s army of occupation. In
1950, no cars were produced in Japan, but the Toyoda fam-
b o o
e/ e 2.1 Craft production
e / e ily and Ohno, with the help of Deming, developed new
manufacturing principles now known as lean production [3].
e /e
://t . m
Before 1911, all manufacturing of cars and other goods and
: / / t . m
t t p s
services used craft production principles. Craft production
tps
In lean production, the space used for manufacturing was
ht
was dependent on the skills of the individual craftsman. less, changeover times were relentlessly reduced, the qual-
h
Supplies were purchased in a disorganized manner and were
variable. The manufacturing process was done one at a time,
ity of the parts and cars dramatically improved, and the costs
of production fell as a result. Concepts such as just-in-time
and there were no standards applied to each car. There was delivery of parts and poka-yoke, ie, error-proofing, were
no standard quality management program and each product introduced.
k e rs
was different. The results were thus variable even for skilled
craftsmen.
ke rs
The supply chain was managed by an inventory-control
eb oo e b oo
system (kanban), involving signaling cards to indicate the
b o o
e/e
2.2 Mass production need to replenish parts as they were used, which was com-
e / e /
Mass production began in 1911 with Henry Ford’s introduc-
m
bined with just-in-time delivery of the parts to the assembly
m
/ /t .
tion of interchangeable parts. In 1914, Ford introduced the
t .
line. The assembly line was “production leveled” (heijunka)
//
ps: ps:
moving assembly line and focused routinely on reducing by sequencing the models of car built by their complexity
htt htt 181
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rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
and components. At the end of the line, all of the cars start- 4 Implementation of lean business methods
t . m e/e
s: / / / /
ps:
ed and ran, and could be immediately transported to the
http htt
freighter for shipping to their intended destination. Quality Each episode of care for a fragility fracture can be broken
was improved continuously using the Deming cycles of plan- down into a series of steps or processes. These processes,
do-check-act (PDCA) and use of frequent “improvements” strung together, will encompass the flow of the patient
(kaizens) to solve problems encountered in the manufactur- through the health system during their care. Using lean
ing process. By the late 1990s, Toyota became the number business methods, these processes can be studied and im-
e rs
one manufacturer of cars in the world.
er s
proved repeatedly to improve the patient flow through the
system, reduce errors, and improve patient satisfaction. This
b o ok 3 here are we now and what is value in

W
bo ok
is called a value stream map [6]. To embark on such a jour-
ney, prerequisites such as the following are needed:
b o o
e/ e healthcare?
e/ e e/e
: // t .m
Based on the business models described above, orthogeri-
• Support of hospital administration is essential.
• Solid leadership from surgeon champion and medical
: / / t .m
s tps
http
atric care is usually delivered in a craft production mode champion [2] is required.
with some mass production features such as a quality man-
agement system, a supply chain, and a large volume of
cases managed in some centers. Typical care produces vari-
that any changes made will “stick”. ht
• The care team should be involved and empowered so
• There must be an element of commitment among the

able results including many readily avoidable adverse events care providers to understand that there are better ways
such as medication errors, and poor sequencing of surgeries to care for their patients.
e r s
and consults, resulting in long delays, depletion of necessary
e r s
• Excellent communication around the lean practices is
ook ok o
supplies, avoidable infections, the ordering of unnecessary also essential with an emphasis that the idea is to
e b tests such as head CT scans and echocardiograms, and the

e b o improve patient care and provider satisfaction rather
b o
e / list goes on.
t . m e/ than to eliminate jobs.
t . m e/e
/ /
If the reader is still not convinced, ask yourself the follow-
/
Some programs will employ a team of consultants to assist
/
ps:
ing question: If I needed urgent surgery on my fracture,
htt
would I like to choose my surgeon and care team? Most
readers would answer “yes, definitely”. Because traditional htt ps:
them with the process of creating a value stream map; oth-
ers employ a facilitator to help oversee the process. In all
cases, employees must participate actively in lean processes
fracture care is highly variable and unorganized, you sure- to ensure a successful outcome. When starting to implement
ly want to choose your craftsman wisely. Of course this is lean processes in a department, choosing a discrete diagno-
highly inefficient and rarely possible in the urgent setting. sis such as hip fracture is important so that the care team
e rs
As cost pressures mount on health systems around the world,
r s
member can focus their efforts clearly.
e
b o ok there is an increasing need to improve quality of care at
b o
lower cost. Fortunately, there is often an inverse relation- ok b o o
e/ e / e
ship between the costs of care and quality of care, ie, high-
e
value care typically costs less. Health systems and patients
5 Examples of wastes and ways to mitigate them
e /e
://t . m
are demanding better value care be delivered [4]. The value A primary focus of lean business methods is to eliminate
: / / t . m
equation is [5]:
t t p s tps
waste from the process [7]. In healthcare, an estimated 30–
ht
47% of delivered services are estimated to be “waste” [8].
h
Outcomes
Costs
= Value
Waste is something that adds no value to the process of care
and is often harmful. Failure of care coordination is an ex-
ample of harmful waste. Processes that add value in health-
In most cases we know the costs. Typically, only outcomes care include a necessary test, time spent with the doctor or
k e rs
as defined by “process measures” like length of stay, mortal-
ity rate, and infection rate are known but not the truly
ke rs
nurse, and a needed surgery.
eb oo important patient-reported outcomes. Patient-reported out-
e b oo b o o
e/e
comes are important to show if the care provided actually
e / m e /
improved the patient’s health status. It is hard to have a
m
t .
true measure of value, but with time this issue will surely
/ / // t .
ps: ps:
be corrected.
182
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rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
Waste comes in many varieties and these are listed below 6.2 Lean business flow model
t . m e/e
s: / / / /
ps:
as the classic seven wastes [2, 3] with relevant examples: For the overall care process of a fracture patient, use of a
http htt
lean business flow model is preferred. This methodology
1. Transportation—transporting a patient too many examines the flow of the patient through the system from
times to radiology when once was enough emergency department admission to hospital discharge. The
2. Inventory—too much or too little inventory process begins at “gemba”, ie, the place where the work is
3. Motion—a staff member running around to find a done. The team leaders and process facilitator walk the flow
e rs needed item
4. Waiting—waiting for surgery, waiting to see the
er s
of the patient through the system, asking questions, taking
notes, and developing an understanding of the complexity
b o ok physician, etc; waiting is aggravating and disrupts the

flow of care
bo ok
of care received. Ideas for improvement are generated but
not yet shared or acted upon.
b o o
e/ e 5. Overprocessing and overtreatment—ordering too
e/ e e/e
: // .m
many tests and/or an unnecessary echocardiogram
t
6. Overproduction—repeatedly performing the same test
6.3 Kaizen
: / / t .m
The next step is to plan a “kaizen”. Kaizen is a Japanese
s tps
http
when the answer was acceptable to begin with word that means to take apart (kai), and to make new (zen).
7. Defects—avoidable errors resulting in rework,
readmission, and reoperation; this is the worst waste ht
To be successful, a kaizen must be carefully planned in ad-
vance. A kaizen is a short burst of activity usually lasting
1–5 days. During this time all participating employees are
An added eighth waste is not seeking employees’ opinions, relieved of their usual job responsibilities and required to
thus wasting their good ideas. attend the entire event:
e r s e r s
ook ok o
As lean processes are implemented, elimination of wastes is • The specific goal of the kaizen is set by hospital
e b b
a focal point of the methodology [6]. Some wastes are read-
e o administration.
b o
e / e/
ily eliminated with the use of standardized order sets, by
m
prescribing only generic medications (with geriatric doses)
t .
• The facilitator may be an employee or a specialist hired
to facilitate the kaizen.
t . m e/e
/ /
and by standardizing the timing and type of laboratory tests
/ /
• Employees are carefully chosen from the usual care
ps:
needed for each day of the hospital stay. This helps to elimi-
htt
nate unnecessary medication costs, duplication of laboratory
tests, and allows for more predictable staffing for phlebotomy. appropriate. htt ps:
team including physicians, nurses, clerical staff,
nursing assistants, and even housekeepers if that is
• Employees selected should be interested in improve-

In surgery, use of a prominently displayed care algorithm ment, engaged, and not naysayers or disruptive
poster to determine the appropriate implant for specific individuals.
e rs
fracture types based upon patient age and functional status
r s
• A complainer is acceptable to include as long as they
e
b o ok enables both good care and tremendous cost savings. It avoids
o
use of costly implants to treat patients with a minimal func-
b ok
are seeking improvement in the system of care.
• The goal of the process improvements is to make them
b o o
e/ e / e
tional status. This is referred to as “demand matching” the
e
implant to the patient’s specific needs and is truly patient-
revenue neutral or cost saving.
e /e
centered care. [9]
://t . m : / / t . m
The event begins with the kaizen leader providing a short
t t p s tps
presentation, typically 30–45 minutes, explaining the prob-
ht
lem and the background, and charging the group with their
6 h
Kaizen—and how is it useful responsibilities. If the team assembled is not familiar with
the process of a kaizen, there is an introductory explanation
6.1 Lean Six Sigma of the process. A kaizen is biased toward action rather than
Once a decision is reached to embark on the process im- analysis and is focused on identifying all relevant processes
k e rs
provement journey and adopt a lean approach, the goals
must be set to allow the leaders to choose the correct meth-
ke rs
and problems.
eb oo odology to employ it. For a single focused problem, like
e b oo
After the introduction of the problem and background, the
b o o
e/e
operating room changeover time, a Lean Six Sigma approach next step is to create a process map or value stream map for
e / e /
is likely best. Lean Six Sigma is focused on detail and employs
m
the care process being studied. One useful way to do this is
m
t .
a specific methodology to improve the processes and reduce
/ / // t .
to put large white sheets of paper on the wall, side to side,
ps: ps:
the process variation greatly. as a first step. The process steps are next mapped out with
htt htt 183
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
smaller uniform color sticky notes. Each individual step is As the kaizen prepares to close, a summary presentation is
t . m e/e
s: / / / /
ps:
mapped in order of occurrence. If there is more than one created by the groups listing the problems, what step they
http htt
pathway, parallel paths are made. When all of the steps from are at in the care process, and the proposed solutions. When
beginning to end have been mapped out, the team looks at each group has come up with solutions to the problems,
each step individually and assigns problems that are associ- they are asked to pilot these solutions in the workplace.
ated with that step (Fig 2.10-1). Sometimes this can be tried right away, and sometimes it
will require a planned pilot phase with a small subgroup of
e s
The next step is to identify the problems that impact each
r
process step. Each individual problem is written on a sticky
er s
the overall organization. Pilot studies may require calling
in employees from the particular area performing the pro-
b o ok note of a different color to the process steps. These are placed

vertically above or below the process step. There are typi-
bo ok
cess to ask if the proposed solution will work. In no instance
is a detailed analysis done, the kaizen is biased toward action.
b o o
e/ e e/
cally many more problems per step then there are steps in e e/e
the process.
: // t .m The final hour of the kaizen is spent presenting the sum-
: / / t .m
mary audiovisual presentation to the institutional leadership.
s tps
http
When the value stream map is completed, the team usu- During this presentation, no questions are permitted. The
ally takes a break to eat. It is important that even for meals,
the team remains together. Therefore, the sponsoring or-
ganization, typically the hospital, should provide good food
ht
solutions are listed, and the team expects that the institu-
tional leadership will support trying these solutions to solve
the problems. This is an essential aspect of the kaizen. It
for the kaizen. Next, the team collects all the problems by requires true support from the institutional leadership. If
process division. These are studied briefly by the team which support is not there, process improvements will not succeed.
e r s
is now split into 2–3 groups. The problems are broken into
e r s
After time has passed, another kaizen may be required for
ook ok o
four groups based on problem impact and difficulty, using the same topic as new problems arise or when some of the
e b the grid shown in Fig 2.10-2.

e b o solutions have failed to solve the original problem. Problems
b o
e / m e/
After all the problems have been assigned to one of the four
t .
assigned to square 2 (ie, high impact/high difficulty) may
often need their own kaizen.
t . m e/e
/ /
squares, problems in squares 3 and 4 are discarded. Problems
/ /
htt ps:
in square 1 (ie, high impact/low difficulty) are assigned
equally amongst the groups. The team is asked to come up
with innovative solutions to the problems they have been htt ps:
assigned. Problems in square number 2 (ie, high impact/
high difficulty) are placed in a “parking lot” for later assess-
ment. The difficulty level of these is typically too high and
e rs
may require its own kaizen or may need to be dealt with
e r s
o ok over time.
ok o
/ebo o
1 2
e/ e b e e /e b
://t . m : / / t . m
t t p s Impact 
tps
h 3
ht 4
k e rs ke rs
oo oo o
Difficulty 
eb e b b o
e /
t . m e / Fig 2.10-2 Difficulty-opportunity analysis grid helps divide problems
t .m
into four groups based on problem impact and difficulty (ie, high
e/e
/
Fig 2.10-1 Process map used at a kaizen session to solve problems
/ //
impact/low difficulty, high impact/high difficulty, low impact/low
ps: ps:
and improve processes. difficulty, and low impact/high difficulty).
184
htt htt
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htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 6.4 Implementation
t . m e / 6.5 Results
t . m e/e
s: / / / /
ps:
Implementing process improvements in the clinical setting Assessment of the results of process improvements is critical.
http htt
is next. This is an ongoing effort. A spreadsheet is devised Lean business methods are data-driven, so the collection of
with the problem, individuals responsible are assigned, and before and after outcomes is essential. Periodic review of
the colors of red (ie, halted, needs attention), green (ie, the progress is important as is asking for employee and pa-
going well) and blue (ie, completed) are assigned to indicate tient feedback, which typically requires data collection. For
the progress (Fig 2.10-3). financial data, the hospital finance department will need to
e rs
A timeline is often assigned as well. Weekly short team
er s
be involved; they should be aware of the specific data points
requested in advance, and these should be compared to
b o ok meetings are held and only processes coded red are reviewed.
b
The meetings continue until the process improvements haveo ok
historical data for reference. Many other process measures
will be already collected by the hospital such as length of
b o o
e/ e e/ e
been completed. Obviously, support from the hospital lead- stay, complication rates, and operating room measures. Some
e/e
: // t .m
ership is required for this to be a success.
: / / .m
metrics, like time to surgery, can require extra effort to col-
t
lect and should have an employee assigned to report these
tps
Initially, employees may be wary of change. This is particu-
ht
larly true for employees in leadership roles of an area where
they feel they “own the processes” already in use. This is ht tps
metrics regularly to monitor progress. For outpatient mea-
sures, additional effort is required to collect data and an
employee will likely need to be tasked with this responsibil-
why it is essential for the members on the kaizen team to ity.
take ownership of the process improvements and sell the
new concepts to their coworkers. When a team takes own- 6.6 Program monitoring
ke r s
ership of process improvements, this greatly reduces back-
e r s
A scorecard or dashboard should be assembled with program
b o o sliding to the old ways. When processes are implemented
b o
in a top-down manner (ie, traditional for medical centers), ok
data and monitored monthly. Outcomes should be available
to team members to help them understand their performance
b o o
e /e m e/ e
employee resistance and backsliding are common. The team
should be praised and supported by leadership during pro-
t .
improvements. Consider creating graphical dashboards for
t . m
employees to view. Visual dashboards are an important ex- e/e
cess changes.
/ / / /
ample of lean business controls (Fig 2.10-3). Regular review
htt ps: htt ps:

of outcomes, progress, and backsliding is essential. With use
of lean business methods, considerable improvement in
program outcomes can be achieved. The dual goals of qual-
ity improvement and cost saving are achievable and more
cost-effective care will be delivered [6]. Lean business meth-
ods are a win for the institution, patients, and healthcare
e rs teams.
e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
185
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Deliverable Benefit
t . m e / Owner Team Time to Due date Status
t . m
Comments e/e
s: / / / /
ps:
complete
http
Registration and checkout
Ask for photo ID and scan Once patient is in the system, no longer
have to ask for ID (saves time and improves
customer satisfaction).
2 weeks 03-Mar
htt Complete
Update and relocate provider board to Reduce patient walking, improves 01-May G Getting info on adding
vestibule communications and customer satisfaction. department names to
s s
front window.
e rBan sales reps from area who do not have Less distractions.
er 12-Mar Complete New signs posted.
b o ok appointments
bo ok No sales reps can enter

clinic area without appt.
b o o
e/ e Call for patient transportation when patients
are roomed
e/ e
Current process is to call for patient transport
(if required) at end of appointment. This
15-Feb Complete Send out policy to
providers and have it
e/e
// t .m
causes long patient wait times and requires
staff to make multiple (4–5) calls to check on
: : / / .m
posted in clinic area.
t
tps tps
transport status (improve customer satisfaction
and staff efficiency).
stages ht
Notify patients of their wait times at all
Have new patient registration forms arrive

Improve patient satisfaction by setting
expectations. Try to give a range of times.
Direct ships, saves on labels (need to estimate
19-Feb
19-Mar
ht Complete
G
Send out email.
directly to CCO annual savings in USD). This will also ensure

that correct info is on labels.
ke r s
Communicate and distribute minors policy.
State during appointment scheduling, with
Reduces loss of revenue, saves patient time,
and increases customer satisfaction.
k e r s 15-Feb Complete
b o o physician liaison and signage

Standardize to one general patient form
b o o
Reduce the need to fill out multiple forms 2 weeks 01-Apr G Draft completed on
b o o
e /e e/e e/e
with specialty areas/one adult and one with the same info. Saves time and increases Feb 15. Need space for
pediatric form. customer satisfaction. stickers on each page.
/ / t . m / /t . m
Revising form.
ps: ps:
Order two new high capacity fax machines Saves time, higher quality faxes, lower supply 1 week R On order.
costs.
X-rays and visits
htt
Post x-ray requirements in modules Improves communication with x-ray team/
efficiency in radiology. Results in quicker
15-Mar htt Complete
patient visit (customer satisfaction) This will

eliminate the 5–10% of x-rays which are
repeated today due to lack of communication.
e rs
Gowns no longer required for most x-rays Eliminates tying up room to hold patient
e r s 05-Mar Complete
ok ok
valuables, huge customer satisfaction issue,
b o o
reduces cycle time and room utilization.
b
Patient is uncomfortable and inattentive in
b o o
e/ e / e
gown. Saves in buying and cleaning gowns.
e e /e
Mandatory for gowned patients to wear
slippers or shoes
://t . m
Hygiene improvement. 2 Days 26-Feb Complete
: / / t . m
Signs are posted in each
room and slippers are
now located next to
t t p s tps
gowns.
h
Fig 2.10-3 Example of a kaizen dashboard.
Abbreviations: appt, appointment; CCO, Clinton Crossings Office; reps, representatives.
ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
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rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Deliverable Benefit
t . m e / Owner Team Time to Due date Status
t . m
Comments e/e
s: / / / /
ps:
complete
http
Internal
Appointment will remind patients to wear
lose-fitting clothing
When two or more patients are waiting in
Helps eliminate the need to change into gown.
Eliminates patient from standing in line

17-Feb
16-Feb
htt
Complete
Complete
Appts informed and are
informing patients.
checkout line, staff will approach line and and waiting when they can leave! Increase
ask who needs a follow-up appointment. customer satisfaction.
If no follow up is required, take encounter
e rs
form, give back yellow copy, tell patient
er s
ok ok
they will be billed or their copay if they
b o
have one.
bo b o o
e/ e Perform 5S–pick a pilot area and set the
standards
e/ e
This will ensure that all forms are stored in the
same place and called by the same name.
15-Mar G Once pilot is complete,
the entire building will
e/e
.m .m
perform 5S. Peg will call.
: // t : / / t
Bill to schedule audit for
mid-April.
Perform 5S–pick a pilot area and set the
standards (Dr’s Bay area)
Need for additional magazines ht tps This will ensure that all forms are stored in the
same place and called by the same name.
Improve customer satisfaction 08-Mar
15-Mar
08-Mar
G
ht tps
Complete Additional magazine
order went out with
renewals.
Team huddle–tech and provider, at start of Improve patient flow, tech and provider TBD G
e r sday and throughout day

Future potential kaizen
satisfaction
e r s
ook ok o
We documented many proposals during
e b the kaizen. We need to add them to this
e b o b o
/ e/ e/e
document.
e Billing issues Insurance not entered correctly
t . m t . m
Allow for copay for x-ray
/ / / /
htt ps: KEY
htt
G
ps:
Complete
Action is on target
Action closed, fully
implemented
R Behind schedule, or
having issues
e rs
Fig 2.10-3 (cont) Example of a kaizen dashboard.
e r s
b o ok b o ok b o o
e/ e e / e e /e
7 References
://t . m : / / t . m
t t p s
1. Giusti A, Barone A, Razzano M, et al. 4. Morden NE, Colla CH, Sequist TD, et al.
tps
7. Womack JP, Jones DT, Roos D.
ht
Optimal setting and care organization Choosing wisely—the politics and The Machine That Changed the World.
h
in the management of older adults with
hip fracture. Eur J Phys Rehabil Med.
2011 Jun;47(2):281–296.
economics of labeling low-value
services. N Engl J Med.
2014 Feb 13;370(7):589–592.
New York: Simon & Schuster; 1990.
8. Berwick DM, Hackbarth AD.
Eliminating waste in US health care.
2. Kates SL. Lean business model and 5. Porter ME. What is value in health JAMA. 2012 Apr 11;307(14):1513–1516.
implementation of a geriatric fracture care? N Engl J Med. 2010 Dec 9. Swart E, Makhni EC, Macaulay W, et al.
rs rs
center. Clin Geriatr Med. 23;363(26):2477–2481. Cost-effectiveness analysis of fixation
6. Wormack JP, Jones DT.
k e 2014 May;30(2):191–205.
3. Ohno T. Toyota Production System:
ke
Lean Thinking: Banish Waste and Create
options for intertrochanteric hip
fractures. J Bone Joint Surg Am.
eb oo Beyond Large-Scale Production.

Cambridge: Productivity Press; 1988.
b
New York: Free Press; 2003.
e oo
Wealth in Your Corporation. 2nd ed. 2014 Oct 01;96(19):1612–1620.
b o o
e /
t . m e /
t .m e/e
/ / //
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/ / t . m // t . m
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k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
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/ / t . m // t . m
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k e rs ke rs
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Section
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Fracturekers
ms:/anagement
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/ / / /
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e rs e r s
b o ok b o ok b o o
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rs
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htt ps: htt ps:
e rs e rs
e b oo Section 3
k
e b oo k
b o o
e / Fracture management
t . m e /
t . m e/e
: / / / /
http
s
3.1 Proximal humerus
Franz Kralinger, Michael Blauth 191 htt ps:
3.2 Humeral shaft
Clemens Hengg, Vajara Phiphobmongkol 243
e rs 3.3 Distal humerus
er s
b o ok Rohit Arora, Alexander Keiler, Michael Blauth
3.4 Elbow
bo ok 269
b o o
e/ e e/ e
Rohit Arora, Kerstin Simon, Marco Keller, Michael Blauth 283
e/e
3.5 Olecranon
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tps tps
Peter Kaiser, Simon Euler 297
ht
3.6 Distal forearm
Rohit Arora, Alexander Keiler, Susanne Strasser 315 ht
3.7 Pelvic ring
Pol M Rommens, Michael Blauth, Alexander Hofmann 339
e r s 3.8 Acetabulum
e r s
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Dietmar Krappinger, Richard A Lindtner, Herbert Resch 373
e b e b o b o
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3.9 Femoral neck
e / Simon C Mears, Stephen L Kates

m e/ 389
m
/ / t .
/ /t .
ps:
htt
3.11 Femoral shaft
405
htt ps:
Elizabeth B Gausden, Dean G Lorich 421
3.12 Distal femur
Jong-Keon Oh, Christoph Sommer 439
e rs 3.13 Periprosthetic fractures around the hip

e r s
b o ok Steven Velkes, Karl Stoffel
b o ok 461
b o o
e/ e /
3.14 Periprosthetic fractures around the knee
e e
Frank A Liporace, Iain McFadyen, Richard S Yoon 479
e /e
3.15 Proximal tibia
://t . m : / / t .m
t p s
Michael Götzen, Michael Blauth
t
501
tps
3.16 Tibial shaft h
Björn-Christian Link, Philippe Posso, Reto Babst 523
ht
3.17 Ankle
Christian CMA Donken, Michael HJ Verhofstad 535
k e rs 3.18 Atypical fractures
ke rs
eb oo Chang-Wug Oh, Joon-Woo Kim
e b oo 559
b o o
e / 3.19 Chest trauma
Hans-Christian Jeske
t . m e / 571
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: / / //
s ps:
3.20 Polytrauma
t t p
Julie A Switzer, Herman Johal
h
579
htt
190
rs
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/ / t . m // t . m
htt ps: htt ps:
Franz Kralinger, Michael Blauth
k e rs ke rs
e b oo e b oo b o o
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t . m e /
t . m e/e
3.1 Proximal humerus / / / /
htt ps:
htt ps:
e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e Since there is no single clear-cut approach to a PHF, treat-
e/e
: // t .m
The treatment of proximal humeral fractures (PHFs) is con-
: / / t .m
ment recommendations depend largely on surgeon experi-
ence, skills, and preference. An improvement of this situation
ht tps
troversial for a number of reasons:
• There is an ongoing debate about the benefits of operative ht tps

can only be achieved with larger and higher level clinical
studies and specifically designed PROMs to address the ge-
riatric population. This chapter summarizes the current
versus nonoperative treatment even of displaced, un- situation from a practical approach to guide proper patient-
stable fractures. and treatment-specific decision making. This seems to be
• The rate of “mechanical” complications after surgical the most important factor in achieving a good outcome as
e r s treatment is 30–35% in prospective studies with surgical

e r s
well as for the most appropriate treatment selection and
ook ok o
revision rates from 20–30% [1–3]. Nevertheless, up to avoidance of complications.
e b 74% of PHFs actually received surgical treatment [4].

e b o b o
e /
t . m e/
• Multiple available operative options from pinning to ar-
throplasty with varying selection criteria are mainly based
1.1 Epidemiology
Proximal humeral fractures:
t . m e/e
/ /
on bone and fracture characteristics without considering
/ /
the patient’s functional status.
htt ps:
• There is a lack of randomized studies investigating distinct
fracture entities and treatment modalities.
60 years.
htt ps:
• Are the third most common fractures in adults older than
• Affect 70–80% of women with a history of osteoporosis

• Unspecific outcome measures. While using the Constant who have fallen from a standing height [1].
and Disabilities of the Arm, Shoulder, and Hand (DASH) • Have been increasing by up to 15% in the past decades
scores, ceiling effects may make it difficult to detect sub- [7, 8]. There are major differences between ethnicities and
e rs stantial advantages of surgical fixation over nonoperative

r s
the rate of fractures are significantly lower in countries
e
b o ok management [5]. If the scores or patient-reported outcome
measures (PROMs) used were more precise, differences
b o ok
like Japan [9] compared to Europe or America.
b o o
e/ e / e
between different procedures might be detected more
e
easily. A ceiling effect of a score describes the fact that a
Interestingly, the clear rise in the rate of low-trauma PHFs
in older Finnish women from the early 1970s until the mid-
e /e
://t . m
score at its upper end of values loses the ability to detect
/ t . m
1990s has stabilized at a high level. The reasons for this are
: /
t t p s
changes in a patient’s health status in a sufficient manner.
tps
largely unknown, but a cohort effect toward a healthier
ht
Therefore ceiling effects can lead to artefactual data, eg, aging population with improved functional ability and re-
is one.
h
showing no effect of an intervention when in reality there duced risk of injurious falls cannot be ruled out [10]. In
Austria, on the other hand, this levelling off effect could
• More traditional ways to evaluate treatment results like not be confirmed and absolute numbers of PHFs are still
range of motion (ROM), muscle strength, fracture reduc- rising due to increased life expectancy [11].
k e rs tion, and bone healing may not apply to the proximal

humerus where objective parameters often do not match
ke rs
eb oo subjective appraisals [6].
e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
191
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
Section 3 Fracture management
k e rs ke rs
e b oo e b oo b o o
e / 1.2 Etiology
t . m e /
t . m e/e
/ / / /
htt ps:
• Proximal humeral fractures occur mostly after low-energy
falls [12].
htt ps:
• Comorbidities increase the risk for PHFs. Factors like de-
creased neuromuscular response, delayed reaction time,
cognitive impairment, impaired balance, intoxication as
e rs well as early menopause are all associated with PHFs [13].

• Middle-aged patients who sustain PHFs are physiologi-
er s
b o ok cally older than their numerical age indicates and have
a higher incidence of medical comorbidities often related
bo ok b o o
e/ e e/ e
to alcohol, tobacco, and drug usage (Case 1: Fig 3.1-1) [14].
e/e
: // t .m : / / t .m
ht tps
Young woman suffering from alcoholism and severe osteoporosis, multiple fractures including bilateral proximal ht tps
CASE 1
humeral fractures with special solution on one side
Patient
e r s A 48-year-old woman with no obvious signs of dementia or confu-

e r s
The intraoperative (Fig 3.1-1j–k), 3-month (Fig 3.1-1l), and 1-year
ook ok o
sion; she was cooperative. She was living with her husband and (Fig 3.1-1m) follow-up x-rays showed an uneventful clinical course.
e b wanted to remain independent. Over the years, she sustained con-

e b o Range of motion was 120° of abduction/flexion and 60° of external
b o
e / proximal tibia.
t . m e/
tinuously major fractures of the distal radius, lumbar spine, and rotation.
t . m e/e
/ / Treatment options
/ /
Comorbidities
• Alcohol addiction
• Nicotine abuse htt ps: htt ps:
• Nonanatomical fixation in valgus of the humeral head and mas-
sive shortening may result in an impaired functional outcome
due to a shorter lever arm of the rotator cuff muscles.
• Chronic obstructive pulmonary disease • Nailing: Head fragment is too short for stable anchorage of the
• Osteoporosis fifth anchor point.
• Grand mal seizures • Hemiarthroplasty: Overtreatment when stable reconstruction is
e rs • Multiple other comorbidities

r s
possible. Midterm function of the shoulder is questionable.
e
b o ok Treatment and outcome
b o ok
• Reverse total shoulder arthroplasty is not indicated with intact
rotator cuff and well-centered shoulder joint.
b o o
e/ e / e
In 2005 the female patient sustained a subcapital fracture of the
e
left humerus (Fig 3.1-1a–c). The fracture was treated nonopera- Key points
e /e
://t . m
tively leading to healing in malalignment. The bone was clearly
/ t .
• Central voids can be successfully filled with massive allografts to
: / m
t t p s
osteoporotic, but no action was taken with regard to this.
tps
prevent early varus failure and subsidence of the head fragment
ht
with cut-through of the screws, even in patients with severe
h
In 2008 she presented with a fracture of the right proximal hu-
merus (Fig 3.1-1d–f). The fracture was first treated nonoperatively,
osteoporosis [15].
• In a retrospective case series, this procedure leads to bony union
which resulted in a painful and debilitating condition. Since fracture in a noncompliant or high-risk patient population [16].
healing was not to be expected, the decision to perform surgery was • Treatment of the underlying osteoporosis may be challenging in
k e rs made.
ke rs
noncompliant patients.
eb oo After the fracture was aligned (Fig 3.1-1g), an almost normal ana-
e b oo b o o
e/e
tomical condition could be reestablished with a massive central
e / m e /
allograft (Fig 3.1-1h). Then the plate was preliminarily fixed
m
(Fig 3.1-1i).
/ /t . // t .
htt ps: htt ps:
rs
rs 26.07.18 10:26
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e a b c
e/ e d e f
e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e/e
g h i j k l m
e / Fig 3.1-1a–m A 48-year-old woman with multiple fractures.
m e/ m
t .
a–c X-rays showing a subcapital fracture of the left humerus.
/ / / /t .
ps: ps:
d–f X-rays showing a fracture of the right proximal humerus.
g–i X-rays showing aligned fracture ( g), an almost normal anatomical condition achieved with a massive central allograft (h) and preliminary
htt htt
plate fixation (i).
j–m Intraoperative result ( j–k), follow-up after 3 months (l), and 1 year (m). Note the different projection in the last picture which can be
read from the PHILOS plate.
e rs e r s
b o ok 2 Diagnostics and classification
b o
2.1
okClinical evaluation
History and physical examination include:
b o o
e/ e / e
In order to give a viable therapeutic recommendation, the
e
preoperative workup must go beyond fracture analysis, al- • Mechanism of injury
e /e
://t . m
though there seems to be a high degree of uncertainty as
/ t .
• Vascular and neurological status, especially distal circu-
: / m
t t p s
how to measure and implement clinical information into lation and the axillary nerve function
tps
ht
the decision-making process. • Soft-tissue injuries, including the skin
h
In a recent study 238 surgeons rated 40 x-rays of patients with
• Muscle status, specifically the muscles of the rotator cuff
(Diagnostics 1: Fig 3.1-2, Fig 3.1-3, Fig 3.1-4)
PHFs. Participants were randomly selected to receive informa- • Preinjury level of function
tion about the patient and mechanism of the injury. Patient • Occupation
k e rs
information, particularly older age, was associated with a
higher likelihood of nonoperative treatment recommendation
ke rs
• Hand dominance
• History of malignancy
eb oo rather than x-rays alone. Clinical information did not improve
e b oo
• History of previous fragility fractures
b o o
e/e
agreement with the actual treatment or the generally poor • Rehabilitation potential
e / interobserver agreement on treatment recommendations [17].

m e / • Presence of concomitant injuries
m
/ /t . t .
• Geriatric workup including comorbidities, functional and
//
ps: ps:
mental status
htt htt 193
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m
Evidence of how the mental status may influence the out- e / Other patient factors like level of independence, housing
t . m e/e
s: / / / /
ps:
come is poor. In most studies, patients with significant men- situation, or the need to use walking aids also potentially
http htt
tal impairment are excluded or this factor is not considered affect outcomes after both operative and nonoperative man-
at all. Advanced age and higher degrees of dementia with agement and should therefore be evaluated very carefully.
increased risk of postoperative delirium usually lead to non- Complications such as infection, nonunion, osteonecrosis,
operative treatment (Case 2: Fig 3.1-5). fixation failure, and compliance with rehabilitation can all
be related to medical comorbidities [13]. Alcohol abuse par-
e rs er s
ticularly increases a patient’s risk of noncompliance and non-
union, and tobacco use increases the risk of nonunion [18].
b o ok bo ok b o o
e/ e e/ e e/e
/ t .m
Evaluation of rotator cuff muscles status with standardized 2-D computed tomographic reconstructions
/ t .m
DIAGNOSTICS 1
: / : /
Patients
ht tps
An 85-year-old woman with chronic rotator cuff deficiency and com-
plete atrophy of the supra- and infraspinatus muscles (Fig 3.1-2).
Discussion
ht tps
A fracture reconstruction in a patient like the one in Fig 3.1-3 does
not seem to be indicated. Even if the pretrauma status of the com-
puted tomographic angiography was compensated, the risk of de-
A 78-year-old woman with posterior and superior cuff deficiency compensation after the reconstruction with the need of revision
(Fig 3.1-3). surgery is high; the authors recommend reverse shoulder arthro-
e r s e r s
plasty in these cases.
ook ok o
An 87-year-old man with no muscle atrophy or fatty degeneration
e b of the rotator cuff muscles (Fig 3.1-4).

e b o b o
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
a b c
e rs Fig 3.1-2 Clinical picture of an

r s
Fig 3.1-3a–c Parasagittal 2-D reconstruction of a 78-year-old woman with posterior and superior cuff
e
ok ok
85-year-old woman with chronic deficiency. Inhomogeneous presentation of the supraspinatus muscle and infraspinatus muscle because
b o rotator cuff deficiency and com-

o
of atrophy and fatty degeneration (a, c). The subscapularis (SSC) is still in good shape in the caudal
b b o o
e/ e plete atrophy of the supraspi-
natus muscle and infraspinatus
aspects (b).
e / e e /e
muscles. The diagnosis can be
easily made by visual inspection.
://t . m : / / t . m
t t p s tps
h ht
k e rs a b
ke rs c
eb oo b oo
Fig 3.1-4a–c In contrast, parasagittal 2-D reconstruction of an 87-year-old man shows no muscle
e b o o
/ / e/e
atrophy or fatty degeneration of the rotator cuff muscles. Note the muscle belly of the supras pinatus
e t . e
muscle (a, c). The head fragment is internally rotated due to the pull of the subscapularis tendon,
m t .m
/ /
and the corresponding muscle is without atrophy (b). The full cuff without significant atrophy or fatty
/ /
ps: ps:
infiltration is visible in the parasagittal plane at the coracoid and base of the spinal junction [19].
194
htt htt
rs rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Evaluation of mental status and comorbidities
. m e /
. m e/e
CASE 2
/ / t / / t
Patient
htt ps:
A 90-year-old slow-go, ie, unfit, female patient, was living in a nurs-
ing home and required a walker to assist with ambulation. htt ps:
pain and could reach her head with her hand. She did not walk any
more but was satisfied with her situation and refused further follow-
ups. Her situation was still the same 2 years later.
Comorbidities
• Dementia Discussion
e rs
• Coronary heart disease
r s
• From a geriatric standpoint, everything should be done to get
e
b o ok • Hypertension
• Multiple falls
bo ok
the patient out of bed: adapt pain medication, keep motivating
her and help her to walk again. Bed rest with loss of muscle
b o o
e/ e e/ e
• A pertrochanteric fracture 2 years ago, treated with a cephalo
medullary nail with an augemented head neck element or
mass, staring at the ceiling all the time and eating in bed has to
be avoided. Nutritional aspects should also be considered.
e/e
/ t .m
so-called proximal femoral nail antirotation plus augmentation
: / / t .m
• To answer the question if surgical treatment under a nerve block
: /
tps tps
• Osteoporosis would improve the patient’s prognosis, her prefracture status needs
ht ht
to be carefully evaluated (ie, “What was she really able to do?“) as
Treatment and outcome well as her mental status, ability to cooperate, and motivation. This
The female patient had a displaced 2-part proximal humeral fracture may take a few days. Finally her risk for surgery must be estimated.
(Fig 3.1-5a–b) and an undisplaced superior and inferior anterior • In this case, despite a low risk for surgery, nonoperative treatment
pelvic ring fracture (Fig 3.1-5c). Her therapy comprised shoulder was recommended, because the patient had poor cognitive func-
e r s
sling, pain medication, and pain-adapted mobilization. She was
r s
tion and did not require high functional demands. In her case
e
ook ok
hospitalized for 16 days, mobilized to sit in a wheelchair, and trans- bone healing took place quickly despite her severe osteoporosis.
b
ferred to a nursing home (Fig 3.1-5d).
b o Surgical stabilization would most probably not have caused any
b o o
e / e e/
The follow-up x-rays at 6 weeks showed a rapid ongoing healing e change in the rehabilitation process.
• From a surgical standpoint, if a nailing procedure would have
e/e
t . m
process in varus malalignment (Fig 3.1-5e–g). She had only little
/ / t . m
been chosen, a low risk for failure would have been expected.
/ /
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
a b
://t . m c d
: / / t . m
t t p s tps
h ht
Fig 3.1-5a–g A 90-year-old woman with a 2-part fracture of the
k e rs ke rs
proximal humerus.
a–b X-ray of a displaced 2-part proximal humeral fracture.
eb oo e b oo
c X-ray showing the undisplaced superior and inferior anterior
pelvic ring fracture.
b o o
e /
t . m e / d T herapy comprised shoulder sling, pain medication, pain-
adapted mobilization.
t .m e/e
/ / /
e–g Postoperative follow-up x-rays after 6 weeks showing a rapid
/
ps: ps:
e f g ongoing healing process in varus malalignment.
htt htt 195
rs
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/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e
To describe the functional status of the patient, a simple
/ The axial view (Diagnostics 4: Fig 3.1-9, Fig 3.1-10):
t . m e/e
s: / / / /
ps:
distinction between go-go, slow-go and no-go patients
http htt
(Table 3.1-1, see topic 3.1 in this chapter) is useful. The P
arker • Is paramount to assess anterior or posterior displacement
Mobility Score and the WHO performance status (Table 3.1-2, of the humeral head in relation to the glenoid
see topic 3.3 in this chapter) may also be helpful. • Determines anteversion and retroversion
• Displays displacement and fragmentation of the GT (Dia-
2.2 Imaging gnostics 5: Fig 3.1-11) and the overlap of the head by the
e rs
2.2.1 Plain x-rays
er s
minor tuberosity
• Shows posterior dislocation of the humeral head associ-
b o ok Surgeons can only make clear and unambiguous statements
bo
if the fracture is clearly visualized by x-ray(s). If criteria are ok
ated with PHF, which is often missed without an appro-
priate axillary lateral view. Alternatively, a dynamic
b o o
e / e defined to classify and treat PHFs, the proximal humerus
e/ e investigation under image intensifier may be performed
e/e
reliably evaluated.
: // t .m
must be displayed in a manner that those criteria can be
: / / t
The Velpeau view is an alternative to the axial view and can.m
ht tps
The trauma series consists of a true AP view, an axial view,
and an outlet view. The first two x-rays are most important
be obtained with the arm in a sling.
ht tps
The lateral view (= lateral scapula, = Y view, = outlet view)
to check the displacement of fragments and the instability (Diagnostics 6: Fig 3.1-12, Fig 3.1-13) is easy to shoot in the
of the fracture. Acute pain should be treated before images trauma situation but often very difficult to interpret because
are taken. of poor quality and superimposed structures. It is definite-
e r s e r s
ly the third most important view of the trauma series. If
ook ok o
Analyzing the projection of the proximal humerus in pub- only two views are done, they should be the true AP and
e b lished serial x-ray studies suggests that the position of the

e b o axial views.
b o
e / e/
patient’s arm often varies within one case. Recommendations
m
about the “standard position” also vary widely. According
t . The lateral view shows:
t . m e/e
/ /
to geometrical studies by Hengg et al [20], especially differ-
: / /
h t p s
ent degrees of internal rotation (IR) distort the measurement
t
of the head-shaft angle on the AP view substantially: 30°,
45°, and 60° of IR result in a projection of the head-shaft htt ps:
• Greater tuberosity posterior displacement due to the pull
of the infraspinatus (ISP) and supraspinatus (SSP) muscles.
• The relation of the head fragment to the glenoid.
angle of 144°, 150°, and 159°. Standardized and above all
comparable visualizations of the proximal humerus are
therefore crucial to make decisions and to collate results
e rs
(Diagnostics 2: Fig 3.1-6).
e r s
b o ok o
The true AP view (Diagnostics 3: Fig 3.1-7, Fig 3.1-8) shows:
b ok b o o
e/ e e / e
• Varus and valgus deformity and amount of displacement
e /e
://t . m
• Medial displacement of the shaft consistently produced
: / / t . m
t t p s
by the pectoralis major muscle
tps
ht
• Posterosuperior displacement of the greater tuberosity
(GT) h
Rotational displacement of the head fragment is due to the
pull of the subscapularis (SSC) in 3-part GT fractures. This
k e rs
pathology needs to be derotated in percutaneous procedures.
When placing the arm in a sling or holding it in a relieving
ke rs
eb oo posture, this type of view cannot be achieved.
e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Comparable projections are of utmost importance
t . m e /
t . m e/e
DIAGNOSTICS 2
/ / / /
htt ps: htt ps:
Fig 3.1-6a–d X-ray series after a displaced 3-part fracture in
a 58-year-old woman (a). In a true AP view taken postop-
eratively the head-shaft angle (HSA) amounts to 135°, which
is equivalent to an anatomical reduction (b). The 8-week
e rs er s
follow-up displays varus malalignment of 120.9° which is due
ok ok
to only another arm rotation and also an x-ray beam projec-
b o bo
tion. This can be easily detected by comparing the projection
of the standard locking plate in both views (c). The 1-year
b o o
e/ e e/ e follow-up shows again the initial situation with a HSA of 133°
and no relevant loss of reduction (d). This example clearly
e/e
a b
: // t .m
c d ized projections.
: / t .m
demonstrates the great importance of comparable standard-
/
ht tps ht tps
True AP view
DIAGNOSTICS 3
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
ps: ps:
Fig 3.1-7a–b The patient’s affected shoulder should be placed
htt htt
against the x-ray plate with his trunk tilted approximately 40° toward
the beam. The scapula of the affected shoulder should be parallel to
the cassette (a). The patient’s arm is in neutral rotation, ie, with the
thumb bent forward; this position is reproducible and complies with
the geometrical reflections of a true AP view (b). The central beam is
a b orientated 20–25° caudally.
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
Fig 3.1-8a–b Orthograde and tangential projection of the glenoid,
ht
and free projection of the humeral head with the greater tuberosity
h (GT) marginalized and the subacromial space visible. Examples of an

uninjured shoulder of a 32-year-old man without pathology (a) and a
3-part GT valgus-impacted proximal humeral fracture in a 42-year-old
a b woman (b), both in correct AP view.
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
197
rs
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/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Axial view
t . m e /
t . m e/e
DIAGNOSTICS 4
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
://t.m .m
a b c
Fig 3.1-9 Axial view in 30–40°
s : / / t
p tps
of abduction and the forearm
t t
parallel to the table. This can be
h
achieved in most acute cases
after administering some pain
ht
medication.
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
htt ps:
d e f
htt gps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
h i
://t . m j
: / / t . m
t t p s tps
h ht
Fig 3.1-10a–k A 72-year-old woman with a 2-part fracture.
a–c True AP, outlet, and axial views of a displaced 2-part fracture in a go-go, ie, fit, 72-year-
rs rs
old female patient. Displacement and instability is best demonstrated in the axial view.
k e e
d–e Fracture fixation with an intramedullary nail.
k
oo oo o
f–g Result after 6 months. Note that the projection is different from the postoperative
eb
views.
e b b o
e/e
k
e / m e /
h–k Functional rehabilitation 8 days after surgery.
m
/ /t . // t .
htt ps: htt ps:
rs rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
DIAGNOSTICS 5
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
a
ht tps
b c
ht tps
Fig 3.1-11a–c The AP and outlet views (a–b) provide sufficient information about the greater tuberosity (GT), shaft and head fragment. The
axial view (c) displays all missing information to classify the HL-G-S fracture. Note the comminution and dorsal displacement of the GT.
e r s e r s
b ook Lateral view
b o ok b o o
DIAGNOSTICS 6
e / e e/ e e/e
/ / t . m / /t . m
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
ht
a b
h
Fig 3.1-12 For the lateral view, the ante-
rior shoulder is placed on the x-ray plate
Fig 3.1-13a–b The AP view (a) of an 80-year-old patient shows a fracture
involving the greater tuberosity, the shaft, and the head fragment. The later-
with the unaffected shoulder tilted forward al view (b) does not add much information. Especially the lesser tuberosity
40°. The beam is placed posteriorly and (LT) cannot be visualized well, be it in the AP view or in the lateral view. The
directed along the scapular spine. axial view generates this critical information, and if unavailable, a computed
k e rs ke rs
tomographic scan is necessary to show the involvement of the LT.
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
199
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 2.2.2 Computed tomographic scan
t . m e / CT scans:
t . m e/e
s: / / / /
ps:
In most hospitals, a CT scan is part of the standard workup
http htt
of PHFs. Certainly, if surgical treatment is an option, a CT • Help to precisely determine fracture lines and pieces, ie,
scan with 3-D reconstructions adds important information fracture characteristics needed for surgical planning.
in fracture dislocations, humeral head-split fractures, and • Provide enhanced understanding of fracture comminu-
comminuted fractures. Three-dimensional CT scan recon- tion, impaction, humeral head involvement and its size
structions have been shown to provide the highest interob- and remaining thickness, and additional glenoid articular
e rs server agreement with regard to classification and treatment

recommendations among upper-extremity specialists [21].
er s
surface injury (Case 3: Fig 3.1-14).
• Allow for manual 2-D reconstructions along the axes of
b o ok bo ok
the humerus to show the exact angulation and displace-
ment of fragments as well as the length of the metaphy-
b o o
e/ e e/ e seal fracture extension.
e/e
: // t .m : / / t
cles. In case of a rotator cuff arthropathy with limited .m
• Facilitate soft-tissue imaging specifically rotator cuff mus-
ht tps ht tps
preoperative function and an indication for surgery, an
inverse prosthesis instead of fracture fixation is indicated.
Importance of a detailed computed tomographic analysis

s s
CASE 3
e r e r
ook ok o
Patient Discussion
e b An 80-year-old woman sustained a low-energy proximal humeral

e b o In cases such as shown in Fig 3.1-14, a sustainable medial bone
b o
e /
t . m e/
fracture and a distal radial fracture of the left upper extremity. contact can only be achieved by reducing the head fragment into
t . m
a slight valgus position. Because the length of the proximal hu- e/e
Comorbidities
/ / / /
merus is then reduced, the plate must be placed in a nonana-
Treatment and outcome htt ps:

• No relevant comorbidities besides osteoporosis—already treated
htt ps:
tomical position, ie, with a gap between lateral cortex and the plate.
An impaction with valgus position and with additional cement aug-

The AP and lateral views showed a 2-part fracture of the surgical mentation of the screws might have helped, but if in doubt a struc-
neck (HGL-S) and the medial calcar seemed comminuted (Fig 3.1- tural allograft could definitely provide the mechanical stability for a
14a–b). Both fractures were initially treated nonoperatively. After 10 functional rehabilitation as desired in orthogeriatrics.
e rs days, progressive tilting of the head fragment with pronounced

e r s
b o ok displacement was visible in the lateral view (Fig 3.1-14c–d). In ad-
b o
dition, the patient was unable to participate in rehabilitation because ok
In a surgical neck 2-part fracture we would not consider arthroplasty.
b o o
e/ e / e
of pain. The surgeon and patient decided on plating. The 2-D
e
computed tomographic scans showed the narrow head fragment
e /e
://t . m
(Fig 3.1-14e–f). Only very few thread pitches of the locked screws
: / / t . m
could be anchored.
t t p s tps
h
Intraoperative x-rays demonstrated a residual varus position of the
head fragment and a lack of medial support due to “wrong impac-
ht
tion” (Fig 3.1-14g–h).
k e rs Insufficient medial support and residual varus together with the

small osteoporotic head fragment led to a mechanical varus failure.
ke rs
eb oo After 4 weeks (Fig 3.1-14i) and 6 months (Fig 3.1-14j–k) the fracture
e b oo b o o
e/e
was malunited with a severe varus deformity; since the screws did
e / not perforate, the patient was not revised.

m e / m
/ /t . // t .
htt ps: htt ps:
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e a b c
e/ e d
e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e / e f
t . m e/ g h
t . m e/e
: / / / /
h t t p s
htt ps:
Fig 3.1-14a–k An 80-year-old woman with a surgical neck
fracture.
a–b AP and lateral views showing a 2-part fracture of the
surgical neck with comminuted medial calcar.
e rs e r s
c–d Lateral view showing progressive tilting of the head
fragment with pronounced displacement.
b o ok b o ok e–f The 2-D computed tomographic scans showing the

narrow head fragment.
b o o
e/ e e / e g–h Intraoperative x-rays showing a residual varus position
of the head fragment.
e /e
://t . m / / t . m
i–k Postoperative x-rays after 4 weeks (i) and 6 months
( j–k) showing malunited fracture with severe varus
:
i
t t
j
p s k deformity.
tps
h ht
2.2.3 Magnetic resonance imaging dard locking plate. The mechanical peak torque correlates
Magnetic resonance imaging (MRI) adds little to the initial with the local bone mineral density (BMD) and screw
k e rs
evaluation of PHFs [22].
ke rs
failure load in anatomical specimens [23].
• With modern picture archiving and communication sys-
eb oo 2.2.4 Local bone quality
e b oo
tems, the local bone density (LBD) can be measured in
b o o
e/e
standardized regions of interest given in Hounsfield units
e / e /
• Promising attempts have been made to experimentally
m
[24] and converted into BMD values. The aforementioned
m
/ /t .
measure the local bone quality (LBQ) with a torque mea- measurement gives an estimate of the LBQ.
// t .
ps: ps:
surement tool (DensiProbe) which was adapted to a stan-
htt htt 201
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
The significance of local osteoporosis for the outcome of the 2.4 Instability and displacement
t . m e/e
s: / / / /
ps:
treatment is unclear. In a multicenter trial, patients with Instability and displacement are often used as criteria for
http htt
mechanical complications after plate fixation of unstable determining the treatment strategy. Imaging usually only
PHFs had the same low BMD as patients with uneventful shows a momentary situation of unstable fractures. Wheth-
healing [1]. er or not fracture fragments are displaced may depend on
the position of the arm while x-rays or CT scans were taken.
Experiments with anatomical specimens have shown that
k e rs periimplant polymethylmethacrylate (PMMA) cement aug-

mentation cannot be injected through a cannulated screw
er s
If in doubt, perform repeat x-rays examinations to help rule
out misinterpretation or secondary displacement.
o o into cancellous bone with normal density [25, 26]. If implant

o ok o o
e/eb b b
augmentation is intended, the LBQ needs to be determined. Signs for stability are [21, 30]:
e/ e e/e
: // t .m
There is a linear biomechanical correlation between LBQ
and cycles to failure [27, 28]. Common sense dictates that
•
•
Minimal comminution
Three or fewer fragments
: / / t .m
s tps
http
osteoporosis is clinically associated with increased rates of • Absence of significant tuberosity displacement
comminution and defects due to impaction, loss of fixation
and reduction after surgical management.
•
•
•
Cortical contact
ht
Relative impaction of the shaft into the head
No history of dislocation
Recent clinical trial results suggest that LBQ constitutes at
most one contributing factor to fixation failures after plating If the fracture is stable, gentle and careful movements of
e r s
[1, 28].
k e r s
the affected arm can be performed with no or very little
b o o For the typical patient with PHF, LBQ must be expected [1].
b o ok
pain during a physical examination. This should only be
done after imaging, though.
b o o
e /e 2.3 Soft-tissue injuries
t . m e/ e Signs of instability are:
t . m e/e
/ /
With fractures of the GT or LT, the rotator cuff is essen-
: / /
h t p s
tially nonfunctional, as expected [13]. Conversely, we may
t
presume that a 4-part PHF only occurs with an intact rota-
tor cuff. Without a functioning rotator cuff, displaced avul- htt ps:
• Significant displacement with segments angulated more
than 45° or displaced more than 0.5–1 cm from their
normal anatomical position, best detected on the axial
sion fractures are rare due to the lack of pulling forces. With view [31].
a preexisting cuff arthropathy, 2-part fractures are more • A difference in fragment angulation between plain x-rays
likely. and CT scans with 2-D reconstruction along the axes of
e rs e r
the humerus.
s
b o ok A complete rotator cuff examination cannot usually be per-
b o
formed in an acute setting due to pain and swelling, but the ok
• Extraordinary pain which does not subside with adequate
pain medication within a few days.
b o o
e/ e / e
rotator cuff function should be monitored throughout the
e
typical clinical course to ensure adequate function [22]. Due 2.5 Classification
e /e
://t . m
to the age of most patients who sustain PHFs previous rota- Codman’s 4-part model laid the foundations of modern un-
: / / t . m
t t p s
tor cuff injuries are likely, and a new rotator cuff tear can
tps
derstanding of PHFs. All of the following classifications were
ht
certainly occur in conjunction with PHFs [29]. As an indirect based on the four parts, ie, the shaft, GT, LT, and the head
h
measurement, the status of the rotator cuff muscle can be
determined with the CT scan (Diagnostics 1: Fig 3.1-2, Fig 3.1-3,
fragment. The most common classifications used over the
last decades were the Neer and the AO/OTA classifications.
Fig 3.1-4). Both systems are characterized by a poor interobserver re-
liability [32, 33] which improves with advanced imaging like
k e rs ke rs
3-D CT scans [34], education and experience [35].
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 2.5.1 Neer’s classification
t . m e /
t . m
therefore indicates the classic 4-part fracture. The letter e/e
s: / / / /
ps:
Neer focused on the patterns of displacement rather than “d”(dislocation) as a prefix to “H” and “c” followed by the
http htt
the location of fracture lines. In his retrospective study he length of the intact calcar fragment in millimeters as postfix
attempted to identify fractures that would benefit from open in brackets can be added as well as “a” for the head-neck
reduction. Similar to Hertel, he also wanted to predict the angulation. The simplicity and intuitive nature of this no-
risk of avascular necrosis (AVN) which again would have menclature may be the reason for a higher reliability com-
an impact on decision making (see topic 2.5.2 in this chap- pared to the original Hertel, AO/OTA, and Neer systems.
e s
ter). Neer’s system remains the most commonly used today,
r
because it is easy to apply and yet has a prognostic value.
er s
Prediction of head necrosis does not play an important role
b o ok Four-part fractures generally have worse outcomes than

2- and 3-part fractures regardless of the treatment.
bo ok
in decision making in geriatric patients. Fracture pattern
interpretation mainly serves to differentiate stable from un-
b o o
e/ e e/ e stable fractures and to forecast the likelihood of achieving
e/e
: // t .m
Neer randomly defined the borderline between displaced
and nondisplaced at a displacement of 1 cm and an angula-
a stable fixation.
: / / t .m
tps
tion of 45°. A fracture that is below this threshold is called
ht
1-part fracture irrespective of the number of fragments.
2.6 Summary
Clinical evaluation:
ht tps
These criteria have evolved to make a displacement of 5 mm • In addition to fracture pattern analysis, the patient’s func-
or more an acceptable indication for fixation provided the tional and cognitive status must be considered to deter-
direction of displacement creates a functional limitation. A mine the best approach.
e r s
good example is the superior displacement of the GT, which
e r s
• Nonfracture-related geriatric parameters play an impor-
ook ok o
has the potential of restricting abduction. tant role in choosing the adequate therapeutic approach
e b e b o for each individual patient.

b o
e / 2.5.2 Hertel’s classification
m e/
Hertel [36] fundamentally changed the approach by using a
t . Imaging:
t . m e/e
/ /
binary system based on Lego bricks. He proposed fracture
: / /
h t p s
planes instead of fracture fragments. To classify a fracture,
t
possible fracture planes between head and GT, GT and shaft,
head and LT, LT and shaft, and finally between GT and LT htt
bility and fragment displacement. ps:
• The main purpose of imaging PHF is to determine insta-
• Standardized views are paramount to determine angula-

need to be identified. tion, displacement, and detection of any changes post-
operatively.
This results in six options for 2-part fractures, five for 3-part • The axial view displays instability and displacement be-
e rs
fractures and obviously just one 4-part fracture. In contrast
r s
tween shaft and head and should be part of the standard
e
b o ok to Neer, Hertel rated any cortical discontinuity as a fracture
o
irrespective of the amount of displacement or angulation.
b ok
trauma x-ray series.
• CT scans should be used for precise fracture analysis and
b o o
e/ e / e
Particular attention has to be paid to seven other parameters,
e
such as the length of the posteromedial metaphyseal head
measurement of local bone density. Two- and three-
e
dimensional reconstructions are essential for precise clas-/e
://t . m
extension, the integrity of the medial hinge with displace- sification and surgical planning.
: / / t . m
t t p s
ment of the shaft in respect to the head, the displacement
tps
ht
of the tuberosities, the amount of angular displacement of Classification:
h
the head, the occurrence of glenohumeral dislocation, a
head impression fracture, a head-split component and the • Codman’s 4-part model and Neer’s classification (1970)
mechanical quality of the bone. are still the basis for understanding PHFs [31].
• Hertel’s system and the HGLS classification are recom-
k e rs
2.5.3 Hertel’s modified classification
Sukthankar et al [37] modified Hertel’s system by replacing
ke rs
mended for more detailed description of the fracture
situation.
eb oo numbers with a comprehensive nomenclature. H(ead),
e b oo
• Other factors like the degree of shaft displacement and
b o o
e/e
G(reater) and L(esser tuberosity) and S(haft) identify pos- angulation/rotation of the head fragment should also be
e / e /
sible fracture parts, a fracture plane is represented by a hy-
m
described.
m
t .
phen (-) and represents a cortical disruption between the
/ / // t .
ps: ps:
parts, regardless of displacement and angulation. H-G-L-S
htt htt 203
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 3 Decision making
t . m e / General remarks and thoughts:
t . m e/e
s: / / / /
http
Since little high-level evidence exists, there is still much
uncertainty about which patients will benefit from non
htt ps:
• The severity of comminution in displaced fractures may
have a more significant effect on functional outcomes
operative treatment, plate fixation, nailing, or arthroplasty than the choice of treatment; there is also a clear differ-
[38, 39]. Overall, conflicting results between studies favoring ence in prognosis between 3- and 4-part fractures, but
operative intervention and others failing to show much not between 2- and 3-part fractures [5]. In many studies
e s
benefit for more displaced and unstable fractures have been
r
described. This demands careful consideration of the patient-
er s
4-part fractures yielded worse outcomes compared to
2- or 3-part fractures regardless of the treatment chosen
b o ok specific benefits and risks of operative and nonoperative

therapy [22].
bo ok
[41].
• The functional outcome is difficult to assess, as many
b o o
e/ e e/ e variables contribute to a successful patient outcome. For-
e/e
: // t .m
Older patients tend to have worse functional outcomes [30].
This trend has been attributed to factors such as fragility,
tunately, functional expectations for older individuals
: / / t
are lower than for younger patients—a less than satisfac-.m
ht tps
cognitive deficits, rotator cuff injuries, osteoporosis, and
poor rehabilitation potential [40].
ht tps
tory result for a young patient can therefore be com-
pletely acceptable for an older person. Even with de-
creased outcome scores, older patients’ perception of
The indication for surgery in PHFs is usually a relative one. outcome and quality of life can be acceptable [30].
Therefore comorbidities play an important role in deciding • As evidence supporting routine operative treatment is
whether or not to perform surgery. In cases where deterio- limited and complication rates are high, decision making
e r s
ration of comorbid medical conditions like renal insuffi-
e r s
should include individual factors such as living situations,
ook ok o
ciency is likely to happen, it is usually better to refrain from comorbidities, and the patient’s attitude towards surgery.
e b surgery even if the fracture type would justify it.

e b o With surgeons’ increasing knowledge about appropriate
b o
e /
t . m e/ patient selection and limits of specific procedures, results
become more predictable. That means, however, that
t . m e/e
/ / / /
more than one operative method is necessary to address
htt ps: different situations.
htt ps:
• If we think about operative fixation, it seems expedient
to ask what kind of difference the patient will experience
after surgery. There must be some tangible benefit in
terms of an increased functional result. This also holds
true if an older patient’s functional status benefits from
e rs e r s
immediate use of the injured extremity by using a cane,
b o ok b o ok
for instance (Case 4: Fig 3.1-15).
• It is helpful to discuss all relevant aspects among the
b o o
e/ e e / e interdisciplinary team members in addition to the patient
and relatives. If the patient seems motivated to make use
e /e
://t . m / t
of an expedited rehabilitation process after surgery and
: / . m
t t p s tps
has no contraindications, the patient may receive the
ht
same treatment as a younger adult (Case 5: Fig 3.1-16).
h • With enhanced techniques like the use of fibular strut
grafting or allograft bone blocks, better and more reliable
results can be achieved both in younger and in geriatric
patients (Case 6: Fig 3.1-17) [16, 42].
k e rs ke rs
• As in other areas, outcomes may also be correlated with
the level of surgeon experience, the time of surgery and
eb oo e b oothe soft-tissue handling. These potentially important fac-

b o o
e/e
tors are hardly ever reported or investigated in studies
e / m e / and neither is the precise amount of displacement with

m
/ /t . a standardized CT scan measurement.
// t .
htt ps: htt ps:
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / m e
Potential benefit of operative fixation in geriatric patients
.
/
. m e/e
CASE 4
/ / t / / t
Patient
htt ps:
A 90-year-old woman sustained a left pertrochanteric fracture after
a fall from standing height and was treated with a proximal femoral htt ps:
Six weeks postoperatively a comparison with previous x-rays was
not possible, as they were blurred by different projections. Active
nail antirotation (PFNA) plus augmentation. She was living alone flexion and abduction was 140°, active rotation in 90°, and abduc-
and mostly self-reliant with some help from her daughter who lived tion 80°. She used a cane to support the right side; she was pain
close by. No signs of dementia and she was cooperative and go-go, free (i–l) and back home.
e rs
ie, fit. Osteoporosis treatment was initiated and the patient has been
er s
b o ok using a walking cane ever since.
bo ok
Other treatment options
• Nonoperative treatment: The patient would be unable to use
b o o
e/ e Comorbidities
• Hypertension
e/ e crutches at least for some time because of pain and she would
depend on care. It is likely that the fracture would displace
e/e
• Chronic renal deficiency
: // t .m / t .m
more and could lead to a more restricted functional outcome.
: /
tps tps
• Heart failure • Proximal nailing would be a good alternative, as the reduction
ht ht
• Osteoporosis (T-score: spine = -3.6, hip = -3.6). in valgus and shortening would be beneficial.
• Hemiarthroplasty and reverse arthroplasty are not an option for
Treatment and outcome this type of fracture (overtreatment).
Five months later the patient presented with a 2-part surgical neck
fracture (HGL-S) after a low-energy trauma at home with medial
e r s
comminution and varus displacement (Fig 3.1-15a–e). After careful
e r s
ook ok
and extensive consultation with the team, the patient and her daugh-
b
ter decided on operative treatment. Stable fixation was achieved
b o b o o
e / e with PHILOS augmentation (Fig 3.1-15f–g). Nonanatomical plate
e/
position was chosen to maintain the medial support, which was e e/e
t . m
achieved by slight shortening and impaction of the shaft into the
/ / / /t . m
ps: ps:
head, as well as a slight valgus position of the head fragment. Peri
htt htt
implant augmentation with 0.5 cc of polymethylmethacrylate cement
per cannulated screw was used. With this measure, additional fixa-
tion was added. Five days after surgery, pain restricted the patient’s
mobilization and usage of the affected arm (Fig 3.1-15h); this made
it impossible for her to return home as early as possible and to
e s
limit care dependency to a minimum. After 12 days the patient was
r
transferred to the internal medicine and rehabilitation department.
e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e/e
a b c d e
e / m e
Fig 3.1-15a–l A 90-year-old woman after a low-energy trauma./ m
/t . / t .
a–e X-rays showing a 2-part surgical neck fracture with medial comminution and varus displacement. Note the poor bone quality and the
/ /
ps: ps:
shallow head fragment in the computed tomographic scan reconstructions (a–d).
htt htt 205
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
f g
: // t .m h
: / / t .m
s tps
http ht
ke r s k e r s Fig 3.1-15a–l (cont) A 90-year-old woman

after a low-energy trauma.
b o o b o o f–g Stable fixation was achieved with
b o o
e /e e/e e/e
PHILOS augmentation. The medial
support is maintained by nonanatomi-
/ / t . m cal plate position.
/ /t . m
h X-ray at 5 days postoperative.
ps: ps:
i–l Six-week postoperative x-rays and
htt htt
i j k l clincal image of pain-free patient.
Operative fixation for rapid rehabilitation

CASE 5
e rs e r s
b o ok Patient
b o
A 71-year-old woman was living an active social life. She was mo- ok
Treatment and outcome
The patient opted for surgery. Due to the osteoporotic bone, an
b o o
e/ e / e
tivated, cooperative and go-go, ie, fit. The patient sustained a valgus-
e
impacted 4-part fracture (H(c0)-G-L-S) (Fig 3.1-16a–c). The me-
anatomomical reduction and stable osteosynthesis with PHILOS
augmentation was accomplished (Fig 3.1-16g–i). Immediate active
e /e
://t . m
dial head extension was 0 mm, which indicated a high risk of
/ t .
rehabilitation without sling and without relevant postoperative pain
: / m
t t p s
avascular necrosis (Fig 3.1-16d–f).
tps
led to an excellent active range of motion (ROM) after 3 weeks
ht
(Fig 3.1-16j).
Comorbidities
• Arterial hypertension
h One year later the fracture healed uneventfully without secondary
• Varicosis displacement (Fig 3.1-16k–l). The patient achieved full ROM without
• Polyarthritis pain (Fig 3.1-16m–o).
k e rs • Osteoporosis
ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Other treatment options
t . m e /
t . m e/e
/ / / /
ps: ps:
• According to the current authors’ treatment algorithm, displaced • Osteotomies after malunions of the GT usually fail to heal in
htt htt
4-part fractures in go-go, ie, fit, patients should be treated op- proper position. With a varus malunion, an anatomical pros-
eratively. thetic solution is also no longer possible.
• Nonoperative treatment may lead to consecutive cranial and/or • According to the current authors’ opinion antegrade nailing is
posterior greater tuberosity (GT) displacement with functional not the first choice in 4-part fractures.
impairment in abduction and rotation. • Arthroplasty was not an option because a stable and anatomical
e rs er s
reconstruction was to be expected.
b o ok bo ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e / a b
t . m c
e/ t . m e/e
: / / / /
h t t p s
htt ps:
e rs e r s
b o ok b o ok b o o
e/ e d e
e / e f
e /e
://t . m : / / t . m
t t p s tps
h ht
Fig 3.1-16a–o A 71-year-old woman with a 4-part
k e rs ke rs fracture.
a–c X-rays showing valgus-impacted 4-part fracture.
eb oo e b oo d–f The medial head extension of 0 mm indicates a

high risk of avascular necrosis.
b o o
e /
t . m e / g–i D
ue to the osteoporotic bone, an anatomomi-
t .m
cal reduction and stable osteosynthesis with
e/e
/ / /
PHILOS augmentation was accomplished. Note
/
ps: ps:
g h i the rasp ( g) to elevate the head fragment.
htt htt 207
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
://t.m .m
j k l
s : / / t
h t t p ht tps
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
ps: ps:
m n o
htt htt
Fig 3.1-16a–o (cont) A 71-year-old woman with a 4-part fracture.
j Clinical photograph showing excellent active range of motion (ROM) after 3 weeks due to immediate active rehabili-
tation without sling and without relevant postoperative pain.
k–l One year later the fracture healed uneventfully without secondary displacement.
m–o The patient achieved full ROM without pain.
e rs e r s
b o ok b o ok
Massive central allograft to ease reduction and prevent secondary displacement of fracture fragments
b o o
e e e
CASE 6
e/ me / m e /
Patient
://t .
A 65-year-old female patient sustained a low-energy trauma result-
: / / t .
with a wide proximal shaft and rarefied cancellous bone, as the
t t p s
ing in a 4-part fracture (H-G-L-S). The patient suffered from chron-
tps
computed tomographic scan of the opposite proximal humerus
pliance was uncertain. h

ic alcoholism. Although she was not cognitively impaired, her com-
ht
showed (Fig 3.1-17a–c). The head fragment was damaged by the
shaft and the patient complained about pain (Fig 3.1-17d). This led
the authors to decide on reconstruction with allograft. The allograft
Comorbidities resembling a champagne cork (Fig 3.1-17e) locked itself in the shaft
• Osteoporosis with a wide proximal shaft and rarefied cancellous and the head fragment and the tuberosities sat on the graft
k e rs bone
e rs
(Fig 3.1-17f–g). The ultrashort greater tuberosity was fixed trans
k
oo oo o
osseously to the graft without additional hardware (Fig 3.1-17h). The
eb Treatment and outcome
e b intraoperative C-arm follow-ups (Fig 3.1-17i–j) demonstrated the

b o
e /
t . m /
The head was in varus, the greater tuberosity severely comminuted
e
and ultrashort, ie, without lateral extension that could be fixed di-
huge allograft supporting the reconstruction (Fig 3.1-17i). Follow-up
x-rays were taken after 1 week (Fig 3.1-17k–m).
t .m e/e
/ /
rectly with the plate. The patient also suffered from osteoporosis
//
htt ps: htt ps:
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e a b
e/ e c
e/e
: // t .m : / / t .m
ht tps f
ht tps
e r s e r s
e b ook d e
e b o ok g h
b o o
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
e rs e r s
b o ok i j
b o k ok l m
b o o
e/ e e / e
Fig 3.1-17a–m A 65-year-old woman with a 4-part fracture after a low-energy trauma.
e /e
://t . m : / t .
a–c X-rays (a–b) showing the head in varus, the greater tuberosity severely comminuted and ultrashort, ie, without lateral extension that
/
could be fixed directly with the plate. Osteoporosis with a wide proximal shaft and rarefied cancellous bone is visible on the computedm
t t p s
tomographic scan of the opposite proximal humerus (c).
tps
ht
d–h X-ray showing the head fragment damaged by the shaft (d). Reconstruction performed with allograft that resembles a champagne cork
h
(e) and locked itself in the shaft and the head fragment and the tuberosities sitting on the graft (f–g). The ultrashort greater tuberosity
was fixed transosseously to the graft without additional hardware (h).
i–j Intraoperative C-arm follow-ups showing the huge allograft supporting the reconstruction (i).
k–m Follow-up x-rays at 1 week.
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
209
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 3.1 Operative or nonoperative?
t . m e / 3.1.1 Outcome
t . m e/e
s: / / / /
ps:
More or less undisputed indications for surgery even in At 1-year follow-up of a randomized controlled trial (RCT),
http htt
older patients are: Fjalestad et al [44] found no evident difference in function-
al outcome between operative treatment and nonoperative
• Head-split fracture treatment of displaced PHFs in older patients. Only radio-
• Fracture dislocation graphic scores turned out to be better after operative inter-
• Segmental fracture ventions.
e s
•
r
•
Open fracture
Complicated fracture with additional vascular injury
er s
Only one RCT exists comparing 3-part PHFs treated nonop-
b o ok Most authors also agree that according to the Neer criteria,

bo ok
eratively versus with a locking plate. Olerud et al [2] inves-
tigated 60 patients aged 74 years on average. The results of
b o o
e/ e e/
undisplaced fractures should usually be treated nonopera- e the study indicate that the locking plate had a positive im-
e/e
: // t .m
tively, irrespective of the number of fragments. Moreover,
a lack of consistently successful surgical techniques and
pact on the functional outcome and health-related quality
: / / t .m
of life (HRQoL), but at the cost of additional surgery in 30%
ht tps
common complications has resulted in a preference for non-
operative treatment over surgery [6, 43].
of the patients.
ht tps
In another RCT, fracture arthroplasty and nonoperative
Clinical experience has shown that patients regularly ben- treatment were compared. 55 patients, aged 77 years, ie,
efit from operative fixation even if it is only for the first few 58–92 years, on average, with displaced 4-part fractures
weeks after the trauma. The effect of a pain-free extremity were randomly allocated to the two treatment options and
e r s
on patients, especially on older ones, may be strikingly
e r s
monitored for 2 years. The Constant score, ROM, DASH
ook ok o
positive. As mentioned in the introduction of this chapter, score and pain (visual or verbal analogue scale) did not dif-
e b b
it may be difficult to measure this kind of success with tra-
e o fer significantly among the patients. The quality of life as-
b o
e / ditional scoring systems.
t . m e/ sessment (EQ-5D) showed significantly better results in

favor of surgery [45].
t . m e/e
/ /
Careful decision making and safe procedures, ie, with a lim-
/ /
ps:
ited risk and performed to the best of the surgeon's knowl-
htt
edge, are required, as everything must be done to avoid
complications. The worst outcomes usually result from poor htt ps:
Metaanalyses of 3- and 4-part fractures revealed that patients
treated nonoperatively had more pain and a worse ROM
than those treated with either fixation or arthroplasty [46].
open surgery and soft-tissue handling during surgery lead-
ing to unstable fracture fixation. Van den Broek et al [47] compared antegrade nailing (n = 27)
with nonoperative treatment (n = 16). The Constant score
e rs
It is often observed that the functional status deteriorates
r s
was 67.1 in the nailing group and 81.4 in the nonsurgical
e
b o ok after sustaining a PHF. Patients immediately become depen-
b o
dent on help and in many instances require full-time nurs- ok
group.
b o o
e/ e / e
ing care, at least temporarily. If this could be prevented by
e
operative fixation, which has been demonstrated only by
Krettek et al [6] compared two PHF studies dealing with
patients after nonoperative and operative treatments re-
e /e
://t . m
anecdotal evidence, operative fixation would be a good op-
/
spectively, supported by the AO Clinical Investigation and
: / t . m
t t p s
tion for some patients. The patient’s living condition also
tps
Documentation (AOCID) team. They found more complica-
ht
has an impact on making a therapeutic decision. tions (34% versus 28.8%), more revision surgeries (19%
h
In Table 3.1-1 different aspects and parameters are discussed.
versus 7.2%) and a 10% lower Constant score in the surgi-
cal group.
The extent to which PHFs impact functionality of geriatric
k e rs ke rs
patients has not yet been thoroughly investigated. Einsiedel
et al [4] described a significant deterioration of walking abil-
eb oo e b oo
ity, leading to two or more new falls in 24% of patients with
b o o
e/e
distal radial fractures (DRFs) and 28% of PHF patients in a
e / m e / prospective study of 104 patients.

m
/ /t . // t .
htt ps: htt ps:
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m
Nonoperative treatment e / Grey zone Operative treatment
t . m e/e
s: / / / /
ps:
Findings in favor of pain • Patient cannot be managed with
http htt
ambulatory care because of fracture-
related pain
• Crepitation as a sign for instability
Displacement of the GT • Nondisplaced • Short GT fragment with lateral • Posterosuperior displacement of GT of

• No displacement during follow-up comminution and impaction: difficult to > 0.5 cm: GT overlaps the posterior
address operatively articular surface with loss of external
e rs er s
• “Functional 2-part fracture” (with multiple
fracture lines of the GT fragment, yet
rotation and early glenoidal impingement
• Cranialization of GT into the subacromial
ok ok
undisplaced), good medial support of the space
b o bo head fragment • Large GT fragment with high success rate

after fixation
b o o
e/ e Displacement shaft • Nondisplaced and stable
e/ e • > 50% displacement
e/e
.m .m
• Impacted • Unstable medial hinge
Angulation head vs shaft

: // t
• < 45° varus/valgus • Stable operative fixation is questionable
: / / t
• > 45° varus/valgus
tps tps
• < 45° anteversion/retroversion because of medial comminution, allograft • > 45° anteversion/retroversion
ht ht
is an alternative
Calcar • Stable surgical fixation is questionable • Calcar can be perfectly reduced

because of medial comminution
• Impaction must result in medial stability,
otherwise bone grafting
Use of walking aids • Has to use walking aids • If the patient cannot be mobilized within
e r s e r s
the first week, augmented fixation may be
ook ok
considered
b
Surgical skills and feasability • Doubts that the surgeon will be able to
b o • The surgeon is able to do it right because
b o o
e / e accomplish it
e
• The worst case is a failed surgery
/ e of the size of the fragments, a long
cortical extension of the GT fragment
e/e
://t . m /t m
and other fracture characteristics like the
.
feasibility of creating intraoperatively
/
ps:
intrinsic stability
t p s
t htt
Concomitant injuries or disabilities • With cuff arthropathy, nonoperative • Compensated cuff arthropathy with good • Multilevel injuries
h treatment may be preferred

• In case of problems, a reversed
arthoplasty is indicated
function may be a good nailing indication
Low bone quality • May have an impact on the choice of operative treatment but not on the question of whether operative treatment is indicated
Age, comorbidities, functional status • No-go or frail patients. They are mostly • Slow-go, intermediate or vulnerable • Go-go or fit patients are functionally
e rs ≥ 85 years, suffer from three or more

r s
patients may be dependent in one or
e
independent in terms of ADLs and IADLs
ok ok
comorbidities and geriatric syndromes, more IADLs but not ADLs, and suffer from and without serious comorbidities or
b o
and are constantly limited in their daily
activities
b o
one to two comorbidities but no geriatric
syndromes
geriatric syndromes
b o o
e/ e Compliance, mental status, abuse • Dementia
e / e
• In patients with polytoxicomania there is
• Demanding and cooperative • Normal or slightly impaired
• Highly motivated
e /e
://t . m
only risk and barely any benefit
: / / t . m
Risk of surgery
t t p s • High • Moderate • Low
tps
ht
Rehabilitation potential • Mostly sitting only, needs constant care • High
Functional expectations
Financial aspects
h • Low
No significant difference between operative and nonoperative treatment [44]

• High
k e rs
either direction is possible are in the “grey zone”.
ke rs
Table 3.1-1 Nonoperative versus operative treatment. Factors that may influence decision making in proximal humeral fractures. Items where
oo oo o
Abbreviations: ADLs, activities of daily living; GT, greater tuberosity; IADLs, instrumental activities of daily living.
eb e b b o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
211
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 3.2 Fixation or arthroplasty?
t . m e / 3.4 Summary
t . m e/e
s: / / / /
ps:
The question whether stable fixation will be possible is much Decision making:
http htt
more important in terms of the predicted outcome than the
presumed extent of AVN. Therefore, if stable fixation is pos- • Though improving, evidence is not yet sufficient to allow
sible, there is no need to be concerned about future osteo- for robust treatment recommendations. Surgeons’ skills
necrosis. and preferences play an important role. Most current
treatment recommendations are based on expert opinion
e s
Whether stable fixation is possible may be questionable
r
mainly in 4-part fractures. In critical cases, ie, cases with a
er s
and low-powered studies.
• Treatment with locked plates and antegrade nails has
b o ok low probability of achieving stable fixation, surgeons should

be prepared to perform joint replacement. In cases where
bo ok
failed to demonstrate better results than nonoperative
treatment and is fraught with a complication rate of ~ 30%.
b o o
e/ e e/ e
stable fixation turns out to be impossible and the surgeon • Selection of patients suitable for a particular treatment
e/e
: // t .m
does not feel comfortable performing arthroplasty, it may
be advisable to get the help of an experienced team to pre-
seems to be of paramount importance. Criteria for a suc-
cessful outcome have not yet been fully identified.
: / / t .m
ht tps
liminarily fix the fracture with K-wires and perform an
early secondary arthroplasty procedure.
ht tps
• In patients older than 60 years, nonoperative and op-
erative protocols, including arthroplasty, yield similar
functional results despite better x-rays after operative
3.3 Treatment algorithm fixation. Operative indications must therefore be well
In the authors’ own practices, approximately 30% of all justified individually.
fractures with pronounced comminution and/or dislocation • Obvious operative indications are fracture dislocations,
e r s
are treated operatively. The majority of all PHFs are mini-
e r s
head-split fractures, open fractures, pathological fractures,
ook ok o
mally or nondisplaced and can therefore be successfully and segmental fractures.
e b treated without surgery. It should also be taken into con-

e b o • For patients unfit for surgery or with important risk fac-
b o
e / e/
sideration that many studies are older and retrospective and
m
focus mainly on objective parameters like ROM or x-rays.
t .
tors indicating deterioration after operative, surgical pro-
cedures should only be suggested with great caution and
t . m e/e
/ /
Patients are getting older nowadays and attitudes and de- in accordance with the whole orthogeriatric team.
/ /
mands may change.
htt ps:
Fragile patients have limited reserves of physical strength
• Nonoperative treatment is indicated in simple and non-
htt
displaced PHFs. The same approach may apply in select-
ed cases of more complex injuries and if patients are
ps:
and even short-term functional decline may be difficult to unfit for surgery.
compensate. Some patients may therefore benefit from op- • Arthroplasty should only be chosen if all other options
erative fixation to restore functionality earlier. will presumably fail.
e rs e r s
b o ok Obviously, one type of treatment does not fit all pathologies
b o
and patient profiles. Most surgical methods can be applied to ok b o o
e/ e / e
a variety of fracture types, but they each have strengths and
e
weaknesses. Avoiding complications is one of the main goals,
e /e
://t . m
so surgeons should be able to choose between modalities Grade Explanation of activity
: / / t . m
t t p s
servicing their actual need, which also includes arthroplasty. 0
tps
Fully active, able to carry on all predisease performance without
ht
restriction
h
The following questions need to be answered in daily practice: 1 Restricted in physically strenuous activity but ambulatory and able to
carry out work of a light or sedentary nature, eg, light house work, office
work
• Are the fracture fragments displaced enough to require
2 Ambulatory and capable of all self-care but unable to carry out any work
surgery? activities. Up and about more than 50% of waking hours
k e rs
• Is the patient a good candidate for surgery ie, mentally
fit and demanding?
3
ke rs Capable of only limited self-care, confined to bed or chair more than 50%
b o o • Is the surgical risk within the normal range?

b oo
4
of waking hours
Completely disabled. Cannot carry on any self-care. Totally confined to
b o o
e/ e • Is it unlikely to produce a surgical complication?
e /e bed or chair
e/e
t . m
The type of treatment will be decided based on the criteria
: / /
5 Dead
// t .m
s ps:
listed in Table 3.1-2. Table 3.1-2 World Health Organization performance status.
h t t p htt
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 4 Therapeutic options
t . m e / 4.1 Nonoperative treatment
t . m e/e
s: / / / /
ps:
The vast majority of PHF are successfully treated nonop-
http htt
Apart from nonoperative treatment, several operative operatively. The rotator cuff, remnants of periosteum and
tions are at the surgeon’s disposal, but there are no evidence- capsular tissue (so-called ligamentotaxis effect) often provide
based recommendations to specifically guide selection. enough intrinsic stability to resist further displacement of
fracture fragments. Minimal tuberosity displacement com-
General remarks and thoughts: bined with controlled shaft impaction reduces the risk of
e rs
• Soft-tissue handling is critical for a successful outcome,
nonunion.
er s
b o ok but it has not been studied in detail. It is the factor often
not considered in any study and may not be comparable
bo ok
4.1.1 Pain treatment
Initial pain control after the injury includes a combination
b o o
e / e e/ e
even if the type of fracture, approach, and implant are of oral medications, topical modalities, and sling immobili-
e/e
the same.
: // t .m
• Open fixation must result in a stable construct which
: / / .m
zation. Providing adequate pain control over the first couple
t
of days after injury is of paramount importance for func-
ht tps
allows for immediate postoperative physiotherapy. If this
is not achievable, a prosthetic replacement should be
used. Sometimes it is necessary to switch strategies dur-
tional recovery.
ht tps
Regional nerve blocks like the interscalene block, ie, Winnie
ing an operation. block, the supraclavicular perivascular (subclavian perivas-
• Angular stable implants alone do not solve the problem. cular) block or the suprascapular nerve block should be
Anatomical reduction with either cortical contact or void considered.
e r s filling must also be provided in order to prevent second-

e r s
ook ok o
ary displacement of parts with subsequent cut-through Exercises should never be painful, otherwise a complex re-
e b or cut-out of screws.
e b o gional pain syndrome may result.
b o
e / e/
• It seems important to mention again that nonoperative
m
treatment is more desirable than a poorly performed op-
t . 4.1.2 Fracture reduction
t . m e/e
/ /
erative procedure regardless of the method of fixation [13].
: / /
Attempts to reduce a PHF have little, if any, effect on rates
h t p s
The surgeon must know the chosen method very well.
t
• At the moment, discussion about anatomical hemiarthro-
plasty and reverse arthroplasty is open; there are no clear htt ps:
of malalignment or functional outcomes. Given the poten-
tial risk for soft-tissue and plexus injuries caused by ma-
nipulation, surgeons should critically reconsider the indica-
guidelines for the orthopedic trauma surgeon to treat tion for fracture reduction (Case 7: Fig 3.1-18) [48]. Moreover,
these disabling fractures in geriatric patients. the typical varus malalignment may develop after several
weeks (Case 8: Fig 3.1-19) and is not predictive of the outcome
e rs [49].
e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
213
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / m
Spontaneous realignment with nonoperative treatment
. e /
. m e/e
CASE 7
/ / t / / t
Patient
htt ps:
Nonoperative treatment of a proximal humeral fracture (PHF) in an
87-year-old woman.
htt ps:
Five years before PHF the patient sustained a displaced, intraar-
ticular right distal radial fracture (Fig 3.1-18a) that healed after non-
operative management with acceptable malalignment
(Fig 3.1-18b–c). Initially, the 2-part PHF was minimally displaced
(Fig 3.1-18d–e).
e rs er s
b o ok bo ok
The patient was treated with a sling. After 1 week pronounced dis-
placement could be seen in a true AP view (Fig 3.1-18f). The fracture
b o o
e/ e e/ e was still markedly displaced 2 and 4 weeks later (Fig 3.1-18g–h).
After 6 weeks the situation improved (Fig 3.1-18i) and after 10
e/e
: // t .m : / / t
weeks the fracture progressed to healing in a good position
.m
tps tps
(Fig 3.1-18j–k).
ht ht
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
a
k e rs b c
k e r s d e
b o o b o o b o o
e/e t . me / e
t . m e /e
s : / / : / /
h t t p ht tps
k e rs f g h i
ke rs j k
eb oo Fig 3.1-18a–k An 81-year-old woman with a 2-part fracture.
e b oo b o o
/ / e/e
a–e X-rays showing a displaced, intraarticular right distal radial fracture (a) that healed with acceptable malalignment after nonoperative treat-
e t . e
ment (b–c). Initial displacement of the 2-part proximal humeral fracture occurred (d–e).
m t .m
/ /
f–k True AP view (f) at 1 week showing pronounced displacement. X-rays showing the still markedly displaced fracture at 2 and 4 weeks
/ /
ps: ps:
( g–h) but improved situation at 6 weeks (i) and fracture progressing to healing in good position at 10 weeks ( j–k).
214
htt htt
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Typical course of nonoperative treatment
. m e /
. m e/e
CASE 8
/ / t / / t
Patient
htt ps:
An 81-year-old woman in excellent condition sustained a 2-part
fracture. htt ps:
Nonoperative treatment was chosen. The patient’s arm was put in
a sling, adequate pain treatment was administered (Fig 3.1-19c–d),
and the arm was mobilized as soon as possible. After 4 weeks the
Comorbidities alignment was good and the patient had little pain (Fig 3.1-19e).
• No relevant comorbidities but obvious radiological signs of severe After 9 weeks the fracture was well aligned and the function improved
e rs osteoporosis.
r s
(Fig 3.1-19f–g). Five months after the injury the typical varus malalign-
e
bo ok
ment by continuous pull of the supraspinatus muscle occurred
(Fig 3.1-19h–i).
b o o
e / e e/ e
The 2-part fracture (Fig 3.1-19a–b) showed obvious radiological
signs of osteoporosis (25-hydroxyvitamin D3: 11.2 ng/mL [28 The function was excellent and the patient was satisfied with the
e/e
/ t .m
nmol/L]; PTH: 56 μg/L; T-score: lumbar spine = -2.0; proximal
: / outcome (Fig 3.1-19j–m).
: / / t .m
tps tps
femur = -2.2). The patient was administered 3 mg IV of ibandronate
ht ht
every 3 months, 1,000 mg of calcium, 400 IU of vitamin D. Other At the 5-year follow-up, the patient broke her right proximal femur
wise, the patient was in excellent condition without relevant which was treated with a proximal femoral nail antirotation aug-
comorbidities. mentation (Fig 3.1-19n–o). The T-score of the opposite hip was
-3.4 and of the lumbar spine was -2.3. A computed tomographic
scan of her right shoulder revealed a stable nonunion of the prox-
e r s e r s
imal humeral fracture without any complaints and near to normal
ook ok
function (Fig 3.1-19p–q).
b b o b o o
e / e e/ e e/e
/ / t . m / /t . m
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e a b
e / e c d e
e /e
://t . m : / / t . m
Fig 3.1-19a–q An 81-year-
t t p s tps
old woman with a 2-part
h ht fracture.
a–b X-rays showing a 2-part
fracture with obvious
radiological signs of
osteoporosis.
c–e X-rays after nonopera-
k e rs ke rs tive treatment, ie, arm

in sling (c–d), showing
eb oo e b oo good alignment (e).

f–g Well-aligned fracture
b o o
e /
t . m e / after 9 weeks.
t .m
h–i X-rays 5 months post
e/e
/ / /
injury showing typical
/
ps: ps:
f g h i varus malalignment.
htt htt 215
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
j k
: // t .m l m
: / / t .m
s tps
http
Fig 3.1-19a–q (cont) An
ht 81-year-old woman with a

2-part fracture.
j–m C linical photographs
showing excellent func-
tion.
n–q F ive-year follow-up
e r s e r s x-rays showing the
ook ok
patient’s right proximal
b b o femur fixed with a

proximal femoral nail
b o o
e / e e/ e antirotation augmenta-
e/e
/ / t . m /t . m
tion (n–o). Computed
tomographic scans
/
ps: ps:
of the right shoulder
htt htt
revealing a stable non-
union of the proximal
n o p q humeral fracture ( p–q).
e rs
4.1.3 Immobilization
r s
4.1.4 Outcome
e
b o ok Generally, the treatment strategy should be as functional
b o
as possible, allowing patients to use their injured shoulder ok
Radiologically, nonoperative treatment usually results in
some malalignment. In 2-part fractures this typically leads
b o o
e/ e / e
as much as pain allows (Table 3.1-1). Prolonged immobiliza-
e
tion with a Gilchrist type of sling has not been proven to be
to a varus position of the proximal fragment with a sub-
acromial position of the GT. In contrast to younger patients
e /e
://t . m
effective. The authors encourage patients to use their upper
/ t
and to patients after operative treatment, this does not in-
: / . m
t t p s
extremity as much as possible while performing daily ac-
tps
terfere with a reasonable or even good function of the shoul-
ht
tivities. With clinical and x-ray follow-ups, those fractures der in older patients [49].
h
that are more unstable than initially anticipated can be iden-
tified. If necessary, the treatment strategy may be changed Retrospective studies have shown a near functional normal-
eventually (Case 9: Fig 3.1-20). ity in 80% of geriatric patients with only minor restrictions
in strength and ROM to vigorous activities especially if the
k e rs
A slab splint from the forearm to the shoulder or Desault’s
bandage may cause iatrogenic problems like skin abrasions,
ke rs
fracture is only minimally displaced [50, 51]. Most patients
should be able to perform activities of daily living (ADLs)
eb oo swelling, or stiffness.
e b oo
(Case 10: Fig 3.1-21). There is robust evidence that nonop-
b o o
e/e
erative management of PHFs is safe and effective, mainly
e / e /
The predicted risk of delayed and/or nonunion is 7% with
m
in AO/OTA type A and B fractures [5].
m
t .
nonoperative management. The risk for nonunion in smok-
/ / // t .
ps: ps:
ers is 5.5 times higher than in nonsmokers.
216
htt htt
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / m
Secondary displacement with change of treatment modality
. e /
. m e/e
CASE 9
/ / t / / t
Patient
htt ps:
An 83-year-old woman with severe osteoporosis and a 2-part frac-
ture after a fall at home. She was go-go, ie, fit, had no relevant
htt ps:
There existed a trauma series of the fracture including an axial view
without relevant displacement. The patient expressly said that she
comorbid conditions, and took only one medication for brady did not want operative treatment so ambulatory nonoperative treat-
arrhythmia. ment was started (Fig 3.1-20a–c).
k e rs r s
The 1-week follow-up showed complete dislocation and the patient
e
o o o ok
had distinct pain despite oral pain medication (Fig 3.1-20d–f).
Operative fixation was therefore recommended.
o o
e/eb t .m e/ e b One day later, operative fixation with 9.5 mm/160 mm intra
t .m e/eb
: // : / /
medullary nail, statically locked, 3 head screws, one screw in screw
tps tps
(Fig 3.1-20g–h).
ht ht
Three months later there was no change in position, bone healing,
and excellent function (Fig 3.1-20i–k). Two years later she pre-
sented again in the emergency department with a knee distortion
after lifting a clothes basket.
e r s e r s
/ e/ e/e
a b c
e t . m t . m
/ / / /
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
d e
://t . m f g
: / / t
h
. m
t t p s tps
h ht
Fig 3.1-20a–k An 83-year-old woman after a fall at home.
k e rs a–c A
ke rs
trauma series of the 2-part fracture including an axial view without
relevant displacement.
eb oo e b
g–h X oo
d–f Follow-up after 1 week showing complete dislocation.
-rays showing fracture treated operatively with 9.5 mm/160 mm intra
b o o
e /
t . m e / medullary (IM) nail, three locked screws in proximal end of IM nail and
standard distal interlocking screws.
t .m e/e
/ / i–k X
/
-rays after 3 months showing no change in position, bone healing, and
/
ps: ps:
i j k excellent function.
htt htt 217
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / m e /
Adequate functional result despite massive malalignment in a very old patient
. . m e/e
CASE 10
/ / t / / t
Patient
htt ps:
A 96-year-old female patient with a 3-part proximal humeral fracture
(HL-G-S) after a fall at home.
Discussion
htt ps:
Progression into varus malalignment within the first 6–8 weeks is
frequent in patients treated nonoperatively. Large series show little
functional impairment in 2-part surgical neck fracture. In contrast,
Treatment and outcome posttraumatic malunion of the GT is problematic to treat. Reverse
Nonoperative treatment was chosen because of the patient’s age. arthroplasty is the preferred choice in this age group, yet the amount
e rs The greater tuberosity (GT) was pulled posteriorly and superiorly

r s
of external rotation depends on the displacement of the GT limiting
e
b o ok (Fig 3.1-21a–e).
bo ok
range of motion in the “hinged door” mechanism of the reversed
polarity.
b o o
e/ e e/ e
Six months later the head fragment was displaced more into varus
and anteversion (Fig 3.1-21f–h). Some anterior part of the GT was
e/e
/ t .m
still attached to the head fragment which allowed some supraspi-
: / : / / t .m
tps tps
natus muscle functions. Posterosuperior displacement of the GT
ht ht
occurred. The pain was tolerable and the patient could flex the arm
150°, reach her mouth and the back of her head; she could also
reach her buttocks.
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
a b c d e
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
f g h
Fig 3.1-21a–h A 96-year-old woman after a fall.
k e rs ke rs
a–e X-rays showing the greater tuberosity (GT) pulled to posterior and superior—note the intact supraspinatus muscle (SSP) (arrows).
f–h Six months later the head fragment was displaced more into varus and anteversion. Some anterior part of the GT was still attached to the
oo oo o
head fragment which allowed some SSP functions. Posterosuperior displacement of the GT.
eb e b b o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 4.2 Locking plate
t . m e /
t
Deltopectoral approach (Approach 1: Fig 3.1-22):
. m e/e
s: / / / /
ps:
After the introduction of the locking plate concept in the
http htt
early 1990s, it rapidly became the most frequently used • Although the skin incision is longer in this approach than
technique for fixation of PHFs. This still holds true today in the deltoid-split approach, the procedure should be as
despite an unacceptably high rate of reported complications. minimally invasive as possible, which can be achieved
Many patients, however, achieve good to excellent results. by preserving periosteal bridges, using sutures to ma-
Factors predicting failure are understood better nowadays nipulate the fracture fragments, and using the plate to
e rs
and can be avoided more easily.
er s
indirectly reduce the fracture. For excellent exposure,
no deeper structures need to be dissected.
b o ok Regardless of the approach, soft-tissue management seems
bo
to be at least as important as biomechanical issues. No data ok
• Manipulation of tuberosities should only be performed
by sutures through the tendon of the rotator cuff. They
b o o
e / e e/ e
exists on the impact of soft-tissue handling on the outcome, should never be pulled directly to avoid further fragmen-
e/e
: // t .m
since it is very difficult to control this in studies. tation and iatrogenic periosteal detachment.
: / / t .m
• The affected arm should be positioned on a Mayo side
tps
Topic 4.2 focuses on lessons that have been learned over
ht
the past years. For a systematic description of the technique,
see Acklin et al [52] and Plecko et al [53]. ht tps
stand in abduction. By internal rotation and abduction,
the deltoid muscle can be retracted and the GT exposed.
• Rounded retractors are inserted underneath the deltoid
muscle.
4.2.1 Approaches • A longitudinal split of the SSP tendon does not cause
Deltoid-split approach for minimally invasive plate osteo- important damage and can be closed easily. The quality
e r ssynthesis (MIPO):
e r s
of the GT reduction can be clinically assessed with the
ook ok o
SSP split and is also easy to extend.
e b • The use of this minimally invasive approach should not

e b o • The so-called tendon-free rotator interval between SSC
b o
e / gus positions of the head fragment.
t . e/
result in malreduction, specifically of the varus and val-
m
and SSP muscles should not be dissected. The whole com-
t . m
plex together with smaller anterior fracture fragments e/e
/ /
• The surgeon should be familiar with MIPO techniques
/ /
act like a hood that can be pulled over the humeral head
htt ps:
such as indirect reduction and the use of joysticks as the
fracture zone cannot be visualized directly.
• It offers complete access to the entire GT, especially when
at the end of the surgery.
htt ps:
• This approach is used for revision surgery as well.
parts of it are posteriorly displaced, and to the plating

area.
• On the other hand, there is an increased risk of limited
e rs access to the head fragment, and the axillary nerve is in

e r s
b o ok danger. Options to extend the approach are limited.
b o
• In a comparative study with the deltopectoral approach, ok b o o
e/ e / e
the use of the deltoid-split approach resulted in a lower
e
Constant score due to poorer ROM. According to a retro
e /e
://t . m
spective study there is no difference between the two
: / / t . m
t t p s
approaches including electrophysiological investigations
tps
ht
[54, 55].
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
219
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
APPROACH 1
htt ps: htt ps:
k e rs a b
er s c
o o o ok o o
e/eb t .m e/ e b
t .m e/eb
: // : / /
d
ht tps e f
ht tps
Fig 3.1-22a–f Deltopectoral approach.
a The skin incision runs along the humerus, starting lateral to the palpable tip of the coracoid.
e r s e r s
b–c T he cephalic vein is retracted laterally and the subdeldoital space is opened by exposing the clavipectoral fascia. The lateral tendon bor-
der of the conjoined tendon and the coracoacromial ligament are identified (not shown in the pictures). By simple abduction of the arm
ook ok o
on a Mayo side stand the tension of the deltoid is relieved and the exposure can be nicely extended laterally (c).
e b b o
d No soft-tissue structures are dissected or stripped including those already injured.
e b o
/ e/ e/e
e Stay sutures through the cuff are placed from anterior to posterior. The anterior suture allows manipulation of the head to place the next
e one until the posterior cuff is reached. The tuberosities are never manipulated with sharp instruments.
t . m t . m
f The authors’ preferred method is first to fix the plate to the shaft and then to manipulate and temporarily fix the fracture with pins with-
/ / / /
ps: ps:
out interfering with the plate position. Two pins, one just below the bony edge of the greater tuberosity and one just behind the bicipital
groove, are used for guidance of the final plate position.
htt htt
4.2.2 Biceps tendon Screw cut-out goes hand in hand with a loss of reduction.
Sutures or cerclages crossing the bicipital groove with the Driven by the pull of the rotator cuff, the humeral head
e rs tendon underneath act like a tenodesis (Fig 3.1-23, Fig 3.1-24,

r s
“moves” into a varus position. Cut-through and cut-out
e
b o ok Case 11: Fig 3.1-25). Therefore, whenever this approach is
b o
necessary, surgeons are advised to tentomize the biceps ten- ok
often occur at the same time and may lead to irreversible
destruction of the glenoid if action is taken belatedly. Revi-
b o o
e/ e / e
don, perform a tenodesis by suturing the distal stump to the
e
insertion of the pectoralis muscle and resect the proximal
sion is challenging and often ends with reverse arthroplas-
ty as a last resort.
e /e
part of the tendon.
://t . m : / / t . m
t t p s tps
Boileau et al [56] described the “unhappy triad after locking
ht
4.2.3 Typical complications plate” fixation as a combination of:
h
Screw cut-through is typically caused by subsidence of the
head fragment over the locked screws. This is possible be- • Humeral head necrosis
cause of some comminution at the fracture zone and the • Loss of reduction with posterior migration of the GT and
big central void that characterizes the proximal humerus in posterosuperior cuff insufficiency
k e rs the elderly. Subsidence may be combined with varus dis-

placement of the head fragment and usually takes place in
ke rs
• Glenoid erosion and destruction because of screw pen-
etration
eb oo the first several weeks after the surgery; it should not be
e b oo b o o
e/e
confused with AVN. Typically, the screw tips perforate the
e / head fragment and damage the glenoid fossa. Changing the

m e / m
t .
screws immediately may prevent serious damage to the joint
/ / // t .
ps: ps:
(Case 11: Fig 3.1-25a–j).
220
htt htt
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
tps tps
a b c
ht ht
Fig 3.1-23a–c
a–b Whenever sutures cross the sulcus of the biceps, the physiological gliding of the biceps in the groove is made impossible. Adhesion
between the interval tissue and the biceps tendon, which is no longer gliding, generates pain and loss of external rotation. Therefore, in
these cases a tenodesis of the long head of the biceps (LHB) tendon is recommended. The authors’ preferred technique is to suture the
tendon to the upper edge of the pectoralis major tendon. The biceps tendon is then cut proximally and the intraarticular portion is har-
vested through the fracture plane between the tuberosities.
e r s e r s
c Note the plane of the intertuberosity fracture, running 8–10 mm behind the sulcus, as the sulcus provides the best bone quality in this
ook ok
area. Frequently the supraspinatus muscle (SSP) tendon is already split minimally at the end of the fracture plane. If needed, eg, in the
b
case of a head-split fracture, when resection of the intraarticular portion of the LHB is difficult, the split of the SSP tendon can be pro-
b o
longed in line of the fibers and the whole posterior part of the cuff can be pushed back like a curtain providing excellent exposure to the
b o o
e / e head fragment.
e/ e e/e
/ / t . m / /t . m
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
a
h b c
ht d
Fig 3.1-24a–d The long head of the biceps tendon is first sutured to the upper border of pectoralis major tendon and then cut above. The
intraarticuar portion can be harvested without compromising the interval through the existing fracture between the tuberosities. If needed, the
supraspinatus tendon can be split along the fibers to extend the needed exposure. Likewise, this method to extend the intraarticular exposure
rs rs
can be used in head-split reconstruction.
k e ke
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
221
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / m e /
Typical “mechanical” complication due to varisation and subsiding of the head fragment
m e/e
CASE 11
/ / t . / / t .
Patient
htt ps:
An 83-year-old patient, living in a nursing home, suffered a fall from
standing height. htt ps:
X-rays after 11 days showed severe displacement and the patient
had great pain (Fig 3.1-25f–g). The geriatric evaluation rated the
patient as slow-go, ie, unfit, and pain treatment was adapted. Mo-
Comorbidities bilization and pain control deteriorated and after another 8 days of
• Hypertension inpatient treatment the decision in favor of surgery was made. In-
e rs • Aortic valve replacement

r s
traoperative x-rays showed good alignment and plate fixation. Me-
e
b o ok • Mitral valve insufficiency
• Atrial fibrillation
bo ok
dial support reconstruction was questionable (Fig 3.1-25h–j).
b o o
e/ e • Left bundle branch block
• Coronary heart disease after bypass surgery
e/ e Within 5 weeks the head fragment subsided and screw penetration
occurred. Revision surgery with shorter screws was performed.
e/e
• Multiple vertebral fractures
: // t .m Arthroscopy demonstrated erosion of the glenoid surface
: / / t .m
tps tps
• Mastectomy after breast cancer 26 years ago (Fig 3.1-25k–l).
Treatement and outcome ht

The patient sustained a 3-part fracture (HG-L-S) with sufficient
ht
Within 1 year the head collapsed (Fig 3.1-25m–n). The patient re-
fused revision surgery, as she was pain free. The function was poor,
alignment for nonoperative treatment (Fig 3.1-25a–b). The com- though.
puted tomographic scan confirmed the diagnosis and classification
r s
(Fig 3.1-25c–e).
ke r s
Within the same year she suffered a pertrochanteric fracture that was
e
ok
treated with a long proximal femoral nail antirotation (Fig 3.1-25o–q).
b o o b o Four years later she suffered a periimplant humeral shaft fracture that
b o o
e /e e e/e
was treated with a long locking compression plate (Fig 3.1-25r–s).
t . m e/ Discussion
t . m
s: / / / /
ps:
Retrospectively, an important reason for failure was the lack of
http htt
medial support, a lesson learned in the past. A well-fixed straight
antegrade nail with impaction might have resulted in sufficient sta-
bility for healing. The further course was characterized by an overall
poor result, but pain was still tolerable. Also in this age group,
secondary fracture prophylaxis was required.
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
a
h b
ht
k e rs ke rs Fig 3.1-25a–s An 83-year-old patient
eb oo e b oo after a fall from standing height.

a–b X-rays showing a 3-part fracture
b o o
e /
t . m e / with sufficient alignment for
t .m
nonoperative treatment.
e/e
/ / /
c–e Computed tomographic scan of
/
ps: ps:
c d e the fracture.
222
htt htt
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
://t.m .m
f g h i j
s : / / t
h t t p ht tps
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
k
htt
l
ps: m
htt ps: n
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
o
h p q r
ht s
Fig 3.1-25a–s (cont) An 83-year-old patient after a fall from standing height.
f–g X-rays after 11 days showing severe displacement.
k e rs ke rs
h–j Postoperative x-rays after surgery showing good alignment and plate fixation.
k–l Within 5 weeks the head fragment subsided and screw penetration occurred. Revision surgery with shorter screws was performed.
eb oo Arthroscopy demonstrating erosion of the glenoid surface (l).

m–n Within 1 year the head collapsed.
e b oo b o o
e /
t . m e /
o–q Pertrochanteric fracture treated with a long proximal femoral nail antirotation.
r–s Periimplant humeral shaft fracture treated with a long locking compression plate.
t .m e/e
/ / //
htt ps: htt ps:
223
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
Boileau et al [56] also stated that a failure after a locking • Controlled impaction of the head fragment onto the hu-
t . m e/e
s: / / / /
ps:
plate fixation cannot be reversed. A revision with hemiarthro meral shaft or vice versa in case of medial comminution
http htt
plasty is not possible because of glenoid erosion and GT and highly osteoporotic bone quality. Impaction may
migration. An anatomical total shoulder arthroplasty cannot contribute to the overall stiffness and has to be done
be performed for the same reasons, specifically because of correctly, ie, no varus malalignment must result.
the posterosuperior cuff insufficiency. Unfortunately, reverse • Accepting a nonanatomical position of the PHILOS plate
shoulder arthroplasty (RSA) will yield poor functional results after shortening. When approximating the humeral shaft
e s
because of stiffness and absence of the external rotator
r
muscles.
er s
to the plate, the achieved medial support will be lost
(Case 13: Fig 3.1-27). If the head is impacted, the plate can-
b o ok There are several ways to avoid these complications:

bo ok
not be applied in an anatomical position (Case 13: Fig 3.1-27).
Frequently the shaft is shifted laterally by the first screw
b o o
e/ e e/ e and pulled out of the medial support, which is to be
e/e
: // t .m
• Careful evaluation of the thickness of the head fragment
in the preoperative CT scan. If it is below 8–10 mm, the
avoided.
: / /
• Under no circumstances should a residual varus positiont .m
tps
risk increases and additional measures like augmentation
ht
should be considered, especially in osteoporotic bone
(Case 3: Fig 3.1-14). ht tps
of the head fragment be accepted. A slight overcorrection
into valgus may be beneficial and is preferred.
• The GT functions as a capstone that completes the corpus
• Careful “percussion” drilling and measuring screw lengths and offers intrinsic stability at least in cases with reason-
without perforating the articular surface. Perforation of able bone quality. The implant must then only keep the
the subchondral bone increases the risk drastically. A position, as loads are transferred by the bone.
e r s blunt probe for length measurement should be used.

e r s
• To support the medial corner and to prevent varus mal
ook ok o
• Filling the void after reduction and supporting the hu- alignment, calcar screws have proven to be effective [59].
e b meral head are other options to prevent fragments from

e b o • In situations with lateral comminution of the GT and/or
b o
e / e/
being displaced. Techniques that used allograft bone or
m
fibular strut graft [57, 58] have turned out to be more
t .
a short GT fragment that is fractured close to the tendon,
insertion the standard plate position does not address the
t . m e/e
/ /
successful even in unfavorable conditions [16, 42]. Ide- superior part of the GT any more. Additional suture
/ /
ps:
ally, massive bone blocks from femoral heads are available
htt
from a local bone bank (Case 12: Fig 3.1-26). This applies
specifically to those cases with a shallow head fragment htt ps:
fixation of the GT through the SSP tendon-bone-interface
to the prepared holes in the plate may be particularly
helpful. In cases with a big central void it is of paramount
(which is particularly pronounced in osteoporotic cases), importance that enough bony substance underneath the
comminution zones, and/or a short or multifragmentary GT and the head fragment is provided to restore mechanical
GT fragment that would not be able to take any screws stability and promote healing. A massive allograft works
e rs but can only be fixed with sutures.

r s
well in these cases.
e
b o ok • Enhancing the anchorage of the screws in the reduced
b o
cancellous subchondral bone is another approach that is ok
• Isolated screws should not be used for fixation of the
lesser tuberosity in this population. The screws often
b o o
e/ e / e
currently under evaluation. Injecting small amounts of
e
PMMA cement through cannulated and perforated screws
loosen and may cause problems culminating in revision
surgery.
e /e
://t . m
leads biomechanically to significantly more cycles to cut
: / / t . m
t t p s
out. This only works in osteoporotic bone structure.
tps
ht
• Medial hinge (calcar) reconstruction either by meticulous
h
reduction or in case of comminution by shortening to
achieve mechanical stability. Indirect techniques like
employing a bone rasp to reduce the head fragment
through the fracture can be used. When the plate is al-
k e rs ready in situ, reduction can be secured by using a pre-

liminary pin through the plate. The quality of medial
ke rs
eb oo calcar restoration should be carefully checked by image
e b oo b o o
e/e
intensification.
e / m e / m
/ /t . // t .
htt ps: htt ps:
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / m e /
Central massive allogenic bone block to prevent secondary loss of reduction
m e/e
CASE 12
/ / t . / / t .
Patient
htt ps:
An 89-year-old woman sustained a 2-part proximal humeral fracture
(PHF) with additional metaphyseal fragments after a fall in her nurs-
htt ps:
The fracture was operatively reconstructed with a massive allo-
genic bone block from the local bone bank (Fig 3.1-26d–f). Three
ing home (Fig 3.1-26a–b). Her World Health Organization performance months later the fracture healed uneventfully (Fig 3.1-26g–i).
status was 4, Parker Mobility Score 3, and she used a cane; CAM 0,
Lachs Score 10, local bone mineral density 70.9 mg/cm3. She had A computed tomographic scan after 6 months showed integration
e rs
sustained an L1 fracture many years ago (Fig 3.1-26c).
r s
of the graft without loss of reduction and also a reasonable function
e
b o ok Comorbidities
bo ok
(Fig 3.1-26j–l).
b o o
e / e • Parkinson´s disease
• Epilepsy
e/ e Discussion
Nonoperative management must be discussed in this case. If surgery
e/e
: // t .m : / / t .m
is chosen, additional measures apart from fixation are necessary,
tps tps
as otherwise failure of any fixation is likely.
ht ht
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
ps: ps:
a b c d e f
htt htt
e rs e r s
ok ok
Fig 3.1-26a–m An 89-year-old
b o b o
woman after a fall.
a–b X-rays showing the 2-part
b o o
e/ e e / e proximal humeral fracture
e
with additional metaphy- /e
://t . m : / t .
seal fragments.
/ m
c X-ray of L1 fracture taken
g h
t t p s i j k
tps
2 years prior to the proxi-
h ht mal humeral fracture.

d–f Operative reconstruction
with massive allograft
bone block from the local
bone bank.
g–i X
-rays after 3 months
k e rs ke rs showing uneventful heal-

ing of the fracture.
eb oo e b oo j–k Computed tomographic

scan at 6 months show-
b o o
e /
t . m e / ing integration of the graft
t .m
without loss of reduction.
e/e
/ / /
l–m F ollow-up range of mo-
/
ps: ps:
l m tion examination.
htt htt 225
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Importance of calcar reconstruction
m e / m e/e
CASE 13
/ / t . / / t .
Patient
htt ps:
A 79-year-old female patient who experienced a fall at home. The
patient sustained a displaced 3-part proximal humeral fracture with
htt ps:
The fracture was reduced and preliminarily fixed with K-wires
(Fig 3.1-27e–g) and the calcar was reconstructed (Fig 3.1-27h–l).
a head-split component (Fig 3.1-27a–d). Moving the shaft to the plate would lead to uncontrolled impaction
of the shaft into the head of the humerus with loss of reduction
Comorbidities (Fig 3.1-27h–i). After 4 weeks (Fig 3.1-27m–n) and 1 year (Fig 3.1-27
e rs • Hypertension
r s
o–q) there was no change in position. Constant score right/left was
e
b o ok • Hyperlipidemia
• Osteoporosis
bo ok
78/77. Range of motion and power were almost equal on both
sides.
b o o
e/ e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
a b c d e f g
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
h i j k l
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
kers kers
m n o p q
b o o Fig 3.1-27a–q A 79-year-old woman after a fall.
b o o
a–d X-rays showing a displaced 3-part proximal humeral fracture with a head-split component.
b o o
e /e e/e
e–g X-rays showing reduced fracture and preliminarily fixed with K-wires.
h–l X-rays showing reconstructed calcar. Note the distance of the plate from the humeral shaft (arrow). Moving the shaft to the plate would
m m e/e
/t . / t .
lead to uncontrolled impaction of the shaft into the head of the humerus with loss of reduction (h–i). Postoperative follow-up x-rays ( j–l).
/ /
ps: ps:
m–q No change in position after 4 weeks (m–n) and 1 year (o–q).
226
htt htt
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 4.2.4 Aftercare
t . m e / 4.3 Antegrade nailing
t . m e/e
s: / / / /
ps:
Postoperative physiotherapy and self-directed exercises play Antegrade humeral nailing has gone through an evolution
http htt
a crucial role in achieving a good outcome. The stability of with regard to nail and screw designs. With improved op-
the fixation should always allow for immediate and active tions of the latest nails, this type of osteosynthesis has become
treatment. an alternative to plate fixation.
Patients should never experience pronounced pain, ie, a A straight nail design seems to be superior to a curvilinear
e s
differentiated pain regimen including nerve blocks is vital.
r
Passive mobilization is allowed from day 1, active motion
er s
one for many reasons [63]. With a modular concept, implant
configuration can be adapted to fracture morphology.
b o ok as soon as pain subsides. Using a sling is not mandatory but
bo
many patients feel more comfortable with a sling at least in ok
Nail insertion via a split of the SSP tendon is more widely
b o o
e/ e the first couple of days.
e/ e accepted in older than in younger patients. Antegrade nail-
e/e
: // t .m
We encourage patients to stretch the elbow and use the
: / / t .m
ing is most often indicated in displaced 2-part PHFs.
4.2.5 Outcome ht tps

hand of the affected arm as soon as possible for ADLs. 4.3.1 Advantages
ht tps
• It is a minimally invasive surgical procedure.
Comparing results from different studies is challenging, be- • Biomechanically, an IM nail comes closer to the calcar
cause the amount of displacement and angulation is rarely than a plate and may support this important structure
quantified and the term unstable is not clearly defined and more effectively (Case 14: Fig 3.1-28). This can be further
e r s
is difficult to measure preoperatively.
e r s
enhanced by an ascending calcar screw and the so-called
ook ok o
screw-in-screw concept to address the posteromedial area
e b Complications are hardly ever monocausal. Krappinger et

e b o of the humeral head [64].
b o
e / e/
al [28] reported that age, local BMD, anatomical reduction,
m
and restoration of the medial cortical support to be impor-
t .
• Some nails offer a modular system with angular stable
proximal and distal locking options.
t . m e/e
/ /
tant predictors for failure. The probability of mechanical
/ /
• Ipsilateral segmental fractures of the proximal humerus
htt ps:
failure increased significantly when at least three of the
following risk factors were present: higher age, lower local
BMD, less than anatomical reduction, no medial cortical
long version of the nail.
htt ps:
and the humeral diaphysis can be stabilized by using a
support. 4.3.2 Disadvantages
A thorough and prospective analysis of 150 patients with • These demanding operative techniques require hands-on
e rs
unstable PHFs failed to show any of the suspected param-
r s
training so as to avoid errors and complications.
e
b o ok eters to be significant including surgical characteristics,
b o
smoking, alcohol consumption, fracture type, medical cook
• Subacromial scarring may cause painful limited ROM.
• Despite improved locking options, loss of reduction and
b o o
e/ e / e
morbidities, and delay of surgery [1]. Loss of reduction and
e
secondary screw loosening with perforation or both were
varus malalignment still occur (Case 15: Fig 3.1-29).
e /e
://t
the most frequent mechanical complications.
. m / t .
For a systematic description of the technique, see Hessmann
: / m
t t p s et al [65].
tps
ht
Spross et al [60] reported 294 patients, aged 72.9 years on
h
average, with a complication rate of 28.2% and 24.5% re-
quired revision surgeries. Screw cut-out was the most fre-
quent reason due to secondary displacement. Smokers with
more than 20 pack years had significantly more complica-
k e rs
tions.
ke rs
eb oo Other studies reported similar rates [3, 61]. Clearly, patients
e b oo b o o
e/e
with complications have worse functional outcomes [1, 62].
e / m e / m
/ /t . // t .
htt ps: htt ps:
227
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / m e /
Straight intramedullary nail to address unstable 2-part fracture
. . m e/e
CASE 14
/ / t / / t
Patient
htt ps:
A 91-year-old female patient fell in her nursing home in the middle
of the night. She suffered a massive hematoma, but her neurovas-
htt ps:
The patient sustained a displaced 2-part proximal humeral fracture
with metaphyseal comminution (Fig 3.1-28a). She was under gen-
cular status was intact. eral anesthesia when closed reduction and fixation with an 8 mm
intramedullary (IM) nail was performed (Fig 3.1-28b–e). Postopera-
Comorbidities tive AP and lateral x-rays showed good alignment (Fig 3.1-28f–g).
e rs • Urinary tract infection with Escherichia coli

er s
b o ok • Atrial fibrillation after myocardial infarction 5 years ago
• Chronic obstructive pulmonary disease
bo ok
After 6 months the patient sustained two minor strokes. The frac-
ture healed in anatomical position. She used a wheelchair, did not
b o o
e/ e e/ e report any pain and had equal range of motion on both sides
(Fig 3.1-28h–i).
e/e
: // t .m : / / t .m
tps tps
Discussion
ht ht
This case shows the power of IM nailing. With IM nailing surgeons
should strive for a medial support. In this case, it was decided not
to open up the fracture and to take some risk in terms of stability.
e r s e r s
e / a b
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
c d
://t . m e f g
: / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo b oo
Fig 3.1-28a–i A 91-year-old woman after a fall.
a A displaced 2-part proximal humeral fracture with metaphyseal comminution.
e b o o
e /
t . m e /
b General anesthesia and positioning of the arm with an arm holder.
c–e Closed reduction and fixation with an 8 mm intramedullary nail.
t .m e/e
/ / f–g Postoperative result with good alignment in AP and lateral views.
//
ps: ps:
h i h–i X-rays showing fracture healed in anatomical position.
228
htt htt
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / m e /
Typical course after intramedullary nailing of a 2-part proximal humeral fracture
m e/e
CASE 15
/ / t . / / t .
Patient
htt ps:
An 81-year-old, clearly go-go, ie, fit, male patient sustained a displaced
2-part proximal humeral fracture 4 days after a fall (Fig 3.1-29a–b).
htt ps:
The fracture was anatomically reduced and fixed including a calcar
screw (Fig 3.1-29d–e).
Two years previously, he had sustained a type A fracture of L1 with
no treatment of the underlying osteoporosis (Fig 3.1-29c). One week (Fig 3.1-29f), 3 weeks (Fig 3.1-29g), 6 weeks (Fig 3.1-29h),
and 8 months (Fig 3.1-29i–k, Fig 3.1-29j in internal rotation) after
e rs
Comorbidities
r s
surgery there was limited loss of reduction into varus and osseous
e
b o ok • Myocardial infaction
• Type 2 diabetes
bo ok
healing. The patient experienced residual pain; flexion/abduction
was 100°.
b o o
e/ e • Chronic renal insufficiency
e/ e e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e / a b
t . m e/ c d e
t . m e/e
: / / / /
h t t p s
htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
f g
://t . m h i j
:
k
/ / t . m
t t p s
Fig 3.1-29a–k An 81-year-old man after a fall.
tps
ht
a–c X-rays showing a displaced 2-part proximal humeral fracture. Note the amount of displacement in the axial view.
h
d–e Anatomical reduction and fixation including a calcar screw.
f–k X-rays 1 week (f), 3 weeks ( g), 6 weeks (h), and 8 months (i–k, j in internal rotation) after surgery showing limited loss of reduction into
varus and osseous healing.
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
229
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 4.3.3 Typical complications
t . m e / Suboptimal initial reduction:
t . m e/e
s: / / / /
ps:
Iatrogenic rotator cuff injury:
http htt
• Preexisting osteoarthritis of the shoulder, shoulder stiff-
• This is the main reason why many surgeons are reluctant ness, and inability to recline the arm may be serious ob-
to use IM antegrade fixation techniques in younger adults. stacles to reaching the optimal entry portal.
Since the rotator cuff already shows some signs of de- • Manipulation of fragments may be difficult. Only mini-
generation, this concern is of less importance in older mally invasive techniques such as K-wires and sutures
e rs adult patients.
• Nails with a straight design are inserted through the mus-
er s
(eg, joystick, stay suture) should be applied.
• In addition to the correct entry point, the direction of the
b o ok cular part of the SSP and the superior part of the hu-
meral head, thus potentially avoiding the delicate tendi-
bo ok
bony canal in the humeral head is extremely important;
it must be parallel to the humeral shaft both horizon-
b o o
e/ e nous part at the footprint of the tendon.
e/ e tally and vertically and cannot be changed. The surgeon
e/e
: // t .m
• Euler et al [16] analyzed CT scans of bilateral proximal
humeri in 200 patients with an average age of 45.1 years
needs to get it right the first time, otherwise the head
fragment may break (Case 17: Fig 3.1-31).
: / / t .m
tps
(SD 19.6; 18–97) without humeral fractures. They defined
ht
the entry point of the nail and the region of interest, ie,
the biggest entry hole that would not encroach on the
Loss of reduction:
ht tps
insertion of the SSP tendon. This showed that 38.5% of • The central entry point offers an additional “fifth” anchor
the humeral heads had to be categorized as critical types point in the humeral head. Prior to the operation the
due to morphology in which the predicted offset of the surgeon should check carefully if the bone quality around
e r s entry point would encroach on the insertion of the SSP

e r s
the entry portal is sufficient. A wrongly chosen entry
ook ok o
tendon that might damage the tendon and reduce the portal cannot be changed. If fixation will not be stable,
e b stability of fixation. The authors recommended studying

e b o the surgeon must be able to switch to a plate or an ar-
b o
e / the preoperative x-rays accordingly and to choose an-
m e/
other treatment option in critical cases (Case 16: Fig 3.1-30).
t .
throplasty.
• Locking screws in the humeral head should aim towards
t . m e/e
/ / / /
areas that are known to be denser even in the older pa-
Subacromial impingement:
htt ps:
• A straight nail design helps to avoid this complication.
tients, ie, the posteromedial part of the head.
htt ps:
• If anatomically possible, the calcar screw should be used.
Instrumentation should allow for precise determination

of the nail’s proximal end.
• Countersunk proximal screw head reduces the risk of
e rs subacromial mechanical impingement.

e r s
b o ok Nail toggling:
b o ok b o o
e/ e e / e
• With two sizes, the diameter of the nail can be adapted
e /e
://t
to the diameter of the medullary cavity.
. m : / / t . m
t t p s
• Angular stability, also distal if required, is possible with
tps
ht
the angular stable locking system.
h
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Importance of correct entry portal
m e / m e/e
CASE 16
/ / t . / / t .
Patient
htt ps:
An 88-year-old woman had a fall from standing height. She was
living alone and had good cognitive function at baseline. The patient htt ps:
a dvantage any longer. The authors’ experience has shown that this
can be compensated with a slight valgus reduction, or else a differ-
sustained a 3-part greater tuberosity (GT) fracture (HL-G-S), yet the ent operative procedure, eg, angular stable plate, has to be chosen.
GT was not displaced (Fig 3.1-30a–c). The reconstruction showed the entry point problem and consecutive
loss of reduction as shown in Fig 3.1-30d–f. Since the insertion was
e rs
r s
lateral, the “fifth” anchoring point was not established (Fig 3.1-30g–i).
e
b o ok The contralateral side was a 2-D reconstruction along the shaft axis;
the shape of a straight nail with 8.5 mm in diameter was superim-
bo ok
Progressive displacement of the reconstruction proved the insuffi-
ciency of the implant (Fig 3.1-30j–k). When the implant becomes
b o o
e/ e e/ e
posed (Fig 3.1-30d–f). Note the estimated insertion site at the lateral
end of the head fragment, even involving part of the supraspinatus
insufficient, the course of the fracture healing process cannot be
predicted (Fig 3.1-30l–m). In this case the patient accepted limited
e/e
/ t .m
footprint. This situation is critical in the use of antegrade straight
: / / t .m
range of motion (90° flexion, external rotation 10°, internal rotation
: /
tps tps
nails, as the so-called “fifth anchoring point” does not offer an to L1), as she could reach her head and pain was tolerable.
ht ht
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
a
htt ps:
b c
htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
d e f
Fig 3.1-30a–m An 88-year-old woman after a fall.
k e rs GT fragment.
ke rs
a–c X-rays showing a 3-part greater tuberosity (GT) fracture without displaced GT. Note the lateral comminution creating a medium length
oo oo o
d–f The contralateral side is a 2-D reconstruction along the shaft axis; the shape of a straight nail with 8.5 mm in diameter is superimposed.
eb b
Note the estimated insertion site at the lateral end of the head fragment, even involving part of the supraspinatus footprint.
e b o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
231
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
://t.m .m
g h i j k
s : / / t
h t t p ht tps
e r s e r s
ook ok o
Fig 3.1-30a–m (cont) An 88-year-old woman after a fall.
e b e b o
g–i Due to the later insertion, the “fifth” anchoring point is not established. Note
b o
/ e/ e/e
the intraoperatively fractured lesser tuberosity (LT) and the displacement of
e t . m
the LT fragment.
j–k X-rays showing progressive displacement of the reconstruction.
t . m
l m
/ / / /
ps: ps:
l–m X-rays showing insufficient implant.
htt htt
Wrong entry point leads to change of procedure
CASE 17
Patient
e rs A 72-year-old male patient presented with a low-energy proximal

r s
without aligning it with the humeral canal, resulting in severe mal
e
b o ok humeral fracture. The patient sustained an unstable, displaced 2-part
surgical neck fracture (HGL-S).
b o ok
alignment when the straight nail was introduced (Fig 3.1-31g). In an
effort to achieve better reduction by manipulating the nail, the head
b o o
e/ e Comorbidities
e / e fragment cracked and the greater tuberosity split off from the head.
Shoulder hemiarthroplasty was then the treatment option selected.
e /e
• Type 2 diabetes
://t . m : / / t . m
• Hypertension
t t p s tps
Postoperatively, the tuberosities were anatomically fixed (Fig 3.1-
ht
• Chronic obstructive pulmonary disease 31i–j). In the following weeks, the tuberosities resorbed and the
• Osteoporosis
• Hyperparathyroidism
h head was migrating cranially (Fig 3.1-31k–l). The patient had only
little pain, but the overall result was poor with less than 40° of
abduction and flexion, 0° of external rotation and internal rotation
Treatment and outcome to the gluteal region.
k e rs The patient was scheduled for antegrade nailing after informed

consent (Fig 3.1-31–b). The computed tomographic scans provided
ke rs
Conclusion
eb oo no additional information for the chosen treatment (Fig 3.1-31c–e).
e b oo
Prosthetic standby may be necessary even in relatively simple
b o o
e/e
cases if severe complications are identified intraoperatively. Prolonged
e / e /
The guide wire might have been placed too far anterior or lateral
m
surgical time combined with increased iatrogenic trauma and co-
m
/ /t .
(Fig 3.1-31f–h). If this was the case, the direction of the guide wire
t .
morbidities increase the risk of complications like infection, malunion
//
ps: ps:
was not checked properly. The hollow reamer was then driven in of the tuberosities, or reabsorption.
232
htt htt
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e a b
e/ e e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e b ook c d e
e b o ok b o o
/ e/ e/e
Fig 3.1-31a–l A 72-year-old man with a
e t . m
proximal humeral fracture.
t . m
a–b X-rays showing unstable, displaced
/ / / /
ps: ps:
2-part surgical neck fracture.
c–e Computed tomographic scans of the
htt htt
fracture.
f–h The guide wire was possibly placed too
far anterior or lateral and the hollow
reamer then driven in without align-
ing it with the humeral canal. When
introducing the straight nail, severe
e rs e r s malalignment must result ( g).
ok ok
i–l P
ostoperative anatomical fixation of
b o b o the tuberosities (i–j), resulting in the

tuberosities resorbing and the head
b o o
e/ e f g
e / e h
migrating cranially in the following
e /e
://t . m weeks (k–l).
: / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
ps: ps:
i j k l
htt htt 233
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 4.3.4 Aftercare
t . m e / • Stable and anatomical reconstruction as well as immedi-
t . m e/e
s: / / / /
ps:
Physiotherapy programs following antegrade nailing are ate postoperative physiotherapy are decisive factors in
http htt
similar to the ones following plating. achieving a good result. The decision to go for SHA may
be taken intraoperatively if attempts to fix the fracture
4.3.5 Outcome with preservation of the humeral head fail.
Reports about procedures with the latest generation of nails
designs are sparse, especially with regard to the geriatric An arthroplasty set should be readily available (Case 17:
e rs
population.
er s
Fig 3.1-31). The best outcome after fracture arthroplasty results
from surgery on day 6 according to the Swedish registry.
b o ok Lopiz et al [63] observed that 9 of 26 patients had rotator

cuff symptoms and 11.5% needed reoperations with the
bo ok
Thus, fractures that are likely to require a joint replacement
procedure should only be operated on if an optimal infra-
b o o
e / e MultiLock nail.
e/ e structure is available.
e/e
: // t .m
Hatzidakis et al [66] reported that the fractures of 38 patients 4.4.2 Approach
: / / t .m
tps
aged 65 years on average were treated with an angular
ht
stable locked antegrade nail. All fractures healed primarily.
The mean follow-up Constant score (and standard deviation) ht tps
The approach most widely used for the anatomical fracture
arthroplasty is the deltopectoral approach which can be
minimally invasive. When releasing the deltoid muscle close
was 71 ± 12 points (range: 37–88 points), with a mean to the clavicle and all the way down to its humeral insertion,
age-adjusted Constant score of 97% (range: 58–119%). All the muscle can be retracted far posteriorly in abduction
fractures but one healed with a neck-shaft angle of
giving full exposure to all aspects of the proximal humerus.
e r s ≥ 125°.
e r s
ook ok o
As mentioned earlier, performing a tenodesis of the long
e b Despite improved locking options and anatomical initial

e b o head of the biceps (LHB) tendon to prevent scarring of an
b o
e / e/
reduction, a minor loss of reduction into varus but without
m
any implant perforations can often be observed. The clinical
t .
insufficient LHB to the SSC-SSP-interval with subsequent
pain and loss of ROM is strongly recommended. Techni-
t . m e/e
/ /
significance has not yet been investigated sufficiently. Al-
/ /
cally, the interval between the SSC and SSP muscles should
ps:
though this may be interpreted as an implant failure, cut-
htt
through or cut-out seem to occur less frequently than in
plate fixation. Fracture healing improves the situation, but htt ps:
not be dissected. The LHB can be sutured to the upper pec-
toralis tendon and cut directly above. The proximal part of
the tendon is resected intraarticularly, in case of fracture
some malalignment is expected. arthroplasty after the head fragment is removed.
4.4 Shoulder hemiarthroplasty 4.4.3 Typical complications
e rs
Because of unpredictable results of shoulder hemiarthro-
r s
Insufficient fixation, malpositioning and resorption of the
e
b o ok plasty (SHA), surgeons tend to choose between fracture
b o
fixation and reverse arthroplasty (Case 18: Fig 3.1-32). If re- ok
tuberosities:
b o o
e/ e / e
construction is not possible possible, the tuberosities are
e
often not good enough to expect anatomical healing and
• Healing in anatomical position is essential for the result
of hemiarthroplasty. “Embracing” fixation of the tuber-
e /e
function with SHA.
://t . m /
osities offers superior fixation strength, even more so
: / t . m
t t p s when applied with flexible cables.
tps
ht
4.4.1 Indications • With most systems, the slim metaphyseal part of the stem
h
• Shoulder hemiarthroplasty may be indicated in nonre-
needs cancellous bone graft underneath the tuberosities to
create the bony socket needed for the fixation in the ana-
constructible 3- and 4-part PHFs, head-split injuries and tomical position. Without this support, the tuberosities are
fracture dislocations in older patients. pulled to the metaphyseal stem with the embracing cerclage
k e rs
• Suspected AVN does not necessarily require joint replace-
ment as long a stable anatomical reconstruction and
ke rs
wires, which results in too low a position. Usually the whole
cancellous part of the head fragment is interposed.
eb oo fixation can be achieved.
e b oo
• Resorption of the tuberosities or consecutive cranializa-
b o o
e/e
tion of the SHA is the reason for inferior functional results
e / m e / comparable to cuff-deficient shoulders. In the worst case

m
/ /t . t .
scenario an anterosuperior escape with a painful disabling
//
ps: ps:
upper extremity might be the result.
234
htt htt
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Typical course of a shoulder hemiarthroplasty
m e / m e/e
CASE 18
/ / t . / / t .
Patient
htt ps:
A 77-year-old male patient sustained a 4-part fracture (H-G-L-S) with
severely displaced fragments after a fall from a ladder (Fig 3.1-32a–b). htt ps:
that time a lower plexus lesion was diagnosed. Four months later, the
proximal humerus was migrating upward indicating an insufficiency
of more than two tendons of the rotator cuff (Fig 3.1-32e–f). Hetero-
topic bone formation was also present indicating the severe soft-tissue
Comorbidities trauma. Eighteen months after the fall, the patient had pain; the range
• Prostate cancer diagnosed 5 years ago of motion of the shoulder was 30° of forward flexion, 0° of external
e rs
• No relevant other comorbidities present
r s
rotation, and when internally rotating he could reach the outer gluteal
e
bo ok
region (Fig 3.1-32g–i). All parts of the deltoid muscle were working.
Almost 3 years after the index trauma the revision to a cemented long
b o o
e / e e/ e
The fracture was considered unsuitable for stable anatomical recon-
struction and treated with an anatomical head-shaft angle with embrac-
stemmed reverse shoulder arthroplasty was carried out, as the patient
had been operated in 2010 for a colon carcinoma (Fig 3.1-32j–k).
e/e
/ t .m
ing flexible cables (Fig 3.1-32c–d). The tuberosities were in a good
: / / t .m
The patient was pain free, function was limited to 80° of forward
: /
tps tps
position and the glenohumeral joint was centered in both planes. By flexion, 0° of external rotation, and the patient could reach the buttocks.
ht ht
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
ps: ps:
a b c d
htt htt
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
e f
t t p s g h i
tps
h ht
Fig 3.1-32a–k A 77-year-old man after a fall from a ladder.
a–b X-rays showing a 4-part fracture with severely displaced fragments.
c–d The tuberosities were in a good position and the glenohumeral joint
k e rs ke rs
centered in both planes.
e–f X-rays taken 4 months later: note the ongoing upward migration of the
eb oo e b oo
proximal humerus indicating an insufficiency of more than two tendons of
the rotator cuff. Heterotopic bone formation is also present indicating the
b o o
e /
t . m e / severe soft-tissue trauma.
g–i X-rays 18 months after the fall.
t .m e/e
/ / /
j–k Almost 3 years after the index trauma, the revision to a cemented long
/
ps: ps:
j k stemmed reverse shoulder arthroplasty was carried out.
htt htt 235
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
Incorrect height and retroversion of the implant are other 4.4.5 Outcome
t . m e/e
s: / / / /
ps:
factors of major importance. The most accurate reference is The outcome of an individual patient is difficult to predict.
http htt
the length of the medial head extension, which can be mea- The results of managing pain are generally good, yet the
sured accurately. With the shaft dislocated for preparation functional results may vary extremely from very good to
and implantation of the shaft component, the head can be unsatisfactory. Anatomical healing of the tuberosities yields
anatomically reduced and in many cases the anatomical good results, outperforming those of RSA (Case 19: Fig 3.1-33).
retrotorsion of the given patient can be mimicked perfectly. Unfortunately, in contrast to the latter, results of SHA are
e s
Too much retrotorsion puts excessive strain on the GT fix-
r
ation, as it has to be reattached more anteriorly, which po-
er s
much less predictable. Radiographic healing can be expect-
ed in about 60% of patients and depends greatly on the
b o ok tentially leads to more healing problems.
bo ok
selection of patients [67].
b o o
e/ e 4.4.4 Aftercare
e/ e Cuff et al [67] followed up 47 patients, aged 74.4 years on
e/e
: // t .m
Early passive ROM is essential to avoid stiffness. Immobili-
zation has not been proven to increase the healing rate of
average, with 3- and 4-part fractures prospectively for a
:
minimum of 2 years. Three patients (13%) in the hemi
/ / t .m
ht tps
the tuberosities but the problem of stiffness.
ht tps
arthroplasty group preferred revision to RSA because of
failed tuberosity healing and resultant shoulder pseudo
paresis. Reverse shoulder arthroplasty resulted in better
clinical outcomes and a similar complication rate compared
with hemiarthroplasty for the treatment of comminuted
PHFs in older adults.
e r s e r s
ook ok o
Ferrel et al [68] performed a systematic review to compare
e b e b o SHA and RSA; they found no significant clinical difference

b o
e /
t . m e/ in either the American Shoulder and Elbow Surgeons Shoul-
der Score (RSA: 64.7, Hemi: 63.0) or the Constant score
t . m e/e
/ / / /
(RSA: 54.6, Hemi: 58.0). Reverse shoulder arthroplasty was
htt ps: htt ps:

associated with an increased rate of clinical complications
(9.6%) and a lower revision rate (0.93%) at short-term to
medium-term follow-ups compared with hemiarthroplasty.
They concluded that “RSA offers an acceptable surgical op-
tion for patients after complex acute PHFs”.
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Healing of tuberosities is unpredictable
m e / m e/e
CASE 19
/ / t . / / t .
Patient
htt ps:
An 87-year-old man suffered a 3-part greater tuberosity head-split
fracture (HL-G-S) resulting from low-energy trauma (Fig 3.1-33a–b). htt ps:
The postoperative series showed good alignment of the tuberosities
and a centered glenohumeral joint (Fig 3.1-33e–f).
Comorbidities At the 4-year follow-up, the healing of the tuberosities was success-
• Condition after cerebral stroke with full recovery and good com- ful (Fig 3.1-33g–h). The joint was centered, the patient was pain free
e rs pliance
r s
and had an almost full range of motion. The absolute values of the
e
b o ok • Type 2 diabetes
bo ok
Constant score were 74 points compared to 81 for the healthy
uninvolved extremity.
b o o
e/ e Treatment and outcome
e/
The supraspinatus tendon insertion was intact, and the muscle e Discussion
e/e
/ t .m
belly was without any fatty degeneration or atrophy (Fig 3.1-33c).
: / / t .m
Although the patient’s result is exceptionally favorable, anatomical
: /
tps tps
The reconstruction (Fig 3.1-33d) revealed that the lesser tuberosity healing of the tuberosities is unpredictable. Nowadays, a combina-
ht ht
was still attached to the head fragment, and due to the pull of the tion of an 87-year-old man, diabetes mellitus and a nonreconstruc-
subscapularis (SSC) tendon the shallow head fragment was rotated table head-split fracture would be treated with a reverse shoulder
internally. The muscle belly of the SSC was without atrophy and arthroplasty giving a reasonable result independently of the healing
fatty infiltration. of the tuberosities.
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
a b c d
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
kers kers
e f g h
Fig 3.1-33a–h An 87-year-old man with a low-energy trauma.
b o o o o
a–b X-rays showing a 3-part greater tuberosity head-split fracture.
b
c–d Supraspinatus tendon insertion was intact, the muscle belly was without any fatty degeneration or atrophy (c). The reconstruction (d)
b o o
e /e head fragment was rotated internally.
t . e/e
revealed that the lesser tuberosity was still attached to the head fragment, and due to the pull of the subscapularis tendon, the shallow
m t .m e/e
/
e–f The postoperative series showed good alignment of the tuberosities and a centered glenohumeral joint.
/ //
ps: ps:
g–h The 4-year follow-up x-rays showed successful healing of the tuberosities with the joint centered.
htt htt 237
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 4.5 Reverse shoulder arthroplasty
t . m e / 4.5.3 Approach
t . m e/e
s: / / / /
ps:
Due to the unpredictability of SHA results, RSA is used more In the literature for primary cuff tear arthropathy, arthro-
http htt
often in orthogeriatric patients. Especially in patients older plasty with RSA, deltopectoral or superior lateral approach-
than 75 years, there seems to be consensus on the use of a es are described. The superior lateral approach is associated
primary RSA if a stable and anatomical reconstruction is with a lower risk of instability and lower incidence of con-
not possible. Results are promising and unaffected by the secutive acromial and scapular spine fractures. In the acute
status of the tuberosities healing. Therefore rehabilitation fracture setting, instability seems to play an inferior role
e rs
is less critical or even unnecessary.
er s
and perfect exposure of the bony glenoid seems essential to
lower the risk of malpositioning of the metaglene and con-
b o ok Be aware that a functioning deltoid muscle is essential and
bo
in the fracture setting the testing might be difficult at times. ok
secutive loosening or scapular notching. Therefore the del-
topectoral approach remains the main approach in acute
b o o
e / e e/ e
Reverse shoulder arthroplasty results in better functional fracture care, as it leaves all options open, including complex
e/e
: // t .m
scores than SHA, especially in forward flexion, whereas the
RSA result for external rotation is lower than that for SHA.
revision if needed.
: / / t .m
tps
The complication rate seems not considerably higher for
ht
patients undergoing RSA compared to SHA, and yet it ac-
counts for lower revision rates.
4.5.4 Implant selection
ht tps
Currently, there are more than 20 different systems on the
market. Medialized or lateralized RSA systems are available.
As all systems promote their given designs, it is difficult to
4.5.1 Indications choose.
e r s• Complex 3- and 4-part fractures that are not suitable for

e r s
4.5.5 Fixation of the tuberosities
ook ok o
a stable and anatomical reconstruction due to poor bone Rival concepts concerning repair of the tuberosities fuel an
e b quality.
e b o ongoing debate. Total resection of the tuberosities to full
b o
e / e/
• Fractures that have “short” and comminuted tuberosities
m
and a high risk of losing the tuberosities when treated
t .
repair maintaining the full cuff (including SSP) are described.
In order to gain more external rotation, some surgeons ad-
t . m e/e
with SHA.
/ / / /
vocate cutting the SSC tendon or resecting the LT and pe-
ps:
• Head-split fractures are selected for SHA or RSA under
htt
the same criteria as already mentioned.
• Preexisting computed tomographic angiography (Case 20: htt ps:
forming an isolated repair of the GT. The authors resect the
SSP and the upper part of ISP with their bony attachment
and fix the LT and the remaining GT with cerclage sutures
Fig 3.1-34). to the prosthesis.
4.5.2 Contraindications For detailed description of the technique, see Reuther et al
e rs [69].
e r s
b o ok • Substantial glenoid bone loss or lack of glenoid bone stock
o
might be a contraindication. Complex bony reconstruc-
b ok
4.5.6 Typical complications
b o o
e/ e / e
tion and revision of metaglene fixation is not yet being
discussed for acute fracture care.
e • Scapular notching is the most common complication,
e /e
://t . m
• Axillary nerve deficiency or palsy. An intact deltoid mus-
/
responsible for polyethylene wear and consequent loos-
: / t . m
t t p s
cle is vital for a functional RSA, therefore axillary nerve ening.
tps
ht
investigation is crucial in the acute fracture patient. Re- • Acromial or scapular spine insufficiency fractures due to
h
verse shoulder arthroplasty is contraindicated in this
situation as the increased risk for instability and the ex-
the high stress levels on the implant-bone-interface are
reported.
pected low functional result do not outweigh the risk of • The risk of infection is supposed to be higher in RSA
the intervention. fracture arthroplasty compared to SHA; however this
k e rs ke rs
could not be proven in recent systematic reviews.
• Neuropathy and instability are other typical complications.
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 4.5.7 Outcome
t . m e /
t .
flexion and functional outcome of RSA, whereas in their
m e/e
s: / / / /
ps:
Three recent systematic reviews and metaanalyses [68–71] study complication rates did not differ substantially. Ferrel
http htt
compare RSA and SHA for acute fracture care. The results et al [68] stated better forward flexion, lower external rota-
concerning complication rates, functional outcome, revision tion, but no statistical differences according to the American
rates, and cost factors are conflicting. Shoulder and Elbow Surgeons Shoulder Score (RSA: 64.7,
Hemi: 63.0) or the Constant score (RSA: 54.6, Hemi: 58.0).
According to Namdari et al [71] both systems have the po- Complication rates for RSA were higher, yet in contrast with
e s
tential to restore pain-free function. They believe that the
r
higher complication rates and costs in RSA should be con- SHA.
er s
this finding revision rates were lower compared with the
b o ok sidered individually. Mata-Fink et al [70] saw better forward
bo ok b o o
e/ e e/ e e/e
Patient
: // t .m : / / t .m
CASE 20
tps
A 78-year-old woman fell from a standing height, sustaining a 2-part
ht
surgical neck fracture (HGL-S) (Fig 3.1-34a–c). One year prior to the
fall the patient was treated with a proximal femoral nail antirotation ht tps
The fracture was addressed with a reverse shoulder arthroplasty
and the tuberosities were reattached in an overlapping mode (tile
technique) with embracing sutures. The supraspinatus muscle and
for a pertrochanteric fracture. No relevant comorbidities are present upper part of infraspintus muscle inserted on top of the greater
and the patient is not cognitively impaired. tuberosity was released (Fig 3.1-34g–h).
e r s
e r s
At the 2-year follow-up the patient herself was satisfied, as her range
ook ok o
The patient sustained a 2-part surgical neck fracture (HGL-S) of motion was 140° of flexion, external rotation in 0° of abduction
e b b
(Fig 3.1-34a–c). She was known from the shoulder outpatient de-
e o was -10°, and in internal rotation she could reach the lower lumbar
b o
e / e/
partment (see Fig 3.1-2, Fig 3.1-3, Fig 3.1-4). Reconstruction in the
m
presence of a preexisting computed tomographic angiography in a
t .
spine. She continued to live independently and could even do some
gardening (Fig 3.1-34i–j).
t . m e/e
/ /
78-year-old patient was not indicated (Fig 3.1-34d–f).
/ /
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
a
h b c
Fig 3.1-34a–j A 78-year-old woman after a fall from standing height.
a–c X-rays showing a 2-part surgical neck fracture.
ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
239
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok d e
bo ok f
b o o
e/ e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
ps: ps:
g h i j
htt htt
Fig 3.1-34a–j (cont) A 78-year-old woman after a fall from standing height.
d–f A preexisting computed tomographic angiography.
g–h Tuberosities reattached in an overlapping mode with embracing sutures. The supraspinatus muscle and upper part of infraspintus muscle
inserted on top of the greater tuberosity is released.
i–j Two-year follow-up x-rays.
e rs e r s
b o ok 4.6 Summary
b o ok b o o
e/ e / e
Reconstruction of complex orthogeriatric PHF remains chal-
e
lenging and high complication rates are reported. In se-
e /e
://t . m
lected patients and with stable and anatomical reconstruc-
: / / t . m
t t p s
tion good results can be achieved. Supportive techniques
tps
ht
like allografts or implant augmentation with cement may
h
improve the outcome. Anatomical SHA is associated with
inconsistent results depending on the status of the tuber-
osities. In more recent studies with modern stem designs
and adequate embracing fixation of the tuberosities, results
k e rs
are comparable with RSA, consistently better regarding ex-
ternal rotation. Reverse shoulder arthroplasty is increasing
ke rs
eb oo in use for primary fracture care. Many surgeons advocate
e b oo b o o
e/e
the exclusive use of this type of joint replacement in patients
e / m e
aged 70 years and over, when treating complex 3- and 4-part/ m
t .
fractures. Outcome data are conflicting and the need for
/ / // t .
ps: ps:
prospective randomized studies is obvious.
240
htt htt
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 5 References
t . m e /
t . m e/e
/ / / /
htt ps:
1. Kralinger F, Blauth M, Goldhahn J, et al.
The Influence of Local Bone Density on
the Outcome of One Hundred and Fifty
Proximal Humeral Fractures Treated
11. Dimai HP, Svedbom A, Fahrleitner-
Pammer A, et al. Epidemiology of
proximal humeral fractures in Austria
between 1989 and 2008. Osteoporos Int.
ps:
24. Krappinger D, Roth T, Gschwentner M,
htt
et al. Preoperative assessment of the
cancellous bone mineral density of the
proximal humerus using CT data.
with a Locking Plate. J Bone Joint Surg 2013 Sep;24(9):2413–2421. Skeletal Radiol. 2012 Mar;41(3):299–304.
Am. 2014 Jun 18;96(12):1026–1032. 12. Lind T, Kroner K, Jensen J. 25. Roderer G, Scola A, Schmolz W, et al.
2. Olerud P, Ahrengart L, Ponzer S, et al. The epidemiology of fractures of Biomechanical in vitro assessment of
e rs Internal fixation versus nonoperative

treatment of displaced 3-part proximal
er s
the proximal humerus. Arch Orthop
Trauma Surg. 1989;108(5):285–287.
screw augmentation in locked plating
of proximal humerus fractures. Injury.
ok ok
humeral fractures in elderly patients: 13. Robinson CM. Proximal humerus 2013 Oct;44(10):1327–1332.
b o a randomized controlled trial. J Shoulder

Elbow Surg. 2011 Jul;20(5):747–755.
o
fractures. In: Bucholz RW, Court-
b
Brown CM, Heckman JD, et al, eds.
26. Unger S, Erhart S, Kralinger F, et al.
The effect of in situ augmentation
b o o
e/ e 3. Sudkamp N, Bayer J, Hepp P, et al.
Open reduction and internal fixation of
e/ e
Fractures in Adults. Philadelphia:
Lippincott Williams & Wilkins;
on implant anchorage in proximal
humeral head fractures. Injury.
e/e
proximal humeral fractures with use of
:
the locking proximal humerus plate.
// t .m 2010:1039–1105.
14. Nguyen TV, Center JR, Sambrook PN,
: / / t .m
2012 Oct;43(10):1759–1763.
27. Gradl G, Knobe M, Stoffel M, et al.
tps tps
Results of a prospective, multicenter, et al. Risk factors for proximal Biomechanical evaluation of locking
ht ht
observational study. J Bone Joint Surg humerus, forearm, and wrist fractures plate fixation of proximal humeral
Am. 2009 Jun;91(6):1320–1328. in elderly men and women: the Dubbo fractures augmented with calcium
4. Einsiedel T, Becker C, Stengel D, et al. Osteoporosis Epidemiology Study. Am J phosphate cement. J Orthop Trauma.
Frakturen der oberen Extremität beim Epidemiol. 2001 Mar 15;153(6):587–595. 2013 Jul;27(7):399–404.
geriatrischen Patienten—Harmlose 15. Euler SA, Kralinger FS, Hengg C, et al. 28. Krappinger D, Bizzotto N, Riedmann S,
Monoverletzung oder Ende der Allograft augmentation in proximal et al. Predicting failure after surgical
Selbstständigkeit? Eine prospektive humerus fractures. Oper Orthop fixation of proximal humerus fractures.
e r s Studie zum Outcome nach distaler

r s
Traumatol. 2016 Jun;28(3):153–163.
e
Injury. 2011 Nov;42(11):1283–1288.
ook ok
Radius- und proximaler 16. Euler SA, Hengg C, Wambacher M, et al. 29. Gallo RA, Sciulli R, Daffner RH, et al.
b
Humerusfraktur bei über 65-jährigen
[Do injuries of the upper extremity in
Allogenic bone grafting for
b o
augmentation in two-part proximal
Defining the relationship between
rotator cuff injury and proximal
b o o
e / e geriatric patients end up in
helplessness? A prospective study for
e/ e
humeral fracture fixation in a high-risk
patient population. Arch Orthop Trauma
humerus fractures. Clin Orthop Relat
Res. 2007 May;458:70–77.
e/e
the outcome of distal radius and
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tps
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rs rs
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k e Arch Orthop Trauma Surg. fractures—a case study.
ke 71. Namdari S, Horneff JG, Baldwin K.
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eb
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reverse arthroplasty for treatment of
b o
e/e
Konservative Therapie dislozierter The PHILOS plate for proximal humeral proximal humeral fractures: a
e / proximaler Humerusfrakturen
[Conservative treatment of dislocated
m e /
fractures—risk factors for complications
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m
2013 Sep 18;95(18):1701–1708.
/t .
proximal humeral fractures]. Zentralbl
/
2012 Mar;72(3):783–792.
// t .
ps: ps:
Chir. 2001 Mar;126(3):205–210.
German.
242
htt htt
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
Clemens Hengg, Vajara Phiphobmongkol
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
3.2 Humeral shaft / / / /
htt ps:
htt ps:
e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e Usually plain x-rays in AP and lateral including the adjacent
e/e
: // t .m
Humeral shaft fractures are common in geriatric patients
: / / t .m
joints are sufficient for diagnosis and classification.
ht tps
with a clinically significant impact on upper extremity func-
tion, independence, gait, balance, and mobilization.
ht tps
Complex or combined fractures of the shaft and the proxi-
mal or distal end of the humerus should be assessed with
computed tomographic (CT) scan.
Historically, nonoperative treatment has been common.
However, surgical fixation may restore patients’ indepen- The AO/OTA Fracture and Dislocation Classification is
dence more rapidly and allow for safer mobilization. As with recommended and can be applied to older patients as well.
e r s
proximal humeral fractures, treatment recommendations
e r s
ook ok o
depend in part on surgeon experience, skills, and preference.
e b e b o
4 Decision making
b o
e / 2 Epidemiology and etiology
t . m e/ 4.1 Nonoperative treatment
t . m e/e
: / / / /
Historically, nonoperative treatment has been widely used
h t p s
Humeral shaft fractures account for 1–3% of all fractures
t
[1]. They are less frequent than fractures of the proximal
humerus. In one series of 2011 humeral fractures 79% were htt ps:
for these injuries [3]. The authors prefer conservative treat-
ment especially in simple long spiral fractures. However,
short oblique or transverse fractures are also suitable for
proximal, 13% shaft, and 8% distal humeral fractures [2]. nonoperative treatment [4, 5].
Fractures of the humeral shaft have a bimodal age distribu-
tion, with a minor peak in the third decade and a major The risk of nonunion and impaired shoulder function after
e rs
peak in the eighth decade. In the younger population, most
r s
nonoperative treatment must not be underestimated (Case 1:
e
b o ok fractures occur in men and are predominantly due to high-
b o
energy trauma. In older adults, simple falls are the most ok
Fig 3.2-1).
b o o
e/ e /
common mechanism of injury and the overwhelming ma-
jority are in women [2].
e e If nonoperative treatment is considered, bone fragments
must align and approximate without suspicion of interposed
e /e
://t . m muscle tissue.
: / / t . m
t t p s tps
ht
3 Diagnostics and classification It may be necessary to revise the decision for nonoperative
h
Patients present with arm pain, swelling and hematoma.
treatment if bone healing appears unlikely and/or if the
burden of nonoperative treatment mainly in terms of pain
Depending on the amount of fracture displacement, axis and and functional restriction cannot be handled by the patient
rotation of the arm may deviate. The arm may be shortened (Case 2: Fig 3.2-2) [6, 7].
k e rs
and may demonstrate crepitus with manipulation. A careful
neurovascular evaluation of the extremity is essential.
ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
243
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
3.2 Humeral shaft
k e rs ke rs
e b oo e b oo b o o
e / Patient
. m e /
. m e/e
CASE 1
/ / t
An 82-year-old man had an unobserved fall. He sustained a fracture
/
Operative treatment—The nonunion was explored and reduced
/ t
Comorbidities htt ps:
of the right humerus (Fig 3.2-1a–b).
htt ps:
using an anterior approach by pushing the biceps muscle medi-
ally and performing a centric split of the upper portion of the bra-
chialis muscle. Reduction was retained temporarily with a reduction
• Alcoholism clamp, while the antegrade nailing was performed (Fig 3.2-1i–j).
• Renal failure The anterolateral approach was used for nailing and the anterior
• Failure to thrive approach to the humeral shaft was used for addressing the nonunion
e rs er s
(Fig 3.1-2k).

Decision making—Due to the fracture type, general state of the
bo ok
Postoperative—Anatomical fracture fixation was achieved with no
b o o
e / e e/ e
patient (eg, alcoholism and frailty), and concerns for noncompliance,
nonoperative fracture treatment was chosen. The x-rays showed
soft-tissue complications and little pain (Fig 3.2-1l–m). At the
6-month follow-up, the fracture had healed with restoration of
e/e
/ t .m
the initial position in a hanging cast (Fig 3.2-1c–d).
: / adequate function (Fig 3.2-1n–r).
: / / t .m
ht tps
Course of treatment—After 3 weeks, the fracture was significantly
displaced by the traction of the deltoid muscle with fracture angula- ht tps
tion of 45°. Due to inability to comply with immobilization the frac-
ture reduction could not be maintained with bracing (Fig 3.2-1e–f).
The patient had little pain and no soft-tissue problems. After 5 weeks
e r s the situation was unchanged so the treatment decision was revised
e r s
ook ok
(Fig 3.2-1g–h).
b b o b o o
e / e e/ e e/e
/ / t . m / /t . m
htt ps: htt ps:
e rs e r s
o ok ok o
/ebo o
a b c d Fig 3.2-1a–r An 82-year-old man
e/ e b e
with a right humeral fracture.
a–b Closed spiral fracture of
e /e b
://t . m the proximal shaft of the
/ / t .
right humerus (AO/OTA 12A1)
: m
t t p s tps
without comminution.
ht
c–d AP (c) and lateral (d) views
h showing almost full restora-

tion of the anatomical position
and acceptable displacement,
respectively.
e–f X-rays showing significant fracture
rs rs
displacement as a result of
k e ke noncompliance to immobilization.
oo oo o
g–h Postoperative x-rays at 5 weeks
eb e f g
e b h
showing a still significantly
b o
/ / e/e
d isplaced fracture.
e t . m e t .m
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e i j
e/ e e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e / k l
t . m e/
m
t . m e/e
/ / / /
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
n o
://t . m : / / t . m
t t p s tps
h ht
Fig 3.2-1a–r (cont) An 82-year-old
man with a right humeral fracture.
i–j Temporary reduction with a
clamp.
k Anterolateral approach (white
arrow) for nailing and anterior
k e rs ke rs approach (black arrow) to the

humeral shaft for treating the
eb oo e b oo nonunion.
l–m Postoperative x-rays.
b o o
e /
t . m e / n–r Postoperative x-rays (n–o) and
t .m
clinical photographs ( p–r) at
e/e
/ / /
6 months showing a healed
/
ps: ps:
p q r fracture with good function.
htt htt 245
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
3.2 Humeral shaft
k e rs ke rs
e b oo e b oo b o o
e / Patient
. m e /
. m e/e
CASE 2
/ / t
A 92-year-old woman with left humeral shaft fracture related to
/ / t
(Fig 3.2-2i). This provides significant stability of fixation in osteopo-
low-energy trauma.
Comorbidities htt ps: htt ps:

rotic bone, which even with the use of many locking head screws
may not be able to withstand the bending and rotational deforming
forces. Through a proximal incision of the deltoid split, PHILOS was
• Dementia inserted submuscularly into position on the lateral aspect of the
• Hypertension humerus. Correct positioning of the plate was confirmed through a
• Diabetes mellitus true AP x-ray of the proximal humerus using image intensification,
e rs • Osteoporosis
r s
then temporarily fixed with a K-wire (Fig 3.2-2j–k). The sharp bony
e
bo ok
spike of the proximal fragment was pushed into the intramedullary
canal of the distal fragment to create primary stability and the screws
b o o
e / e e/ e
History—The patient was initially treated with a sugar-tong splint and
arm sling in another hospital (Fig 3.2-2a–b). There was significant
were fixed in compression holes close to the fracture site to add
more stability (Fig 3.2-2l–m). An iliac bone graft was impacted in
e/e
/ t .m
displacement and angulation. At the 3-month follow-up (Fig 3.2-2c),
: / / t .m
the fracture gap on the medial side after complete plate fixation
: /
tps tps
the alignment was unacceptable and the skin was tenting with a (Fig 3.2-2n–p). Immediate postoperative x-rays showed good align-
ht ht
bone spike. The patient still had pain and there was no sign of bone ment and stable bone-implant construction (Fig 3.2-2q–r).
union. Despite this, this treatment plan was continued for 4 months.
Postoperative care—Gentle active assistive exercise for range of
Current situation—The treatment decision was revised to operative motion (ROM) of the shoulder and elbow were started on the
treatment. Soft-tissue irritation also was a cause of pain (Fig 3.2‑2d–f). second day postoperatively. No pushing or pulling were allowed
e r s e r s
until bone union (Fig 3.2-2s–t). The patient could flex the shoulder
ook ok
Diagnosis and classification—The initial diagnosis was closed fracture forward (Fig 3.2-2u–v), though her ROM was limited due to her
b
of the proximal shaft of the left humerus (AO/OTA 12A1). The
b o prolonged preoperative immobility and her dementia, both of which
b o o
e / e current diagnosis is nonunion.
e/ e limited rehabilitation capabilities. She could perform adequate,

pain-free flexion and extension of the elbow. Rotational movement
e/e
t . m
Indication for surgery—A painful nonunion of the proximal shaft of
/ / t . m
of the humerus was done gently in light of risk of screw failure due
/ /
ps: ps:
the left humerus. Skin complication due to bony spike. to severe osteoporosis. The patient had no pain and had good
htt htt
ability to perform daily living activities (Fig 3.2-2s–v).
Treatment planning:
• Fixation: open reduction and internal fixation (ORIF) with a narrow
locking compression plate and iliac bone grafting
• Positioning: supine on transparent x-ray table
e rs • C-arm: located on the opposite side

• Preparation and draping: from shoulder to hand and free to move
e r s
b o ok in any direction
• Surgical approach: anterolateral, direct reduction
b o ok b o o
e/ e e / e e /e
://t . m
Intraoperative technique—Soft tissues were removed at the fracture
site and the bone ends were freshened (Fig 3.2-2g). The sharp spike
: / / t . m
t p s
of the proximal fragment (Fig 3.2-2h) and the V-shaped cortical
t tps
h
fracture site of the distal fragment corresponding with the shape of
the proximal end (behind the sharp spike in Fig 3.2-2g) could be
seen. The incision was extended distally to identify and protect the
a b ht c
Fig 3.2-2a–v A 92-year-old woman with a fracture of the left hu-

radial nerve. The sharp spike of the proximal fragment was pushed meral shaft after a low-energy trauma.
into the intramedullary canal through a V-shaped opening of the a–c Initial AP (a) and lateral (b) x-rays showing significant displace-
k e rs distal fragment to create a stable bone construction before plating
ke rs
ment and angulation. The 3-month follow-up (c) showing unac-
ceptable alignment and no sign of bone union.
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
://t.m .m
d e f
s : / / t
h t t p ht tps
e r s e r s
e / g
t . m h e/ i
t . m e/e
: / / / /
h t t p s
htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
j
t t p s k
tps
ht
Fig 3.2-2a–v (cont) A 92-year-old woman with a fracture of the left humeral shaft after a low-energy trauma.
h
d–f Nonunion after 4 months.
g–h Removal of soft tissue at the fracture ends ( g). Note the sharp spike of the proximal fragment (h) and the V-shaped cortical fracture
site of the distal fragment.
i Clinical photograph showing the radial nerve (blue tape).
j–k Clinical photograph ( j) showing proximal incision of the deltoid-split approach and AP x-ray (k) of the proximal humerus.
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
247
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
3.2 Humeral shaft
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e la m
e/ e e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e / a
n o
t . m e/ p
t . m e/e
/ / / /
htt ps: htt ps:
e rs e r s
b o ok b o ok Fig 3.2-2a–v (cont) A 92-year-old woman
with a fracture of the left humeral shaft after
b o o
e/ e e / e a low-energy trauma.
l–m X-rays showing the proximal fragment
e /e
q r
://t . m / / t .
pushed into the distal fragment (l) and
the screws in compression holes close
: m
t t p s tps
to the fracture site (m).
ht
n–p X-rays and clinical photograph showing
h the iliac bone graft impacted into the

fracture gap on the medial side (n–o)
and the separate skin incisions of an-
terolateral and deltoid split approaches
( p), respectively.
k e rs ke rs q–r Immediate postoperative x-rays show-

ing good alignment.
oo oo o
s–v Postoperative x-rays and clinical pho-
eb e b tographs at 16 months showing bone

b o
/ / e/e
union (s–t) and adequate forward
e t . m e flexion of the shoulder and extension of

the elbow (u–v).
t .m
/ / //
ps: ps:
s t u v (Courtesy of Dr Suthorn Bavonratanavech)
248
htt htt
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 4.2 Operative treatment
t . m e / 4.3 Plating versus nailing
t . m e/e
s: / / / /
ps:
Operative treatment of the humeral shaft should be consid- Plating and nailing can achieve similar reduction. Antegrade
http htt
ered in the following situations: nailing can potentially cause shoulder pain or restricted
range of motion because the involvement of the rotator cuff.
• Inability to maintain nonoperative fracture reduction. We are not aware of any study focussing on shoulder prob-
This depends on fracture patterns and the degree of dis- lems after antegrade nailing in older patients [14].
placement, comminution, whether short oblique or trans-
k e rs verse fractures, as well as patient factors, such as obesity

or ability to comply with activity and weight-bearing
er s
In their metaanalysis, Liu et al [15] found that intramedul-
lary (IM) nailing appears comparable to plate fixation in
o o restrictions.
o ok
terms of rates of nonunion, postoperative infection, and
o o
e/eb b b
• Complicated mobilization because of concomitant frac- radial nerve palsy. The only minor difference they identified
tures of the lower extremities
e/ e was a higher delayed healing rate in patients treated with
e/e
: // t .m
• Bilateral humeral fractures: fixation of at least one side
to maximize the patient’s independence with activity
a nail.
: / / t .m
tps
• Ipsilateral fracture of the proximal or distal humerus,
ht
especially articular fracture extension
• Ipsilateral fracture of the elbow joint or forearm ht tps
Kumar et al [16] came to a similar conclusion in their pro-
spective study of 30 patients: finding that plating offered
advantages in less time to union, better joint function, and
• Open fractures reduced reoperation, whereas nailing offers a minimally
• Polytrauma invasive approach, less infection, less nerve injury, and less
• Pathological fractures chance of implant failure.
e r s
• Fractures associated with a neurovascular injury
e r s
ook ok o
Retrograde nailing became unpopular mainly because of
e b b o
In addition, operative fixation may help to preserve patients’
e
the somehow unpredictable risk of creating iatrogenic distal
b o
e / independence by earlier and safer mobilization.
t . m e/ humeral fractures while inserting the nail.
t . m e/e
/ /
Management of humeral shaft fractures associated with radial
/ /
As the literature does not clearly support a superior proce-
htt ps:
nerve palsy is controversial [8–11]. Radial nerve injury is a
common complication of humeral shaft fractures, occurring
in up to 18% of closed injuries [4, 12]; spontaneous recovery
also be considered.
htt ps:
dure, the experience and preference of the surgeon must
can be expected in 90% of cases at 4 months after injury. 4.4 inimally invasive plate osteosynthesis versus
M
open reduction and internal fixation
If there are no objective clinical signs of radial nerve recov- Selecting minimally invasive plate osteosynthesis (MIPO)
e rs
ery at 6 weeks postinjury (ie, return of brachioradialis, ex-
r s
or open reduction and internal fixation (ORIF) depends on
e
b o ok tensor carpi radialis longus, and brevis muscle function),
electromyography and nerve conduction studies should be
b o ok
the fracture type: in case of type A fractures (simple fracture),
ORIF is preferred to close the fracture, create adequate con-
b o o
e/ e / e
performed. In the absence of recovery at 12 weeks, as indi-
e
cated by clinical examination and neurophysiological testing,
tact, and reduce the strain of the fracture site [17].
e /e
://t . m
surgical exploration of the radial nerve is recommended [4].
/ t .
On the other hand, in case of type C (multifragmentary)
: / m
t t p s tps
fractures of the midshaft of the humerus, bridging plate with
ht
If in doubt, ultrasonographic assessment of the integrity of MIPO on the anterior surface is a good option, as the strain
h
the radial nerve may inform the treatment decision [13]. of the fracture sites is lower and the procedure preserves
the blood supply of the fragments [18, 19].
The treatment decision in type B fractures is controversial:
k e rs ke rs
it depends on many details such as size, type of wedge,
displacement, and quality of reduction, if indirect reduction
eb oo e b oo
leaves a significant gap and creates so-called high-strain
b o o
e/e
condition, ORIF to reduce the fracture with adequate soft-
e / m e / tissue handling is required to preserve nutritional soft-tissue

m
/ /t . attachment to the fracture fragments.
// t .
htt ps: htt ps:
249
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
3.2 Humeral shaft
k e rs ke rs
e b oo e b oo b o o
e / 5 Treatment
t . m e / After 2–3 weeks of cast immobilization, the authors switch
t . m e/e
s: / / / /
ps:
to functional bracing for 6–8 weeks until the fracture is
http htt
5.1 Nonoperative techniques healed.
The fracture should be reduced to ensure length, axis, and
rotation. Then it has to be immobilized (Desault plaster, shows nonoperative treatment of a
Case 3: Fig 3.2-3 [20, 21]
hanging cast, U-plaster splint). The achieved reduction midshaft humeral fracture.
should be documented and monitored radiographically.
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
Patient
t .m Discussion
t .m
CASE 3
: //
A 68-year-old woman fell and had right arm pain and swelling.
s : / /
Nonoperative treatment was possible in this case as there were
Comorbidities
• Hypertension http
many favorable factors including:
ht tps
• Mild displacement with adequate apposition visible on the initial
• Diabetes mellitus x-rays
• Previous cerebrovascular accident • Axial alignment was adequate with acceptable angulation
• Osteopenia • No distraction at the fracture site
e r s e r s
ook ok o
Treatment and outcome These x-ray findings reflect the condition of the periosteum around
e b Diagnosis—The diagnosis was a closed fracture of the right hu-

e b o the fracture which might be intact.
b o
e / no distraction (Fig 3.2-3a).
t . e/
meral shaft (AO/OTA 12A3). There was minimal displacement and
m t . m e/e
/ / / /
htt ps:
Treatment plan—Nonoperative treatment with a coaptation splint
and arm sling. After closed manipulation and immobilization in a
U-slab, AP and lateral x-rays of the right humerus showed adequate htt ps:
apposition (Fig 3.2-3b–c), the axial alignment was acceptable in
both views. X-ray at the 2-week follow-up with coaptation splint
showed that alignment was maintained (Fig 3.2-3d). At the 2-month
e rs follow-up, there were signs of callus formation at the fracture site

e r s
b o ok (Fig 3.2-3e–f). The patient had minimal pain, good elbow flexion/
b o
extension (Fig 3.2-3g–h), and forward flexion of the shoulder ok b o o
e/ e / e
(Fig 3.2-3i). At the 3-month follow-up, there was adequate callus
e
formation. The patient was pain free, and the splint was removed
e /e
(Fig 3.2-3j–k).
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
tps tps
a b c d e f
ht ht
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
g h i
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
Fig 3.2-3a–k A 68-year-old woman with a right humeral shaft fracture.
a Initial x-ray of the right humerus showing a transverse midshaft fracture with minimal displace-
ment and no distraction.
b–d A P and lateral x-rays of the right humerus showing adequate apposition (b–c) with acceptable
axial alignment. The 2-week follow-up x-ray showing maintained alignment (d).
e–i Two-month follow-up x-rays and clinical photographs showing callus formation at the fracture site
k e rs
j k
k rs
(e–f) with good elbow flexion/extension ( g–h) and forward flexion of the shoulder (i).
e
j–k X-rays 3 months postoperative showing adequate callus formation.
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
251
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
3.2 Humeral shaft
k e rs ke rs
e b oo e b oo b o o
e / 5.2
t . m
pen reduction and plate fixation in proximal
O e /
t . m e/e
/ / / /
ps: ps:
shaft fractures
htt htt
Open reduction and plate fixation with PHILOS plate via the
standard anterolateral approach is one treatment option for
long spiral fractures of the proximal shaft; additional wiring
helps achieve reduction, maintain alignment, and provide
stability (Case 4: Fig 3.2-4) [22, 23].
e rs er s
b o ok Patient
bo ok b o o
e e e/e
CASE 4
e/ fall with pain and deformity of the right arm.

t e/
An 80-year-old woman with severe osteoporosis. She had a minor
.m
Intraoperative technique—Direct reduction and wiring is simple and
.m
effective to reduce the fracture and maintain the alignment. Due to
t
: // : / /
the fracture location, PHILOS was selected. Plate positioning is cru-
Comorbidities
• Dementia
• Osteoporosis ht tps ht tps
cial and should be checked by image intensification. In true AP view,
proximal and distal temporary K-wire fixation ensures the correct
positioning (Fig 3.2-4g–i). As many locking head screws (LHSs) as
• Hypertension possible were used proximally together with four distal screws in
• Coronary heart disease this osteoporotic bone (Fig 3.2-4j–k). Postoperative x-rays in AP and
• Chronic kidney disease lateral views showed good alignment, implant positioning, and ad-
e r s • Thoracic and lumbar spine spondylosis with kyphoscoliosis.

e r s
equate fixation (Fig 3.2-4l–m). Leaving cerclage wires in place helps
ook ok o
Multiple thoracic compression fractures (Fig 3.2-4a–d) to maintain fracture stability in osteoporotic fractures. Lag screw
e b b o
• Severe osteoporosis with multiple levels of collapsed vertebra.
e
fixation was not used because lag screw application in osteopo-
b o
e / The patient had never been treated for osteoporosis.
t . m e/ rotic bone may not provide adequate stability and lead to iatro-
genic fractures.
t . m e/e
/ / / /
ps:
Diagnosis and classification—Closed fracture of the proximal shaft
htt
of the right humerus (AO/OTA 12A1), spiral fracture without com-
minution. A long spiral fracture is a common finding in geriatric htt ps:
Postoperative care—The rehabilitation program was started early for
the right shoulder and elbow. Early patient mobility and rehabilitation
is often necessary to prevent common complications and loss in
patients after low-energy trauma (Fig 3.2-4e–f). overall functional status. The postoperative x-rays at 2 months
(Fig 3.2-4n–o) revealed a stable construct without change in implant
Indications for surgery: position and the ones at 4 months (Fig 3.2-4p–q) showed good
e rs • Displaced fracture with severe pain

r s
bone healing. The patient could return to her daily activities without
e
b o ok • Malalignment in the proximal shaft after nonoperative treatment
b o
• Requirement for functional independence for acceptable quality
pain.
ok b o o
e/ e of life
e / e e /e
Treatment planning:
://t . m : / / t . m
t t p s
• Fixation: open reduction and internal fixation with PHILOS
tps
ht
• Positioning: supine on a radiolucent table, C-arm located on the
opposite side h
in any direction
• Surgical approach: deltopectoral approach with extension to the
k e rs anterolateral approach
ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
a
: // tb.m c d
: / / t .m
ht tps ht tps
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
ps: ps:
e f g h i
htt htt
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
j k
://tl. m m n
:o
/ / t . m
t t p s tps
h ht
Fig 3.2-4a–q An 80-year-old woman with multiple thoracic compression
fractures.
a–d X-rays showing severe osteoporosis with multiple levels of collapsed
vertebra.
e–f X-rays of a long spiral fracture.
k e rs ke rs
g–i Proximal and distal temporary K-wire fixation.
j–k Locking head screws used proximally together with four distal screws in
eb oo e b oo
this osteoporotic bone.
l–m Postoperative AP and lateral x-rays showing good alignment, implant
b o o
e /
t . m e / positioning, and adequate fixation.
t .m
n–o Two-month postoperative x-rays showing a stable construct without
e/e
/ / change in implant position.
//
ps: ps:
p q p–q F our-month postoperative x-rays showing good bone healing.
htt htt 253
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
3.2 Humeral shaft
k e rs ke rs
e b oo e b oo b o o
e / 5.3
t . m
pen reduction and plate fixation in distal shaft
O e /
t . m e/e
/ / / /
ps: ps:
fractures
htt htt
Distal humeral fractures can be nicely approached and fixed
by posterior approach and posterior plating (Case 5: Fig 3.2-5)
[24, 25].
e rs er s
b o ok Patient
bo ok b o o
e e e/e
CASE 5
e/ ously hemiparetic arm from a minor fall in her house 5 weeks

t e/
A 70-year-old woman sustained a left humeral fracture in a previ-
.m
Intraoperative technique—In prone position, the elbow was flexed
.m
to facilitate exposure and fracture reduction as gravity helped balance
t
: //
previously. She had persistent pain and deformity of the left arm
: / /
the rotational force. Skin markings to identify all structures were
ht tps
and no new neurological deficit. X-rays showed malalignment, a
large gap, and no sign of healing.
ht tps
important to clarify appropriate surgical orientation (Fig 3.2-5c), to
clearly identify the humerus, fracture site, olecranon, and course of
the radial nerve. Figure 3.2-5d shows the plane of dissection via a
Comorbidities lateral paratriceps approach. The radial nerve was identified proxi
• Coronary artery disease mally and along the course distally.
• Coronary artery bypass graft 3 years ago
e r s • Cardiac arrhythmia
e r s
The radial nerve was identified and protected during the entire
ook ok o
• Atrial fibrillation operation (Fig 3.2-5e–g). The plate was long and needed to be fixed
e b • Old cerebrovascular accident with left hemiparesis

e b o proximally to the area of the radial nerve crossing the posterior
b o
e / • Obesity
• Dementia
t . m e/ aspect of the midshaft of the humerus. The nerve was elevated and
t . m
freed from the humeral shaft, and then the plate was inserted close e/e
/ /
• Osteopenia on dual energy x-ray absorptiometry scan to the cortex, under the nerve.
/ /
htt ps:
Diagnosis and classification—Spiral fracture of the distal shaft of the htt ps:
Postoperative care—Early gentle range of motion (ROM) of the elbow
and shoulder. No pushing or pulling activity is allowed until the bone
left humerus (AO/OTA 12A1). The AP and lateral x-rays of the left heals. The fracture is in good alignment, and the patient could
humerus taken 5 weeks after nonoperative treatment showed ma- perform pain-free active ROM exercises of the elbow from 10° to
lalignment, a large gap, and no sign of healing (Fig 3.2-5a–b). 120° (Fig 3.2-5h–m).
e rs e r s
b o ok Indication for surgery—Displaced fracture of the humeral shaft with
failure of nonoperative treatment.
b o ok
Discussion
There were options in both surgical approach and implant selection:
b o o
e/ e Treatment planning:
e / e • An anterior approach and straight LCP anteriorly would be possible
but—due to short distal segment—may not result in adequate
e /e
• Open reduction and internal fixation
://t . m / t .
distal fixation. In addition, the distal tip of the plate and screws
: / m
t t p s
• Positioning: prone, on x-ray transparent table with the elbow
tps
should not be placed in the coronoid fossa and obstruct elbow
ht
flexed and dropped down at the side of the table flexion.
h
• C-arm: located on same side
• Anterolateral plating with contoured LCP on the anterolateral
surface was also an option, but the plate must be contoured well
in any direction in three dimensions and the radial nerve must also be identified
• Surgical approach: posterior approach, lateral paratriceps and protected.
k e rs • Implant: locking compression plate (LCP) extraarticular distal

humerus plate
ke rs
• Posterior plating with a well-designed anatomical plate for fixation
along the lateral column of the distal humerus and the more
eb oo e b ooproximal shaft provides good stability but the radial nerve must
b o o
e/e
be identified, protected, and elevated. In this case, the plate was
e / m e / placed carefully and the patient had no radial nerve complications.

m
/ /t . // t .
htt ps: htt ps:
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e a b c
e/ e d
e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e / e f
t . m g e/ t . m e/e
: / / / /
h t t p s
htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h i
h j k l
Fig 3.2-5a–m A 70-year-old woman with a fracture of the distal shaft of the left humerus.
m
ht
a–b AP and lateral x-rays of the left humerus at 5 weeks after nonoperative treatment showing malalignment, a large gap, and no sign of
healing.
c–d Skin markings to identify all structures and clarify appropriate surgical orientation (c). A lateral paratriceps approach used for the plane
k e rs of dissection (d).
ke rs
e–g The radial nerve was identified and protected during the operation (e). Immediate postoperative x-rays (f–g).
oo oo o
h–m X-rays showing 2 weeks (h–i), 5 weeks ( j–k), and 10 weeks (l–m) postoperative follow-up.
eb e b b o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
255
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
3.2 Humeral shaft
k e rs ke rs
e b oo e b oo b o o
e / 5.4
t . m
Anterior minimally invasive plate osteosynthesis e /
t . m e/e
/ / / /
ps: ps:
shows minimally invasive plate os-
Case 6: Fig 3.2-6 [19, 26]
htt htt
teosynthesis with anterior plating technique for humeral
shaft fracture (straight locking compression plate).
rs Patient
r s
CASE 6
ok e A 69-year-old man tripped and fell; he had pain and swelling in his
right arm.
ok e
After reduction was achieved and plate positioning was assured,
cortical screw fixation of the proximal and distal fragments was
o
eb o e bo initially preformed on each main fragment. This stabilized the frac-
b o
e/ Comorbidities
• Hypertension
t .m e/ ture and guided the plate closer to the anterior cortex. Then, locking
.m
head screws were fixed on each side of the fragment to stabilize
t e/e
• Osteoporosis
: // : / /
the whole shaft with relative stability. Three AP x-rays confirmed

ht tps
Diagnosis and classification—Long spiral intact wedge fracture of the ht tps
good alignment and screw fixation (Fig 3.2-6f–h). Further imaging
showed the bridging plate with relative stability (Fig 3.2-6j–k,
Fig 3.2‑6l–m). Four screws on each side of the fragment should be
midshaft of the right humerus (AO/OTA 12B2) (Fig 3.2-6a–b). adequate to stabilize the fracture in relative stability mode, suitable
After a primary treatment with a plaster splint, the alignment of the for this type C shaft fracture.
fracture was unacceptable and the patient consented to operative
e r s repair.
e
Discussion
r s
ook ok o
There are many techniques and implant options in this case:
e b b o
Indication for surgery—Painful, displaced fracture, and failure of
e
• Long spiral wedge fractures can be addressed with open direct
b o
e / nonoperative treatment.
t . m e/ reduction with lag screw or wiring to maintain alignment and
t . m
fixation with neutralization plate. However, soft-tissue damage e/e
Treatment planning:
/ / / /
is always a risk during an open technique. Preservation of the
terior plating ps:

• Minimally invasive plate osteosynthesis (MIPO) technique, an-
htt
• Positioning: supine on x-ray transparent table
union or nonunion.
htt ps:
spiral wedge fragment blood supply is essential to prevent delayed
• Closed reduction and bridge plating technique is technically de-

• C-arm: located on the opposite side manding, especially for MIPO technique. These procedures require
• Preparation and draping: from shoulder to hand and free to move specific training in manipulation for closed reduction, plate place-
in any direction ment and fixation, and prevention of radial nerve injury. Once
e rs • Surgical approach:
r s
MIPO is achieved with good alignment with bridge plating sta-
e
b o ok –– Proximal incision: anterior incision for the proximal humerus
b o
–– Distal incision: anterior approach to the distal humeral shaft ok
bilization for relative stability, the postoperative rehabilitation can
start early and good bone healing can be expected.
b o o
e/ e / e
• Implant: 12-hole narrow locking compression plate (LCP)
(4.5/5 mm)
e
• Closed intramedullary nailing is also a good option, however,
this is also technically demanding and carries risk of radial nerve
e /e
://t . m injury and further displacement of the fragment.
: / / t . m
t t p s
Intraoperative technique—After the proximal and distal incisions, a
tps
ht
supraperiosteal tunnel was created anteriorly, the 12-hole narrow
h
LCP was inserted from distal to proximal, passing the plate on the
anterior surface of the humerus. The plate was positioned using
image intensifier guidance. As this fracture had lateral angulation,
reduction was performed by direct pressure outside the skin on the
k e rs lateral aspect to correct the axis (Fig 3.2-6c). A thin bump of cloth
can be used to support the humerus to correct sagittal plane align-
ke rs
eb oo ment. This was followed by temporary K-wire fixation (Fig 3.2-6d–e).
e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:27
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e a b c
e/ e d e
e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e / f g
t . m e/
h
t . m e/e
: / / / /
h t t p s
htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
i j
://t . m k l m
:n
/ / t . m
t p s
Fig 3.2-6a–n A 69-year-old man with a wedge fracture of the midshaft of the right humerus.
t tps
h
a–b Initial x-rays of the right humerus showing a long spiral wedge fracture at the midshaft.
ht
c–e Direct pressure outside the skin was applied on the lateral aspect to correct the axis (c), followed by temporary K-wire fixation (d–e).
f–h AP x-rays confirming good alignment and screw fixation.
i–k Bridging plate with relative stability.
l–n X-rays of the anterior bridge-plating technique in AP and lateral views (l–m). Skin incisions of minimally invasive plate osteosynthesis
rs rs
technique is shown in (n).
k e ke
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
257
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
3.2 Humeral shaft
k e rs ke rs
e b oo e b oo b o o
e / 5.5
t . m
nterolateral minimally invasive plate
A e /
t . m e/e
/ / / /
ps: ps:
osteosynthesis
htt htt
Minimally invasive plate osteosynthesis can be safe and ap-
propriate for osteoporotic fractures (Case 7: Fig 3.2-7) [27, 28].
rs Patient
r s
CASE 7
ok e A 57-year-old man with osteopenia suffered a low-energy injury

while sitting in the back seat of a public taxi. The injury occurred
ok e
such as the long-head biceps tendon or the insertion of the deltoid.
Furthermore, it provides fewer screw options for the proximal frag-
o
eb o during sudden braking while he was grasping a grab handle on the
e bo ment than the PHILOS plate. An intramedullary nail with multiple
b o
e/ pain and deformity.
t .m e/
roof. He was taken directly to the hospital for evaluation of severe locking screws in the proximal part is another option. This is techni-
cally demanding and there is no tolerance for error.
t .m e/e
: // : / /
Comorbidities
• Diabetes
• Osteopenia ht tps ht tps
The deltoid-split incision is to prevent injury to the deltoid branch
of the axillary nerve which lay just 1–2 cm from the distal part of
this incision (Fig 3.2-7c1). Figure 3.2-7c2 shows the longitudinal
split of the deltoid fiber to identify the lateral part of the proximal
Treatment and outcome humerus. A string-like structure, just distal to this point under the
Diagnosis and classification—Multifragmentary fractures involving deltoid muscle, is the branch of the axillary nerve. Care must be
e r s the proximal one third to middle of the left humeral shaft (AO/OTA
e r s
taken not to stretch or cut this nerve. Use a periosteal elevator to
ook ok o
12C3) (Fig 3.2-7a). After primary treatment with a splint from an separate the subdeltoid space and lateral surface of the proximal
e b emergency department, the x-rays were done. The alignment of the

e b o humerus to create a tunnel for plate insertion (Fig 3.2-7c3).
b o
e / fracture was unacceptable.
t . m e/ t . m
The length of the distal incision is 5–6 cm (Fig 3.2-7d). After open- e/e
/ /
Indication for surgery—A displaced fracture with malalignment after
: / /
ing the anterior fascia to identify the biceps muscle, the musculo-
reduction and immobilization.
h t t p s
Treatment planning—Due to the configuration of the AO/OTA Frac- htt ps:
cutaneous nerve was identified under the biceps muscle (between
the two retractors). The biceps and nerve were retracted and pro-
tected medially to expose the anterior surface of the brachialis
ture and Dislocation Classification type muscle.
C shaft fracture, minimally invasive plate osteosynthesis (MIPO) When splitting the brachialis muscle anteriorly in the middle, care
e rs technique was the treatment of choice. Conventional plating would

r s
must be taken not to use any bone retractor (eg, Hohmann retrac-
e
b o ok have damaged the blood supply of the middle fragments and like-
ly resulted in delayed or nonunion.
b o ok
tor) to retract directly between the lateral cortex of the humerus
and the muscles as the radial nerve is at risk of traction injury
b o o
e/ e • Positioning: supine on x-ray transparent table
e / e (Fig 3.2-7e).
e /e
• C-arm: located on the opposite side
://t . m / t .
In this case, only a simple soft-tissue retractor was used on the skin
: / m
t t p s
tps
and subcutaneous tissue, and deeper on the brachialis muscle just
ht
in any direction enough to gently expose the anterior cortex for plate positioning
h
• Surgical approach: proximal incision, deltoid split
• Distal incision: anterior approach to distal humeral shaft
and screw fixation. At this step, a periosteal elevator (or a tunneller,
if available) was used to create a submuscular tunnel to connect to
• Implant: PHILOS (long) the previously created tunnel from the proximal surgical wound
(Fig 3.2-7f).
k e rs PHILOS is appropriate to fix the proximal part with various locking

screws. This well-designed low plate profile can be fixed suitably in
ke rs
To protect the axillary nerve branch during insertion, the plate was
eb oo this high-level fracture with short proximal main fragment (Fig 3.2‑7b).
e b oo
passed along the previously created submuscular plane, supraperi-
b o o
e/e
Narrow locking compression plate can also be contoured and fixed osteal tunnel by pointing anteriorly. This prevents slipping into the
e / e /
on the anterior surface with MIPO technique but it is a relatively
m
wrong tract and injuring the radial nerve at the distal lateral surface
m
/ /t .
thick implant. This may interfere with the proximal anterior structures of the shaft (Fig 3.2-7g).
// t .
htt ps: htt ps:
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e
Reduction was done indirectly by manipulation with traction and
/ Discussion
t . m e/e
s: / / / /
ps:
rotational control followed with temporary K-wire fixation or unicor- Fixation in this case can be done by IM nailing or MIPO. Minimally
http htt
tical drill bits for proximal and distal plate stabilization (Fig 3.2-7h). invasive plate osteosynthesis with long PHILOS can be done with
For MIPO with PHILOS, screw fixation was limited above the axillary or without helical plate-like contouring. If the plate is not contoured
nerve area leaving some screw holes empty (Fig 3.2-7i). There was to a helical type, the distal incision should be lateral and the radial
initial distal fixation with a positioning screw (cortical screw) before nerve has to be identified.
performing the locking head screw fixation (Fig 3.2-7j, Fig 3.2-7k).
e rs
Immediate postoperative x-rays show proper alignment and good
er s
b o ok plate positioning as planned preoperatively (Fig 3.2-7l). This was a
bo
bridge plating with relative stability which is suitable for multifrag- ok b o o
e/ e mentary fractures.
e/ e e/e
: // t .m
Postoperative care—An arm sling was used to support and rest the
: / / t .m
ht tps
muscle and soft tissue on the first day. The patient was allowed to
start early active gentle range-of-motion exercise as tolerated
(Fig 3.2‑7m, Fig 3.2-7n–o). ht tps
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
a1 a2 a3 a4
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs
b1 b2 b3
ke rs
eb oo e b oo
Fig 3.2-7a–o A 57-year-old man with multifragmentary fractures after a low-energy injury.
b o o
e/e
a X-rays showing multifragmentary fractures involving the proximal one third to middle of the left humeral shaft.
e / m e /
b A long PHILOS (b1) was prepared and contoured with a plan to fix it proximally to the normal lateral surface and distally to the anterior
m
/ / .
template to contour it like a helical plate.
// .
surface to avoid manipulation and retraction of the radial nerve on the lateral surface of the shaft (b2–b3). Plastic bone was used as a
t t
htt ps: htt ps:
259
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
3.2 Humeral shaft
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok c1 c2
bo ok c3
b o o
e/ e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
d e f
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
g1 g2
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
h1 h2 h3
Fig 3.2-7a–o (cont) A 57-year-old man with multifragmentary fractures after a low-energy injury.
k e rs mion and extend not more than 5 cm.

ke rs
c Acromion landmarks and a longitudinal deltoid-split incision were marked starting from the anterior one third of the length of the acro-
oo oo o
d The distal incision on the anterior surface of the left arm.
eb b
e Splitting of the brachialis muscle anteriorly in the middle fracture site and full range of motion (ROM) of the elbow and shoulder.
e b o
/ / e/e
f A periosteal elevator (or a tunneller, if available) was used to create a submuscular tunnel to connect to the previously created tunnel
e from the proximal surgical wound.
t . m e
g The plate was passed along the previously created submuscular plane, supraperiosteal tunnel by pointing anteriorly.
t .m
/ / //
ps: ps:
h The plate was inserted and set for proper positioning by direct visualization and use of image intensification.
260
htt htt
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e i1 i2
e/ e j1 j2
e/e
: // t .m : / / t .m
ht tps ht tps
k1
e r s e r s
e / k2 l1
t . me/ l2 m1 m2
t . m e/e
: / / / /
h t t p s
htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
n1 n2 n3
://t . m n4
: / / t .
Fig 3.2-7a–o (cont) A 57-year-old man with multifragmentary fractures
m
t t p s after a low-energy injury.
tps
h ht
i Proximal screw fixation was performed. For minimally invasive plate
osteosynthesis (MIPO) with PHILOS, the screw fixation was limited
above the axillary nerve area, leaving some screw holes empty.
j Distal fixation with positioning screws (cortical screws).
k The skin incisions after fixation from anterior (k1) and lateral views (k2).
l Immediate postoperative x-rays show proper alignment and good
k e rs ke rs
plate positioning as planned preoperatively.
m Wound conditions and active ROM 10 days after MIPO.
eb oo e b oo
n X-rays of the humerus at the 1-month follow-up (n1–n2) and clinical
photographs showing ROM of the elbow (n3–n4).
b o o
e /
t . m e / The patient was pain free during continued ROM exercises.
t .m
o T he follow-up x-rays at 3 months (o1–o2) and 9 months (o3–o4)
e/e
/ / /
show union of the fragments. The patient had no pain at the fracture
/
ps: ps:
o1 o2 o3 o4 site and full ROM of the elbow and shoulder.
htt htt 261
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
3.2 Humeral shaft
k e rs ke rs
e b oo e b oo b o o
e / 5.6
t . m
A ntegrade nailing with a long nail— e /
t . m e/e
/ / / /
ps: ps:
Case 8: Fig 3.2-8
Patient
htt Treatment and outcome
htt
CASE 8
An 83-year-old woman had a fall at home and sustained a fracture Treatment decision—Initial treatment was nonoperative with a plas-
of the right humerus (Fig 3.2-8a–c). One year previously she sus- ter cast. Because of the patient’s dementia and inability to comply
e rs tained a pertrochanteric fracture of the left femur, which was treat-

ed with a proximal femoral nail.
er s
with restrictions, nonoperative treatment was not tolerated.
bo ok
Closed reduction and internal fixation (using a multilocking nail)
was performed (Fig 3.2-8d–e). The displacement of the shaft frag-
b o o
e / e • Alzheimer’s disease
e/ e ment due to the traction of the deltoid muscle was acceptable.
e/e
• Chronic renal insufficiency
• Depression
: // t .m : / / t .m
Postoperative x-rays showed that length and rotation were restored;
• Osteoporosis
ht tps ht tps
the displacement of the shaft fragment is clearly visible (Fig 3.2‑8f–g).
At the 5-month follow-up, the patient was satisfied and did not
attend further follow-up examinations (Fig 3.2-8h–i).
At the 3-year follow-up, the nonreduced shaft fragment healed
ke r s e r s
(Fig 3.2-8j–l). The patient had no pain and good function
b o o b o ok
(Fig 3.2-8m–o). The x-rays show that the displaced fragment healed
completely.
b o o
e /e t . m e/ e
t . m e/e
/ / / /
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
a b
://t . m c
: / / t . m
t t p s tps
h ht
kers rs
Fig 3.2-8a–o An 83-year-old woman with a right humeral
o ke
fracture.
b o b oo a–c The patient had a multifragmentary fracture type, which

involved the proximal humerus (greater tuberosity) with a
b o o
e /e t . m e /e nondisplaced fracture line demonstrated on the computed
tomographic scan (c).
t .m e/e
/ / /
d–e Closed reduction and internal fixation with a multilocking
/
ps: ps:
d e nail.
262
htt htt
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
tps tps
f g h i
ht ht
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
j
htt ps: k l
htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t .m
t t p s tps
m
h n
ht
o
Fig 3.2-8a–o (cont) An 83-year-old woman with a right humeral fracture.
f–g X-rays taken 2 days after surgery (f) and after physical therapy had already started ( g).
rs rs
h–i These x-rays show that the implant is still in place; there is no loosening and some callus formation.
k e e
j–l Additional images 3 years postoperatively obtained during evaluation of a pertrochanteric fracture of the right femur.
k
oo oo o
m–o These clinical photographs were taken in bed because of the recent pertrochanteric fracture of the right femur.
eb e b b o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
263
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
3.2 Humeral shaft
k e rs ke rs
e b oo e b oo b o o
e / 5.7
t . m
Antegrade nailing for segmental fractures— e /
t . m e/e
/ / / /
ps: ps:
Case 9: Fig 3.2-9
Patient
htt Treatment and outcome
htt
CASE 9
An 82-year-old man had a fall on the street. He sustained a fracture Preoperative imaging—As the patient was relatively active and would
of the left humerus at two levels (Fig 3.2-9a–c). have had difficulty complying with immobilization, operative repair
e rs Comorbidities
er s
was planned. The surgeon performed antegrade nailing because of
its less invasive approach (Fig 3.2-9a–c).
b o ok • Chronic heart failure

• Dementia
bo ok
Intraoperative imaging—The correct entry point is the key step in
b o o
e/ e • Malnutrition
e/ e intramedullary nailing, and must be checked and documented with
e/e
• Vitamin D deficiency
• Osteoporosis
: // t .m : / / .m
intraoperative image intensification in two planes (Fig 3.2-9d–i).
t
ht tps ht tps
Postoperative—The patient had physical therapy during his hospi-
talization but refused outpatient therapy (Fig 3.2-9j–k). His abduc-
tion was 110° after 5 weeks and 170° after 3 months.
Six-month follow-up—After 6 months the patient was pain free with

full symmetrical function for both upper extremities (Fig 3.2-9l–m).
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
a
htt
b
ps: c
htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
d
t t p s e f
tps
h ht Fig 3.2-9a–m An
82-year-old man with a
left humeral fracture after
a fall.
a–c The patient had
k e rs ke rs humeral fractures at
two levels, similar to
eb oo e b oo the AO/OTA Fracture

and Dislocation
b o o
e /
t . m e /
t
Classification 12C2.
.m
d–i Intraoperative imag-
e/e
/ / // ing, AP and lateral
ps: ps:
g h i views.
264
htt htt
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok Fig 3.2-9a–m (cont) An 82-year-old man with a
b o o
e / e e/ e left humeral fracture after a fall.
j–k Postoperative imaging.
e/e
://t.m .m
j k l m
s : / t
l–m Postoperative imaging at 6 months.
/
5.8 h t t p
ntegrade nailing with a very short distal
A ht tps
fragment— Case 10: Fig 3.2-10
e r s e r s
ook ok o
Patient
CASE 10
e b A 75-year-old woman had a fall on the street. She sustained a
e b o Alternatively, antegrade nailing (closed reduction and internal fixa-
b o
e / fracture of the left humerus (Fig 3.2-10a–b).
t . m e/ tion) was considered. The sitting beach chair position was advanta-
geous for respiration during anaesthesia.
t . m e/e
Comorbidities
/ / / /
• Type 2 diabetes mellitus
• High blood pressure
• Obesity htt ps: distal fragment (Fig 3.2-10e–g).
htt ps:
The challenge for antegrade nailing was locking the nail in the short
• Myocardial infarction 16 years ago and on anticoagulation Surgery—intraoperative imaging—The intraoperative imaging demon-
• Preexisting ipsilateral rupture of the supra- and infraspinatus strates correct length and rotation of the fracture, but the borderline
tendons anchoring and locking of the distal nail end; only the most distal screw
e rs e r s
options were feasible (Fig 3.2-10h–i).
o
Treatment decision—In this case nonoperative treatment was the
b ok
Postoperative imaging—The AP projection shows good alignment,
b o o
e/ e / e
initial choice, but neither cast fixation nor bracing were possible due
to obesity (Fig 3.2-10c–d).
e
the lateral projection again demonstrates the critical implant
anchorage (Fig 3.2-10j–k).
e /e
://t . m : / / t . m
t t p s
Surgical planning—This very obese patient would have needed a
tps
Aftercare—In this case aftercare was very conservative: The patient
ht
long plate in combination with a large posterior approach to span was managed in a shoulder sling for 4 weeks because of the short
h
the whole bone, and eventually two plates. Prone lateral decubitus
positioning was not felt to be safe from the anesthesiology consul-
distal fragment, and passive mobilization was performed for 6 weeks.
Active exercises were allowed thereafter.
tation, due to the patient’s obesity. The surgical team wanted to
avoid a large open approach because of the patient’s obesity and One-year follow-up—The 1-year follow-up x-rays show that the frac-
k e rs
diabetes.
ke rs
ture was healed (Fig 3.2-10l–m). Clinically, the patient had poor
function due to the preexisting rotator cuff tear: abduction 60°,
eb oo e b oo
anteversion 60°.
b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
265
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
3.2 Humeral shaft
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
://t.m .m
a b c d
s : / / t
h t t p ht tps
e r s e r s
e b ook e f
e b o ok g
b o o
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e h i
e / e j k
e /e
://t . m : / / t . m
t t p s tps
h ht
Fig 3.2-10a–m A 75-year-old woman with a left humeral fracture after a fall.
a–b T he patient sustained a fracture, which affected almost the whole shaft.
k e rs fragment.
ke rs
Proximally it reached the humeral head, distally there was only a short shaft
eb oo b oo
c–d X-rays showing suboptimal results from nonoperative treatment.
e–g A multiplanar reconstruction of the distal humeral fragment and the borderline
e b o o
e /
t . m e /(ie, short) length of its intramedullary canal (25 mm).
h–i Intraoperative imaging.
t .m e/e
/ / j–k AP postoperative images.
//
ps: ps:
l m l–m Postoperative imaging at 1-year follow-up.
266
htt htt
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 6 Complications [29, 30]
t . m e /
t . m
• Arterial injury can occur with drilling when inserting the e/e
s: / / / /
ps:
locking bolt for IM nailing.
http htt
• Radial nerve injury [26]: • Shoulder dysfunction in antegrade nailing is of concern,
–– The radial nerve is at risk during fracture reduction so the approach has to be done properly.
for both nailing and plating. • Loss of fixation is not uncommon in osteoporotic bone
–– Screw fixation from anterior to posterior in the hu- (Fig 3.2-11):
meral midshaft should be avoided to prevent radial –– Plate loosening
e rs nerve injury at the site of its crossing at the posterior

cortex.
er s
–– Nail protrusion at entry point
–– Backing out of proximal locking bolts
b o ok –– Do not harm the radial nerve by traction, direct or

indirect injury during plating, or fixation of locking
bo ok
• Nonunion (Fig 3.2-12, Fig 3.2-13)
• Refractures after implant removal
b o o
e/ e bolt in the distal shaft.
e/ e • Periimplant fracture:
e/e
: // t .m –– After plating
: / / t
–– Supracondylar fracture with retrograde nailing .m
ht tps • Infection in open fracture
ht tps
e r s e r s
e b ook e b o ok Fig 3.2-12 These x-rays of a
b o o
e /
t . m e/ 65-year-old man show failure of
t . m
fixation after open reduction and
e/e
/ / /
internal fixation with multiple
/
ps: ps:
Fig 3.2-11a–b A 72-year-old wiring and dynamic compression
htt htt
woman after a car accident plate. The patient had pain for 10
with a closed fracture of the months following the initial fixation.
humeral shaft. The x-rays 1 Note that many wires in the open
month after initial fixation with technique may cause biological
dynamic compression plate disturbance during the healing
a b show loosening of the screws. process.
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
Fig 3.2-13a–d A 77-year-old woman with a transverse fracture. The pa-
tient was treated with minimally invasive plate osteosynthesis but failure
occurred after 5 months. X-rays (a–b) and computed tomographic scans
(c–d) demonstrate a significant gap with nonunion of the fracture site.
k e rs
a b c d
ke rs
Reduction by indirect technique left a small gap and created a high strain
to reparative tissue which resulted in nonunion.
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
267
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
3.2 Humeral shaft
k e rs ke rs
e b oo e b oo b o o
e / 7 References
t . m e /
t . m e/e
/ / / /
htt ps:
1. Ekholm R, Adami J, Tidermark J, et al.
Fractures of the shaft of the humerus.
An epidemiological study of 401
11. Ekholm R, Ponzer S, Tornkvist H, et al.
Primary radial nerve palsy in patients
with acute humeral shaft fractures.
J Orthop Trauma.
ps:
20. Carroll EA, Schweppe M, Langfitt M,
htt
et al. Management of humeral shaft
fractures. J Am Acad Orthop Surg.
2012 Jul;20(7):423–433.
2006 Nov;88(11):1469–1473. 2008 Jul;22(6):408–414. 21. Sarmiento A, Kinman PB, Galvin EG,
2. Bergdahl C, Ekholm C, Wennergren D, 12. Pollock FH, Drake D, Bovill EG, et al. et al. Functional bracing of fractures of
et al. Epidemiology and patho- Treatment of radial neuropathy the shaft of the humerus. J Bone Joint
e rs anatomical pattern of 2,011 humeral

fractures: data from the Swedish
er
humerus. J Bone Joint Surg Am.
s
associated with fractures of the Surg Am. 1977 Jul;59(5):596–601.
22. Ring D. Current concepts in plate and
ok ok
Fracture Register. BMC Musculoskelet 1981 Feb;63(2):239–243. screw fixation of osteoporotic proximal
b o Disord. 2016 Apr 12;17:159.

3. Hu X, Xu S, Lu H, et al. Minimally
bo
13. Bodner G, Buchberger W, Schocke M,
et al. Radial nerve palsy associated
humerus fractures. Injury.
2007 Sep;38(Suppl 3):S59–S68.
b o o
e/ e invasive plate osteosynthesis vs
conventional fixation techniques for
e/ e
with humeral shaft fracture: evaluation
with US—initial experience. Radiology.
23. Egol KA, Kubiak EN, Fulkerson E, et al.
Biomechanics of locked plates
e/e
surgically treated humeral shaft
: // t
fractures: a meta-analysis. J Orthop .m 2001 Jun;219(3):811–816.
14. Ouyang H, Xiong J, Xiang P, et al.
: /
2004 Sep;18(8):488–493.
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and screws. J Orthop Trauma.
.m
tps tps
Surg Res. 2016 May 11;11(1):59. Plate versus intramedullary nail 24. Alonso-Llames M. Bilaterotricipital
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4. Walker M, Palumbo B, Badman B, fixation in the treatment of humeral approach to the elbow. Its application
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2011 Jul;20(5):833–844. 2013 Mar;22(3):387–395. Acta Orthop Scand. 1972;43(6):479–490.
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Extra-articular distal-third diaphyseal Meta-analysis of the outcomes of distal. In: Rüedi TP, Buckley RE,
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e r s of functional bracing and plate fixation.

r s
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Management. 2nd ed. Switzerland:
ook ok
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26. Apivatthakakul T. Humerus, shaft.
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e / e Proximal humerus and humeral shaft
nonunions. J Am Acad Orthop Surg.
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7. Marti RK, Verheyen CC, Besselaar PP.
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27. Khong KS KR, Ghista DN.
/t . m
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e/ e a systematic review. J Bone Joint
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Arm, and Forearm. In: Azar FM,
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10. Liu GY, Zhang CY, Wu HW. Comparison
of initial nonoperative and operative
management of radial nerve palsy
://t . m Bavornratanavech S. Minimally
invasive plate osteosynthesis (MIPO)
of the humeral shaft fracture.
Beaty JH, Canale ST, ed. Campbell’s
: / / t .
Operative Orthopaedics. 13 ed.
Philadelphia: Elsevier Health Sciences;
m
t t p s
associated with acute humeral shaft Is it possible? A cadaveric study 2017:2927–3016.
tps
ht
fractures. Orthopedics. and preliminary report. Injury.
h
2012 Aug 1;35(8):702–708. 2005 Apr;36(4):530–538.
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
3.3 Distal humerus / / / /
htt ps:
htt ps:
e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e 2 Epidemiology and etiology
e/e
: // t .m
Distal humeral fractures (DHFs) in adults are complex and
: / / t .m
Distal humeral fractures account for 7–8% of all adult frac-
tps
technically demanding injuries. In contrast to proximal hu-
ht
meral and distal radial fractures, operative fixation is indi-
cated in most cases due to the impact of limited elbow func- ht tps
tures in the western world [1]. Of more than 2,000 humer-
al fractures documented in the Swedish fracture registry
between 2011 and 2013, only 8% were of the distal third,
tion on activities of daily living. Many controversial and 79% of the proximal third, and 13% in the shaft. About
challenging issues include: 83% of humeral fractures affect patients older than 50 years
[2]. Robinson et al [3] estimated an incidence of 5.7 cases per
e r s
• Difficult exposure (with or without olecranon osteotomy)
e r s
100,000 people per year with a nearly equal male to female
ook ok o
• Comminution in the metaphyseal and/or epiphyseal re- ratio. Of these, approximately 6% are isolated fractures of
e b gion (with or without bone graft)

e b o
the capitulum humeri [4].
b o
e / • Fixation strategies
• The role of primary total elbow arthroplasty
t . m e/ t . m
Looking at patient age reveals a bimodal peak: the first one e/e
: / / / /
represents 12–19-year-old men with fractures mostly due
h t p s
In order to achieve acceptable function, immobilization of
t
the elbow should generally be avoided or at least limited to
2–3 weeks with intermittent mobilization. htt ps:
to high-energy trauma or athletic activities; the second peak
is induced by women typically older than 80 years with
osteoporotic bone who sustain the fracture after a ground
level fall [5–7]. The latter group of patients demonstrated an
increasing prevalence from 11 out of 100,000 in 1970 to 30
out of 100,000 in 1995 [8].
e rs e r s
b o ok b o ok
With the nondominant arm being affected in up to 89% of
patients [7], the mechanism of injury in this population nor-
b o o
e/ e e / e mally involves falling on the outstretched arm with a direct
e /e
axial force transmitted to the capitulum humeri via the radial
://t . m / t . m
head [9]. The spontaneous reduction of a posterolateral elbow
: /
t t p s tps
subluxation with shearing or compression force to the
ht
capitulum and/or the trochlea humeri represents a variant
h mechanism of injury [10].
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
269
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
3.3 Distal humerus
k e rs ke rs
e b oo e b oo b o o
e / 3 Classification
t . m e / 4 Decision making
t . m e/e
s: / / / /
http
In general, we distinguish between extra- and intercondy-
lar DHF as well as capitellar and trochlear fractures. Sev-
htt ps:
The combination of complex anatomy, fracture comminu-
tion, short distal fracture segment, and osteoporotic bone
eral classifications of DHFs exist. Fractures are considered quality makes these fractures difficult to treat [10, 15]. In
“distal” if they are located distal to the fossa olecrani: older patients, a stable fixation to allow for functional treat-
ment is the most important goal. Smaller gaps or steps in
e s
• In 2003, Ring et al [11] described five injury patterns based
r on radiographic and intraoperative findings.
er s
the joint surface are of minor importance. An olecranon
osteotomy should be avoided so as not to cause additional
b o ok • The most commonly used classification is from the AO

Foundation/Orthopaedic Trauma Association (AO/OTA),
bo ok
problems.
b o o
e/ e with letters from A to C for extraarticular, partial articu-
e/ e 4.1 Approach
e/e
: // t .m
lar, and complete articular fractures. To describe the de-
gree of comminution or give a further definition of the
Numerous approaches to the elbow have been described.
:
Functional outcome does not appear to depend on the ap-
/ / t .m
with numerals [5]. tps
fracture location, the classification is further amended
ht
• Distal coronal fractures (AO/OTA type B3 fractures) are ht tps
proach used [16, 17]. The approaches can be divided into
posterior, medial, and lateral approaches. From posterior,
we may use an olecranon osteotomy, triceps-splitting, tri-
specified and divided in subtypes by Bryan et al and ceps-reflecting [18], and triceps-sparing approaches.
modified by McKee (Table 3.3-1) [12].
Our preferred approach is the triceps-sparing paratricipital
ke r s e r s
posterior approach according to Alonso-Llames [19]. It allows
b o o Fracture type Description
b o ok
the surgeon to address medial and lateral aspects of the
distal humerus and may be complemented by an olecranon
b o o
e /e I
(Hahn-Steinthal)
e/ e
Coronal shear fracture resulting in osteochondral
fragment extending up to the lateral ridge of the trochlea
m
osteotomy if necessary. In older patients, there should always
be an attempt to manage fractures without olecranon oste-
m e/e
/ / .
or minimally over it
t / /t
otomy (Case 1: Fig 3.3-1). A tourniquet is not applied rou- .
ps: ps:
II Coronal shear fracture resulting in cartilaginous fragment
(Kocher-Lorenz) with little or no subchondral bone attached tinely.
III
IV
htt
Fractures resulting in comminution of the capitellar
fragment
Coronal shear fracture of the capitulum and trochlea as a
htt
AO/OTA C1 and C2 fractures are addressed via this approach
without compromising the quality of reduction. In severe-
(McKee modification) [13] single fragment
ly comminuted fractures, olecranon osteotomy may be nec-
Table 3.3-1 Bryan and Morrey classification of capitellar fractures essary.
e rs
modified by McKee [12, 14].
e r s
b o ok b o ok
Due to the uncompromised extensor apparatus, immediate
postoperative flexion/extension can be encouraged. Fur-
b o o
e/ e e / e thermore, this approach seems to be associated with fewer
wound healing problems, shorter surgery time, and reduced
e /e
://t . m blood loss compared to approaches involving an olecranon
: / / t . m
t t p s osteotomy (Case 1: Fig 3.3-2) [20].
tps
h ht
In case of coronal fracture types, leaving the anconeus
muscle attached to the proximal ulna, an arthrotomy
anterior to the collateral ligaments can be performed
(Case 2: Fig 3.3-3).
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Patient
. m e / Treatment and outcome
. m e/e
CASE 1
/ / t
A 79-year-old woman sustained an AO/OTA type C3 DHF after
: / / t
Surgery was performed in prone position without olecranon oste-
Comorbidities ht t p s
falling from standing height (Fig 3.3-1a–b).
htt ps:
otomy. Using the bilateral paratricipital approach, the distal fracture
fragments were fixed to each other using joysticks. Applying an
interfragmentary screw created one joint block, which was then fixed
• Osteoporosis to the radial and ulnar column of the distal humerus using dorso-
• Hypertension lateral and ulnar plates according to the 90° plating technique.
• Insulin-dependent diabetes mellitus Follow-up at 13 months showed fracture union with active range
e rs er s
of motion of 0–15–120° (Fig 3.3-1c).
b o ok bo ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e b ook a b
e b o c ok d
b o o
e / e/
Fig 3.3-1a–c Female patient with an AO/OTA type C3 distal humeral fracture.
m
a–b A 3-D computed tomographic scan showing metaphyseal and epiphyseal comminution.
t . t . m e/e
/
c–d The 13-month follow-up x-ray showing fracture union.
/ / /
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
a
t t p sb c
tps
h ht
Fig 3.3-2a–f Triceps-sparing paratricipital
posterior approach. A double curved skin
incision is performed (a). Ulnar and radial
full-thickness skin flaps are created and re-
k e rs ke rs tracted to expose the triceps tendon (b). The

ulnar nerve is identified and secured with a
eb oo e b oo vessel loop (c). We do not routinely transpose

the nerve at the end of surgery. The triceps
b o o
e /
t . m e / tendon is mobilized and looped (d). Now,
t .m
the radial and ulnar aspect of the elbow can
e/e
/ / /
be addressed alternatively by retracting the
/
ps: ps:
d e f triceps tendon (e–f).
htt htt 271
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
3.3 Distal humerus
k e rs ke rs
e b oo e b oo b o o
e / Patient
. m e /
. m e/e
CASE 2
/ / t
A 75-year-old woman fell on the street from standing height.
/ / t
the trochlear fracture fragment was reduced through the medial

htt ps:
Initial AP and lateral x-rays and 3-D computed tomography identified
fracture (Fig 3.3-3h).
htt ps:
approach and an ulnar plate was applied to fix the supracondylar
a dislocated elbow joint fracture with a fracture of the capitellum The multifragmented capitellar and trochlear fracture was fixed di-
and trochlea (Fig 3.3-3a–e). rectly using three headless screws. The supracondylar fracture was
fixed by posterolateral and medial plates. The fractured radial epicon-
e rs An extended lateral approach was performed. Before the lateral col-

r s
dyle was stabilized with an independent screw. Intraoperative AP and
e
b o ok lateral ligament complex the already ruptured capsule was dissected
bo
and the capitellar fracture fragment addressed (Fig 3.3-3f). Because ok
lateral x-rays confirmed correct reduction and fracture fixation. To avoid
stress rising at the end of the locking plates the most proximal screw
b o o
e/ e e/ e
fracture reduction was not possible from the radial approach alone,
an additional extended medial approach was performed (Fig 3.3-3g).
of the ulnar plate was used as a conventional screw (Fig 3.3-3i–j).
e/e
: // t .m : / / t .m
AP and lateral postoperative x-rays showed acceptable bone union.
ps tps
Before the intermuscular septum, the ruptured joint capsule was Range of motion was measured as 0–20–120° with unrestricted
htt ht
detached, and preserving the medial collateral ligament complex, pronation and supination (Fig 3.3-3k–l).
e r s e r s
e /
t . m e/ t . m e/e
a
/ / b c d e
/ /
htt ps: htt ps:
e rs e r s
o ok ok o
/ebo o
f g h
e/ e b e e /e b
://t . m : / / t . m
t t p s tps
h ht
kers kers
i j k l
Fig 3.3-3a–l A 75-year-old woman with an elbow fracture dislocation and a fracture of the capitellum and trochlea.
b o o o o
a–e X-rays images and 3-D computed tomographic scans showing a displaced capitellar and trochlear fracture with epiphyseal/metaphyseal fracture.
b
f Clinical photograph showing the ruptured capsule with the capitellar fracture fragment on the radial side.
b o o
e /e g Clinical photograph of the ulnar incision.
m e/e
h Fixed ulnar column of the supracondylar fracture by ulnar plate.
t . t .m e/e
/
i–j Intraoperative image intensifier x-rays showing good fracture alignment.
/ //
ps: ps:
k–l Final follow-up x-rays showing fracture union.
272
htt htt
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 4.2 Nonoperative treatment
t . m e /
t . m
der the surgical intervention life-threatening. It should be e/e
s: / / / /
ps:
Even initially nondisplaced fractures tend to displace sec- noted that plaster immobilization alone usually leads to
http htt
ondarily [15]. These facts render nonoperative treatment of nonunion (Case 3: Fig 3.3-4). In case of nonoperative manage-
DHF limited primarily to patients with contractures, a short ment, splinting only assists with pain management.
life expectancy, or an abundance of comorbidities that ren-
e rs
Patient
er
Discussion s
ok ok
CASE 3
b o A 92-year-old woman living in a nursing home. Type and time of
trauma could not be recalled. Due to mild dementia and multiple
bo Distal humeral fractures are “absolute” indications for internal fixa-
tion. This case impressively demonstrates an exception to the rule.
b o o
e/ e e/ e
falls, she sustained a distal humeral fracture that was initially treat- In the geriatric population, there is a fine line between causing
e/e
ed by a general practitioner.
: // t .m : / / t .m
additional harm to patients and withholding an invasive treatment
step that would help to keep them more autonomous. This patient
Comorbidities
• Mild dementia
• Multiple falls ht tps after half a year.
ht tps
obviously tolerated the nonunion surprisingly well with a follow-up

After roughly 3 weeks, the patient presented to our department
e r s
with a loose plaster splint and few complaints (Fig 3.3-4a). Con-
e r s
ook ok o
tinuation of nonoperative treatment with development of a nonunion
e b (Fig 3.3-4b). Two weeks later she sustained a minimal displaced

e b o b o
e / odontoid fracture type II according to Anderson and D’Alonzo
m e/
(Fig 3.3-4c) that was also treated nonoperatively. Three months
t . t . m e/e
/ /
later a pertrochanteric femoral fracture was fixed (Fig 3.3-4d). Mo-
/ /
htt ps:
bilization and rehabilitation was not impaired by the humeral non-
union nor did she complain about pain.
htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
a b c d
rs rs
Fig 3.3-4a–d A 92-year-old woman with a distal humeral fracture (DHF).
k e a Metaphyseal DHF around 10 days after trauma.

b Same patient treated with above-elbow cast at 3 weeks after trauma.
ke
eb oo c
oo
Computed tomographic scan showing displaced odontoid fracture type II according to Anderson.
e b b o o
e/e
d Intratrochanteric femur fracture treated with long proximal femoral nail antirotation nail with bone union.
e / m e / m
/ /t . // t .
htt ps: htt ps:
273
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
3.3 Distal humerus
k e rs ke rs
e b oo e b oo b o o
e / 4.3 Open reduction and internal fixation
t . m e / Biomechanically, parallel plate configuration is superior to
t . m e/e
s: / / / /
ps:
Distal humeral fractures almost always require a stable fixa- perpendicular positioning in osteoporotic bone [21].
http htt
tion, usually provided by plates and screws (Case 4: Fig 3.3-5).
We prefer anatomically preshaped locking plates.
rs Patient
s
r
CASE 4
ok e An 80-year-old woman sustained a ground-level-fall with impact on

the left hand, with pain at the left elbow, swelling, and no soft-tissue
ok e
The patient sustained a displaced, very low fracture of the left distal
humerus (Fig 3.3-5a–d) and was treated with open reduction and
o
o o o
e/eb b b
or skin lesions. plating of the distal columns (Fig 3.3-5e–f). Immediate postopera-
e/ e tive mobilization resulted in satisfactory active and passive range of

e/e
: // t .m : / / .m
motion and radiological results at the final follow-up at 1 year.
t
ht tps ht tps
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
ps: ps:
a b c d
htt htt
e rs e r s
b o ok b o ok b o o
e/ e e / e Fig 3.3-5a–f An 80-year-old woman with a fracture of the left distal
humerus.
e /e
://t . m No articular involvement.
: / t .
a–d Very distal (distal to the olecranon fossa), unstable humeral fracture.
/ m
t t p s tps
e–f Follow-up x-rays at 3 months show trabecular bridging at the fracture
e
hf implant loosening.
ht
site of the ulnar column indicating delayed fracture union. No signs of
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m
Closed reduction and fixation with percutaneous K-wires e /
t . m
immobilization (Fig 3.3-6). Open reduction and osteosynthe- e/e
s: / / / /
ps:
should no longer be used in older patients because it does sis with single screws and/or K-wires regularly leads to a
http htt
not provide enough stability, even with additional plaster nonunion.
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
a b c d e
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
Fig 3.3-6a–o A 73-year-old woman with
an unstable intraarticular fracture of the
f
e rs e r s distal humerus.
ok ok
a–b Conventional x-rays showing an
b o b o c
intraarticular distal humeral fracture.
O pen reduction and internal fixation
b o o
e/ e e / e Ulnar nerve
was performed using K-wires and
screws.
e /e
://t . m : / t .
d At 4 months, loss of fracture fixation
/
and unstable nonunion was estab-
m
t t p s lished.
tps
h f
ht
e At first step, implants were removed
and an infection was excluded.
T he patient was not able to control
her lower arm.
Olecranon g–i A rthrolysis of the elbow joint, reorien-
tation of the distal fragment into an
k e rs
g h i
ke rs anatomical position, and stable fixa-
tion with two plates and bone grafting.
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
275
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
3.3 Distal humerus
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e j k
e/ e l
e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
/ e/ e/e
m n o
e . m
Fig 3.3-6a–o (cont) A 73-year-old woman with an unstable intraarticular fracture of the distal humerus.
t t . m
j–o G
/ / / /
ood functional outcome after treatment. After 3 months uneventful healing with extension–flexion 0–15–130° and pronation–
ps: ps:
supination 75–0–85° [22].
htt htt
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e
Occasionally, in patients with significant contraindications
/
t . m e/e
/ / / /
ps: ps:
to general anesthesia or in extremely frail patients with
htt htt
simple supracondylar fractures, a closed reduction and per-
cutaneous X-type screw fixation can lead to a satisfactory
result (Case 5: Fig 3.3-7) [23].
rs Patient
s
r
CASE 5
ok e A 93-year-old female patient with supracondylar distal humeral
fracture and pronounced osteoporosis (Fig 3.3-7a–b).
ok e
After closed reduction, two crossing screws were percutaneously
inserted (Fig 3.3-7c–d). After 6 weeks of immobilization, the fracture
o
o o o
e/eb b b
was healed (Fig 3.3-7e–f).
Comorbidities
e/ e e/e
• Osteoporosis
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
a htt b
ps: c htt d
ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
kers rs
e f
o ke
oo o
Fig 3.3-7a–f A 93-year-old woman with a distal humeral fracture.
b o b
a–b Conventional x-rays showing a supracondylar extraarticular fracture of the distal humerus.
b o
e /e /e e/e
c–d Intraoperative x-rays showing two crossing screws inserted percutaneously after closed reduction. Additionally, an above-elbow splint was
applied for 6 weeks.
t . m e
e–f Six-week postoperative x-ray showing healed fracture with minimal varus deformity.
t .m
/ / //
htt ps: htt ps:
277
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
3.3 Distal humerus
k e rs ke rs
e b oo e b oo b o o
e / 4.4 Total elbow arthroplasty
t . m e / tures, McKee et al [24] concluded that TEA is a preferred
t . m e/e
s: / / / /
ps:
In a multicenter randomized controlled trial of open reduc- alternative for ORIF in older patients with complex distal
http htt
tion and internal fixation (ORIF) versus total elbow arthro- humeral fractures not amenable to stable fixation (Case 6:
plasty (TEA) for displaced intraarticular distal humeral frac- Fig 3.3-8).
rs Patient
s
r
CASE 6
ok e A 93-year-old female patient fell while riding her bicycle and sus-
tained a comminuted distal humeral fracture (Fig 3.3-8a–d).
ok e
After intraoperative examination, the decision was taken to replace
the elbow joint with a Coonrad-Morrey prosthesis leading to a func-
o
o o o
e/eb b b
tional result after 3 months (Fig 3.3-8e–k).
Comorbidities
e/ e e/e
• None
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e /
t . m e/ t . m e/e
a b
/ / c d
/ /
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
e
://t . m
f g h
: / / t . m
t t p s tps
h ht
Fig 3.3-8a–k A 93-year-old woman
with a comminuted very distal humeral
fracture.
a–d Conventional x-rays and com-
puted tomographic scans showing
a comminuted fracture of the distal
k e rs ke rs humerus.
e Intraoperatively, anatomically stable
eb oo e b oo fixation for immediate postoperative

mobilization was not possible. The
b o o
e /
t . m e / decision was made to perform a
replacement.
t .m e/e
/ / /
f–k Three-month follow-up showing
/
ps: ps:
i j k good radiographic and clinical results.
278
htt htt
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m
The term “amenable to stable fixation” may be dependent e /
t .
mentioned before, most fractures are feasible for ORIF, even
m e/e
s: / / / /
ps:
on the experience and skills of the surgeon in charge. Ac- with comminution and osteoporosis (Case 7: Fig 3.3-9).
http htt
cording to our own experience, and with the principles
rs Patient
s
r
CASE 7
ok e A 75-year-old female patient fell while in a bus and sustained an
osteoporotic distal humeral fracture with intraarticular component
ok e
Open reduction and internal fixation via a posterior approach was
performed (Fig 3.3-9c–g). No postoperative immobilization with
o
o o o
e/eb b b
and comminution on the radial side (Fig 3.3-9a–b). immediate physiotherapy. Excellent functional result after 3 months
e/ e (Fig 3.3-9h–k).
e/e
Comorbidities
• None
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
a
htt ps:
b
htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
c
h d e f
ht g
Fig 3.3-9a–k A 75-year-old woman with a very distal humeral fracture.
a–b The computed tomographic scans showing comminution on the radial column.
k e rs ke rs
c–g Six-week postoperative x-rays after fracture fixation with open reduction and internal fixation showing some bone resorption at the radial column.
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
279
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
3.3 Distal humerus
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
h i
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
tps tps
j k
ht ht
Fig 3.3-9a–k (cont) A 75-year-old woman with a very distal humeral fracture.
h–k Clinical photographs at 3 months showing good functional results.
e r s
5 Complications
e r s
For older patients with comminuted displaced intraarticular
ook ok o
fractures, primary total arthroplasty may be a superior treat-
e b The risk of complications during the treatment of DHFs in

e b o ment option, as stable internal fixation is difficult to achieve
b o
e /
t . m
nonunion seems to be higher after high-energy trauma, e/
adults is low and uneventful healing is typical. The risk of in osteoporotic bone [5, 27].
t . m e/e
/ /
open fractures, and nonoperative treatment, whereas the
/
Joint instability may originate from associated ligament
/
for nonunion [3].
htt ps:
fracture classification type does not seem to be a predictor
htt ps:
insufficiency or when the fracture extends beyond the troch-
lear ridge and leads to ulnohumeral dissociation [7]. Post-
traumatic osteoarthritis caused by an articular step-off is a
Fractures of the capitellum and the trochlea may lead to long-term complication [28].
fragments that are devascularized and at high risk of b
ecoming
necrotic. The danger of osteonecrosis seems to be especially
e rs
high in fractures involving both the medial and lateral columns
e r s
b o ok of the distal humerus. Ulnar nerve neuropathy and poor soft-
b o
tissue conditions make these fractures challenging [25, 26]. ok b o o
e/ e e / e
Short-term complications in fracture treatment might con-
e /e
://t . m
sist of joint stiffness or instability. Older patients are in par-
: / / t . m
t t p s
ticular danger of developing joint stiffness in the setting of
tps
ht
cast fixation longer than 2–3 weeks or with inadequate
h
early functional aftercare, often as a consequence of poor
postoperative pain control. To ensure a good functional
outcome, early postoperative motion is essential to prevent
the elbow joint capsule from developing fibrosis.
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 6 References
t . m e /
t . m e/e
/ / / /
1. Court-Brown CM, Caesar B.
htt ps:
Epidemiology of adult fractures: a
review. Injury. 2006 Aug;37(8):691–697.
2. Bergdahl C, Ekholm C, Wennergren D,
11. Ring D, Jupiter JB, Gulotta L.
Articular fractures of the distal part
of the humerus. J Bone Joint Surg Am.
2003 Feb;85-A(2):232–238.
ps:
21. Stoffel K, Cunneen S, Morgan R, et al.
htt
Comparative stability of perpendicular
versus parallel double-locking plating
systems in osteoporotic comminuted
et al. Epidemiology and patho- 12. Bryan RS, Morrey BF. Fractures of the distal humerus fractures. J Orthop Res.
anatomical pattern of 2,011 humeral distal humerus. In: Morrey BF, ed. The 2008 Jun;26(6):778–784.
fractures: data from the Swedish Elbow and Its Disorders. Philadelphia: 22. Blauth M, Becker T, Regel G.
e rs Fracture Register. BMC Musculoskelet

Disord. 2016 Apr 12;17:159.
Saunders; 1985:302–339.
er s
13. McKee MD, Jupiter JB, Bamberger HB.
Ellbogengelenknahe, transepikondyläre
Humeruspseudarthrosen. Oper Orthop
ok ok
3. Robinson CM, Hill RM, Jacobs N, et al. Coronal shear fractures of the distal Traumatol. 1997 Dec;9(4):277–287.
b o Adult distal humeral metaphyseal

fractures: epidemiology and results
bo
end of the humerus. J Bone Joint Surg
Am. 1996 Jan;78(1):49–54.
German.
23. Paryavi E, O’Toole RV, Frisch HM, et al.
b o o
e/ e of treatment. J Orthop Trauma.
2003 Jan;17(1):38–47.
e/ e
14. Trinh TQ, Harris JD, Kolovich GP, et al.
Operative management of capitellar
Use of 2 column screws to treat
transcondylar distal humeral fractures
e/e
4. Widhalm HK, Seemann R, Wagner FT,
et al. Clinical outcome and
: // t .m fractures: a systematic review.
: / / t .m
in geriatric patients. Tech Hand Up
Extrem Surg. 2010 Dec;14(4):209–213.
tps tps
osteoarthritic changes after surgical 2012 Nov;21(11):1613–1622. 24. McKee MD, Veillette CJ, Hall JA, et al.
ht ht
treatment of isolated capitulum humeri 15. Srinivasan K, Agarwal M, Matthews SJ, A multicenter, prospective,
fractures with a minimum follow-up et al. Fractures of the distal humerus in randomized, controlled trial of open
of five years. Int Orthop. the elderly: is internal fixation the reduction—internal fixation versus
2016 Dec;40(12):2603–2610. treatment of choice? Clin Orthop Relat total elbow arthroplasty for displaced
5. Nauth A, McKee MD, Ristevski B, et al. Res. 2005 May(434):222–230. intra-articular distal humeral fractures
Distal humeral fractures in adults. 16. Lee JJ, Lawton JN. Coronal shear in elderly patients. J Shoulder Elbow
J Bone Joint Surg Am. fractures of the distal humerus. J Hand Surg. 2009 Jan-Feb;18(1):3–12.
e r s 2011 Apr 06;93(7):686–700.

r s
Surg Am. 2012 Nov;37(11):2412–2417.
e
25. Wiggers JK, Ring D. Osteonecrosis after
ook ok
6. Throckmorton TW, Zarkadas PC, 17. Ljungquist KL, Beran MC, Awan H. open reduction and internal fixation of
b
Steinmann SP. Distal humerus
fractures. Hand Clin.
Effects of surgical approach on
b o
functional outcomes of open reduction
a bicolumnar fracture of the distal
humerus: a report of four cases. J Hand
b o o
e / e 2007 Nov;23(4):457–469, vi.
7. Mighell M, Virani NA, Shannon R, et al.
e/ e
and internal fixation of intra-articular
distal humeral fractures: a systematic
Surg Am. 2011 Jan;36(1):89–93.
26. Dubberley JH, Faber KJ, Macdermid JC,
e/e
Large coronal shear fractures of the
/ /
capitellum and trochlea treated with
t . m review. J Shoulder Elbow Surg.
2012 Jan;21(1):126–135.
/ /t . m
et al. Outcome after open reduction
and internal fixation of capitellar and
ps: ps:
headless compression screws. J Shoulder 18. Bryan RS, Morrey BF. Extensive trochlear fractures. J Bone Joint Surg
htt htt
Elbow Surg. 2010 Jan;19(1):38–45. posterior exposure of the elbow. Am. 2006 Jan;88(1):46–54.
8. Palvanen M, Kannus P, Niemi S, et al. A triceps-sparing approach. Clin Orthop 27. Simone JP, Streubel PN, Sanchez-
Secular trends in the osteoporotic Relat Res. 1982 Jun;(166):188–192. Sotelo J, et al. Low transcondylar
fractures of the distal humerus in 19. Alonso-Llames M. Bilaterotricipital fractures of the distal humerus: results
elderly women. Eur J Epidemiol. approach to the elbow. Its application of open reduction and internal fixation.
1998 Feb;14(2):159–164. in the osteosynthesis of supracondylar J Shoulder Elbow Surg.
9. Bilsel K, Atalar AC, Erdil M, et al. fractures of the humerus in children. 2014 Apr;23(4):573–578.
e rs Coronal plane fractures of the distal

humerus involving the capitellum and
r s
Acta Orthop Scand. 1972;43(6):479–490.
e
20. Zhang C, Zhong B, Luo CF. Comparing
28. Giannicola G, Sacchetti FM, Greco A,
et al. Open reduction and internal
b o ok trochlea treated with open reduction

internal fixation. Arch Orthop Trauma
b o ok
approaches to expose type C fractures
of the distal humerus for ORIF in
fixation combined with hinged
elbow fixator in capitellum and
b o o
e/ e Surg. 2013 Jun;133(6):797–804.
10. Heck S, Zilleken C, Pennig D, et al.
e / e
elderly patients: six years clinical
experience with both the triceps-
trochlea fractures. Acta Orthop.
2010 Apr;81(2):228–233.
e /e
Reconstruction of radial capitellar
fractures using fine-threaded implants
(FFS). Injury. 2012 Feb;43(2):164–168.
://t . m sparing approach and olecranon
osteotomy. Arch Orthop Trauma Surg.
2014 Jun;134(6):803–811.
: / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
281
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
3.3 Distal humerus
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
Rohit Arora, Kerstin Simon, Marco Keller, Michael Blauth
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
3.4 Elbow / / / /
htt ps:
htt ps:
e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e 2 Epidemiology
e/e
: // t .m
Older adults with elbow fracture dislocations (EFDs) present
: / / t .m
Elbow dislocations are the most common dislocations after
tps
with a wide range of functional, physical, and cognitive
ht
impairments. Therefore, the surgical solution must be cus-
tomized and adapted to the functional needs and ability to ht tps
those involving the shoulder, with an incidence of 6–13
cases per 100,000 person-years [8]. A systematic review of
elbow dislocations between 2002 and 2006 in 102 hospitals
comply with postoperative care and rehabilitation. The most in the US reveal an incidence of 5.21 dislocations per 100,000
important goal is a stable joint to allow early postoperative person-years, a slight male predominance (53%), with the
motion [1]. Geriatric patients with a stiff elbow joint may majority caused by falls and in the home setting (51.5%)
e r s
lose independence in activities of daily living.
e r s
[9]. Elbow dislocations account for 11–28% of all elbow in-
ook ok o
juries and involve the nondominant extremity in approxi-
e b Geriatric EFD usually occur after low-energy falls from stand-

e b o mately 60% of the cases [10–12].
b o
e / ing height with the elbow joint in extension and abduction,
m
while the forearm is in supination. They are typically
t . e/ t . m
While some authors report concomitant coronoid fractures e/e
associated with poor bone quality [2, 3].
: / / / /
in about 10% of the elbow dislocations [13], others claim
h t t p s
Patients generally present suffering from pain, swelling, and
limited range of motion (ROM) of the elbow [4]. In older
ps:
that almost every elbow dislocation is associated with a
htt
coronoid fracture as a result of shear forces caused by pos-
terior translation against the humeral trochlea [2] after falls
patients, simple elbow dislocations with ligamentous injuries on the outstretched hand [4]. An additional rupture of the
only are rare because of the reduced bone quality. Elbow anterior bundle causes compression fractures of the radial
dislocations are mostly associated with fractures of the dis- head [14].
e rs
tal humerus or the olecranon [5].
e r s
b o ok In EFD, the extent of concomitant bony and ligamentous
b o ok
McKee et al [15] demonstrated a lesion of the lateral col-
lateral ligament (LCL) complex in 100% of elbow dislocations
b o o
e/ e / e
injuries is proportional to the functional outcome and com-
e
plications [6]. Retrospective studies show primary total elbow
and involvement of medial collateral ligament (MCL) com-
plex in 80% of cases.
e /e
://t . m
replacement in elbow dislocation fractures produces good
: / / t . m
t t p s
to excellent results [5, 7]. With the goal of single-shot surgery,
tps
ht
the ideal treatment modality is often the one least prone to
complications. h
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
283
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
3.4 Elbow
k e rs ke rs
e b oo e b oo b o o
t . m e / 3.2 Varus posteromedial instability
t . m e/e
s: / / / /
ps:
This injury is characterized by an anteromedial coronoid
http htt
There are three major patterns of traumatic EFD: postero- fracture with LCL complex rupture. In most cases, the cor-
lateral, anterior, and posterior transolecranon fracture dis- onoid is fractured at the level of the anteromedial facet,
locations. which is also known as the sublime tubercle, where the
MCL inserts. The lateral ulnar collateral ligament is mostly
3.1 Posterolateral instability (terrible triad) avulsed from the dorsal radial epicondyle. The radial head
e rs Posterolateral EFD include fractures of the radial head and

the coronoid with a rupture of the LCL complex (Fig 3.4-1).
er s
stays intact in most of the cases (Case 1: Fig 3.4-2).
b o ok In most cases, at the time of trauma the elbow pivots around

the MCL leaving this ligament complex intact. Posterolat-
bo ok b o o
e/ e e/ e
eral impaction fractures of the capitellum are frequent [16].
e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e b ook e b o ok Fig 3.4-1a–c Posterior elbow
b o o
e/e
dislocation (a) and sagittal com-
e / m e / puted tomographic scan after
m
://t . / /t .
closed reduction with coronoid
and radial head fractures as
s ps:
patterns of a terrible triad injury
a
h t t p b c
htt
(b–c).
Patient Treatment and outcome

CASE 1
e rs A 75-year-old woman fell at home from standing height and sus-

tained an elbow fracture dislocation with intraarticular fragments
e r s
The coronoid is fractured with its anteromedial facet (sublime tu-
bercle) as the insertion point of the anterior part of the medial
b o ok (Fig 3.4-2a–b).
b o ok
collateral ligament complex. Additionally, the lateral ulnar collateral
ligament is avulsed with a bone fragment from the posterolateral
b o o
e/ e Comorbidities
e / e aspect of the distal humerus (Fig 3.4-2c–f). After closed reduction,
e /e
• Hypertension
• Hypothyroidism
://t . m the joint was unstable in < 40° of flexion.
: / / t . m
t t p s tps
Intraoperatively, the lateral ulnar collateral ligament was avulsed
h ht
with a bony fragment from the posterolateral humeral surface
(Fig 3.4-2g).
Open reduction and plate fixation of the radial distal humeral column
was performed. The ulnar ligament complex was fixed to the plate
k e rs ke rs
using fiber wire. This resulted in a stable elbow joint in full extension
oo oo o
(Fig 3.4-2h–j).
eb e b b o
e /
t . m e / The 12 month follow-up demonstrates concentric reduction of the
t .m
ulnohumeral joint and a good functional result (Fig 3.4-2k–p). e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok a b
bo ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e/e
c d e f
e / m e/ m
/ / t . / /t .
htt ps: htt ps:
e rs e r s
b o ok g h
b o
i
ok j k l
b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
m n o p
k e rs
Fig 3.4-2a–p Elbow fracture dislocation with intraarticular fragments.
a–b Elbow fracture dislocation with intraarticular fragments.
ke rs
oo oo o
c–f The anteromedial facet of the coronoid is fractured (sublime tubercle, black arrow) (e) and the lateral ulnar collateral ligament avulsed
eb with a bone fragment (red arrow) (f).
e b b o
/ / e/e
g Intraoperative clinical photograph showing avulsion of the ulnar collateral ligament with a bony fragment.
e t . e
h–j Plate fixation of the anteromedial fracture fragment and a dorsal plate buttressing the avulsed posterolateral fragment.
m t .m
/
k–l Twelve-month follow-up x-rays showing concentric reduction of the ulnohumeral joint.
/ //
ps: ps:
m–p Final follow-up with good clinical results.
htt htt 285
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
3.4 Elbow
k e rs ke rs
e b oo e b oo b o o
e / 3.3
t . m
Anterior transolecranon fracture dislocation e / 3.4 Posterior transolecranon fracture dislocation
t . m e/e
s: / / / /
ps:
In this pattern, the distal humerus displaces across the f acets In this type, the proximal ulnar fractures and the radius
http htt
lunaris of the proximal ulna, fracturing the olecranon with dislocate posteriorly leading to shear fractures of the radial
variable involvement of the coronoid or the proximal ulnar head and neck. Coronoid fractures also belong to this type
shaft, leaving the radial head intact (Fig 3.4-3). of injury (Fig 3.4-4).
In those cases in which the proximal radioulnar joint is
e rs er s
disrupted, the subtype is called Monteggia equivalent. The
proximal radioulnar dislocation may best be detected on
b o ok bo ok
axial computed tomographic (CT) scan views.
b o o
e/ e e/ e Ligaments are avulsed with bone fragments so that bone
e/e
: // t .m : / / .m
fixation restores the ligamentous instability (Case 2: Fig 3.4-5).
t
ht tps ht tps
Fig 3.4-4 Posterior
transolecranon frac-
e r s e r s ture dislocation with

posterior displace-
ook ok o
ment of the proximal
e b e b o radius and proximal

b o
/ e/ e/e
ulna as a unit without
e t . m
disruption of the
. m
proximal radioulnar
t
/ / / /
ps: ps:
joint. The posterior
displacement leads
htt htt
to a radial head and
coronoid fracture.
Fig 3.4-3 Anterior transolecranon fracture dislocation with an ante-
rior displacement of the proximal radius and proximal ulna without a
disruption of the proximal radioulnar joint.
e rs e r s
ok Patient
ok
o
CASE 2
/ e b o / e b o
An 83-year-old man fell on the extended right arm while skiing and
sustained a Monteggia equivalent fracture dislocation with associ-
Surgery was performed in prone position. Findings showed a com-
plete rupture of the medial collateral ligament complex. The radial
/e b o
e . me
ated radial head and neck fractures. He presented with moderate head was dislocated posteriorly out of the proximal radioulnar joint.
. m e
://t / t
swelling and pain (Fig 3.4-5a–h). The attempt to reconstruct the radial head and neck failed so the
s : /
tps
remaining radial head was resected, making the exposure to the
Comorbidities
h t t p
• No comorbidities were documented ht
fractured coronoid easier. Cannulated screw fixation of the coronoid
process and plate fixation of the olecranon was performed. The
radial head was replaced by a prosthesis and repair of the lateral
collateral ligament complex resulted in a stable condition on the
ulnar site. Intraoperative x-rays showed no subluxation or dislocation.
k e rs ke rs
Follow-up x-rays at 16 months showed a concentric radio- and ul-
eb oo e b oo
nohumeral joint with bone union (Fig 3.4-5i–j).
b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
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e rs er s
b o ok bo ok b o o
e/ e a
e/ e e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e / b c
t . m e/d e f
t . m e/e
: / / / /
h t t p s
htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
g
t t p s h i j
tps
h
Fig 3.4-5a–j An 83-year-old man with a posterior transolecranon fracture dislocation.
a–f Posterior transolecranon fracture dislocation with associated radial head and neck fractures. ht
g Intraoperative x-ray showing the radial head resected. Reduction of the coronoid fragment was performed through the radial exposure.
The fragment was fixed indirectly with screws from the dorsal aspect of the ulna and the olecranon fixed using a plate.
h Intraoperative x-ray showing the final fixation with radial head replacement.
rs rs
i–j Postoperative x-rays taken at 16 months show a concentric radio- and ulnohumeral joint with bone union.
k e ke
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
287
rs
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/ / t . m // t . m
htt ps: htt ps:
3.4 Elbow
k e rs ke rs
e b oo e b oo b o o
t . m e /
t
The goals of operative treatment are restoration of the os-
. m e/e
s: / / / /
ps:
seous anatomy and reconstruction of the ligamentous re-
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4.1 Nonoperative treatment straints to provide stability for early motion [2, 19].
The majority of EFD are treated operatively to avoid osseous
nonunion or recurrent dislocation [17]. Operative interven- 4.2.1 Approach
tion restores stability and permits early motion of the elbow. The authors prefer a single dorsal skin incision for all com-
Chan et al [17] demonstrated that a small subset of patients plex elbow fracture dislocations with the patient in prone
e s
can be treated nonoperatively. Criteria for the nonoperative
r
management include:
er s
position. Dissecting radial and ulnar skin flaps exposes the
medial und lateral aspects of the elbow joint.
b o ok • Concentric elbow reduction, documented by CT scan

bo ok
In transolecranon fracture dislocations, the radial skin flap
b o o
e/ e • Stable arc of active motion to a minimum of 30° exten-
e/ e is retracted anteriorly and the radial head is addressed
e/e
sion
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• Small and minimally displaced radial head fracture
through a Kocher interval between the extensor carpi ra-
: / /
dialis muscle and the anconeus muscle. The coronoid frag- t .m
tion types 1 or 2)
ht tps
• Smaller coronoid tip fracture (Regan-Morrey classifica-
ht tps
ments can usually be exposed through the olecranon fracture
site. In anteromedial coronoid fractures the ulnar skin flap
is retracted anteriorly and the coronoid fracture is exposed
In these cases, the elbow fracture dislocation should be re- using the flexor carpi ulnaris (FCU) splitting approach. The
duced and immobilized in an elbow cast with the forearm FCU is split in line with the anterior margin of the medial
in neutral rotation for a maximum of 3 weeks. Frequent epicondyle and anterior part of the MCL complex (Fig 3.4-6).
e r s
clinical and x-ray examinations can reveal potential com-
e r s
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plications like recurrent subluxation or dislocation which
e b must initiate operative fixation. Physiotherapy can be initi-

e b o In terrible triads, the radial skin flap is retracted anteriorly
b o
e / ated as soon as pain subsides and starts with passive and
active exercises around the neutral position.
t . m e/ and the radial head is addressed through the rent of the
t . m
lateral ligament complex. If the radial head has to be replaced, e/e
/ / /
resection of the fracture fragments allows good exposure
/
4.2 Operative treatment
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For the remaining fracture presentations, nonoperative
methods can otherwise lead to recurrent instability and long- htt
tional medial approach can be avoided (Fig 3.4-7).ps:
and access to the coronoid fracture for fixation. An addi-
term fixation-induced stiffness [18].
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
oo oo o
Fig 3.4-6 Intraoperative image of the flexor carpi ulnaris (FCU) split- Fig 3.4-7 Intraoperative image showing the coronoid fracture after
eb b
ting approach (the left of the image is distal and the top is anterior).
e
the radial head has been resected (white arrow showing the proximal
b o
/ / e/e
The ulnar nerve is looped and retracted dorsally. The anterior part radial shaft stump). The forceps are holding down the tip of the
e t . m e
of the FCU is retracted anteriorly by the upper Langenbeck retractor.
The anteromedial facet of the coronoid (sublime tubercle) is held in
coronoid (yellow arrow showing the base of the coronoid). The origin
t .m
of the lateral collateral ligament complex (black arrow) has been
/ / //
ps: ps:
the forceps. avulsed from the lateral epicondyle.
288
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rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 4.2.2 Radial head
t . m e / 4.2.3 Coronoid process
t . m e/e
s: / / / /
ps:
It is important to fix the radial head fracture if technically The significance of coronoid fractures with regard to elbow
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feasible. In cases of complex elbow instability, partial or stability can be difficult to determine. Some authors tend
entire radial head resection aggravates instability and should to ignore fractures affecting less than 30% of the height
not be performed. Replacement is considered for fractures [23]. In clinical practice, there are more parameters to con-
with more than four fragments, and in cases where the sider than the size of the coronoid fragment alone. Espe-
radial head fracture has no periosteal contact with the neck cially if the fracture contains the anterior and the medial
e rs
[20, 21].
er s
facet of the coronoid process, it should always be fixed. For
this reason, each patient with a coronoid fracture must be
b o ok Otherwise, open reduction and internal fixation with plate

fixation in the “safe zone” is attempted to avoid impinge-
bo ok
assessed individually intraoperatively. In valgus postero-
medial injuries, the authors fix each coronoid fracture when
b o o
e / e ment. Plating may be associated with impaired forearm ro-
e/ e there is joint incongruity in 90° of flexion or if there is
e/e
: // t .m
tation; oblique screws may be an alternative. Comminution
at the head-neck junction may require corticocancellous (Fig 3.4-9) [24].
: / / .m
instability under varus stress, regardless of fragment size
t
tps
bone grafting, for example, from the posterolateral surface
ht
of the distal humerus (Fig 3.4-8) [22].
ht tps
Larger coronoid fragments should be fixed by retrograde
cannulated screws (Fig 3.4-10). The anteromedial facet frag-
ments are best fixed using buttress plates (Case 3: Fig 3.4-11).
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
ps: ps:
Fig 3.4-8 Intra-
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operative situation
showing the triceps
reflected ulnarly and
the radial column of Fig 3.4-10a–b Fixation of larger
the distal humerus, coronoid fragments.
with the defect a After resection of the radial
head, the coronoid fragment
e rs (arrow), where the

bone graft has been
e r s was reduced from the radial
ok ok
side and fixed indirectly us-
b o
harvested.
b o ing a cannulated screw
b o o
e/ e e / e inserted from the dorsal
ulna.
e /e
://t . m / / t m
b Follow-up x-ray showing the
.
replaced radial head and
:
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anatomically fixed coronoid
ht
fragment. Mild anterolateral
h a ossification can be seen.
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
Fig 3.4-9 Posterior dislocation in 90° flexion, confirming the loss of
the buttress function of the fractured coronoid. In these cases, the
t .m e/e
/ / //
ps: ps:
coronoid should always be fixed regardless of its size. b
htt htt 289
rs
rs 26.07.18 10:28
/ / t . m // t . m
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3.4 Elbow
k e rs ke rs
e b oo e b oo b o o
e / Patient
. m e/e
CASE 3
/ / t
A 71-year-old woman fell down the stairs and presented with mod-
: / / t
Surgery was performed in prone position: The medial collateral
ht p s
erate swelling but intact perfusion, function, and sensibility after
t
elbow fracture dislocation. Initial x-rays and 3-D computed tomo-
graphic scans showed a displaced fracture of the left elbow with htt ps:
ligament (MCL) complex was partially ruptured, with a multifrag-
mentary coronoid process fracture. The ulnar approach with split of
the flexor carpi ulnaris was performed. The anterior part of the MCL
coronoid fracture (Fig 3.4-11a–e). was attached to the fracture fragment. The anteromedial fracture
fragment was stabilized using two cannulated screws and a plate.
Comorbidities For capsule refixation, nonresorbable sutures were used. The lat-
e rs • Hypertension
r s
eral ligament complex was fixed through the radial side using bone
e
b o ok • Smoker
bo ok
anchors. Intraoperative extension x-rays demonstrate no tendency
for dislocation (Fig 3.4-11f–h).
b o o
e/ e e/ e After 14 months, good functional and radiographic results were
e/e
: // t .m obtained (Fig 3.4-11i–n).
: / / t .m
ht tps ht tps
e r s e r s
e / a b c
t . m e/ d e
t . m e/e
: / / / /
h t t p s
htt ps:
e rs e r s
b o ok b o ok b o o
e/ e f g
e / e h i j
e /e
://t . m : / / t . m
t t p s tps
h ht
kers kers
k l m n
b o o b o o
Fig 3.4-11a–n A 71-year-old woman with fracture dislocation of the left elbow.
a–e X-rays and 3-D computed tomographic scans showing a displaced fracture of the left elbow with a displaced multifragmentary coronoid
b o o
e /e fracture.
e/e
f Intraoperative image showing a ruptured medial collateral ligament with a multifragmentary coronoid process fracture.
m m e/e
/t .
g-h Intraoperative passive extension under image intensifier showed no tendency for instability.
/ // t .
ps: ps:
i–n X-rays and clinical photographs at 14 months demonstrating good x-rays and functional results.
290
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rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 4.2.4 Ligaments
t . m e / 4.2.5 Hinged external fixator
t . m e/e
s: / / / /
ps:
The LCL complex is ruptured in most terrible triad patterns A hinged external fixator should be used in any case of
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and varus posteromedial injuries. In acute cases, transosse- residual instability after reconstruction of all repairable bony
ous repair to its origin in the center of the lateral epicondyle and soft-tissue structures. The advantage of a dynamic ex-
using bone anchors with nonabsorbable sutures is sufficient ternal fixator applied in the concentric axis of the elbow is
and should always be performed. the start of early protected motion even in complex instabil-
ity (Case 4: Fig 3.4-12).
e s
The MCL complex is only addressed, if, after reconstruction
r
of the coronoid radial head and LCL complex, the elbow
er s
b o ok tends to dislocate with passive extension above 60° [24]. In
these cases, the MCL complex and the common flexor/pro-
bo ok b o o
e/ e nator muscles are stripped from the origin and are repaired
e/ e e/e
: // .m
using bone anchors with nonabsorbable sutures.
t : / / t .m
Patient ht tps ht tps
CASE 4
An 83-year-old woman fell on her extended arm and was complain- During the revision surgery no signs of a repair of the lateral ligament
ing of pain in the elbow and inability to move. Peripheral perfusion complex were found. The lateral collateral ligament complex was
and function were found intact. The patient reported a spontaneous avulsed from its origin. The radial head was not amenable for re-
e r s
reduction of the elbow joint. Fracture of the coracoid process and
e r s
construction. Radial head replacement and reconstruction of the
ook ok o
a displaced radial head fracture were noted (Fig 3.4-12a–d). lateral ligament complex using an anchor was performed. As the
e b e b o surgery was done 4 days after the initial procedure, an additional

b o
e / Comorbidities
• Alcohol abuse
t . m e/ medial approach was avoided for reconstruction of the medial liga-
t . m
ment complex. A hinged external fixator for 3 weeks was applied. e/e
/ /
• Chronic obstructive pulmonary disease
/ /
Mobilization was started immediately after surgery to avoid joint

htt ps:
At index surgery, the radial head fragment was fixed with screws
stiffness (Fig 3.4-12h).
htt ps:
After 1 year some heterotopic ossification occurred: range of motion
(Fig 3.4-12e–f). Two days postoperative, increasing pain and redis- extension–flexion was 0–15–120° and pronation–supination was
location of the elbow joint occurred (Fig 3.4-12g). 70–0–60° (Fig 3.4-12i–j).
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
a b c d
Fig 4.3-12a–j An 83-year-old woman with a coracoid process fracture.
k e rs
a–d X-rays showing fracture of the coracoid process and displaced radial head.
ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
291
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
3.4 Elbow
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
e f
: // t .m g
: / / t .m
s tps
http ht
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
h
htt ps: i
Fig 4.3-12a–j (cont) An 83-year-old woman with a coracoid process fracture.

j
htt ps:
e–f Postoperative x-rays showing radial head fragment fixed with screws.
g X-ray showing instability of the elbow joint.
h X-rays after revision surgery showing the radial head replaced and a hinged external fixator applied. The lateral ligament complex was
reattached using a bone anchor.
e rs e r s
i–j Follow-up x-rays at 1 year demonstrating a concentric elbow joint with some heterotopic ossification.
b o ok b o ok b o o
e/ e e / e e /e
5 Complications
://t . m : / / t . m
t p s
The most common complications after elbow fracture dis-
t tps
h
locations are chronic instability due to errors in identifying
instabililty at the time of initial examination and/or after
operative repair (Case 5: Fig 3.4-13, Case 6: Fig 3.4-14), elbow
ht
stiffness due to postoperative pain or immobilization over
2–3 weeks and heterotopic ossification (HO). Risk factors
k e rs
for HO include age, lesions of the central nervous system,
ke rs
oo oo o
burns, and genetic factors. Operative or nonoperative treat-
eb ment and surgical timing do not seem to influence the

e b b o
e / occurrence of HO, which can occur in up to 56% of cases.
t . m
Heterotopic ossification can result in limited ROM due toe /
t .m e/e
bony impingement [13, 25–27].
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Patient
. m e /
. m e/e
CASE 5
/ / t
A 78-year-old woman fell on her extended forearm and sustained
/ / t
One month later, at the time of cast removal, the patient did not
htt ps:
a terrible triad elbow fracture dislocation. The patient was treated
initially at another trauma hospital.
htt ps:
complain about pain but showed remaining instability with sublux-
ation of the ulnohumeral joint (Fig 3.4-13f). To stabilize the elbow
joint, closed reduction of the elbow joint was performed and an
Comorbidities external fixator applied (Fig 3.4-13g). This device was removed after
• Mild dementia 6 weeks and physiotherapy was initiated.
• Hypertension
k e rs • Parkinson’s disease
r s
The patient presented 1.5 years after the trauma at the authors’
e
o o Treatment and outcome
o ok
department. She was unable to move actively and had a painful
passive range of motion (ROM) of 0–0–120°. X-rays showed
o o
e/eb e/ e b e/eb
The trauma x-rays showed a posterior elbow dislocation with osteoarthritis and a subluxed elbow joint (Fig 3.4-13h–i).
associated radial head fracture and fracture of the coronoid tip
/ t .m
(Fig 3.4-13a–e). Initially, the dislocated elbow joint was reduced
: / / t .m
Total elbow arthroplasty was performed. The patient presented pain
: /
ps tps
and fixed in a cast in another hospital. free and satisfied 2 years after trauma and 5 months after elbow
htt ht
joint replacement. Final ROM was 0–15–120° and forearm rotation
was 80–0–65° (Fig 3.4-13j–o).
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
a b c
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs
d e
ke rs f
eb oo e b oo
Fig 3.4-13a–o A 78-year-old woman with a triad elbow fracture dislocation.
b o o
e/e
a–e X-rays and computed tomographic scans showing a posterior elbow dislocation with associated radial head fracture and fracture of the
e / coronoid tip (terrible triad injury).
m e / m
/ / .
f X-ray after 4 weeks showing instability with subluxation of the ulnohumeral joint.
t // t .
htt ps: htt ps:
293
rs
rs 26.07.18 10:28
/ / t . m // t . m
htt ps: htt ps:
3.4 Elbow
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e g h i
e/ e j k
e/e
: // t .m : / / t .m
ht tps ht tps
l m n o
e r s e
Fig 3.4-13a–o (cont) A 78-year-old woman with a triad elbow fracture dislocation.
r s
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g At 4 weeks, closed reduction was performed and an external fixator applied.
e b
h–i After 1.5 years, osteoarthritis and a subluxed elbow joint.
e b o b o
/ e/ e/e
j–o X-rays and clinical photographs taken 2 years after trauma and 5 months after elbow joint replacement.
e t . m t . m
/ / / /
Patient
htt ps: Treatment and outcome
htt ps:
CASE 6
A 74-year-old man fell while cycling and sustained a multifragment- Primarily, a nonoperative treatment with cast immobilization was
ed fracture of the anteromedial coronoid fragment (Fig 3.4-14a–b). initiated. In the follow-up x-ray after 1 week, ulnohumeral instability
with subluxation (drop sign) was recognized (Fig 3.4-14c).
Comorbidities
e rs • No comorbidities were documented

r s
The anteromedial coronoid fracture was fixed by buttress plating
e
b o ok b o ok
using the flexor carpi ulnaris splitting approach, and the tip of the
coronoid was fixed indirectly using a cannulated screw (Fig 3.4-14d–f).
b o o
e/ e e / e On the first postoperative x-rays after 4 days, a subluxation of the
e /e
://t . m / t .
ulnohumeral joint on the lateral x-ray (Fig 3.4-14g) was recognized,
: / m
t t p s tps
as well as insufficiency of the lateral ligament complex (widening
ht
of the radiohumeral joint on AP x-ray (Fig 3.4-14h).
h In the revision surgery, an additional posterolateral approach was
performed and the posterior part of the lateral collateral ligament
complex was fixed to its origin at the lateral epicondyle using bone
k e rs ke rs
anchors (Fig 3.4-14i–j).
eb oo e b oo
Final follow-up showed a concentrically reduced elbow joint with
b o o
e/e
acceptable range of motion (Fig 3.4-14k–p).
e / m e / m
/ /t . // t .
htt ps: htt ps:
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e a b
e/
c e d
e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e / e f
t . m e/ g h
t . m e/e
s: / / / /
http htt ps:
e rs e r s
b o ok b o ok b o o
e/ e i j
e / e k l
e /e
://t . m : / / t . m
t t p s tps
m h n o ht p
Fig 3.4-14a–p A 74-year-old man with a multifragmented fracture of the anteromedial coronoid fragment.
a–b Computed tomographic scans showing a multifragmented fracture of the anteromedial coronoid fragment and bony avulsions from the
medial and lateral epicondyles.
k e rs ke rs
c Follow-up x-ray after 1 week of cast immobilization showing ulnohumeral instability with subluxation.
d Intraoperative image showing a medial flexor carpi ulnaris split approach with the anteromedial fracture fragment held by the forceps.
eb oo b
of the coronoid with concentric reduction of the elbow joint.
e oo
e–f Intraoperative image intensification showing buttress plate to fix the anteromedial coronoid fracture and a cannulated screw to fix the tip
b o o
e /
t . m
radiohumeral joint on the AP x-ray (h) was recognized.
e /
g–h A subluxation of the ulnohumeral joint on the lateral x-ray ( g) as well as insufficiency of the lateral ligament complex (widening of the
t .m e/e
/ /
i–j Intraoperative images showing the posterior part of the lateral collateral ligament complex avulsed from the lateral epicondyle.
/ /
ps: ps:
k–p Final follow-up x-rays and clinical photographs showing a concentrically reduced elbow joint with acceptable range of motion.
htt htt 295
rs
rs 26.07.18 10:29
/ / t . m // t . m
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3.4 Elbow
k e rs ke rs
e b oo e b oo b o o
e / 6 References
t . m e /
t . m e/e
/ / / /
htt ps:
1. McKee MD, Pugh DM, Wild LM, et al.
Standard surgical protocol to treat
elbow dislocations with radial head and
coronoid fractures. Surgical technique.
10. Hobgood ER, Khan SO, Field LD.
Acute dislocations of the adult elbow.
Hand Clin. 2008 Feb;24(1):1–7.
11. Josefsson PO, Johnell O, Wendeberg B.
ps:
19. Papatheodorou LK, Rubright JH,
htt
Heim KA, et al. Terrible triad injuries of
the elbow: does the coronoid always
need to be fixed? Clin Orthop Relat Res.
J Bone Joint Surg Am. Ligamentous injuries in dislocations of 2014 Jul;472(7):2084–2091.
2005 Mar;87(Suppl 1[Pt 1]):22–32. the elbow joint. Clin Orthop Relat Res. 20. Acevedo DC, Paxton ES, Kukelyansky I,
2. Bohn K, Ipaktchi K, Livermore M, et al. 1987 Aug;(221):221–225. et al. Radial head arthroplasty:
e rs Current treatment concepts for “terrible

triad” injuries of the elbow. Orthopedics.
er s
12. Josefsson PO, Nilsson BE. Incidence of
elbow dislocation. Acta Orthop Scand.
state of the art. J Am Acad Orthop Surg.
2014 Oct;22(10):633–642.
ok ok
2014 Dec;37(12):831–837. 1986 Dec;57(6):537–538. 21. Iannuzzi NP, Leopold SS. In brief: the
b o 3. Xiao K, Zhang J, Li T, et al. Anatomy,

definition, and treatment of the
bo
13. Heck S, Gick S, Dargel J, et al. Die
Behandlung der akuten Luxation und
Mason classification of radial head
fractures. Clin Orthop Relat Res.
b o o
e/ e “terrible triad of the elbow” and
contemplation of the rationality of
e/ e
Luxationsfraktur des Ellenbogens –
Bewegunsfixateur [External fixation
2012 Jun;470(6):1799–1802.
22. Pike JM, Grewal R, Athwal GS, et al.
e/e
this designation. Orthop Surg.
2015 Feb;7(1):13–18.
: // t .m with motion capacity in acute
dislocations and fracture dislocations of
: / / t .m
Open reduction and internal fixation
of radial head fractures: do outcomes
tps tps
4. Chen NC, Ring D. Terrible Triad Injuries the elbow. Fixation with motion differ between simple and complex
ht ht
of the Elbow. J Hand Surg Am. capacity]. Unfallchirurg. injuries? Clin Orthop Relat Res.
2015 Nov;40(11):2297–2303. 2011 Feb;114(2):114–122. German. 2014 Jul;472(7):2120–2127.
5. Siebenlist S, Stöckle U, Lucke M. 14. Sheps DM, Kiefer KR, Boorman RS, 23. Rouleau DM, Sandman E, van Riet R,
Problematik osteoporotischer et al. The interobserver reliability of et al. Management of fractures of the
Frakturen am Ellenbogen [Osteoporotic classification systems for radial head proximal ulna. J Am Acad Orthop Surg.
fractures of the elbow]. Obere fractures: the Hotchkiss modification of 2013 Mar;21(3):149–160.
Extremität. 2009;4(3):160–167. German. the Mason classification and the AO 24. Giannicola G, Calella P, Piccioli A, et al.
e r s
6. Siebenlist S, Braun KF.
r s
classification systems. Can J Surg.
e
Terrible triad of the elbow: is it still a
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Ellenbogenluxationsfrakturen [Elbow 2009 Aug;52(4):277–282. troublesome injury? Injury.
b
dislocation fractures]. Unfallchirurg.
2017 Jul;120(7):595–610. German.
15. McKee MD, Schemitsch EH, Sala MJ,
b o
et al. The pathoanatomy of lateral
2015 Dec;46(Suppl 8):S68–S76.
25. Englert C, Zellner J, Koller M, et al.
b o o
e / e 7. McKee MD, Veillette CJ, Hall JA, et al.
A multicenter, prospective,
e/ e
ligamentous disruption in complex
elbow instability. J Shoulder Elbow Surg.
Elbow dislocations: a review ranging
from soft tissue injuries to complex
e/e
randomized, controlled trial of open
/
reduction—internal fixation versus
/ t . m 2003 Jul–Aug;12(4):391–396.
16. Chan K, King GJ, Faber KJ. Treatment 2013;2013:951397.
/ /t . m
elbow fracture dislocations. Adv Orthop.
ps: ps:
total elbow arthroplasty for displaced of complex elbow fracture-dislocations. 26. Mittlmeier T, Beck M. Luxation des
htt htt
intra-articular distal humeral fractures Curr Rev Musculoskelet Med. Ellenbogengelenks des Erwachsenen
in elderly patients. J Shoulder Elbow 2016 Jun;9(2):185–189. [Dislocation of the adult elbow joint].
Surg. 2009 Jan–Feb;18(1):3–12. 17. Chan K, MacDermid JC, Faber KJ, et al. Unfallchirurg.
8. Wyrick JD, Dailey SK, Can we treat select terrible triad 2009 May;112(5):487–505. German.
Gunzenhaeuser JM, et al. Management injuries nonoperatively? Clin Orthop 27. Noblin J, Geissler W, Bass D.
of complex elbow dislocations: a Relat Res. 2014 Jul;472(7):2092–2099. The incidence of heterotopic ossification
mechanistic approach. J Am Acad 18. Chen HW, Liu GD, Ou S, et al. Operative with elbow injuries. Orthop Trans.
e rs Orthop Surg. 2015 May;23(5):297–306.

9. Stoneback JW, Owens BD, Sykes J, et al.
r s
Treatment of Terrible Triad of the
Elbow via Posterolateral and
e
1995;19:162.
b o ok Incidence of elbow dislocations in the

United States population. J Bone Joint
o
2015;10(4):e0124821.
b ok
Anteromedial Approaches. PLoS One.
b o o
e/ e Surg Am. 2012 Feb 01;94(3):240–245.
e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
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rs
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k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
3.5 Olecranon / / / /
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e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e and vulnerable soft-tissue conditions, operative complica-
e/e
: // t .m
Olecranon fractures account for 80% of all fractures of the
: / / t .m
tions are frequently reported at rates up to 70% [7, 8]. Due
to the frailty of this group of patients, even displaced
tps
proximal ulna. Similar to distal radius and vertebral fractures,
ht
olecranon fractures may serve as a “sentinel fracture” that
indicates widespread poor bone quality [1]. ht tps
olecranon fractures are often treated nonoperatively, lead-
ing to reasonable results without the risk of anesthetic or
operative complications [1, 9. 10]. This chapter provides an
overview and treatment algorithm for olecranon fractures
There is a steep increase in incidence of proximal ulna frac- in older adults.
tures in the seventh decade of life with a peak in the ninth
e r s
decade for both male and female patients. The incidence
e r s
ook ok o
increases from 12 per 100,000 in the general population to 2 Diagnostics
e b 70–80 per 100,000 in the geriatric population (> 65 years).

e b o b o
e / e/
There seems to be no gender predominance and open fractures
m
are relatively rare [1]. About 25–30% of the patients with a
t .
Diagnostic and therapeutic recommendations should be
t . m
based on the unique medical, cognitive, and social condi- e/e
/ /
fracture of the proximal ulna sustain a concomitant injury
/ /
tions as well as the functional needs of each patient. A
ps:
to the ipsilateral limb most frequently a proximal radius frac-
htt
ture followed by a proximal humerus, forearm, metacarpal
and classic geriatric hip and pelvic fractures (Case 3: Fig 3.5-7, htt ps:
thorough medical history examination including the patient’s
general condition and health status, comorbidities as well
as functional expectations are mandatory prior to the plan-
Case 4: Fig 3.5-8 , Case 5: Fig 3.5-9, Case 15: Fig 3.5-19) [1, 2]. ning of the individual treatment. Patients should also be
carefully reviewed for any cognitive disabilities, as those
The most common cause of this type of injury is the direct may limit adequate patient compliance with the treatment
e rs
impact from a fall from standing height [1]. In such cases, course.
e r s
b o ok the olecranon impacts on the distal humerus, potentially
resulting in a comminuted fracture pattern. Indirect trauma
b o 2.1 ok
Clinical evaluation
b o o
e/ e / e
as a result of a powerful contraction of the triceps muscle
e
during a fall on the outstretched arm typically results in a
The history should ask the following questions:
e /e
://t . m
simple transverse or oblique fracture pattern [3, 4]. Overall,
/ t .
• How did the injury happen (ie, mechanism of injury)?
: / m
t t p s
the simple 2-part fracture represents the most frequent frac-
tps
• Was it a single injury or are there additional injuries and
ht
ture type (Mayo 2A; AO/OTA 2U1B) [1]. Fracture displacement locations of pain?
h
occurs as a result of triceps muscle pull in cases of a ruptured
periosteum and triceps aponeurosis, which can lead to a
• What was the preinjury level of function and activity (eg,
independent, walking aids, or bedridden)?
considerable loss of function [3]. However, older patients • Was the dominant hand injured?
may demonstrate satisfactory function that meets their per- • What is the level of care available at the patient’s current
k e rs
sonal needs despite gross displacement (Case 5: Fig 3.5-9).
ke rs
residence (ie, independent, family, or nursing home)?
• What are the patient’s medical comorbidities and chronic
eb oo Based on a combination of case series review and tradi-
e b ootreatments including anticoagulation?

b o o
e/e
tional experience, the standard treatment for displaced • What is the patient’s mental status and expected ability
e / e /
olecranon fractures is open reduction and operative fixation
m
to comply?
m
t .
including tension band wiring or one of a variety of plate
/ / // t .
ps: ps:
fixation methods [5, 6]. However, due to osteoporotic bone
htt htt 297
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.5 Olecranon
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
The clinical examination should address the following aspects: 2.2 Imaging
t . m e/e
s: / / / /
ps:
Plain AP and lateral x-rays are usually sufficient (Fig 3.5-1).
http htt
• Fracture crepitus, soft-tissue status, open bursa, or
even an open fracture? A computed tomographic scan should be obtained in cases
• Severe pain or pseudoparalysis? without adequate conventional x-rays to clearly identify
• Joint stability? the fracture pattern (Case 1: Fig 3.5-2 , Case 2: Fig 3.5-3). This is
• Active range of motion (ROM)? especially important for operative planning and for visual-
e rs • Vascular and neurological status?

• Damage to the ulnar nerve (ie, proximity to the
er s
ization of concomitant fractures of the radial head or the
coronoid process.
b o ok fracture site)?
• Complaints of pain at other locations (ie, concomitant
bo ok b o o
e/ e injury)?
e/ e e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
ook ok o
Fig 3.5-1a–b Correct AP
e b e b o (a) and lateral (b) x-rays of a

b o
/ e/ e/e
74-year-old woman with an
e a
t . m b
olecranon fracture after a bike
t . m
: / / accident.
/ /
h t t p s
htt ps:
Patient
CASE 1
An 87-year-old woman fell down the stairs.
e rs Comorbidities
• Rheumatoid arthritis
e r s
b o ok • Degenerative changes of the joint
b o ok b o o
e / e a
e /e
://t . m
Owing to an insufficient view of the fracture on conventional x-rays,
a computed tomographic scan was obtained, which revealed a
: / / t . m
t p s
simple Mayo type IA fracture pattern. The patient was treated non-
t tps
h
operatively (Fig 3.5-2a–b).
The lateral view 4 months after the initial injury showed a nonunion
ht
and destruction of the elbow joint. The patient could reach her
mouth but could not perform any overhead activities (range of
k e rs motion 0–0–90°). However, the patient refused any further treat-

b
ke rs c
oo oo o
ment and was referred to physical therapy (Fig 3.5-2c).
eb e b Fig 3.5-2a–c An 87-year-old woman after a fall.

b o
e /
t . m e / a–b Computed tomographic scan showing a simple Mayo type IA
fracture pattern.
t .m e/e
/ / /
c Lateral view 4 months after the initial injury showing a non-
/
ps: ps:
union and destruction of the elbow joint.
298
htt htt
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Patient
. m e /
. m e/e
CASE 2
/ / t
A 79-year-old man had a fall while rock climbing.
/ / t
The patient was treated with open reduction and internal fixation

htt ps:
The computed tomographic scan was essential to assess the complete htt ps:
using a locking plate, followed by 3 weeks of cast fixation and
physical therapy without cast fixation. Six months after surgery, the
patient was satisfied and pain free with almost full range of motion
fracture pattern and to accurately plan the surgery (Fig 3.5-3a–b). (Fig 3.5-3c).
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
a b c
e r s
Fig 3.5-3a–c A 79-year-old male patient after a rock climbing accident.
e r s
ook ok o
a–b Computed tomographic scan used to assess the complete fracture pattern and to accurately plan the surgery.
e b b o
c Treatment with open reduction and internal fixation using a locking plate.
e b o
e /
t . m e/ t . m e/e
/ / / /
ps: ps:
3 Classification 3.2 Mayo classification
htt htt
The system is based on stability, displacement, and com-
There are four major classification systems commonly used minution (Fig 3.5-4) [12, 16]:
for olecranon fractures: Colton [11], Mayo [12], Schatzker
[13], and the AO/OTA Fracture and Dislocation Classification • Type I—nondisplaced noncomminuted (IA) and com-
[14]. They are based on the fracture pattern and do not con- minuted (IB) olecranon fractures
e s
sider the patient’s age or bone quality. Overall, all systems
r
are associated with low reproducibility and none has yet
e r s
• Type II—displaced but stable noncomminuted (IIA) and
comminuted (IIB) olecranon fractures with more than 3
b o ok been universally accepted [15, 16].
b o ok
mm of fragment displacement but intact collateral liga-
ments and a stable forearm in relation to the humerus
b o o
e/ e 3.1
e / e
AO/OTA Fracture and Dislocation Classification • Type III—displaced and unstable noncomminuted (IIA)
e /e
following three types:
://t . m
The AO/OTA classification differentiates between the
: / / t .
and comminuted (IIB) olecranon fractures with an un-
stable forearm in relation to the humerus (fracture dis- m
t t p s location)
tps
h
• Type 2U1A —extraarticular fracture
• Type 2U1B —partial articular fracture
• Type 2U1C —complete articular fracture, of olecranon and
ht
coronoid (C3)
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
299
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.5 Olecranon
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
a
: // t .m b
: / / t .m
IA—nondisplaced noncomminuted
s IB—nondisplaced comminuted
tps
http ht
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
c
htt ps: d
htt ps:
IIA—displaced stable noncomminuted IIB—displaced stable comminuted
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
e f
IIIA—displaced unstable noncomminuted IIIB—displaced unstable comminuted
k e rs ke rs
Fig 3.5-4a-f Mayo classification demonstrated with x-ray of mostly geriatric patients.
eb oo a
oo
A 73-year-old woman fell on her right elbow during a cerebral infarction.
b
b A 74-year-old woman slipped and fell directly onto her right elbow.
e b o o
e / c A 91-year-old woman slipped and fell on the sidewalk.
t . m
d A 79-year-old man fell while rock climbing.
e /
t .m e/e
/
e A 47-year-old woman jumped from the second floor.
/ //
ps: ps:
f A 73-year-old woman collapsed and fell on the floor sustaining a multifragmentary transolecranon fracture dislocation.
300
htt htt
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
t . m e /
t . m
These fragility fractures have the potential to heal nonop- e/e
s: / / / /
ps:
eratively with osseous union (Case 3: Fig 3.5-7) or nonunion
http htt
Due to the increased risk of anesthetic and operative com- (Case 4: Fig 3.5-8 , Case 6: Fig 3.5-10). Either way, the clinical
plications in older adults, nonoperative treatment is a rea- outcome is usually satisfactory in older adults, resulting in
sonable treatment option in many cases. The American nearly normal extension and, in the authors’ experience,
Society of Anesthesiologists (ASA) score is known to correlate adequate pain control, even in cases with a large displaced
with the rate of intraoperative complications as well as the fragment (Case 5: Fig 3.5-9) or multiple fracture fragments
e rs
operative outcome [17, 18, 19]. Nondisplaced Mayo type I
fractures can be successfully treated nonoperatively and
er s
(Case 4: Fig 3.5-8).
b o ok avoid the risk of operative or anesthetic complications. Un-

eventful fracture healing is frequent, and there remains no
bo ok
Displaced fragments can be addressed operatively by tension
band wiring, which does have the potential to provide good
b o o
e / e significant functional loss even in cases of nonunion.
e/ e fracture consolidation and satisfactory clinical outcomes as
e/e
: // t .m
Displaced Mayo type II fractures remain controversial regard-
: / / t
cases with poor bone quality, K-wires might loosen and.m
early as 3 months postinjury (Case 9: Fig 3.5-13). However, in
tps
ing the treatment of choice. Recent studies demonstrate good
ht
clinical outcomes for low-demand geriatric patients with a
nonoperative approach [20, 21]. However, displaced fragments ht tps
fracture dislocation can occur. In older adults, revision sur-
gery then has to be considered very carefully, as adequate
fracture healing, sufficient ROM, and good clinical outcome
may significantly reduce elbow function, leading to a de- is still possible without reoperation (Case 8: Fig 3.5-12). Even
creased ROM. Furthermore, the overlying skin may be com- with significant loss of reduction, surgical revision can be
promised, potentially resulting in severe skin irritation and avoided in cases of satisfactory elbow function. A more spe-
e r sulceration. For these cases, the ASA score can predict indi-
e r s
cific indication for operative revision is surgical hardware
ook ok o
vidual patient’s risk for operative treatment. The anticipated causing ongoing soft-tissue compromise.
e b functional benefits of surgery should be carefully balanced

e b o b o
e / e/
against the risks in this patient group, with interdisciplinary
m
decision making involving orthopedic surgeons, geriatricians,
t .
Locking plate fixation with functional aftertreatment is an-
t . m
other preferred option in older patients. In our experience, e/e
/ /
anesthesiologists, and the patient and family.
/ /
plate fixation often leads to satisfactory results with com-
htt ps:
The decision for nonoperative or operative treatment can
be made depending on the fracture classification and the htt ps:
parable ROM to the uninjured contralateral extremity
(Case 11: Fig 3.5-15, Case 12: Fig 3.5-16 , Case 14: Fig 3.5-18). There
are various plating systems without evidence of one plate
ASA score (Fig 3.5-5). Ideally, the final decision should be being superior to another [22]. In osteoporotic bone, a lock-
made based on an orthogeriatric discussion. ing plate has been shown to be advantageous in various
other fracture locations, and should be used in osteopo-
e rs
In Mayo type II and III fractures, nonoperative treatment
r s
rotic bone to decrease the risk of cut out and secondary
e
b o ok has been shown to provide reasonable clinical results in
older, low-demand patients [20, 21].
b o ok
fracture dislocation [23–26]. One exception involves Mayo
type IIA fractures in which there was no benefit of plate
b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s Nondisplaced
Nonoperative
tps
ht
Mayo type I
h
treatment
fracture
Olecranon fracture
High functional
Surgery
demand / ASA ≤3
kers rs
Displaced
o
Mayo type II
ke
oo o
fracture
b o b
Low functional Nonoperative
b o
e /e /e e/e
demand / ASA ≥3 treatment
t . m e t .m
/
Fig 3.5-5 Treatment algorithm for olecranon fractures.
/ //
ps: ps:
Abbreviation: ASA, American Society of Anesthesiologists.
htt htt 301
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.5 Olecranon
k e rs ke rs
e b oo e b oo b o o
e /
t . m
fixation over tension band wiring [27, 28]. In a multifrag- e / 5 Therapeutic options
t . m e/e
s: / / / /
ps:
mentary fracture type Mayo IIB plating offers more options
http htt
for fragment fixation and provides overall a more stable There are various nonoperative and operative treatment
construct compared to wiring. options, depending on the fracture classification (Fig 3.5-6).
Operative treatment of osteoporotic bones is less successful 5.1 Nonoperative treatment

and may lead to complications, potentially resulting in salvage Nonoperative treatment (Case 3: Fig 3.5-7, Case 4: Fig 3.5-8 , Case
e s
procedures. Because of skin irritation, wound breakdown,
r
or pain, implant removal (Case 11: Fig 3.5-15) becomes necessary
er s
5: Fig 3.5-9, Case 6: Fig 3.5-10d-f) should include initial func-
tional passive physical therapy without limitation and elbow
b o ok in up to 80% of all cases following open reduction and in-

ternal fixation of olecranon fractures in older adults [29].
bo ok
cast fixation for comfort for up to a maximum of 3 weeks
depending on the patient’s pain level. For nonoperative
b o o
e/ e Salvage procedures include fragment excision, arthroplasty,
e/ e treatment, suggestions for the maximally acceptable frag-
e/e
: // t .m
or revision surgery with or without bone grafting. In the
absence of adequate randomized controlled trials of operative
ment displacement range from 2 mm to 5 mm in the literature
: /
[10, 30]. However, even higher degrees of displacement can
/ t .m
ht tps
versus nonoperative approaches, the optimal treatment of
displaced olecranon fractures remains controversial [6]. ROM (Case 5: Fig 3.5-9).
ht tps
have the potential for a pain-free result with satisfactory
e r s e r s
/ e/ e/e
Functional
e . m
Nondisplaced
t t . m
/ /
Mayo type I
/ /
ps: ps:
fracture
htt htt
Cast fixation
k e rs k e r s Functional
b o o b o o Nonoperative
b o o
e/e t . me / e Cast fixation
t . m e /e
s /
Displaxed
: / : / /
tps
Mayo type II
h t t p fracture
Tension band
wiring in vertical
fracture patterns ht
Surgery
Plate fixation in
multifragmentary
k e rs ke rs or oblique fracture
patterns
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
ps: ps:
Fig 3.5-6 Possible therapeutic options for each fracture pattern in olecranon fractures.
302
htt htt
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Patient
. m e /
. m e/e
CASE 3
/ / t
A 67-year-old male patient fell at home and sustained a nondisplaced
/ / t
Both fractures were treated nonoperatively (Fig 3.5-7d–e). After
olecranon fracture.
Treatment and outcome htt ps: htt ps:

3 weeks of elbow cast fixation and initial physical therapy, the patient
was pain free. He was dismissed from the outpatient clinic 6 weeks
postinjury.
X-rays showed a nondisplaced fracture of the olecranon (Mayo type
IA) (Fig 3.5-7a), accompanied by a distal radial fracture (Fig 3.5-7b–c)
on the ipsilateral side. For more information on the Mayo classifica-
e rs
tion, see topic 3 in this chapter.
er s
b o ok bo ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
kea
r s b c d
k e r s e
boo o o
Fig 3.5-7a–e A 67-year-old man after a fall.
a–c X
b o
-rays showing a nondisplaced olecranon fracture (Mayo type IA) (a), accompanied by a distal radius fracture (b–c) on the ipsilateral side.
b o
e /e e/e e/e
d–e Nonoperative treatment of both fractures with elbow cast fixation for 3 weeks.
/ / t . m / /t . m
Patient
htt ps: htt ps:
CASE 4
A 95-year-old woman fell in the nursing home. Before the accident, cast fixation for the olecranon fracture and operatively with a hemi-
she was fully mobile and independent. arthroplasty for the femoral neck fracture.
k e s
r
The patient sustained a multifragmentary olecranon fracture (Fig 3.5-
e r s
After 3 weeks, both the fracture gap and the grade of displacement
had increased (Fig 3.5-8c). However, 7 weeks after the injury, the
b o o 8a), a medial femoral neck fracture, and a superior and inferior
b o
pubic ring fracture (Fig 3.5-8b). She was treated nonoperatively with ok
patient was pain free with an active range of motion of 0–5–150°
and was able to manage her activities of daily living independently.
b o o
e/e . me / e
. m e /e
t p s ://t tps : / / t
h t ht
k e rs ke rs
eb oo e b oo b o o
e/e
a b c
e / Fig 3.5-8a–c A 95-year-old woman after a fall.

m e / m
/t . / t .
a–b X-rays showing a multifragmentary olecranon fracture (a), a medial femoral neck fracture, and a superior and inferior pubic ring fracture (b).
/ /
ps: ps:
c Three-week postoperative x-ray showing increased fracture gap and grade of displacement.
htt htt 303
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.5 Olecranon
k e rs ke rs
e b oo e b oo b o o
e / Patient
. m e /
. m e/e
CASE 5
/ / t
A 91-year-old woman sustained a Mayo type IIB fracture after slip-
/ / t
Six weeks postinjury, the hip fracture was treated operatively using
Treatment and outcome htt ps:

ping and falling on the sidewalk.
htt ps:
a trochanteric femoral nail (TFN) and the patient was initially mo-
bilized with a wheeled walker (Fig 3.5-9d). Olecranon and proximal
humerus were treated nonoperatively (Fig 3.5-9e). Active range of
The patient sustained a Mayo type IIB fracture (Fig 3.5-9a) with a motion of the olecranon was 0–5–130°, the patient was pain free
concomitant ipsilateral hip fracture (Fig 3.5-9b) and proximal hu- and had no complaints. Because of a malrotation of the femur after
meral fracture (Fig 3.5-9c). the initial TFN implantation, the patient underwent revision surgery
e rs er s
with a derotation of the femur and new TFN implantation. She was
b o ok bo ok
able to walk independently using a walking stick on the injured side
6 weeks after the injury.
b o o
e/ e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
/ e/ e/e
a b c
e t . m t . m
/ / / /
htt ps: htt ps:
e rs e r s
Fig 3.5-9a–e A 91-year-old female patient after a fall on the sidewalk.
b o ok b o ok
a–c X-rays showing a Mayo type IIB fracture (a) with a concomitant
ipsilateral hip fracture (b) and proximal humeral fracture (c).
b o o
e/ e e / e d–e O perative treatment of the hip fracture 6 weeks postinjury
u sing a trochanteric femoral nail (d). Nonoperative treatment
e /e
d e
://t . m of the olecranon and proximal humerus (e).
: / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Patient
. m e /
. m e/e
CASE 6
/ / t
A 91-year-old healthy woman fell at home and sustained a Mayo
/ / t
Two years later, this patient fell again in her nursing home and sus-
type IIB fracture (Fig 3.5-10a).

tained a contralateral Mayo type IA olecranon fracture (Fig 3.5-10d).
This time, she was treated with an above-the-elbow cast for
2 weeks and functional training thereafter. Three months after
The patient was operated by open reduction and tension band the injury, the x-ray showed a tight nonunion. The patient was
wiring (Fig 3.5-10b–c). Two months after surgery the x-ray barely satisfied, pain free and had a ROM of 0–20–100° on her left side.
showed the former fracture line. The patient was satisfied and pain The extension deficit in comparison to the other side did not
e rs
free and had a range of motion (ROM) of 0–5–140° and free rota-
r s
bother her (Fig 3.5-10e–g).
e
b o ok tion (Fig 3.5-10f–g). The hardware did not bother her at all.
bo ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e b ook a b
e
c
b o ok d e
b o o
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
f g
e rs
Fig 3.5-10a–g A 91-year-old female patient after a fall.
e r s
b o ok a–c, f–g X
b o ok
-rays showing a Mayo type IIB fracture (a) that was operated by open reduction and tension band wiring (b–c). Two months after
surgery, the patient had a range of motion (ROM) of 0–5–140° and free rotation (f–g).
b o o
e/ e d–f
e / e
X -ray showing a contralateral Mayo type IA olecranon fracture sustained 2 years later (d). Three-month postinjury x-ray showing a
e
tight nonunion (e). Clinical images of the patient with a ROM of 0–20–100° on her left side and an extension deficit in comparison
/e
to the other side (f–g).
://t . m : / / t . m
t t p s tps
5.2 h
Operative treatment
Operative procedures include tension band wiring, and plate
ht
Intraoperatively, implant position needs to be checked care-
fully. The K-wires should be positioned parallel to the ulnar
or screw fixation in Mayo type II and III fractures. shaft and just perforating the ventral ulnar cortices. Other-
wise, the K-wire might impinge on the radial tuberosity,
k e rs
5.2.1 Tension band wiring
e rs
which can result in pain and a diminished rotation ROM
k
oo oo o
Mayo type IIA and B fractures with a vertical fracture line (Case 10: Fig 3.5-14).
eb may be treated successfully using tension band wiring (Case

e b b o
e /
t . m
Case 9: Fig 3.5-13, Case 10: Fig 3.5-14). Single fragments may
/
6: Fig 3.5-10a-c , Fig 3.5-10f, Case 7: Fig 3.5-11, Case 8: Fig 3.5-12 ,
e t .m e/e
/ /
additionally be fixed using separate screws (Case 9: Fig 3.5-13).
//
htt ps: htt ps:
305
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.5 Olecranon
k e rs ke rs
e b oo e b oo b o o
e / Patient
. m e/e
CASE 7
/ / t
An 89-year-old man slipped and fell on the sidewalk sustaining a
: / / t
This Mayo type IIA fracture was treated with tension band wiring
Mayo type IIA fracture (Fig 3.5-11a).
htt ps:
(Fig 3.5-11b). Following operative treatment, the patient was placed
in a cast for 3 weeks and prescribed initial physical therapy. Seven
months after the initial injury, the fracture showed substantial bony
• Hypereosinophilic syndrome healing and the patient was pain free with a range of motion of
• Coronary heart disease 0–15–110° as well as free rotation.
• Pacemaker
e rs• Status postpulmonary embolism

er s
b o ok • Status post total hip arthroplasty
bo ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
e r s a b
e r s
e b ook o
Fig 3.5-11a–b An 89-year-old male patient after falling on the sidewalk.
e b ok b o o
/ e/ e/e
a X-ray showing a Mayo type IIA fracture.
e b Operative fracture treatment with tension band wiring.
t . m t . m
/ / / /
Patient htt ps: htt ps:
CASE 8
A 91-year-old woman fell in the nursing home and sustained a She presented with a fracture displacement and pin loosening
Mayo type IIB olecranon fracture (Fig 3.5-12a). 22 days after surgery (Fig 3.5-12c). Because the patient was low-
demand, further treatment was chosen to be nonoperative and all
e rsTreatment and outcome

r s
material was left in situ. Six months after surgery, the patient was
e
b o ok The patient was treated with tension band wiring 1 day after the
b o
injury and dismissed after 6 days with a cast fixation (Fig 3.5-12b). ok
pain free and had a range of motion of 0–10–110°. She had no
complaints and the fracture was healed (Fig 3.5-12d).
b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs a b c
ke rs d
eb oo Fig 3.5-12a–d
e b oo b o o
/ / e/e
a X-ray showing a Mayo type IIB olecranon fracture.
e m e
b One-day postinjury x-ray of fracture treated with tension band wiring.
t . t .m
c
/
X-ray 22 days postoperative showing fracture displacement and pin loosening.
/ //
ps: ps:
d Nonoperative treatment with all material left in situ showing healed fracture 6 months after surgery.
306
htt htt
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Patient
. m e/e
CASE 9
/ / t
A 91-year old female patient fell from a stair and sustained a Mayo
: / / t
The patient was treated with tension band wiring and screw fixation
ht t p s
type IIB olecranon fracture (Fig 3.5-13a).
htt ps:
(Fig 3.5-13b). Three months after surgery, the patient was satisfied
and pain free with a range of motion of 0–15–110°. She could
handle her activities of daily living in the nursing home without
complaints. The fracture had healed by this follow-up.
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
a b
e r s
Fig 3.5-13a–b A 91-year-old woman after a fall.
a X-ray showing a Mayo type IIB olecranon fracture.
e r s
ook ok o
b Treatment with tension band wiring and screw fixation.
e b e b o b o
e /
t . m e/ t . m e/e
/ / / /
ps: ps:
Patient
CASE 10
htt htt
An 86-year-old patient fell while bicycling and sustained a Mayo The patient was revised and the radial pin was shortened. Five
type IA fracture (Fig 3.5-14a). months after the injury the patient was satisfied, pain free, with free
rotation and a range of motion of 0–10–130° (Fig 3.5-14d–e). Hard-
Treatment and outcome ware removal was not necessary.
The Mayo type IA fracture (Fig 3.5-14a) was treated by tension band
e s
wiring (Fig 3.5-14b–c). Three weeks after surgery, the patient had
r
persistent complaints and pain with forearm rotation. The x-rays showed
e r s
b o ok the radial K-wire impinging with the radial tuberosity (Fig 3.5-14c).
b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e/e
a b c
e / m e /
Fig 3.5-14a–e A 86-year-old patient after a bicycling accident.
m
t .
a–b X-rays showing a Mayo type IA fracture (a), which was treated by tension band wiring (b–c).
/ / // t .
ps: ps:
c Three-week postoperative x-ray showing the radial K-wire impinging with the radial tuberosity.
htt htt 307
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.5 Olecranon
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok Fig 3.5-14a–e (cont)
b o o
e/ e d e
e/ e d–e T
he patient was revised and the radial pin
e/e
.m .m
was shortened.
: // t : / / t
5.2.2 Plate fixation ht tps ht tps
Multifragmentary Mayo type IIB fractures may be treated
with open reduction and plate fixation. All fragments can
be fixed adequately, resulting in a stable construct. (Case 11:
e r s Fig 3.5-15 , Case 12: Fig 3.5-16 , Case 13: Fig 3.5-17, Case 14: Fig 3.5-18 ,
e r s
ook ok
Case 15: Fig 3.5-19).
b b o b o o
e / e e/ e e/e
Patient
t . m t . m
CASE 11
/ / / /
ps: ps:
An 87-year-old woman fell down the stairs and sustained a Mayo However, the skin was irritated by the implant. Therefore, plate
htt htt
type IIB fracture (Fig 3.5-15a). removal was conducted with an improvement of range of motion
to 0–5–130° and free rotation (Fig 3.5-15c).
The patient was treated operatively with open reduction and inter-
nal locking plate fixation. Postoperative physical therapy was started
e rs immediately without any restrictions. Nine months after surgery, the

fracture was healed and the patient was pain free and had a range
e r s
b o ok of motion (ROM) of 0–10–120° (Fig 3.5-15b).
b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo a b
e b oo c
b o o
e / Fig 3.5-15a–c A 87-year-old female patient after a fall.
t . m e /
a–b X-ray showing a Mayo type IIB fracture (a) that was treated operatively with open reduction and internal locking plate fixation.
t .m e/e
/
The fracture was healed 9 months postoperatively (b).
/ //
ps: ps:
c Plate removal due to skin irritation, which led to better range of motion and free rotation.
308
htt htt
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Patient
. m e/e
CASE 12
/ / t
A 74-year-old man fell while mountain biking and sustained a Mayo
: / / t
The patient was treated operatively with open reduction and locking
ht t p s
htt ps:
plate fixation. Postoperative physical therapy was started immedi-
ately without any restrictions. Six weeks after surgery, the patient
was satisfied and pain free. He had a range of motion of 0–0–135°
and refused any further ambulatory follow-ups (Fig 3.5-16b).
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
a b
Fig 3.5-16a–b X-rays showing a Mayo type IIB fracture (a) that was treated operatively with open reduction and locking plate fixation with
e r s
satisfactory results 6 weeks postoperative (b).
e r s
e / Fragments can be approached best from a dorsal position,
t . m
but this comes with a risk of skin irritation and implant e/ possible in order to avoid skin irritation, but not all fracture
fragments may be able to be addressed properly.
t . m e/e
/ / / /
ps: ps:
removal. Plate positioning on the lateral side of the ulna is
htt htt
Patient
CASE 13
A 76-year-old woman fell on the sidewalk and sustained a Mayo Two weeks after surgery, she presented with secondary fragment
e rs
e r s
displacement and screw penetration into the joint (Fig 3.5-17d–e).
Revision surgery using a femoral head allograft was conducted.
b o
The fracture was treated operatively with plate fixation (Fig 3.5-17b–c). ok
Three months after the initial injury, the patient was able to manage
her activities of daily living sufficiently with some minor functional
b o o
e/ e e / e complaints. Range of motion was 0–20–135° with free rotation
e /e
://t . m (Fig 3.5-17f).
: / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e / a
t . m b e / c
t .m e/e
s: / / //
ps:
Fig 3.5-17a–f X-rays showing a Mayo type IIB fracture (a) which was treated operatively with plate fixation (b–c).
http htt 309
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.5 Olecranon
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e d e
e/ e f
e/e
: / t .m
surgery using a femoral head allograft was conducted.
: / / t .m
Fig 3.5-17a–f (cont) Two-week postoperative x-ray of secondary fragment displacement and screw penetration into the joint (d–e). Revision
/
ht tps ht tps
Patient
CASE 14
An 87-year-old patient fell on the sidewalk and sustained a Mayo However, 4 days after surgery, the x-ray showed cut through, loss
e r s type IIA fracture with a concomitant wound dehiscence (tissue

r s
of reduction, and fragment redisplacement (Fig 3.5-18c).
e
ook ok
separation) (Fig 3.5-18a).
b b o The injury was revised and the separated fragment was treated by
b o o
e / e Treatment and outcome
e/ e
The patient was treated with open reduction and plate fixation. Intra-
fiberwire tensioning and wire cerclage. Two months after surgery,
the patient was pain free and satisfied with a range of motion of
e/e
t . m
operative image intensification showed good reduction and fixation
/ / t
0–5–120°. The x-ray showed fracture healing (Fig 3.5-18d).
/ / . m
ps: ps:
(Fig 3.5-18b).
htt htt
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
a
t t p s b c
tps
h ht
kers rs
Fig 3.5-18a–d An 87-year-old patient after a fall.
o ke
a X-ray of a Mayo type IIA fracture with a concomitant wound dehiscence.
b o oo
b Intraoperative image intensification showing good reduction and fixation after fracture
b
treatment with open reduction and plate fixation.
b o o
e /e t . m e /e
c Four-day postoperative x-ray showing cut through, loss of reduction, and fragment
redisplacement.
t .m e/e
/ / /
d X-ray showing fracture healing after revision of injury and treatment of the separated
/
ps: ps:
d fragment by fiberwire tensioning and wire cerclage.
310
htt htt
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m
The positioning of the plate has to be taken into consider- e / 5.3 Complications
t . m e/e
s: / / / /
ps:
ation. The plate must be long enough at the olecranon end 5.3.1 Implant cut out
http htt
to act as a buttress against cut through and secondary dis- Beware of screw cut through in osteoporotic bone (Case 13:
placement. In osteoporotic bone, a plate that is too short at Fig 3.5-17, Case 14: Fig 3.5-18 , Case 15: Fig 3.5-19). Screw fixation
the olecranon might not sufficiently fix the proximal frac- can fail in osteoporotic bone. Consider longer cast fixation,
ture fragment and might more easily result in cut through especially in patients with impaired ability to comply with
(Case 18: Fig 3.5-17). This can also be the case if the proximal activity restrictions, due to a potential stronger triceps pull.
e s
screw does not retain single fragments adequately (Case 14:
r
Fig 3.5-18). For these reasons, a long cortical screw should
er s
Screw loosening and concomitant fracture dislocation can
also occur in cases of infection. Revision surgery and delayed
b o ok be placed, fixing the proximal fragment with the inserting

triceps tendon. In addition, the plate should be long enough
bo ok
treatment of open wounds have an increased risk for infec-
tion and wound complications. In cases of failed operative
b o o
e/ e in its proximal extension to additionally buttress against
e/ e fixation or symptomatic nonunion, a salvage procedure like
e/e
: // t .m
proximal fragment dislocation. Additional suture augmen-
tation using nonabsorbable material can be another reason- al outcome.
: / / .m
fragment excision can still result in a satisfactory function-
t
ht tps
able option to fix the triceps tendon to the construct and
decrease distraction forces by an offloading triceps suture
technique [31]. ht tps
e r s
Patient
e r s
CASE 15
ook ok o
A 68-year-old woman fell and sustained a Mayo type IIA fracture Eleven days postinjury, the patient was operatively revised using a
e b (Fig 3.5-19a).
e b o “twin” plate fixation (Fig 3.5-19h–i). Partial cut through was again
b o
e / Comorbidities
t . m e/ detected 4 days after the second surgery, which was not seen dur-
ing operative image intensification (Fig 3.5-19j–k).
t . m e/e
• Osteoporosis
/ / / /
• Alcoholic cirrhosis

In the meantime, the patient developed a wound dehiscence, which
resulted in another revision surgery 24 days after the initial injury.
Implant removal was conducted, the fracture fragment was excised,
The patient sustained a Mayo type IIA fracture (Fig 3.5-19a), and tissue samples were acquired, and a negative-pressure wound clo-
periprosthetic femoral (Fig 3.5-19b) and pubic fractures (Fig 3.5-19c). sure and an external fixator were applied. After antibiotic treatment,
the wound healed uneventfully, and the patient was satisfied with
e rs
Two days postinjury, the fracture was treated operatively with tension
r s
a painless active range of motion of 0–20–150°. Compared to the
e
b o ok band plate fixation (Fig 3.5-19d–e). Cut through of the proximal
ulnar fragment 5 days after surgery (Fig 3.5-19f–g).
b o ok
uninjured contralateral side, the elbow extension force was reduced
and did not limit the patient (Fig 3.5-19l–m).
b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
/ / e/e
a b c
e . m
Fig 3.5-19a–m A 68-year-old female patient after a fall.
t e t .m
/ /
a–c X-rays showing a Mayo type IIA fracture (a), and periprosthetic femoral (b) and pubic fractures (c).
//
htt ps: htt ps:
311
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.5 Olecranon
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e d e
e/ e f
e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e / g h
t . m e/ i
t . m e/e
: / / / /
h t t p s
htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
j
://t .
k m l
: / / t . m
t t p s tps
h ht
Fig 3.5-19a–m (cont) A 68-year-old female patient after a fall.
d–g Operative fracture treatment with tension band plate fixation 2 days postinjury (d–e)
k e rs ke rs
and cut through of the proximal ulnar fragment 5 days after surgery (f–g).
h–k Operative revision 11 days postinjury using a “twin” plate fixation (h–i). Partial cut
eb oo b oo
through was again detected 4 days after the second surgery, which was not seen dur-
ing operative image intensification ( j–k).
e b o o
e /
t . m e /
l–m A nother revision surgery 24 days after the initial injury following wound dehiscence.
t .m
Implant was removed, the fracture fragment was excised, tissue samples were aquired,
e/e
/ / /
and a negative-pressure wound closure and an external fixator were applied. Unevent-
/
ps: ps:
m ful healing after antibiotic treatment.
312
htt htt
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 5.3.2 Nonunion
t . m e /
t . m
Operative options include fragment excision with triceps e/e
s: / / / /
ps:
Nonunion of olecranon fractures can occur following both tendon reattachment (Case 15: Fig 3.5-19l–m), plate fixation,
http htt
operative and nonoperative treatment [9]. While in the gen- or tension band wiring with or without bone grafting and
eral population 1% of operatively treated olecranon fractures joint replacement [32].
result in a nonunion [32], nonunion rates as high as 78% have
been described in the geriatric population [20, 21]. Most non- If the fracture fragment is smaller than 50% of the troch-
unions of the olecranon are asymptomatic fibrous nonunions lear articular surface, fragment excision and triceps tendon
e s
without the need for further treatment (Case 4: Fig 3.5-8,
r
Case 5: Fig 3.5-9, Case 6: Fig 3.5-10 , Case 16: Fig 3.5-20) [32].
er s
reattachment may lead to satisfactory results in older adults
with minor triceps weakness [33]. However, it is important
b o ok Retrospective analyses of older low-demand patients

bo ok
to rule out any elbow instability prior to excision of the
fragment. This technique may also be considered as a salvage
b o o
e/ e e/
following nonoperatively treated olecranon fractures have e procedure in cases of postoperative infection.
e/e
: // t .m
shown that, even in cases of displaced Mayo type II fractures,
no patient required operative treatment for a symptomatic
: / / t .m
If the fragment is larger than 50% with a symptomatic func-
tps
nonunion [20, 21]. In the case of symptomatic nonunion in
ht
combination with functional loss and extension deficit, pain,
or elbow stiffness, operative treatment may be appropriate. ht tps
tional deficit, or in cases of an unstable elbow joint, recon-
structive measures including bone grafting and total elbow
arthroplasty must be considered [29, 32].
e r s
Patient
e r s
CASE 16
ook ok o
A 77-year-old patient sustained a Mayo type I fracture (Fig 3.5-20a) Nonoperative treatment with passive motion exercises was chosen
e b after slipping and falling down the stairs.

e b o initially. Three months postinjury, there was no bone healing but
b o
e / Comorbidities
t . m e/ increased displacement. However, the clinical outcome was satisfac-
t . m
tory with a pain-free range of motion of 0–0–130° similar to the e/e
• Alcohol abuse
/ / contralateral uninjured side (Fig 3.5-20b).
/ /
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
ht
a b
h
Fig 3.5-20a–b A 77-year-old patient after a fall.
a X-ray showing a Mayo type I fracture.
b X-ray showing no bony healing but increased displacement 3 months after the injury and following nonoperative treatment.
k e rs ke rs
oo oo o
Nonunion following both nonoperative and operative treat-
eb ments of olecranon fractures in older adults appears to be

e b b o
e / frequent but mostly asymptomatic. In most cases, no further
t . m e
treatment is necessary as patients typically are pain free /
t .m e/e
with adequate ROM.
/ / //
htt ps: htt ps:
313
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.5 Olecranon
k e rs ke rs
e b oo e b oo b o o
e / 6 References
t . m e /
t . m e/e
/ / / /
htt ps:
1. Duckworth AD, Clement ND, Aitken SA,
et al. The epidemiology of fractures
of the proximal ulna. Injury.
14. Müller ME, Allgöwer M, Perren S.
Manual of internal fixation: techniques
recommended by the AO-ASIF group.
htt ps:
24. Ring D, Kloen P, Kadzielski J, et al.
Locking compression plates for
osteoporotic nonunions of the
2012 Mar;43(3):343–346. Berlin: Springer Verlag, 1991. diaphyseal humerus. Clin Orthop Relat
2. Rommens PM, Kuchle R, Schneider RU, 15. Tamaoki MJ, Matsunaga FT, Silveira JD, Res. 2004 Aug(425):50–54.
et al. Olecranon fractures in adults: et al. Reproducibility of classifications 25. Snow M, Thompson G, Turner PG.
factors influencing outcome. Injury. for olecranon fractures. Injury. A mechanical comparison of the
e rs 2004 Nov;35(11):1149–1157.
3. Newman SD, Mauffrey C, Krikler S.
2014 Nov;45 Suppl 5:S18–S20.
er s
16. Benetton CA, Cesa G, El-Kouba Junior G,
locking compression plate (LCP) and
the low contact-dynamic compression
b o ok Olecranon fractures. Injury.

2009 Jun;40(6):575–581.
bo ok
et al. Agreement of olecranon fractures
before and after the exposure to four
plate (DCP) in an osteoporotic bone
model. J Orthop Trauma.
b o o
e/ e 4. Sahajpal D, Wright TW. Proximal
ulna fractures. J Hand Surg Am.
e/ e
classification systems. J Shoulder Elbow
Surg. 2015 Mar;24(3):358–363.
2008 Feb;22(2):121–125.
26. Stoffel K, Booth G, Rohrl SM, et al.
e/e
.m .m
2009 Feb;34(2):357–362. 17. Clement ND, Green K, Murray N, et al. A comparison of conventional versus
5. Ring D. Elbow fractures and
: // t
dislocations. In: Rockwood C, Green D,
Undisplaced intracapsular hip fractures
in the elderly: predicting fixation
: / / t
locking plates in intraarticular
calcaneus fractures: a biomechanical
tps tps
Buchholz R, eds. Rockwood and Green’s failure and mortality. A prospective study in human cadavers. Clin Biomech
ht ht
Fractures in Adults. 7th ed. Philadelphia study of 162 patients. J Orthop Sci. (Bristol, Avon). 2007 Jan;22(1):100–105.
Lippincott Williams & Wilkins; 2013 Jul;18(4):578–585. 27. Amini MH, Azar FM, Wilson BR, et al.
2010:905–944. 18. Ginsel BL, Taher A, Ottley MC, et al. Comparison of Outcomes and Costs of
6. Symes M, Harris IA, Limbers J, et al. Hospital mortality after arthroplasty Tension-Band and Locking-Plate
SOFIE: Surgery for Olecranon using a cemented stem for displaced Osteosynthesis in Transverse
Fractures in the Elderly: a randomised femoral neck fractures. J Orthop Surg Olecranon Fractures: A Matched-
e r s controlled trial of operative versus

non-operative treatment.
e r s
(Hong Kong). 2014 Dec;22(3):279–281.
19. Muller F, Galler M, Zellner M, et al.
Cohort Study. Am J Orthop (Belle Mead
NJ). 2015 Jul;44(7):E211–E215.
ook ok
BMC Musculoskelet Disord. The fate of proximal femoral fractures 28. Schliemann B, Raschke MJ, Groene P,
b
2015 Oct 27;16:324.
7. Helm RH, Hornby R, Miller SW.
b o
in the 10th decade of life: an analysis
of 117 consecutive patients. Injury.
et al. Comparison of tension band
wiring and precontoured locking
b o o
e / e The complications of surgical treatment
of displaced fractures of the olecranon.
e/ e
2015 Oct;46(10):1983–1987.
20. Duckworth AD, Bugler KE, Clement ND,
compression plate fixation in Mayo
type IIA olecranon fractures. Acta
e/e
Injury. 1987 Jan;18(1):48–50.
/ / t . m et al. Nonoperative management of

t . m
Orthop Belg. 2014 Mar;80(1):106–111.
/ /
ps: ps:
8. Romero JM, Miran A, Jensen CH. displaced olecranon fractures in 29. Baecher N, Edwards S. Olecranon
Complications and re-operation rate low-demand elderly patients. J Bone fractures. J Hand Surg Am.
htt htt
after tension-band wiring of olecranon Joint Surg Am. 2014 Jan 01;96(1):67–72. 2013 Mar;38(3):593–604.
fractures. J Orthop Sci. 21. Gallucci GL, Piuzzi NS, Slullitel PA, 30. Veillette CJ, Steinmann SP. Olecranon
2000;5(4):318–320. et al. Non-surgical functional treatment fractures. Orthop Clin North Am.
9. Danziger MB, Healy WL. Operative for displaced olecranon fractures in 2008 Apr;39(2):229–236, vii.
treatment of olecranon nonunion. the elderly. Bone Joint J. 31. Izzi J, Athwal GS. An off-loading triceps
J Orthop Trauma. 1992;6(3):290–293. 2014 Apr;96-B(4):530–534. suture for augmentation of plate
10. Veras Del Monte L, Sirera Vercher M, 22. Edwards SG, Martin BD, Fu RH, et al. fixation in comminuted osteoporotic
e rs Busquets Net R, et al. Conservative

r s
Comparison of olecranon plate fixation
e
fractures of the olecranon. J Orthop
ok ok
treatment of displaced fractures in osteoporotic bone: do current Trauma. 2012 Jan;26(1):59–61.
b o
of the olecranon in the elderly. Injury.
1999 Mar;30(2):105–110.
technologies and designs make a
b o
difference? J Orthop Trauma.
32. Papagelopoulos PJ, Morrey BF.
Treatment of nonunion of olecranon
b o o
e/ e 11. Colton CL. Fractures of the olecranon in
adults: classification and management.
e / e2011 May;25(5):306–311.
23. Kim T, Ayturk UM, Haskell A, et al.
1994 Jul;76(4):627–635.
e /e
Injury. 1973 Nov;5(2):121–129.
12. Morrey BF. Current concepts in the
://t . m Fixation of osteoporotic distal fibula

fractures: A biomechanical comparison
/ / t .
33. Gartsman GM, Sculco TP, Otis JC.
Operative treatment of olecranon
: m
t t p s
treatment of fractures of the radial
head, the olecranon, and the coronoid.
of locking versus conventional plates.
J Foot Ankle Surg.
tps
fractures. Excision or open reduction
with internal fixation. J Bone Joint Surg
h
Instr Course Lect. 1995;44:175–185.
13. Schatzker J. Fractures of the Olecranon
(12-B1). The rationale of operative fracture
care. Berlin: Springer; 2005:123–129.
2007 Jan–Feb;46(1):2–6.
ht
Am. 1981 Jun;63(5):718–721.
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
Rohit Arora, Alexander Keiler, Susanne Strasser
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
3.6 Distal forearm / / / /
htt ps:
htt ps:
e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e • The differentiation between DRFs and distal forearm frac-
e/e
: // t .m
Two hundred years ago, Abraham Colles stated that after a
: / / t .m
tures (DFFs) is crucial. The treatment options are differ-
ent in DFFs in which the distal ulnar fracture causes more
tps
distal radial fracture (DRF) ”…the limb will again enjoy
ht
perfect freedom in all its motions, and be completely free
of pain” [1]. From today’s point of view, this is not the case.
open fractures on the ulnar side.
ht tps
instability. Additionally, DFFs are often grade 1 or grade 2
• The treatment of DRF in older adults is controversial.

Despite an impressive body of literature and a multitude of Nondisplaced DRFs are treated nonoperatively, and stan-
technical solutions, we still do not have enough evidence dard operative fixation is recommended for palmar dis-
to guide all specific treatment options. placed DRFs (Fig 3.6-2), DFFs, open fractures, and fracture
e r s e r s
dislocations.
ook ok o
Due to increasing age and activity level of older adults, • Early functional physical and occupational therapy after
e b appropriate management of these fractures is of growing

e b o operative fixation prevents joint stiffness and improves
b o
e / concern. Prevention of wrist arthrosis and restoration of
t . m e/
wrist function allowing a rapid return to an active and in-
the clinical outcome significantly.
t . m e/e
dependent lifestyle are major goals.
/ / / /
htt ps:
In this chapter, we discuss the typical characteristics of this
injury, their significance for fragility fracture patients (FFPs), htt ps:
current treatment options, and possible complications. Some
of the challenges are:
e rs
• The impact on the function of an individual patient is
e r s
b o ok variable and can be difficult to predict. Generally, toler-
ance for anatomical deviations is higher, mostly due to
b o ok b o o
e/ e / e
limited functional needs. The radiographic outcome does
e
not correlate well with the clinical and functional outcome
e /e
(Fig 3.6-1).
://t . m : / / t . m
t t p s
• Internal fixation in DRFs with multifragmented intraar-
tps
ht
ticular distal fracture fragments in osteoporotic bone is
h
challenging. Even with the use of locking implants, sub-
sidence of the joint fragments lead to secondary intraar-
ticular screw penetration.
• Due to intraarticular comminution, dorsal metaphyseal
k e rs instability, and poor bone quality, some DRFs are not

restorable. In these cases, arthroplasty of the distal ra-
ke rs
eb oo dius may be an alternative treatment option.
e b a
oo b
b o o
e/e
• The surgeon needs to closely attend to optimal plate po-
e / sition to minimize the risk of implant removal in the

m e / Fig 3.6-1a–f An 81-year-old woman with a malunion.
m
a–b AP (a) and lateral (b) x-ray views of malunion after nonopera-
future.
/ /t . / t .
tively treated distal radial fracture with loss of dorsal inclination,
/
ps: ps:
shortening, and ulnar-plus position.
htt htt 315
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.6 Distal forearm
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok c
bo d
ok b o o
e / e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
e r s e f
e r s
e b ook Fig 3.6-1a–f (cont) An 81-year-old woman with a malunion.
e b o ok b o o
e/e
c–f Despite the malunion, there is a good clinical outcome with satisfactory function and without subjective impairment (c–f) with an average
e / e/
Disabilities of the Arm, Shoulder and Hand score of 8, Patient-Rated Wrist Evaluation score of 10, Visual Analog Scale for pain of 0 (for no
m m
/ / . / /t .
pain), average extension of 50°, flexion of 45°, unrestricted pronation and supination, and a grip strength of 78% of the contralateral side.
t
htt ps: htt ps:
with approximately 70% of the fractures of the adults oc-
curring in women between 61 and 69 years [4]. In the
younger population, these fractures are most often the result
of high-energy trauma or falls from a height. In contrast, in
e rs e r s
older adults, these fractures mostly result from low-energy
b o ok b o ok
trauma from falls from a standing height or lower. Some
recent studies identify a correlation between wrist fracture
b o o
e/ e e e
Fig 3.6-2 Sagittal view of a computed
/
tomographic scan of a 78-year-old
(ie, “indicator fracture”) and future osteoporotic fractures
at other sites [5, 6]. In women, the risk of a hip fracture in-
e /e
. m
female patient suffering from a distal
://t
radial fracture with palmar displace-
: / /
creases 1.4–1.8 times after a previous wrist fracture. In
t . m
t t s
ment.
p tps
older men, the risk of hip fracture increases 2.3–2.7 times
ht
[7]. Distal radial fractures have significant associated socio-
h economic costs [8].
2 Epidemiology and etiology Epidemiological studies are scarce because only a small pro-
portion of this fracture type requires hospital admission.
k e rs
Distal radial fractures are the most common upper extrem-
ity fractures in individuals aged 65 years and older, ranking
ke rs
However, incidence rates of DRF/DFFs have been shown to
be comparable to hip fracture incidence rates where data
eb oo second in total fracture frequency after vertebral compres-
e b oo
are available [9]. Furthermore, depending on the population
b o o
e/e
sion fractures [2]. The overall incidence varies in different investigated, trend analysis on DRF/DFF incidence has shown
e / countries. In Scandinavia it is about 30 per 10,000 people

m e / increases, decreases, or a stable pattern over the period of
m
/ /t .
per year [3]. Across populations there is a bimodal fracture observation [9–11].
// t .
ps: ps:
distribution with peaks in young men and older women,
316
htt htt
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 3 Diagnostics
t . m e /
t . m
the DRUJ is stable, the ulnar styloid fracture can be treated e/e
s: / / / /
ps:
nonoperatively.
http htt
Distal radial fractures usually cause immediate pain, tender-
ness, bruising, and swelling. In most cases, the fracture de- In stable conditions of the DRUJ, a nonunion of the ulnar
formity is visible. For further treatment, it is essential to styloid is usually asymptomatic. None of the most recent
consider patients’ functional lifestyle (eg, practiced sports), studies demonstrate that acute fixation of ulnar styloid frac-
the activity of daily living (ADL) needs (eg, living indepen- tures has been beneficial [12]. For very rare cases of chron-
e s
dently or requiring the use of a cane or walking frame), and
r
other functional demands.
er s
ic ulnar symptoms, results of secondary repair have been
encouraging, making late fixation of ulnar styloid in symp-
b o ok 3.1 Plain x-rays

bo ok
tomatic patients an acceptable option.
b o o
e/ e e/ e
In simple fracture patterns, plain AP and lateral x-rays are
e/e
performed before and after reduction.
: // t .m : / / t .m
3.2 C
imaging
ht tps
omputed tomography and magnetic resonance
Computed tomography (CT) is often used in multifragment- ht tps

ed intraarticular fractures for preoperative planning to assess
associated injuries and sometimes for decision making. Com-
puted tomography scans performed after reduction gener-
e r sally provide more information than those performed while

e r s
ook ok o
the fracture is displaced. In acute DRFs, magnetic resonance
e b imaging (MRI) examination is not of clinical importance.

e b o b o
e / 3.3 Radiographic parameters
t . m e/ t . m e/e
/ /
Specific radiographic parameters with biomechanical and
s:
Fig 3.6-3 Palmar tilt is mea-
/ /
Fig 3.6-4 Radial inclination is
ps:
sured as the angle subtended assessed as the angle between
http
clinical implications have been developed to assess the ra- by the line perpendicular to the longitudinal axis of the
diocarpal joint:
• Palmar tilt—angle subtended by the line perpendicular

the long axis of the radius and
a second line drawn from the
dorsal to palmar cortex of the
htt
radius and a line connecting the
radial cortex of the apex of the
radial styloid and the central
distal radius. point of the sigmoid notch of
to the long axis of the radius and a line drawn from the the distal radius.
dorsal to palmar cortex of the distal radius (average:
e rs 10–12°) (Fig 3.6-3).

e r s
b o ok • Radial inclination—angle between the longitudinal axis of
b o
the radius and a line connecting the radial cortex of the ok b o o
e/ e / e
apex of the radial styloid and the central point of the sigmoid
e
notch of the distal radius (average: 22–23°) (Fig 3.6-4).
e /e
://t . m
• Radial length—distance between the apex of the radial
: / / t . m
t t p s
styloid and the level of the ulnar head at the distal radio-
tps
ht
ulnar joint (DRUJ) (average: 11–12 mm) (Fig 3.6-5).
h
• Ulnar variance—difference in axial length between the
central point of the ulnar corner of the sigmoid notch of
the distal radius and the most distal extension of the
ulnar head on the AP view (Fig 3.6-6).
kers kers
Fig 3.6-5 Radial length is as- Fig 3.6-6 Ulnar variance is
3.4 Assessment of distal radioulnar joint instability sessed as the distance between defined as the difference in
b o o o
The distal radioulnar joint is dynamically tested for instabil-
b o the apex of the radial styloid and
the level of the ulnar head at the
axial length between the central
point of the ulnar corner of
b o o
e /e e/e
ity intraoperatively and after anatomical reconstruction of
the DRF. In neutral position, the ulna translates in com-
m
distal radioulnar joint. the sigmoid notch of the distal
radius and the most distal ex-
m e/e
/ /t .
parison with the uninjured side. The testing of the DRUJ is
/ t .
tension of the ulnar head on the
/
ps: ps:
of high clinical importance, as for example in cases where AP view.
htt htt 317
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.6 Distal forearm
k e rs ke rs
e b oo e b oo b o o
t . m e / 4.2.4 Chauffeur’s fracture
t . m e/e
s: / / / /
ps:
This intraarticular fracture of the radial styloid process with
http htt
4.1 O/OTA Fracture and Dislocation Classification
A subluxation of the carpus, which is attached to the styloid
and others fracture fragment, is also known as a Hutchinson’s fracture
There are a number of fracture classifications, such as AO/ or backfire fracture. The radial styloid is within the fracture
OTA, Frykman, Melone, Fernandez, Pechlaner, etc, and no fragment, although the fragment can vary markedly in size.
single gold standard system. Andersen et al [13] compared The fracture extends proximally in a variable oblique direc-
e s
the Frykman, Melone, Mayo, and AO/OTA classification
r
systems and reported a low degree of interobserver and
er s
tion from essentially transverse to almost sagittal from the
distal radial articular surface through the lateral cortex of
b o ok intraobserver agreement for plain x-rays. Arealis et al [14]
b
reported that even the use of CT scans does not increase theo ok
the distal radius, thus separating the radial styloid from the
rest of the radius (Fig 3.6-10) [18, 19].
b o o
e/ e e/ e
interobserver or intraobserver reliability for various clas-
e/e
sification systems.
: // t .m : / / t .m
ht tps
In scientific papers comparing results of DRFs, the AO/OTA
classification is most often used. Eponyms describe the frac-
ture pattern more clearly, as for example a Colles’ fracture ht tps
defined as dorsally and a Smith’s fracture as palmarly dis-
placed.
e r s
4.2 Frequently used eponyms
e r s
ook ok o
4.2.1 Colles’ fracture
e b b o
Colles’ fracture is a fracture of the distal radius with dorsal
e b o
e / e/
and radial displacement of the wrist and hand. Dorsal me-
m
taphyseal comminution is typical. The fracture is sometimes
t . t . m e/e
/ /
referred to as a “dinner fork” or “bayonet” deformity due
/ /
htt
4.2.2 Smith’s fracture
ps:
to the shape of the resultant forearm (Fig 3.6-7) [15].
htt ps:
This fracture of the distal radius is also sometimes known
as a reverse Colles’ fracture or Goyrand-Smith’s fracture.
The distal fracture fragment is displaced palmarly, as opposed Fig 3.6-7 Colle’s fracture— Fig 3.6-8 Smith’s fracture—
e rs
to a Colles’ fracture where the fragment is displaced dor-
r s
dorsal displacement of the distal
e
palmar displacement of the
ok ok
fracture fragment with dorsal distal fracture fragment.
sally. Depending on the severity of the impact, there may
b o o
be one or many fragments, and it may or may not involve
b
metaphyseal comminution.
b o o
e/ e / e
the articular surface of the wrist joint (Fig 3.6-8). Smith’s
e
fractures are less common than Colles’ fractures [16].
e /e
://t . m : / / t . m
4.2.3 Barton’s fracture
t t p s tps
ht
This fracture is an intraarticular fracture of the distal radius
h
with dislocation of the radiocarpal joint. There are two types
of Barton’s fractures, ie, dorsal and palmar, the latter being
more common. The Barton’s fracture is caused by a fall on
an extended and pronated wrist, increasing carpal compres-
k e rs
sion force on the dorsal rim. The intraarticular component
distinguishes this fracture from a Smith’s or a Colles’ fracture
ke rs
eb oo (Fig 3.6-9) [17].
e b oo
Fig 3.6-9 Barton’s fracture— Fig 3.6-10 Chauffeur’s
b o o
/ / e/e
fracture—radial styloid fracture
e t . m e fracture dislocation with either

dorsal or palmar displacement with subluxation of the carpus
t .m
/ / of the carpus together with the
//
attached to the styloid fracture
ps: ps:
fracture fragment. fragment.
318
htt htt
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 4.3 The three-column concept
t . m e /
t . m e/e
/ / / /
ps: ps:
This concept by Rikli et al [20] helps understand the fracture
htt htt
pattern in complex and intraarticular DRFs:
• The radial column includes the radial styloid with the Fig 3.6-11 Lateral x-ray view of
scaphoid facet. an 89-year-old female patient
• The intermediate column consists of the lunate facet and with palmar and dorsal depres-
e rs the sigmoid notch, forming the distal radioulnar joint.

• The ulnar column consists of the distal ulna along with
er s sion (die-punch fragment) of
the intermediate column (lunate
b o ok the triangular fibrocartilaginous complex (TFCC).
bo ok facet); the critical corner of the

intermediate column is the die-
b o o
e/ e 4.4 Distal forearm fractures
e/ e punch fragment which includes
the distal radioulnar joint.
e/e
: // t .m
Distal ulnar head and/or ulnar neck fractures associated with
DRFs are defined as DFFs. Isolated ulnar styloid fractures
: / / t .m
ht tps
must be distinguished from distal ulnar fractures (DUF). In
6% of cases, widely displaced DRFs in older adults are as-
sociated with DUF [21]. Of those, 13% are grade 1 open ht tps
fractures according to Gustilo and Anderson, where the dis-
tal ulnar shaft penetrates the skin on the ulnar side.
e r s
4.5 Fracture dislocations
e r s
ook ok o
In these fracture patterns, the carpus follows either the pal-
e b mar or the dorsal fracture fragment (usually the palmar or

e b o b o
e / dorsal rim fragment of the intermediate column, lunate
m e/
facet fragment) and leads to a carpal subluxation. Fracture
t . t . m e/e
/ /
dislocations should be treated operatively even in older adults.
/ /
ps: ps:
Fig 3.6-12 Fracture dislocation Fig 3.6-13 AP view of an
with small palmar (teardrop) or 84-year-old female patient
htt htt
dorsal rim fracture. The carpus with distal radial fracture and
4.6 Practical approach
follows the fracture fragment re- associated fractures of the ulnar
Instead of using strict classification systems, we usually de- sulting in radiocarpal subluxation. column.
scribe the following parameters:
• Palmar or dorsal displacement of the distal fracture frag-
e rs ment. As palmarly displaced DRFs, these should be treat-

e r s
b o ok ed operatively.
b o
• Intraarticular or extraarticular fracture characteristics ok b o o
e/ e help describe the fracture severity.
e / e
• Metaphyseal comminution results in increased instability.
e /e
://t . m
• Palmar or dorsal depression (die-punch fragment) of the
: / / t . m
t t p s
intermediate column (lunate facet), the critical corner
tps
ht
involving the DRUJ), is a factor (Fig 3.6-11).
h
• Any signs of fracture displacement with small palmar
(teardrop) or dorsal rim fracture where the carpus follows
a b
Fig 3.6-14a-c The x-rays in AP

the fracture fragment resulting in radiocarpal subluxation
(a) and lateral view (b) of an
(Fig 3.6-12). older female patient with distal
k e rs
• Associated fractures of the ulnar column (ie, distal ulnar
fracture) (Fig 3.6-13). These increase the instability and
ke rs radial fracture and associated
carpal and soft-tissue injuries.
eb oo require treatment of the ulnar column.
e b oo The computed tomographic

scans demonstrate the intraop-
b o o
e/e
• Associated carpal or soft-tissue injuries (Fig 3.6-14). These
e / e /
require additional treatment (eg, suture of intrinsic liga-
m
erative arthroscopic finding of a
m
complete scapholunate-ligament
ments).
/ /t . / t .
rupture seen through the mid-
/
ps: ps:
c carpal portal (c).
htt htt 319
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.6 Distal forearm
k e rs ke rs
e b oo e b oo b o o
t . m e /
t
Patient age has been shown to correlate with fracture insta-
. m e/e
s: / / / /
ps:
bility. Cumulative risk factors for the loss of reduction are:
http htt
The treatment of DRF in older adults is controversial. Stable
fractures can be treated with cast immobilization, usually • Age greater than 60 years
with satisfactory outcomes. For unstable DRFs in which • More than 20° of dorsal angulation or 5 mm of radial
fracture reduction cannot be maintained with cast immo- shortening
bilization, additional fixation is suggested. Some authors • Dorsal comminution
e rs
have suggested that unstable DRFs should be managed non-
operatively because fracture reduction and anatomical align-
er s
• Ulnar fracture or intraarticular radiocarpal involvement
ok ok
[28]
b o ment on x-rays are not correlated with better functional

outcomes in older adults. On the other hand, several case
bo Osteoporosis weakens the metaphyseal bone by decreasing
b o o
e/ e e/ e
series have documented excellent results of internal fixation trabecular bone volume, commonly resulting in a large me-
e/e
: // t .m
with very low complication rates of dorsally displaced DRF
with the use of locking implants in this population (see
taphyseal void after reduction, which increases fracture in-
: / / t .m
stability [29, 30]. Nesbitt et al [23] reported that age is the only
Rikli et al [22]).
5.1 ht tps
Fracture manipulation versus splinting ht tps
significant risk factor in predicting secondary displacement
and instability in DRFs treated by closed reduction and im-
mobilization. Considering these outcomes, the question
Historically, displaced DRFs were reduced under local or arises whether reduction of displaced DRFs should be at-
general anesthesia in the emergency department and then tempted. After reduction, the majority of these fractures will
immobilized with a below elbow plaster cast. Fracture re- lose reduction and go on to radiographic malunion, but
e r s
duction was assessed using x-rays after closed reduction and
e r s
without evidence that this reliably leads to poor functional
ook ok o
cast application. Nowadays it is controversial if acute DRF outcome. In our practice closed fracture reduction by fracture
e b b o
should be reduced initially in older adults for the following
e
manipulation is indicated only in specific situations such as:
b o
e / reasons:
t . m e/ • Simple fractures with dorsal angulation less than 20° and

t . m e/e
/ /
• Decreased bone mineral density (BMD) is associated with
: / /
radial shortening of less than 5 mm, as fracture manipu-
h t p s
DRF instability and a 50% risk for secondary displacement
t
after closed reduction and casting [23].
• There is a high incidence in loss of reduction after cast
reduction [31].
• If patients are polytraumatized. htt ps:
lation is more likely to lead to better anatomical fracture
treatment; 30% displace during the first 10 days and an- • If surgery is planned, in cases where the soft tissues are
other 29% after 10 days [24]. at risk or nerves are compressed by fracture fragments.
• Closed remanipulation after secondary displacement in
e rs patients treated nonoperatively is not successful [25].

r s
In most other situations, painful fracture manipulations can
e
b o ok • There is no correlation identified between fracture clas-
b o
sification, initial displacement, or final radiographic out- ok
be avoided. Finger trap traction and below elbow cast applica-
tion without any fracture manipulation as initial treatment
b o o
e/ e / e
come in low demand patients, particularly in those with
dementia in nursing homes [26].
e
option for acute DRF is suggested. After decrease of swelling,
the cast is changed without any further manipulation. Wrists
e /e
://t . m
• The risk for displacement with an unacceptable radio-
/ t .
are immobilized in a short arm cast in a neutral position for
: / m
t t p s
graphic result increases in patients older than 58 years
tps
5 weeks. Active finger exercises are started immediately. Af-
ht
[23]. ter cast removal, physiotherapy is recommended.
h
• Sakai et al [27] reported a significant correlation between
increasing displacement of distal fracture fragment and 5.2 Operative versus nonoperative
lower BMD. Several studies have demonstrated a high correlation be-
tween the anatomical result and the functional outcome in
k e rs ke rs
young, active, and high-functioning patients. Malunion of
distal radial fractures can result in posttraumatic wrist ar-
eb oo e b oo
throsis and unsatisfactory functional outcomes with a de-
b o o
e/e
formed and painful wrist [32, 33]. Thus, restoring articular
e / m e / congruity and radial length with open reduction and inter-

m
/ /t . nal fixation (ORIF) is recommended for the treatment of
// t .
ps: ps:
DRFs in younger patients [34, 35].
320
htt htt
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
The therapeutic choice in FFPs is often inappropriately based
t . m
time period (P < .05), but there were no significant differ- e/e
s: / / / /
ps:
on the results of fracture treatment in much younger patients ences between the groups at 6 and 12 months. However,
http htt
[32]. Distal radial fractures are a good example illustrating grip strength was significantly better at all times in the op-
how decision making in older patients should differ consid- erative group (P < .05). Furthermore, dorsal radial tilt, ra-
erably: dial inclination, and radial shortening were significantly
better in the operative than in the nonoperative treatment
• Older patients are a heterogenous group and with diverse group at the time of the latest follow-up (P < .05). The
e rs demands.
• Comorbidities contribute to increased perioperative risk.
er s
number of complications was significantly higher in the
operative treatment group (thirteen compared with five,
b o ok • Consequences of malunited fractures are much less pre-

dictable and often clinically insignificant.
bo ok
P < .05). At the 12-month follow-up examination, the ROM,
pain rating, and the PRWE and DASH scores were not dif-
b o o
e/ e e/ e ferent between the operative and nonoperative treatment
e/e
: // t .m
Presently, there is no consensus regarding the best treatment
for unstable DRFs in the older population [36].
groups (Case 1: Fig 3.6-15, Fig 3.6-16) [37].
: / / t .m
ht tps
In a single center prospective trial, the authors randomized
73 patients with a displaced and unstable DRF to ORIF with ht tps
Achieving anatomical reconstruction did not produce any
improvement in ROM or ability to perform ADLs [37].
a palmar locking plate or to closed reduction and cast im- Treatment of DRFs not only depends on patient age but also
mobilization. There were no significant differences between on geographic variation, local culture, the surgeon’s train-
the groups in terms of the range of motion (ROM) or pain ing, or on the surgeon’s age [38, 39]. Nelson et al [40] re-
e r s
relief during the entire follow-up period (P > .05). Patients
e r s
ported that even among highly active older adults, distal
ook ok o
in the operative group had lower Arm, Shoulder and Hand radius malunion did not affect functional outcomes.
e b (DASH) and Patient-Rated Wrist Evaluation (PRWE) scores,

e b o b o
e /
t . m e/
indicating better wrist function in the early postoperative
t . m e/e
/ / / /
Patient
htt ps: htt ps:
CASE 1
A 78-year-old woman with a distal radial fracture.
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e/e
a b c d
e / Fig 3.6-15a–h
m e / m
t .
a–b Initial x-rays showing AP and lateral views.
/ / // t .
ps: ps:
c–d The radiographic outcome after fracture healing.
htt htt 321
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.6 Distal forearm
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok e
bo f
ok b o o
e / e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
g h
e r s e r s
Fig 3.6-15a–h (cont) Functional outcome of the same 78-year-old patient in flexion (e), extension (f ), pronation ( g ) and supination (h).
e / m
Chung et al [41] systematically reviewed the literature for
t . e/ Decision making for operative or nonoperative treatment
t . m e/e
/ /
the treatment options of DRFs in patients older than 60 years
: / /
must involve the patient. Patients and caregivers should be
h t p s
treated with five common techniques, ie, palmar locking
t
plate system, nonbridging external fixator (EF), bridging
EF, percutaneous K-wire fixation and cast immobilization.
informed that:
htt ps:
• Nonoperatively treated unstable DRFs will end up in
The authors concluded that despite worse radiographic re- malunion and a visible deformity. Some patients will not
sults in the group with cast immobilization, functional results accept the visible deformity of malunion and therefore
were not different from those in the operatively treated surgery should be considered for them.
e rs
groups. There were no significant differences for all five
r s
• Not all malunions are symptomatic and if there will be a
e
b o ok treatment groups regarding active ROM, grip strength or
the DASH scores though significantly better radiographic
b o ok
symptomatic malunion, there exist options to treat this
condition later [42].
b o o
e/ e / e
results were noticed in the group treated with palmar lock-
e
ing plates. Major complications not requiring reoperation After DRFs, pain, grip strength, and ROM continue to improve
e /e
://t . m
were mostly in the group of bridging EF, whereas major for up to 2–4 years. Patients with malunion had more dis-
: / / t . m
t t p s
complications requiring secondary surgeries were found in
tps
ability at 1 year but showed significant improvement at
ht
the palmar locking plate group. 2–4 years [43]. The poor correlation between the radiograph-
h
The main goal of surgeons treating older adults with DRFs
ic and functional outcomes in older adults might be related
to decreased functional demand on the wrist associated with
should be a pain-free patient with satisfactory functional aging [44]. In summary, there are no significant differences
hand and wrist motion for performance of ADLs, specifi- between long-term functional outcomes after nonoperative
k e rs
cally in hygiene, feeding and mobility.
ke rs
or operative treatment of unstable DRFs in older adults, save
better grip strength in those treated with palmar locking plates.
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 5.2.1 Fracture-related factors
t . m e /
t . m
• Distal radial fracture combined with distal ulnar fracture e/e
s: / / / /
ps:
Nondisplaced DRFs are treated nonoperatively. For the fol- and involvement of all three columns leads to a highly
http htt
lowing fracture patterns, we recommend standard operative unstable situation. Nonoperative treatment will end up
fixation even in older adults: in severe malunion (Fig 3.6-17). Nonoperative treatment
of these fractures leads to unpredictable results. Malalign-
• Palmarly displaced DRF where the carpus is malaligned ment of the radius and ulna as well as disruption of the
relatively to the forearm shaft (Fig 3.6-16) [45]. DRUJ cause functional impairment of forearm rotation
e rs er s
and wrist motion [21]. Failure to achieve stable anatom-
ical reduction and congruity of the DRUJ compromises
b o ok bo ok
the ability to reestablish ulnar variance and stability of
the DRUJ, which may cause local dysfunction, nonunions
b o o
e/ e e/ e of the distal radius and ulna, ulnar-sided wrist pain, and
e/e
: // t .m : / / t .m
posttraumatic arthritis [46–48]. Malalignment with angu-
lar deformity of DUF of more than 10° in any direction,
ht tps ht tps
translation of more than half of the ulnar head relative
to the radius, and articular displacement are considered
to be unstable and ORIF of DUFs is recommended [49].
• For open fractures (Fig 3.6-18) and displaced fractures
(Fig 3.6-19, see topic 4.2.3 in this chapter) operative fixa-
tion is recommended.
e r s e r s
ook ok o
a b In unstable DRFs, where fracture reduction cannot be main-
e b e b o tained with cast immobilization, additional fixation is sug-

b o
/ e/ e/e
Fig 3.6-16 The Fig 3.6-17a–b AP (a) and lateral (b) views
gested [25].
e computed tomographic
scan in the sagittal
show a distal radial fracture combined
. m
with a distal ulnar fracture. The involve-
t t . m
/ / / /
ps: ps:
plane of a 76-year-old ment of all three columns leads to a highly
female patient shows unstable situation.
htt htt
a palmarly displaced
distal radial fracture.
e rs e r s
b o ok b o ok Fig 3.6-18a–d Pre-
b o o
e/ e e / e e
and an x-ray in AP (c)/
operative finding (a–b)
e
://t . m : / t . m
and lateral (d) views of
/
an 89-year-old female
t t p s tps
patient with an open
ht
a b c d distal radial fracture.
k e rs ke rs
eb oo Fig 3.6-19 The computed
b
tomographic scan of a 76-year-
e oo b o o
e /
t . m e /
old female patient shows a
displaced distal radial fracture
t .m e/e
/ /
after closed reduction (see topic
//
ps: ps:
4.2.3 in this chapter).
htt htt 323
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.6 Distal forearm
k e rs ke rs
e b oo e b oo b o o
e / 5.2.2 Patient-related factors
t . m e /
t .
Patients treated with EF had significantly better radiograph-
m e/e
s: / / / /
ps:
Because of the variabilty in patient demands, functional ic results with no difference in function.
http htt
outcomes, and individual patient perioperative risk, the
factors in Table 3.6-1 should be included in the decision- In general, major complications associated with external
making process: fixation and percutaneous pinning are pin-track infection
and iatrogenic injury of the superficial radial nerve. Over-
5.3 Choice of implants distraction of the wrist joint may lead to complex regional
e s
5.3.1 Percutaneous pinning
r
Pinning alone may not be enough to maintain articular and
er s
pain syndrome (CRPS) [52]. Especially in osteoporotic bone,
with weak bony purchase of the pins, additional casting is
b o ok metaphyseal support, as K-wires are not load-bearing de-

vices. Additionally, a forearm splint is necessary to neutral-
bo ok
necessary and loosening of the pins occurs quite early so that
they have to be removed before definitive bone healing.
b o o
e/ e ize the bending forces across the metaphysis. The wires are
e/ e Gehrmann et al [53] reported that the risk of pin-track infec-
e/e
: // t .m
left up to 4 weeks and the forearm cast is worn for 6 weeks.
Percutaneous pinning is a relative simple method of fixation
tions is eliminated through the use of ORIF and advises the
: / / t
use of fixed-angle plating of DRF through a palmar approach..m
tps
that is recommended for reducible extraarticular and simple
ht
intraarticular DRFs without metaphyseal comminution and
with good bone quality. In multifragmented intraarticular ht tps
Last, adults with cognitive impairment are likely to find it
difficult to safely comply with EF and weight bearing or ROM
limitations, making complications due to EF more likely.
fractures with impacted joint fragments it is quite difficult Because of these issues, we no longer use percutaneous K-
to reduce these fragments by percutaneous pinning. In these wire fixation or external fixation as definitive treatment op-
cases, other procedures like a plate osteosynthesis might be tion for treating unstable DRF in the FFP.
e r sthe appropriate therapy option.

e r s
ook ok o
5.3.3 Plating
e b Azzopardi et al [50] concluded that percutaneous pinning of

e b o Open reduction and internal fixation allows anatomical re-
b o
e / unstable, extraarticular DRFs provides only minimal im-
provement in the radiographic parameters compared with
t . m e/ duction and stable fixation with early postoperative wrist
mobilization. As DRFs are hyperextension injuries and the
t . m e/e
/ /
immobilization in a cast alone. This did not correlate with
/ /
dorsal cortex of the distal radius is weak, most displace dor-
an improved functional outcome in older adults.
5.3.2 External fixation htt ps: htt ps:

sally. Traditionally, all dorsally displaced DRFs were treated
through a dorsal approach using a dorsal buttress plate. The
problems of dorsal plating are extensor tenosynovitis with
External fixation as a treatment option for DRFs was primar- tendon rupture due to hardware prominence. To improve
ily reserved for highly unstable and severely comminuted this, special low-profile steel plates and dorsal Pi-shaped
fractures where reconstruction of the articular surface plates were designed [54]. To adapt to the anatomy of the
e rs
seemed impossible, in open fractures with soft-tissue prob-
r s
dorsal distal radius, the Pi-plate was designed to fit close to
e
b o ok lems, and as a part of orthopedic damage control in poly-
traumatized patients.
b o ok
the dorsal aspect around the Lister’s tubercle. However,
Campbell [55] reported attrition ruptures of extensor tendons
b o o
e/ e In a prospective randomized study, Roumen et al [51] com-
e / e after dorsal Pi-plate application and Kambouroglou and
Axelrod [56] described tendon ruptures and failure of the
e /e
pared external fixation with closed reduction and immobi-
://t . m Pi-plate system.
: / / t . m
t t p s
lization for redisplaced DRFs in patients older than 55 years.
tps
ht
In biomechanical evaluations, the palmar fixed-angle plate
In favor of operative management

h In favor of nonoperative management
is efficient in restoring the normal axial force distribution,
superior to conventional palmar and dorsal T-plate fixation
Younger age Advanced age [57]. The fixed-angle screws lock into the plate and do not
Short immobilization time Risk of postoperative delirium rely on engagement of the screw threads in bone, leading
kers rs
High level of acitivity and independence Low demand with a low level of activity to better fixation especially in osteoporotic bone. The other
o ke
advantage of locking plates is the good subchondral support
oo o
Low Charlson Comorbidity Index High Charlson Comorbidity Index
/eb o Early return to daily and sport activities High degree of osteoporosis
e b
of the distal fragments even in very short distal fracture
b o
e/e
fragments. The latest generation of locking plates offer the
e
Associated fractures
High cosmetic demand
Dementia
Frailty
m e / option of variable locking screws, which allow a total an-
m
/ /t . gulation of 30° for screw placement.
// t .
ps: ps:
Table 3.6-1 Patient-related factors to be included in decision making.
324
htt htt
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
In a prospective multicenter study, Rikli et al [22, 58] did not
t . m
shaft. Direct pressure is then applied to the distal fragment e/e
s: / / / /
ps:
find that poor bone quality increased the risk of loss of re- to a palmar direction with a counterpressure on the pal-
http htt
duction, screw and plate pull-out for patients older than mar surface of the forearm. During this maneuver, the
50 years with DRFs treated with palmar locking plates. In palmar cortices are reduced and used as a hinge to ma-
patients with an average low local BMD, the authors showed nipulate the dorsally displaced fragment into neutral wrist
that treatment with a palmar locking plate was associated position (closed reduction). While still in traction, a well-
with a low risk of complications related to fracture type and molded dorsal splint is applied. A circumferential cast is
e rs
implant.
er s
not recommended to avoid cast-induced compartment
syndrome.
b o ok 6 Therapeutic options—radial fractures

bo ok
• After the primary swelling has decreased, the splint is
converted to a below elbow cast.
b o o
e/ e e/ e • In total, DRFs are immobilized in a forearm cast in neu-
e/e
6.1
: // .m
Closed reduction and cast immobilization
t
Especially in nondisplaced DRF, an obvious hematoma of
: / / .m
tral position of the wrist for 5 weeks. No study has been
t
able to show any significant differences between long
tps
the third dorsal extensor compartment should be evacu-
ht
ated to avoid secondary rupture of the extensor pollicis
longus (EPL) tendon (Fig 3.6-20) [59]. We perform finger trap ht tps
and short arm cast for the treatment of DRFs. The elbow,
fingers, and the thumb should be left free to avoid stiff-
ness.
traction and apply a dorsal below elbow splint without any
fracture manipulation as initial treatment. After local edema Secondary loss of primary reduction can occur up to 2 weeks
subsides, the fractured wrist is immobilized in a short arm after primary closed reduction. In these cases, repeated ma-
e r s
cast in a neutral position for 5 weeks. Active exercises of
e r s
nipulation, especially in the osteoporotic bone, is not recom-
ook ok o
the fingers are started immediately. After cast removal, phys- mended and has been associated with the development of
e b iotherapy is started.
e b o CRPS type 1 [26].
b o
e / m e/
Fracture reduction should always be performed under local
t . m
Active and passive finger motion is encouraged early. If
t . e/e
/ /
anesthesia or under hematoma block in the emergency de-
: / /
nonoperative treatment is chosen, cast disease, namely at-
h t p s
partment, as follows (Fig 3.6-21):
t
• Application of finger traps to the thumb and index finger htt ps:
rophy and joint stiffness, must be avoided. Fingers in older
adults may be arthritic and are particularly susceptible to
detrimental stiffness if the joints are not moved shortly af-
with the arm put on horizontal traction with 3 kg using ter injury. Finger stiffness is quite avoidable through early
countertraction along the upper arm to disimpact the identification and prompt physiotherapy referral. A therapy
fracture by ligamentotaxis should be used. After 10 min- program after cast removal including active-assisted motion
e rs utes of traction, the initial dorsal displacement is exag-

r s
of the wrist and grip strengthening is started at 5 weeks
e
b o ok gerated to mobilize the distal fracture fragment from the
b o ok
after bone healing.
b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e / a
t . m e / b
t .m e/e
s: / / //
ps:
Fig 3.6-20a–b Hematoma in the third dorsal extensor compartment before (a) and after (b) puncture.
http htt 325
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.6 Distal forearm
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs
a b
er s c
b o ok bo ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
d e f
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
g
htt ps: h i
htt ps:
Fig 3.6-21a–i Closed reduction and cast immobilization. The fracture hematoma is aspirated to ensure the fracture gap is reached and local
anaesthesia is injected (a–c). A finger trap is applied and the arm is put on horizontal traction with 3 kg using countertraction along the upper
arm to disimpact the fracture by ligamentotaxis (d). After traction, the initial dorsal displacement is exaggerated to mobilize the distal fracture
fragment from the shaft. Direct pressure is applied to the distal fragment to a palmar direction with a counterpressure on the palmar surface
e s e r s
of the forearm. During this maneuver, the palmar cortices are reduced and used as a hinge to manipulate the dorsally displaced fragment into
r
neutral wrist position (e–f). While still on traction ( g), a well-molded dorsal splint is applied (h–i).
b o ok b o ok b o o
e/ e 6.2 Palmar locking plate fixation
e / e Fragment-specific fixation and double plate fixation tech-
e /e
://t . m
To overcome the problems that can come with dorsal plat-
/ t
niques may be helpful to treat various fracture types, espe-
: / . m
t t p s
ing, many authors favor the palmar approach [60]. The most
tps
cially intraarticular fractures with a large metaphyseal void
ht
appropriate plates should be selected to correspond with (Fig 3.6-22):
h
the fracture pattern. There is no single plate that is univer-
sally successful or devoid of any potential complications for • Henry palmar approach between the flexor carpi radialis
all types of unstable DRFs, including intraarticular and ex- (FCR) tendon and the radial artery.
traarticular fracture patterns. • The FCR tendon together with the flexor pollicis longus
k e rs ke rs
tendon is retracted ulnarly to indirectly protect the me-
dian nerve.
eb oo e b oo
• The pronator quadratus muscle is released from its ra-
b o o
e/e
dial insertion and reflected ulnarly to gain access to the
e / m e / fracture site.
m
/ /t . • Careful reduction of fracture fragments, as poor bone
// t .
ps: ps:
quality can lead to iatrogenic fractures.
326
htt htt
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m
• Insertion of two K-wires from the palmar rim and one e /
t . m
a subcortical buttress against fracture subsidence. The e/e
s: / / / /
ps:
percutaneously from the radial styloid under image in- subcortical plate retains greater loading capacity than the
http htt
tensification. osteopenic compressed cancellous metaphyseal bone.
• A fixed-angle plate is first fixed at the gliding hole to al- Exact drilling with special drill guides that are screwed
low appropriate plate positioning under image intensi- the distal plate holes is essential to guarantee perfect
fier control proximally to the watershed line, defined as engagement of the locking screws into the plate. Espe-
a transverse ridge that closes the concave surface of the cially with variable locking plate systems, which allow a
e rs palmar radius distally. Distal to this line, the radius slopes

in a dorsal-distal direction and becomes prominent pal-
er s
range of about 30° of screw insertion, intraarticular screw
placement can be performed quite easily. If fracture in-
b o ok marly (Fig 3.6-23). Plates beyond or distal to the watershed

line can exert pressure on the flexor tendons and can
bo ok
stability demands distal placement of hardware, close
follow-up investigations and hardware removal should
b o o
e/ e cause tendon rupture (Fig 3.6-24).
e/ e be considered at first sign of flexor tendon irritation.
e/e
: // t .m
• In intraarticular fractures, wrist arthroscopy detects in-
traarticular steps and associated soft-tissue injuries.
: / / .m
• Intraoperative control with image intensifier is used to
t
check plate and screw position. The lateral tilt x-ray vi-
ht tps
• In comminuted intraarticular fractures the locking screws
are placed in the most distal subcortical position to act as
ht
surface and intraarticular hardware. tps
sualizes, with the wrist angulated 20–30°, the articular
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
a
htt ps: b
htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
c
://t . m d a
: / /b
t . m
t t p s
Fig 3.6-22a–d After open reduction via a palmar approach (a), the fracture is secured with K-
tps
Fig 3.6-23a–b The watershed line (black
ht
wires (b) and a palmar distal radial plate is applied (c). After an arthroscopic fine-tuning of the dots) on an anatomical specimen in AP (a)
h
articular surface, the plate is adjusted (d) and secured by variable angle locking screws. and lateral (b) views.
k e rs ke rs
eb oo e b oo b o o
e /
t . m e / Fig 3.6-24a–b Intraoperative situs of
t .m
a flexor tendon injury of a 70-year-old
e/e
: / / //
female patient that occurred 6 months after
ps:
a b
t p s surgical treatment.
h t htt 327
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.6 Distal forearm
k e rs ke rs
e b oo e b oo b o o
e /
t . m
• Extensor tendon ruptures may occur because of exces-e /
t
• No immobilization is necessary in extraarticular metaph-
. m e/e
s: / / / /
ps:
sively long screws overlaying the dorsal cortex (Fig 3.6‑25a). yseal fractures and in simple intraarticular DRFs where
http htt
Because of the triangular shape of the dorsal cortex, the intraoperatively a stable fixation can be achieved.
most ulnar and radial screws are typically shorter than • Immobilization—in DRFs with metaphyseal void or severe
the central screws (Fig 3.6-25b). The “skyline view” is used intraarticular involvement, a palmar slab splint is applied
to detect excessively long screws penetrating the dorsal for 3 weeks.
cortex (Fig 3.6-26) [61]. • Physiotherapy is helpful. Active and passive wrist mobi-
e s
• Reattachement of the pronator quadratus muscle to pro-
r tect the flexor tendons (Case 2: Fig 3.6-27).
er s
lization out of the splint can prevent finger and wrist
joint stiffness.
b o ok 6.2.1 Tips and tricks

bo 6.3 ok
Dorsal locking plate fixation
b o o
e/ e In comminuted intraarticular and metaphyseal fractures,
e/ e Some fracture patterns require the dorsal approach to ad-
e/e
: // t .m
conventional palmar plates require additional metaphyseal
support like bone grafts, bone substitutes, or additional dor-
dress the dorsal ulnar fragment of the lunate fossa as well
: / / t
as a dorsally comminuted fracture. Dorsal plate fixation was.m
tps
sal plates to avoid loss of reduction due to metaphyseal
ht
instability. Palmar fixed-angle plates improve mechanical
rigidness and make dorsal metaphyseal bone grafting re- ht tps
associated with higher rates of extensor tendon complica-
tions including irritation, synovitis, and rupture due to direct
contact with bulky dorsal plates. However, the latest implants
dundant [62]. They act like an internal fixator, unloading are significantly thinner in their profile and the locking
the comminuted dorsal metaphyseal bone. mechanism has decreased the number of soft-tissue problems
using dorsal plates. Matschke et al [63] compared palmar
e r s
6.2.2 Aftercare
e r s
with dorsal locking plate fixation in DRFs and reported no
ook ok o
Aftercare includes: significant differences in functional results and rate of com-
e b b
• For control of pain and swelling, a below-the-elbow splint
e o plications at 2 years.
b o
e / started immediately.
t . e/
can be applied for 1 week. Active digital mobilization is
m t . m e/e
/ / / /
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m Fig 3.6-25a–b Screws are too long, pro-
/ t .
truding through the dorsal cortex (a). Mag-
: / m
a
t t p s b
tps
netic resonance imaging scan illustrating the
triangle shape of the dorsal cortex (b).
h ht
Fig 3.6-26a–b Skyline view. The image in-
tensifier is placed on top of the surgical table
to perform the skyline views. The elbow is
flexed 75° with the forearm in maximum
supination and the wrist maximally flexed.
k e rs ke rs Under image intensifier control, the elbow

position is changed into flexion or extension
eb oo e b oo until an optimal position is obtained that en-

ables visualization of the dorsal cortex of the
b o o
e /
t . m e / radius with its entire width, Lister’s tubercle,
t .m
and the distal radioulnar joint (a). In this po-
e/e
/ / /
sition screws crossing the dorsal cortex can
/
ps: ps:
a b be visualized and then changed (b).
328
htt htt
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Patient
. m e/e
CASE 2
/ / t
An 86-year-old woman sustained a complex comminuted distal
: / / t
To restore the articular surface, a palmar rim plate was used that
ments (Fig 3.6-27a–d).

ht t p s
radial fracture with separation of palmar and dorsal articular frag-
htt ps:
was covered with a flap of the pronator quadratus muscle (Fig 3.6-
27e–h ). The pronator quadratus muscle was removed on the
ulnar side and the plate was attached (Fig 3.6-27i). Following
anatomical reduction and internal fixation, the pronator quadratus
flap was reattached (Fig 3.6-27j–k) to protect the flexor tendons
(Fig 3.6-27l).
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
e r sa b c
e r s d
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
e rs e r s
o ok ok o
/ebo o
e f g h
e/ e b e e /e b
://t . m : / / t . m
t t p s tps
h ht
kers kers
i j k l
Fig 3.6-27a–l An 86-year-old woman with a fracture of the distal radius.
b o o o o
a–d X-rays showing a complex comminuted fracture of the distal radius with separated palmar and dorsal articular fragments.
b b o o
e /e e/e e/e
e–h Articular surface reconstruction with a palmar rim plate.
i Removal of the pronator quadratus muscle on the ulnar side and attachment of the plate.
the flexor tendons (l).

/ / . m // t .m
j–l Clinical images showing anatomical reduction and internal fixation followed by reattachment of the pronator quadratus flap ( j–k) to protect
t
htt ps: htt ps:
329
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.6 Distal forearm
k e rs ke rs
e b oo e b oo b o o
e /
t . m
To prevent extensor tendon problems, a retinaculum flap e / After ORIF the ulnarly based retinaculum flap is passed
t . m e/e
s: / / / /
ps:
to cover the implant can be used. In this technique, the underneath the extensor tendons and is used to cover the
http htt
extensor retinaculum is divided in two parts, ie, one radi- distal part of the plate. The radially based flap is fixed ulnarly
ally and one ulnarly based. Both flaps are elevated from the over the extensor tendons to prevent tendon bowstringing
fractured Lister’s tubercle and the EPL tendon is exposed. (Case 3: Fig 3.6-28, Case 4: Fig 3.6-29).
e rs Patient
er s
ok ok
CASE 3
b o A 78-year-old man sustained a complex distal radial fracture with

comminution and isolated fragments of the radial styloid process
bo As a biological support to avoid loss of reduction due to metaphy-
seal instability, an allograft was used (Fig 3.6-28c–d). One and a
b o o
e/ e e/ e
together with separation of palmar and dorsal articular fragments half years after surgery, x-ray controls show sufficient healing with
e/e
(Fig 3.6-28a–b).
: // t .m functional result is seen (Fig 3.6-28g–j).

: / / .m
incorporation of the graft (Fig 3.6-28e–f). Clinically, a very satisfying
t
ht tps ht tps
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
a
htt ps: b c
httd ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m
g h
: / / t . m
t t p s tps
h ht
kers kers
e f i j
b o o b o o
Fig 3.6-28a–j A 78-year-old man with a complex distal radial fracture.
a–b Complex distal radial fracture with comminution and isolated fragments of the radial styloid process together with separation of palmar
b o o
e /e and dorsal articular fragments.
e/e
c–d Use of allograft as a biological support to avoid loss of reduction due to metaphyseal instability.
m m e/e
/t .
e–f X-rays at 1.5 years postoperative show sufficient healing with incorporation of the graft.
/ // t .
ps: ps:
g–j Clinical images show a very satisfying functional result.
330
htt htt
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Patient
. m e /
. m e/e
CASE 4
/ / t
A 70-year-old man with a multifragmented distal radial fracture with
/ / t
ps:
radial impaction and fracture of the styloid process.
htt htt ps:
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
a ht tps b c ht d
tps
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
e f g h
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
i
h j k
ht
Fig 3.6-29a–k Multifragmented distal radial fracture with radial impaction and fracture of the styloid process (a–d). For reconstruction,
a dorsal plate was applied (e–h). To prevent extensor tendon problems, a retinaculum flap to cover the implant was used (i–j). The extensor
rs rs
retinaculum was divided in two parts, ie, one radially and one ulnarly based. Both flaps were elevated from the fractured Lister’s tubercle
k e e
and the extensor pollicis longus tendon was exposed (i). After open reduction and internal fixation, the ulnarly based retinaculum flap was
k
oo oo o
passed underneath the extensor tendons and was used to cover the distal part of the plate ( j). The radially based flap was fixed ulnarly over
eb
the extensor tendons to prevent tendon bow-stringing (k).
e b b o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
331
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.6 Distal forearm
k e rs ke rs
e b oo e b oo b o o
e / 6.4 Radiocarpal prosthesis
t . m e /
t . m e/e
/ / / /
ps: ps:
Following the concept of primary joint replacement in prox- 76 years and some comorbidities but were living at home
htt htt
imal and distal humeral fractures in older adults, Herzberg and were independent in ADLs. Hemiarthroplasty produced
et al [64] described the primary use of wrist hemiarthro- earlier return to preinjury independence in daily activities
plasty in multifragmented, impacted, and irreparable acute with shorter operative time and fewer complications com-
DRFs in an older cohort. Participants had an average age of pared to palmar plating (Case 5: Fig 3.6-30) [64].
e rs er s
ok Patient
ok
o
CASE 5
eb o A 77-year-old woman with status postmastectomy due to breast
e bo Following the concept of primary replacement, wrist hemiprosthesis

b o
e/ e/ e/e
cancer sustained a multifragmented, impacted, and irreparable acute was implanted (Fig 3.6-30c–d). Ten months after surgery, the patient
distal radial fracture (Fig 3.6-30a–b). showed a good clinical outcome and mobility despite a residual
: // t .m lymphatic swelling due to the mastectomy (Fig 3.6-30e–h).

: / / t .m
ht tps ht tps
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
ps: ps:
a b c d
htt htt
e rs e r s
b o ok b o ok b o o
e/ e e
e / e f
e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo g
e b h
oo b o o
e /
t . m e /
Fig 3.6-30a–h A 77-year-old woman with a distal radial fracture.
a–b X-rays showing multifragmented, impacted, and irreparable acute fracture of the distal radius.
t .m e/e
/
c–d X-rays showing implanted wrist hemiprosthesis.
/ //
ps: ps:
e–h Clinical images at 10 months after surgery showing a good clinical outcome and mobility.
332
htt htt
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 7
t . m
Therapeutic options—distal forearm fractures e / 7.3 Bridging plate
t . m e/e
s: / / / /
ps:
Treatment of intraarticular DRFs with extensive comminu-
http htt
At this time, treatment regimens are controversial and vary tion extending up to the metaphyseal-diaphyseal junction
from ORIF of the ulna, percutaneous pin fixation and ex- remains challenging for the following reasons:
ternal fixation, or cast immobilization [65–68]. These injury
patterns often go hand in hand with large metaphyseal de- • External fixation, which neutralizes compressive forces
fects in both radius and ulna. A common difficulty in main- on the articular segment, may not provide sufficient sta-
e s
taining reduction is the large metaphyseal defect after res-
r
toration of the length of radius and ulna. To overcome this,
er s
bility and immobilization to allow healing of the me-
taphysis to the diaphysis proximally. Using an EF would
b o ok we use corticocancellous iliac bone grafts to restore length
bo
and prevent metaphyseal collapse. If bone graft is not avail- ok
require a longer working distance for the EF and a pro-
longed duration of application because the metaphyseal-
b o o
e/ e e/ e
able, locking plates can help to maintain radial length. Re- diaphyseal has a longer healing time than the metaphy-
e/e
: // t .m
duction and fixation of the small fragments of the distal ulna
is challenging. After reduction and fixation of DRFs, 75%
seal region.
: / / t .m
• Open reduction and internal fixation is challenging too,
stable [69].
ht tps
of the associated ulnar fractures remain displaced or un-
ht tps
because the articular fracture is difficult to restore using
plates, due to the metaphyseal void with no support of
the articular fragments.
7.1 onoperative treatment of the distal ulnar
N • A bridging plate achieves more stability (Case 6: Fig 3.6-31),
fracture avoiding hybrid options using plate and external fixation
Biyani et al [21] recommended ORIF of DRF as the standard or multiple plates [72].
e r s
of care treatment in the operative therapy of DRF associ-
e r s
ook ok o
ated with DUF. In simple ulnar neck fractures, where after Ligamentotaxis is used to restore radial length and radio-
e b anatomical reconstruction of DRF the ulnar head fractures

e b o carpal alignment, which can be preserved with the applica-
b o
e / may be considered [70].
t . e/
remains aligned and stable, nonoperative treatment of DUF
m
tion of a bridging plate. Additional fixation for the articular
t . m
fragments can be used when necessary to achieve a more e/e
/ / anatomical reduction.
/ /
ps:
The fovea of the ulnar head is the center of forearm rotation
htt
whereas the radius rotates around the ulnar head. In cases
of ulnar head fractures, an above elbow cast for 6 weeks is htt ps:
The surgery is performed without tourniquet control with
the patient lying supine on a radiolucent table. A 4 cm inci-
recommended to neutralize the deforming forces during the sion is made dorsally over the third metacarpal bone. The
forearm rotation. extensor tendons at this level are retracted. A second, 4–6 cm
incision is made at the dorsal radial aspect of the radius at
e rs
7.2 Operative treatment using locking plates
r s
least 4 cm proximal to the fracture site. According to the
e
b o ok Distal radial fractures are treated using palmar locking plates
as described above. In cases with metaphyseal comminution
b o ok
fracture pattern, a locking compression plate 3.5 is then
passed from distal to proximal along the floor of the fourth
b o o
e/ e /
of DRF and DUF, the radius can be primary shortened to
e e
overcome the metaphyseal void. The proximal fragment is
dorsal extensor compartment. At the Lister’s tubercle, a
third 2 cm incision is made to retract the EPL tendon and
e /e
://t . m
impacted into the distal fragment to neutralize the metaph-
/ t . m
care is taken to ensure that the plate does not irritate either
: /
t t p s
yseal defect and avoid secondary axial displacement forces.
tps
the EPL or the digital extensor tendon as it is passed proxi-
ht
Fixation of the shortened radius without bone grafting and mally under the tendons with use of the plane between the
h
leaving the ulnar fracture untreated may cause the late de-
velopment of posttraumatic arthritis, ulnar-sided wrist pain,
extensor tendons (fourth compartment) and the periosteum
and joint capsule. The plate is fixed to the third metacarpal
DRUJ instability, and limited rotation of the forearm. bone, with care taken to drill the holes in the midline of the
metacarpal, thereby avoiding subsequent rotatory displace-
k e rs
The advent of low-profile locking plates made early mobi-
lization possible, and good functional results were reported
ke rs
ment of the hand relative to the forearm. If the DRUJ is
stable postoperatively, no immobilization is used. In cases
eb oo after fixation of these fractures in association with DRFs
e b oo
with comminuted ulnar head fractures, the forearm is main-
b o o
e/e
(see AO Principles of Fracture Management) [70, 71]. tained in a sugar-tong splint for 4 weeks following stabiliza-
e / m e / tion, whereby active digital and elbow movement are initi-

m
/ /t . t .
ated immediately. The bridging plate is retained for 3 months
//
ps: ps:
and removed after confirmation of bone healing [72].
htt htt 333
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.6 Distal forearm
k e rs ke rs
e b oo e b oo b o o
e / Patient
. m e / m
was done (Fig 3.6-31d), and an external fixator was applied. Soft-
. e/e
CASE 6
/ / t
An 83-year-old woman sustained a distal radial fracture.
: / / t
tissue damage was covered by a local flap (Fig 3.6-31e–f). Over

ht t p s
Initially, pin fixation was chosen as the operative treatment (Fig 3.6- htt ps:
time, further displacement occurred (Fig 3.6-31g–h) and a bridging
plate fixation was chosen (Fig 3.6-31i–j). The plate was used for
3 months and after bone healing was confirmed the implant was
31a–b). Subsequent pin-track infection occurred (Fig 3.6-31c). The removed (Fig 3.6-31k–l). The soft tissue also showed a satisfying
pins had to be removed, extended operative wound debridement healing process (Fig 3.6-31m–n).
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
: // t .m c d
: / / t .m
ht tps ht tps
e r s e r s
ook ok
a b e f
b b o b o o
e / e e/ e e/e
/ / t . m / /t . m
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e g h i
e / e j k l
e /e
://t . m : / / t . m
t t p s tps
h ht
Fig 3.6-31a–n An 83-year-old woman with a distal radial
fracture.
a–b Operative treatment with pin fixation.
c Clinical image of pin-track infection.
rs rs
d Removal of the pins and extended wound debridement.
k e ke e–f Application of an external fixator and coverage of soft-
oo oo o
tissue damage by a local flap.
eb e b
g–h X-rays showing further displacement.
b o
/ / e/e
i–j X-rays of bridging plate fixation.
e t . m e k–l Implant removal after 3 months.
.m
m–n C linical images showing satisfying healing process of
t
m
/ /n
//
ps: ps:
the soft tissue.
334
htt htt
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 8
t . m
Therapeutic options—fracture dislocations e /
t . m e/e
/ / / /
htt ps:
Fracture dislocations require operative treatment regardless
of the age of the patient. Usually, the palmar ulnar corner
htt ps:
of the distal radial joint surface is involved. This fragment
is the critical corner and should be stabilized properly. In
these cases, it is impossible to fix the fragment using a con-
e s
ventional palmar locking plate placed proximally to the
r
watershed line. The distal screws are too proximal to reach
er s
b o ok and stabilize the rim fragment.
bo ok b o o
e/ e e/ e
For these reasons, fragment-specific fixation techniques
e/e
: // t .m
should be used. Small screws, pin plates, or special hook
plates help to fix, buttress and support the palmar rim frag-
: / / t .m
tps
ments until bone healing. Appropriate implant position on
ht
the palmar rim should be confirmed intraoperatively on
true lateral and tilt lateral views. Implant prominence with
a
ht tps b
Fig 3.6-32a–b The carpus follows the palmar fracture fragment and
contact to flexor tendons must be avoided (Fig 3.6-32). leads to a carpal subluxation (a). Fragment-specific fixation techniques
with a small screw and a hook plate were used (b).
In DRFs with small dorsal rim fragments, dorsal plating is
e r s
performed. In these dorsal shear fractures, mostly the dor-
e r s
ook ok o
sal rim of the lunate facet is displaced. This fragment should
e b b o
be fixed, as it is part of the sigmoid notch forming the DRUJ.
e b o
e / to this fragment.
t . e/
Additionally, the dorsal radioulnar ligaments are attached
m t . m e/e
/ / / /
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
335
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.6 Distal forearm
k e rs ke rs
e b oo e b oo b o o
e / 7 References
t . m e /
t . m e/e
/ / / /
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htt ps:
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er s
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ok ok
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: / / t .m
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tps tps
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ht ht
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ook ok
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b o ok
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b o o
e/ e 9. Dimai HP, Svedbom A, Fahrleitner-
Pammer A, et al. Epidemiology of distal
e / eon the rate of mechanical failure after
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Surg Am. 2003 Oct;85-A(10):1956–1960.
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://t . m fractures: a prospective multicentre
cohort study including 249 patients.
Arch Orthop Trauma Surg.
radiological predictors of functional
: / / t .
outcome following fractures of the
distal radius? J Bone Joint Surg Br.
m
t t p s
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tps
2011 Feb;93(2):145–150.
ht
et al. Trends in fracture incidence: 23. Nesbitt KS, Failla JM, Les C. Assessment 36. Handoll HH, Madhok R. WITHDRAWN:
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a population-based study over 20 years.
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et al. Economic and social impact of distal radius. Intermediate and end 37. Arora R, Lutz M, Deml C, et al.
rs rs
upper extremity fragility fractures in results in relation to radiologic A prospective randomized trial
k e elderly patients. Aging Clin Exp Res.

2015 Aug;27(4):539–546. 1987 Jul(220):241–252.
ke
parameters. Clin Orthop Relat Res. comparing nonoperative treatment
with volar locking plate fixation for
eb oo 12. Kramer S, Meyer H, O’Loughlin PF, et al.

The incidence of ulnocarpal complaints
b oo
25. McQueen MM, MacLaren A, Chalmers J.
The value of remanipulating Colles’
e
displaced and unstable distal radial
fractures in patients sixty-five years of
b o o
/ / e/e
after distal radial fracture in relation to fractures. J Bone Joint Surg Br. age and older. J Bone Joint Surg Am.
e the fracture of the ulnar styloid. J Hand

Surg Eur. 2013 Sep;38(7):710–717.
t . m e
1986 Mar;68(2):232–233. 2011 Dec 07;93(23):2146–2153.
t .m
/ / //
htt ps: htt ps:
rs
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e b oo e b oo b o o
e / 38. Fanuele J, Koval KJ, Lurie J, et al.
t . m e /
50. Azzopardi T, Ehrendorfer S, Coulton T,
. m
61. Haug LC, Glodny B, Deml C, et al.
t e/e
/ /
Distal radial fracture treatment:
:
et al. Unstable extra-articular fractures
/ /
A new radiological method to detect
s ps:
what you get may depend on your age of the distal radius: a prospective, dorsally penetrating screws when using
ht t p
and address. J Bone Joint Surg Am.
2009 Jun;91(6):1313–1319.
39. Waljee JF, Zhong L, Shauver MJ, et al.
randomised study of immobilisation in
a cast versus supplementary
percutaneous pinning. J Bone Joint Surg
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volar locking plates in distal radial
fractures. The dorsal horizon view.
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The influence of surgeon age on distal Br. 2005 Jun;87(6):837–840. 2013 Aug;95-B(8):1101–1105.
radius fracture treatment in the United 51. Roumen RM, Hesp WL, Bruggink ED. 62. Orbay JL, Fernandez DL. Volar
States: a population-based study. J Hand Unstable Colles’ fractures in elderly fixed-angle plate fixation for unstable
Surg Am. 2014 May;39(5):844–851. patients. A randomised trial of external distal radius fractures in the elderly
e rs
40. Nelson GN, Stepan JG, Osei DA, et al.
The impact of patient activity level on
er
Surg Br. 1991 Mar;73(2):307–311.s
fixation for redisplacement. J Bone Joint patient. J Hand Surg Am.
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b o ok wrist disability after distal radius

malunion in older adults. J Orthop
bo ok
52. Margaliot Z, Haase SC, Kotsis SV, et al.
A meta-analysis of outcomes of
63. Matschke S, Wentzensen A, Ring D,
et al. Comparison of angle stable plate
b o o
e/ e Trauma. 2015 Apr;29(4):195–200.
41. Chung KC, Shauver MJ, Birkmeyer JD.
e/ e
external fixation versus plate
osteosynthesis for unstable distal radius
fixation approaches for distal radius
fractures. Injury.
e/e
.m .m
Trends in the United States in the fractures. J Hand Surg Am. 2011 Apr;42(4):385–392.
: //
the elderly. J Bone Joint Surg Am. t
treatment of distal radial fractures in 2005 Nov;30(6):1185–1199.
53. Gehrmann SV, Windolf J, Kaufmann RA.
: / / t
64. Herzberg G, Burnier M, Marc A, et al.
Primary wrist hemiarthroplasty for
tps tps
2009 Aug;91(8):1868–1873. Distal radius fracture management in irreparable distal radius fracture in the
ht ht
42. Pillukat T, van Schoonhoven J, elderly patients: a literature review. independent elderly. J Wrist Surg. 2015
Prommersberger KJ. Ist die J Hand Surg Am. Aug;4(3):156–163.
Korrekturosteotomie der fehlverheilten 2008 Mar;33(3):421–429. 65. Melamed E, Danna N, Debkowska M,
distalen Radiusfraktur auch beim 54. Carter PR, Frederick HA, Laseter GF. et al. Complex proximal ulna fractures:
älteren Menschen indiziert? Open reduction and internal fixation of outcomes of surgical treatment.
[Is corrective osteotomy for malunited unstable distal radius fractures with a Eur J Orthop Surg Traumatol.
e r s distal radius fractures also indicated for

elderly patients?]. Handchir Mikrochir 73 fractures. J Hand Surg Am.
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66. Nieto H, Billaud A, Rochet S, et al.
ook ok
Plast Chir. 2007 Feb;39(1):42–48. 1998 Mar;23(2):300–307. Proximal ulnar fractures in adults:
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43. Brogren E, Hofer M, Petranek M, et al.
55. Campbell DA. Open reduction and
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internal fixation of intra articular and
a review of 163 cases. Injury.
2015 Jan;46(Suppl 1):S18–S23.
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e / e Fractures of the distal radius in women
aged 50 to 75 years: natural course of
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using the AO distal radius plate. J Hand
67. Zumsteg JW, Molina CS, Lee DH, et al.
Factors influencing infection rates after
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t
patient-reported outcome, wrist motion
/ / . m Surg Br. 2000 Dec;25(6):528–534.

t . m
open fractures of the radius and/or
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and grip strength between 1 year and 56. Kambouroglou GK, Axelrod TS. ulna. J Hand Surg Am.
2–4 years after fracture. J Hand Surg Complications of the AO/ASIF titanium 2014 May;39(5):956–961.
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Eur. 2011 Sep;36(7):568–576. distal radius plate system (pi plate) in 68. Yi PH, Weening AA, Shin SR, et al.
44. Young BT, Rayan GM. Outcome internal fixation of the distal radius: Injury patterns and outcomes of open
following nonoperative treatment a brief report. J Hand Surg Am. fractures of the proximal ulna do not
of displaced distal radius fractures 1998 Jul;23(4):737–741. differ from closed fractures. Clin Orthop
in low-demand patients older than 57. Leung F, Zhu L, Ho H, et al. Palmar plate Relat Res. 2014 Jul;472(7):2100–2104.
60 years. J Hand Surg Am. fixation of AO type C2 fracture of distal 69. Walz M, Kolbow B, Mollenhoff G.
2000 Jan;25(1):19–28. radius using a locking compression Distale Ulnafraktur als
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45. Marcano A, Taormina DP, Karia R, et al. plate—a biomechanical study in
e r s Begleitverletzung des körperfernen
ok ok
Displaced intra-articular fractures a cadaveric model. J Hand Surg Br. Speichenbruchs. Minimal-invasive
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involving the volar rim of the distal
radius. J Hand Surg Am.
2003 Jun;28(3):263–266.
o
58. Rikli D, Goldhahn J, Kach K, et al.
b
Versorgung mittels elastisch-stabiler
intramedullärer Nagelung (ESIN)
b o o
e/ e 2015 Jan;40(1):42–48.
46. Ring D, Prommersberger KJ, Gonzalez
e / eErratum to: The effect of local bone
mineral density on the rate of
[Fracture of the distal ulna
accompanying fracture of the distal
e /e
del Pino J, et al. Corrective osteotomy
for intra-articular malunion of the
://t . m mechanical failure after surgical

treatment of distal radius fractures:
/ / t .
with elastic stable intramedullary
: m
radius. Minimally invasive treatment
t t p s
distal part of the radius. J Bone Joint
Surg Am. 2005 Jul;87(7):1503–1509.
a prospective multicentre cohort study
including 249 patients. Arch Orthop
tps
nailing (ESIN)]. Unfallchirurg.
2006 Dec;109(12):1058–1063. German.
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47. Fernandez DL, Capo JT, Gonzalez E.
Corrective osteotomy for symptomatic
increased ulnar tilt of the distal end of
the radius. J Hand Surg Am.
Trauma Surg. 2015 Jul;135(7):1043.
59. Hirasawa Y, Katsumi Y, Akiyoshi T,
et al. Clinical and microangiographic
studies on rupture of the E.P.L. tendon
ht
70. Dennison DG. Open reduction and
internal locked fixation of unstable
distal ulna fractures with concomitant
distal radius fracture. J Hand Surg Am.
2001 Jul;26(4):722–732. after distal radial fractures. J Hand Surg 2007 Jul–Aug;32(6):801–805.
48. Fernandez DL, Ring D, Jupiter JB. Br. 1990 Feb;15(1):51–57. 71. Rüedi T, Buckley R, Moran C. AO
rs rs
Surgical management of delayed union 60. Hove LM, Nilsen PT, Furnes O, et al. Principles of Fracture Management. 2nd
k e and nonunion of distal radius fractures.

e
Open reduction and internal fixation of
k
ed. Stuttgart New York: Thieme Verlag;
oo oo o
J Hand Surg Am. displaced intraarticular fractures of the 2007.
eb
2001 Mar;26(2):201–209.
49. Lee SK, Kim KJ, Park JS, et al. Distal
distal radius. 31 patients followed for
e b
72. Ruch DS, Ginn TA, Yang CC, et al.
b o
e/e
3–7 years. Acta Orthop Scand. Use of a distraction plate for distal
e / ulna hook plate fixation for unstable

distal ulna fracture associated with
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1997 Feb;68(1):59–63. radial fractures with metaphyseal and
m
diaphyseal comminution. J Bone Joint
/t
distal radius fracture. Orthopedics.
/ . / t .
Surg Am. 2005 May;87(5):945–954.
/
ps: ps:
2012 Sep;35(9):e1358–e1364.
htt htt 337
rs
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3.6 Distal forearm
k e rs ke rs
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e /
t . m e /
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/ / / /
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e rs er s
b o ok bo ok b o o
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t . m e/ t . m e/e
/ / / /
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e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
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/ / //
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rs
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Pol M Rommens, Michael Blauth, Alexander Hofmann
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
3.7 Pelvic ring / / / /
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htt ps:
e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e 2 Epidemiology and etiology
e/e
: // t .m
Pelvic ring disruptions in younger patients are typically high-
: / / t .m
In some countries, the incidence of hip fractures is declining
tps
energy injuries resulting from traffic accidents, falls from
ht
great height, or crush traumas. Very often, these patients
are multiply injured, need hemodynamic resuscitation and ht tps
while the number of pelvic and acetabular fractures is in-
creasing. In the US, hip fractures peaked in 1996 and declined
by 25.7% until 2010. During the same 18-year period, pel-
provisional pelvic stabilization with a pelvic binder, clamp vic fractures increased by 24%. Absolute numbers, how-
or another type of external fixation. Selective angiograph- ever, remained different with 167,000 hip fractures and
ic arterial embolization and pelvic packing are often indi- 33,000 pelvic fractures in 2010 [4]. In Finland, the age-ad-
e r s
cated [1].
e r s
justed incidence of hip fractures has also steadily declined
ook ok o
since 1997. From 1970 to 2013, the number of age-adjust-
e b b
Fragility fractures of the pelvis present a totally different
e o ed incidences of pelvic fractures has increased from 73 to
b o
e / e/
clinical picture. They occur in frail, older patients and are
m
the result of a low-energy trauma such as a ground-level
t .
364. The incidence increased in all age groups (ie, ages
t . m
80–84 years, 85–89 years, and 90+ years) of women and e/e
/ /
fall. In some patients, the history of their injuries is not
/ /
men during the entire study period. If both the fracture
ps:
obtainable. Repetitive “harmless” events such as the trans-
htt
fer from the bed to a chair or from a chair to the toilet,
sneezing, coughing, which may not be regarded as trau- htt ps:
incidence and rate of the aging population continue to rise
at the current pace, the number of low-trauma pelvic frac-
tures in Finland will be 2.4 times higher in 2030 than it was
matic, have been described as causing fragility fractures of in 2013 [5].
the pelvis [2].
Both advancing age and comorbidities are associated with
e rs
Pelvic ring injuries in advanced age may also result from a
r s
the increase of the risk of suffering a fragility fracture of the
e
b o ok high-energy trauma. A typical accident mechanism is a
b o
trauma from being struck by a vehicle while crossing the ok
pelvic ring (FFP). Many patients have a history of osteopo-
rosis, vitamin D deficiency, long-term immobilization, long-
b o o
e/ e / e
street. These patients find themselves quickly in a life-threat-
e
ening situation; resuscitation must follow the rules of ad-
term glucocorticoid use, pelvic irradiation for malignancy,
or bone graft harvest at the posterior ilium for lumbar spine
e /e
://t . m
vanced trauma life support similar to younger adults [3]. In surgery (Fig 3.7-1) [6].
: / / t . m
t t p s
this chapter, we discuss the characteristics, diagnostic, and
tps
ht
therapeutic measures pertaining to fragility fractures of the
h
pelvis. In this chapter, “fragility fractures of the pelvis” is
abbreviated as FFP; note that this abbreviation is used for
“fragility fracture patient” in other chapters.
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
339
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.7 Pelvic ring
k e rs ke rs
e b oo e b oo b o o
e /
t . m e
Fragility fractures of the pelvic ring occur in osteoporotic
/ The leading symptom in patients who have suffered an FFP
t . m e/e
s: / / / /
ps:
bone. With increasing age, bone mass is decreasing con- is pain in the pelvic region. Sitting and standing are difficult
http htt
tinuously. Wagner et al [7] demonstrated that this decrease or impossible, while lying quietly in bed minimizes the pain
is following a specific and consistent pattern in the sacrum. level. Most patients are unable to walk. A minority are still
The sacral body is far less affected than the sacral ala. In able to walk short distances with walking aids. Pain typi-
advanced cases, areas of very low bone mineral density cally starts immediately after the fall and has an acute and
without any bone, called an alar void, can be seen in the sharp character. In some patients, history of pain is longer
e rs
region lateral of the S1 and S2 neuroforamina (Fig 3.7-2).
er s
and related to previous events, which have been unrecog-
nized, undiagnosed, or inadequately treated (Case 1: Fig 3.7-3).
b o ok bo ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
/ e/ e/e
a b c d
e . m
Fig 3.7-1a–d A 75-year-old woman with a history of spondylodesis. Cancellous bone grafts were taken from the left posterior ilium.
t t . m
/ / / /
a Transverse computed tomographic (CT) cut through the posterior pelvic ring showing the bone defect at the left posterior ilium (arrow).
ps: ps:
b Coronal CT cut showing the large cortical defect and a fracture line through the ilium (arrows).
htt htt
c Transverse CT cut through the anterior pelvic ring showing a right superior pubic ramus fracture.
d Transverse magnetic resonance imaging picture showing the bone defect at the left posterior ilium (arrow) and bone bruise in the
whole sacrum.
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
a
h b c
htd
Fig 3.7-2a–d Averaged morphology of the nontraumatized sacrum of 92 Europeans, derived from their pelvic computed tomographic data.
a Group of Europeans with bone mineral density above 100 Hounsfield Units (HUs) measured in the center of the L5 vertebral body.
k e rs neuroforamen S1.
ke rs
There are only small areas with bone mineral density below 0 HUs. They are colored in yellow and situated just lateral and below the
eb oo b oo
b Group of Europeans with bone mineral density below 100 HUs measured in the center of the L5 vertebral body. There are large areas
with bone mineral density below 0 HUs. They are colored in yellow and are situated in the left and right sacral ala and extend from S1–3.
e b o o
e /
t . m e /
There are smaller areas of low bone mineral density in the sacral bodies S2 and S3 (Courtesy of Wagner et al [7] ).
t .m
c Computed tomographic cut through the posterior pelvis of an 89-year-old woman. Large areas without trabecular bone are visible in the
e/e
/
left and right sacral ala (arrows). They are called “alar voids”.
/ //
ps: ps:
d A 3-D reconstruction of the pelvic ring of the same person as in c. The alar voids in the sacral ala are clearly visible.
340
htt htt
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Patient
. m e /
. m e/e
CASE 1
/ / t
A 75-year-old woman sustained a right anterior pelvic ring fracture
/ / t
patient had intractable pain which increased over time. Two months

after slipping from a chair, 4 weeks before admission.
htt ps:
later, bilateral sacral ala fractures and another anterior pelvic ring
fracture on the left side were diagnosed on a pelvic computed to-
mographic scan (Fig 3.7-3b–d). She was seen in multiple clinical
• No relevant comorbidities departments, was bedridden because of pain, and developed pres-
sure ulcers on both heels. She also developed recurrent urinary
Treatment and outcome tract infection and weight loss. Fixation with two iliosacral screws in
e rs
The primary x-ray revealed a right superior and inferior pubic rami
r s
S1 helped lessen the pain, and mobilization with weight bearing as
e
b o ok fracture (Fig 3.7-3a). Initially, treatment was nonoperative. But the
bo ok
tolerated was started (Fig 3.7-3e). Two months later, the fractures
seemed to have healed. The patient was very satisfied, completely
b o o
e/ e e/ e pain free, and walked without crutches (Fig 3.7-3 f).
e/e
: // t .m : / / t .m
ht tps ht tps
a
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
b
htt ps: c d
htt ps:
Fig 3.7-3a–f A 75-year-old woman with a fracture of the right
anterior pelvic ring.
a X-ray showing the right anterior pelvic ring fracture.
e rs e r s
b–d Transverse and coronal computed tomographic (CT) cuts
ok ok
through the posterior pelvis and a coronal CT cut through
b o b o the anterior pelvis.

e AP pelvic x-ray after surgical stabilization.
b o o
e/ e e f
e / e f AP pelvic x-ray 2 months postoperative showing healed
e /e
://t . m fractures.
: / / t . m
t t p s tps
3 Diagnostics h ht
• Manual compression on both iliac wings enhances pain
intensity dramatically without demonstrating major in-
3.1 Physical examination stability. Direct palpation of the pubic symphysis, the
Pain is localized at the pubic symphysis, the groin, and/or groin, and the sacrum will additionally provoke pain.
k e rs
in the posterior pelvis or the low back. In the latter cases,
e rs
• Inspection of the skin and soft tissues around the pelvic
k
oo oo o
the physician may be confused and focus on diagnostic ex- ring, including the low back and the perineal region, is
eb aminations of the lumbar spine:

e b necessary to rule out local infections or decubitus ulcers.
b o
e /
t . m e / • Neurological and vascular status of the lower extremities
should be evaluated.
t .m e/e
/ / //
htt ps: htt ps:
341
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/ / t . m // t . m
htt ps: htt ps:
3.7 Pelvic ring
k e rs ke rs
e b oo e b oo b o o
e / 3.2 Creeping hemorrhage
t . m e / Especially in patients taking anticoagulants, there must be
t . m e/e
s: / / / /
ps:
Hemodynamic instability due to continuing bleeding after a high index of suspicion for continuing bleeding. Arterio-
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low-energy pelvic trauma is not typical, but has been de- sclerosis impairs the ability of vasospasm with less chance
scribed [8, 9]. There is an eightfold increase in odds of pelvic of spontaneous cessation of arterial bleeding.
hemorrhage in patients older than 55 years (Case 2: Fig 3.7-4).
e rs Patient
er s
ok ok
CASE 2
b o An 81-year-old woman suffered a left superior and inferior pubic

rami fracture after a fall at home.
bo An x-ray of the pelvis showed a slightly displaced superior and infe-
rior pubic ramus fracture (Fig 3.7-4a). Transverse computed tomo-
b o o
e / e e/ e graphic cuts through the anterior pelvic ring were performed showing
e/e
Comorbidities
: // t .m : / / .m
the left-sided superior pubic ramus fracture and a large hematoma
t
inside the small pelvis, which stayed in direct connection with the
• Cardiac insufficiency
Treatment and outcome ht tps ht tps

fracture (Fig 3.7-4b–c). The patient was taken to the angiography ward
where an active bleeding of the pubic branch of the left inferior
epigastric artery was discovered (Fig 3.7-4d). A selective embolization
Nonoperative treatment with pain medication was started. The he- and coiling was performed (Fig 3.7-4e). The hemodynamic situation
modynamic situation of the patient deteriorated within the first few of the patient improved. She was taken to the operating room 4 days
hours after admission. A swelling above the pubic symphysis was later for operative removal of the hematoma. The patient recovered
e r s noticed.
e r s
well and was discharged 18 days after admission (Courtesy of Dietz
ook ok o
et al [9]).
e b e b o b o
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
a
k e rs b
k e r s c
b o o b o o b o o
e/e t . me / e
t . m e /e
s : / / : / /
h t t p ht tps
d e
rs rs
Fig 3.7-4a–e An 81-year-old woman with a left superior and inferior pubic rami fracture.
k e ke
a AP x-ray of the pelvis showing a slightly displaced superior and inferior pubic ramus fracture (white arrows).
b–c Transverse computed tomographic cuts through the anterior pelvic ring showing the left-sided superior pubic ramus fracture and a large
eb oo e b oo
hematoma inside the small pelvis, which stays in direct connection with the fracture (white arrow).
b o o
e/e
d Angiographic image showing where an active bleeding of the pubic branch of the left inferior epigastric artery was discovered
e / (the white arrow shows the contrast flush).
m e / m
/ / .
e Intraoperative x-ray of the left symphyseal region after coiling.
t // t .
htt ps: htt ps:
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / It is recommended to monitor the hemodynamic condition
t . m e / Inlet and outlet views
t . m e/e
s: / / / /
ps:
of these patients for at least 24 hours. A flowchart for early There is controversy whether inlet and outlet views should
http htt
clinical and radiological monitoring of patients with FFP is be taken in this patient cohort. Some authors recommend
presented in Fig 3.7-5 [9]. In case of bleeding, arterial angi- taking them as a reference for a later follow-up. Others rely
ography with selective embolization represents a highly on computed tomographic (CT) scans in case of any fracture
effective treatment of choice. Patients are at risk of exsan- visible on the AP pelvic x-ray. Computed tomographic scans
guinating with delayed diagnosis and undertreatment. may also be added to AP x-rays during follow-up.
e rs
3.3 Imaging
er s
The inlet view gives a good idea of the amount and direction
b o ok 3.3.1 Plain x-rays

AP pelvic x-ray
bo ok
of rotation of the innominate bone. Integrity of the inner
curve of the innominate bone and the anterior cortex of the
b o o
e/ e Fractures of the superior and inferior pubic rami or the
e/ e sacrum can best be analyzed in the inlet view (Fig 3.7-6b).
e/e
: // t .m
pubic bone near the symphysis are easily recognized. In case
of a lateral impact, the fracture line at the superior pubic
: / / .m
The outlet view gives the best information about the poste-
t
rior pelvis, the shape and symmetry of the sacrum, the neu-
ht tps
ramus runs horizontally and there is a slight overriding of
the fracture fragments, the lateral fracture fragment being
displaced medially (Fig 3.7-6a). ht tps
roforamina and the sacroiliac joints (Fig 3.7-6c). We recommend
taking these three views as a reference for later follow-ups.
e r s e r s
e b ook Patient > 65 years
Fracture of superior pubic ramus
e b o ok b o o
e /
t . m e/ t . m e/e
/ / / /
ps: ps:
Anticoagulant/antiplatelet
htt htt
therapy
Yes No
Monitoring ward (24 hours) Ward
e rs e r s
ok ok
Clinical examination
b o
every 2 hours
b o b o o
e/ e Distend/tender abdomen
Suprapubic swelling
e / e e /e
No Yes
Bruising around groin
://t . m No
: / / t . m
t t p s tps
h
Computed tomographic
angiography
Ward (after 24 hours) ht
k e rs Arterial bleeding?
ke rs
eb oo e b oo b o o
e/e
Yes
e / m e / m
Angiographic embolization
/ /t . // t .
Fig 3.7-5 Flowchart for clinical and radiological monitoring of patients
s: ps:
with fragility fractures of the pelvic ring (Courtesy of Dietz et al [9] ).
http htt 343
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.7 Pelvic ring
k e rs ke rs
e b oo e b oo b o o
e /
t . m
The large, often obese soft-tissue envelope, bowel content, e /
t .
Posterior pelvic ring pathology may be missed with inadequate
m e/e
s: / / / /
ps:
and bowel gas overlie bony structures and joints. Moreover, treatment as consequence [10]. Additional pelvic fractures may
http htt
due to rarefaction of cortical and cancellous bone, fissures and occur and enhance complexity and instability (Fig. 3.7-7).
nondisplaced fractures may not be recognized on plain x-rays.
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
a
ht tps b c
ht tps
Fig 3.7-6a–c A 76-year-old woman sustained a fracture of the right superior pubic ramus after a fall at home.
a AP pelvic x-ray showing the visible horizontal fracture of the right superior pubic ramus.
b Pelvic inlet view showing a slight internal rotation of the right hemipelvis.
e r s e r s
c Pelvic outlet view showing a symmetrical posterior pelvis. Fractures, displacement, or dislocations are not visible.
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
a b c
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
d h e ht
Fig 3.7-7a–e A 57-year-old woman with a bilateral pubic rami fracture after a fall at home.
a AP x-ray showing a bilateral, nearly nondisplaced superior and inferior pubic rami fracture (white arrows). The fractures were treated
nonoperatively.
k e rs ke rs
b AP pelvic x-ray taken 2 weeks later showing more displacement of the pubic rami fractures on both sides (white arrows).
c AP pelvic x-ray after 3 months showing complete displacement of all fractures. There is also a horizontal fissure in the right ilium starting
eb oo from the sacroiliac joint (white arrow).
b oo
d A computed tomographic scan of the pelvis was only taken 5 months after the fall. The 3-D reconstruction with view from the front showing
e b o o
e /
t . m
e A 3-D reconstruction with view from the back.
e /
a complete iliac fracture with displacement and further displacement of the anterior butterfly fragment.
t .m e/e
/ / //
ps: ps:
(Images courtesy of Dr Guy Putzeys, AZ Groeninghe, Kortrijk, Belgium.)
344
htt htt
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 3.3.2 Computed tomographic scan
t . m e /
t . m
In some patients, signs of an older injury may be visible. e/e
s: / / / /
ps:
A pelvic CT scan is recommended when a lesion of any kind Bone resorption at a fracture site is a sign of chronic insta-
http htt
of the pelvic ring has been diagnosed on plain x-rays. In a bility, and callus formation is a sign of bone healing. Chron-
cohort of 245 patients with FFP, more than 80% had a ic instabilities at or around a joint may end in bone resorp-
posterior pelvic ring fracture. When only a plain x-ray is tion, joint widening, inclusion of nitrogen bubbles, and free
obtained on admission, there is a high risk of missing pos- intraarticular or periarticular bone fragments (Fig 3.7-9,
terior pelvic ring fractures [11]. Fig 3.7-10, Fig 3.7-11).
e rs
In coronal reconstructions, a fracture of the lateral mass of
er s
b o ok the sacrum is sometimes better seen than in transverse sec-
bo
tions. A horizontal sacral fracture with more or less severe ok b o o
e/ e e/ e
angulation can only be recognized in sagittal reconstructions
e/e
(Fig 3.7-8).
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e /
t . m e/ . m
Fig 3.7-8a–d An 80-year-old woman with a frac-
t e/e
: / / / /
ps:
ture of the right superior and inferior pubic ramus
t p s after a fall.
t htt
a AP x-ray of the pelvis showing a superior
a
h b (white arrow) and inferior pubic ramus frac-
ture on the right.
b Transverse computed tomographic (CT)
cut through the posterior pelvis showing a
bilateral fracture through the sacral ala (white
e rs e r s arrows).
ok ok
c Coronal CT cut through the sacrum showing
b o b o
bilateral complete and displaced sacral alar
fractures (white arrows).
b o o
e/ e e / e d Sagittal CT cut through the midsacrum show-
ing a horizontal fracture component between
e /e
c
://td. m t . m
S1 and S2 with slight displacement in flexion
(white arrow).
: / /
t t p s tps
h ht
Fig 3.7-9a–b A 74-year-old woman with rheuma-
toid arthritis.
a AP pelvic x-ray showing bone resorption and
rs rs
widening of the pubic symphysis (white ar-
k e ke row) due to chronic instability.

b Coronal computed tomographic cut through
eb oo e b oo the sacrum showing a complete fracture of
b o o
e/e
the right sacral ala, bone resorption, callus
e / m e / formation, and widening of the right sacroiliac
m
/ /t . // .
joint (white arrows). On the contralateral side,
t
there is nitrogen inside the joint as a sign of
ps: ps:
a b
instability (white arrow).
htt htt 345
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.7 Pelvic ring
k e rs ke rs
e b oo e b oo b o o
e / 3.3.3 Magnetic resonance imaging
t . m e / 4 Classification
t . m e/e
s: / / / /
ps:
This is the most sensitive examination and can detect bone
http htt
bruise within the sacrum, fissures, and fractures before they The Tile [13], AO/OTA Fracture and Dislocation [14], and
become visible using other modalities (Fig 3.7-12). Magnetic Young-Burgess [15] classifications have been developed to
resonance imaging (MRI) may be indicated where conven- distinguish different types of high-energy pelvic ring lesions.
tional diagnostic measures cannot explain the clinical picture The Tile [13] and AO/OTA [14] classifications distinguish ro-
or the persistent complaints of pain. If pathology is detect- tationally unstable from rotationally and vertically unstable
e s
ed with MRI, it rarely has consequences in terms of an op-
r
erative treatment. Differentiation between bone marrow
er s
injuries after AP, lateral, or vertical impacts. According to
the direction of traumatic force, the Young-Burgess classi-
b o ok edema and malignancy is also possible with MRI [12]. With

MRI, studies demonstrate up to 95% involvement of the
bo ok
fication [15] differentiates AP displacement, lateral compres-
sion, vertical shear, and combined pelvic ring injuries. The
b o o
e/ e posterior ring.
e/ e Denis classification divides the sacrum into three zones.
e/e
: // t .m Denis I refers to the sacral ala, Denis II to the zone around
: /
the neurforamina and Denis III to the sacral body, medial
/ t .m
ht tps to the neuroforamina [16].
ht tps
e r s e r s
e/e
Fig 3.7-10a–b A 75-year-old woman with a history
e / m e/ of pelvic pain.
m
/ / t . / / .
a AP x-ray of the patient’s pelvis. There is an
t
intrusion of the sacrum into the small pelvis
ps: ps:
(white arrows).
htt htt
b Transverse computed tomographic cut
through the sacrum showing bilateral bone
resorption, joint widening, and intraarticular
a b nitrogen (white arrows).
Fig 3.7-11a–b A 73-year-old woman with a history
e rs e r s of chronic pain after a fall.
ok ok
a AP x-ray of the pelvis showing bilateral pubic
b o b o rami fractures with callus formation and
b o o
e/ e e / e bilateral widening of the sacroiliac joints with
nitrogen bubbles inside (white arrows).
e /e
://t . m b Transverse computed tomographic cut through
/ / t .
the posterior pelvis revealing a left-sided ilium
: m
t t p s tps
fracture with bridging callus, bilateral sacral alar
ht
fractures, and confirming the nitrogen inside
a
h b the irregular sacroiliac joints (white arrows).
kers rs Fig 3.7-12a–b A 72-year-old man with bone bruise
o ke of the sacral ala.
b o b oo a AP pelvic x-ray of the patient with chronic

pelvic pain after a long walk, showing no
b o o
e /e t . m e /e fractures, dislocations, or irregularities.
t .m
b Magnetic resonance imaging depicting right-
e/e
/ / /
sided bone bruise of the sacral ala without
/
ps: ps:
a b fracture.
346
htt htt
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
High-energy pelvic trauma is complicated by additional in- 4.1 Fragility fracture of the pelvis type I
t . m e/e
s: / / / /
ps:
juries of neurological and vascular structures, hollow organs, Fragility fractures of the pelvis type I are anterior pelvic ring
http htt
and the skin, with additional impacts on prognosis and out- fractures without involvement of the posterior pelvic ring.
comes. These are the lesions with the lowest degree of instability.
Type Ia are unilateral (Fig 3.7-13) and type Ib are bilateral
In contrast, low-energy FFPs have completely different anterior lesions (Fig 3.7-14). The latter is much less frequent.
trauma mechanisms. Concomitant injuries of the soft tissues Type I comprised 17.5% of all FFP in the authors’ case series.
e s
are rare. It is not the direction of the traumatic impact but
r
the areas of very low bone density that are responsible for
er s
Conversely, more than 80% of patients had a posterior pel-
vic ring injury. These findings support the use of CT evalu-
b o ok the fracture morphology [17]. Instability of FFP may increase

over time, when the original lesion has been overlooked or
bo ok
ation for all low-energy pelvic ring fractures with anterior
pelvic ring fractures, as there is a high risk of a concomitant
b o o
e/ e e/ e
undertreated (Fig 3.7-7). This is unique to FFP. The above- posterior ring fracture that is often missed on conventional
e/e
: // t .m
mentioned characteristics of FFP led to the development of
a new, specific, and comprehensive classification system.
x-rays.
: / / t .m
tps
The classification of FFP is based on an analysis of both
ht
conventional x-rays and CT data of 245 patients, 65 years
or older with FFPs [18]. ht tps
Fragility fracture of the pelvis type I should be treated non-
operatively. The authors hospitalize the patient and perform
hemodynamic monitoring for the first 24 hours (see topic
4.2 in this chapter). When mobilization is not possible or
The most important criterion is the degree of instability. delayed due to significant pain, pelvic stability should be
Instability is defined as the inability of a structure to with- reevaluated. If additional fractures are detected or primar-
e r s
stand physiological loads without displacement. Also in
e r s
ily nondisplaced fractures displaced, operative management
ook ok o
older adults, this criterion is crucial for identifying an indi- may be considered. External fixation can be regarded as a
e b b
cation for surgery. Fracture displacement is the leading hint
e o minimally invasive stabilization of anterior pelvic ring le-
b o
e / crush zone or a fracture without deformation. Displaced
t . e/
of instability. Nondisplaced lesions are characterized by a
m
sions. But there is little data on morbidity and outcome of
t . m
pelvic external fixation in older adults. We assume that e/e
/ /
lesions are characterized by a crush or a fracture with de-
/ /
patients requiring anterior stabilization have posterior pel-
ps:
formation of the anatomical landmarks. The second crite-
htt
rion is the localization of the fracture in the posterior pelvis.
The localization of the instability determines type and in- htt ps:
vic ring instability as well. Secondary fractures of the pos-
terior ring may be induced over time in the stiff, older pel-
vis after initial anterior disruption (Fig 3.7-7).
vasiveness of the surgical treatment.
Four different categories with slight, moderate, high, and
e rs
highest instability were identified, namely types I–IV. The
e r s
b o ok subtypes were characterized by a, b, or c. The main goals of
b o
treatment are restoration of prefracture stability and mobil- ok b o o
e/ e / e
ity. Due to instability, FFP generates intense pain and im-
e
mobilization. Immobilization leads to rapid deterioration of
e /e
://t . m
the physical condition of the patient with higher morbidity
: / / t . m
t t p s
and mortality due to secondary complications. The decision
tps
ht
for an operation is needed, and the decision on which type
h
of osteosynthesis should be performed is based on the sever-
ity of instability of the pelvic ring. It is therefore of utmost
importance to thoroughly analyze the characteristics of the
fractures and classify them within the new classification
k e rs
system, as this will ultimately form the basis for decision
making.
ke rs
eb oo e b oo b o o
e/e
In the following topics, the different types and subtypes of
e / FFP are presented and a recommendation for treatment is

m e / m
t .
given for all types. The operative techniques to be used are
/ / // t .
ps: ps:
described in topic 7 of this chapter.
htt htt 347
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.7 Pelvic ring
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
ok ok
a b c
b o bo
Fig 3.7-13a–c Type Ia—unilateral isolated anterior pelvic ring fracture.
b o o
e / e a Illustration of a type Ia fracture.
b Conventional AP pelvic x-ray.
e/ e e/e
c Transverse computed tomographic cut.
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e/e
a b c
e / e/
Fig 3.7-14a–c Type Ib—bilateral isolated anterior pelvic ring fracture.
m m
a Illustration of a type Ib fracture.
/ / t . / /t .
ps: ps:
htt htt
4.2 Fragility fracture of the pelvis type II
Fragility fractures of the pelvis type II are characterized by Fragility fractures of the pelvis type II must be regarded as
e s
nondisplaced posterior pelvic ring fractures. Type II lesions
r
suffer more instability than type I lesions. Type IIa is a non-
e r s
posterior pelvic fractures before completion and displace-
ment. They are more unstable than isolated anterior lesions
b o ok displaced isolated posterior pelvic ring fracture (Fig 3.7-15),
b o
type IIb is a sacral crush with anterior disruption (Fig 3.7-16), ok
but less unstable than displaced posterior lesions. They are
typically associated with anterior instabilities. The trauma-
b o o
e/ e e / e
and type IIc is a nondisplaced sacral, sacroiliac, or iliac frac- tizing vector of FFP type IIb and FFP type IIc comes from a
e /e
://t . m
ture with anterior disruption (Fig 3.7-17). Type II fractures
account for more than half of FFP [18]. Sacral fractures or position with a lateral compression injury.
: / / t .
lateral direction, reflecting a sideways fall from a standing
m
t p s
crush zones of the sacral ala are much more frequent than
t tps
h
sacroiliac dislocations or fractures of the posterior ilium.
Fractures through the sacrum have unique and consistent
fracture patterns [17]. The reason for this is the decrease in
ht
Nonoperative treatment with weight bearing as tolerated
is initiated if patients are able to be mobilized within a few
days. As the pelvic ring is broken posteriorly and anteri-
bone mass in the sacral ala, lateral to the neuroforamina in orly, we expect more pain and a longer rehabilitation time
older patients. This has been demonstrated in a statistical compared to FFP type I. It is important to listen to the
k e rs
model of the sacrum by Wagner et al [7, 19] based on CT data
e rs
complaints of the patient. If, after a maximum of 1 week,
k
oo oo o
of 92 older Caucasians. the pain is subsiding and the patient is able to mobilize
eb e b independently, nonoperative therapy is continued. Follow-

b o
e /
t . m e / up x-rays after mobilization, and at 3, 6, and 12 weeks are
recommended. Secondary fracture displacement with a
t .m e/e
/ / higher degree of instability and transformation into a
//
htt ps: htt ps:
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m
higher FFP type must be ruled out. Displacement of frac- e /
t
Complaints are another reason for changing therapy. When
. m e/e
s: / / / /
ps:
tures of the posterior pelvic ring leads to a higher degree there is intense pain and patient transfer out of bed is
http htt
of instability and to classification in a higher FFP category. impossible, operative fixation is recommended (Case 3:
Nonoperative therapy must then be switched to operative Fig 3.7-18). If the fracture fragments of the posterior pelvic
therapy. ring are not displaced, percutaneous stabilization techniques
such as iliosacral screw fixation seem most useful.
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
a b c
e r s
Fig 3.7-15a–c Type IIa—nondisplaced isolated posterior pelvic ring injury.
a Illustration of a type IIa fracture.
e r s
ook ok
b
c Coronal computed tomographic cut.
b o b o o
e / e e/ e e/e
/ / t . m / /t . m
htt ps: htt ps:
k
a
e rs b
e r
c
s
b o o Fig 3.7-16a–c Type IIb—sacral crush with anterior pelvic ring fracture.
a Illustration of a type IIb fracture.
b o ok b o o
e/e e e
me / m e /
://t . : / / t .
t t p s tps
h ht
k e rs ke rs
eb oo a b
e b oo c
b o o
/ / e/e
Fig 3.7-17a–c Type IIc—nondisplaced sacral fracture, nondisplaced iliosacral or iliac fracture with anterior pelvic ring fracture.
e a Illustration of a type IIc fracture.

t . m e t .m
/ / //
ps: ps:
htt htt 349
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.7 Pelvic ring
k e rs ke rs
e b oo e b oo b o o
e / Patient
. m e /
. m e/e
CASE 3
/ / t
An 85-year-old woman had a fall at home and sustained a fragility
/ / t
A coronal computed tomographic (CT) cut through the sacrum was

fracture of the pelvic ring type IIc.
htt ps:
performed and showed a complete fracture of the left sacral ala
(white arrows in Fig 3.7-18d). The transverse CT cut through the
anterior pelvic ring showed the left-sided pubic fracture (Fig 3.7-18e).
• Hypothyreosis After a 3-week nonoperative treatment, operative fixation was per-
• Arterial hypertension formed. The sacral alar fracture was fixed with two iliosacral screws,
the pubic ramus fracture with a retrograde transpubic screw. The
e rs Treatment and outcome

r s
AP x-ray of the pelvic ring after 2 years showed complete healing
e
b o ok The AP x-ray of the pelvis showed a left-sided pubic ramus fracture.
Due to intense pain, mobilization was not possible for 3 weeks
bo ok
of the anterior and posterior pelvic ring (Fig 3.7-18f). Another pelvic
inlet and outlet view were obtained (Fig 3.7-18g–h).
b o o
e/ e e/ e
(Fig 3.7-18a). Inlet and outlet views were obtained (Fig 3.7-18b–c).
e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
ook ok
a b c
b b o b o o
e / e e/ e e/e
/ / t . m / /t . m
htt ps: htt ps:
d e
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
f
h g h
ht
Fig 3.7-18a–h Example for change in treatment—an 85-year-old woman with fragility fracture of the pelvis type IIc.
a AP pelvic x-ray of a left-sided pubic ramus fracture.
k e rs b Pelvic inlet view.

c Pelvic outlet view.
ke rs
eb oo b oo
d Coronal computed tomographic (CT) cut through the sacrum showing a complete fracture of the left sacral ala.
e Transverse CT cut through the anterior pelvic ring showing the left-sided pubic fracture.
e b o o
e /
t . m e /
f The AP x-ray of the pelvic ring after 2 years showing complete healing of the anterior and posterior pelvic ring. This AP x-ray is showing
t .m
that the sacral alar fracture is fixed with two iliosacral screws and the pubic ramus fracture with a retrograde transpubic screw.
e/e
g Pelvic inlet view.
/ / //
ps: ps:
h Pelvic outlet view.
350
htt htt
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 4.3
t . m
Fragility fracture of the pelvis type III e /
t . m e/e
/ / / /
ps: ps:
Fragility fractures of the pelvis type III are characterized by Fragility fracture of the pelvis type IIIa involves a displaced
htt htt
a displaced unilateral posterior injury combined with an unilateral ilium fracture (Fig 3.7-19).
anterior pelvic ring lesion. Displaced unilateral posterior le-
sions represent the smallest subtype in the group of 245 FFP, Fragility fracture of the pelvis type IIIb is a displaced uni-
occurring in 11% [18]. They have a higher instability than lateral sacroiliac fracture dislocation (Fig 3.7-20).
type II lesions. Displacement must be assessed on both CT
k e rs transections and conventional x-rays. Major displacement

in the anterior pelvic ring must always be combined with
er s
Fragility fracture of the pelvis type IIIc is a displaced unilat-
eral sacral fracture (Fig 3.7-21).
o o some displacement in the posterior pelvic ring. Also, larger

o ok o o
e/eb b b
fracture gaps and changes of anatomical landmarks are signs
of displacement.
e/ e e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e b ook a b
e b o ok c
b o o
/ e/ e/e
Fig 3.7-19a–c Type IIIa—a displaced unilateral iliac fracture with anterior pelvic ring fracture.
e a Illustration of a type IIIa fracture.

t . m t . m
/ / / /
ps: ps:
htt htt
e rs e r s
o ok ok o
/ebo o
a b c
e/ e b Fig 3.7-20a–c Type IIIb—a displaced unilateral sacroiliac fracture-dislocation with anterior pelvic ring fracture.
a Illustration of a type IIIb fracture.
e e /e b
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo a b
e b oo c
b o o
e / a Illustration of a type IIIc fracture.
t . m e /
Fig 3.7-21a–c Type IIIc—a displaced unilateral sacral fracture with anterior pelvic ring fracture.
t .m e/e
/ / //
ps: ps:
htt htt 351
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.7 Pelvic ring
k e rs ke rs
e b oo e b oo b o o
e /
t . m
It cannot be expected that these lesions will heal spontane- e /
t . m
ity. With limited displacement of the sacrum, sacroiliac joint, e/e
s: / / / /
ps:
ously. Due to severe pain, the patients are bedridden and or posterior ilium, percutaneous stabilization is possible
http htt
mobilization is impossible. Operative treatment is therefore (Case 4: Fig 3.7-22). In case of gross displacement or a fracture
recommended as an urgent procedure. The type of internal through the ilium, an open reduction and internal fixation
fixation depends on the localization of the posterior instabil- (ORIF) is required (Case 5: Fig 3.7-23).
e rs Patient
er s
ok ok
CASE 4
b o An 85-year-old woman sustained a fragility fracture of the pelvic

ring type IIIb lesion after a fall at home.
bo were obtained (Fig 3.7-22b–c). A transverse computed tomographic
(CT) cut through the sacrum showed a fracture-dislocation of the left
b o o
e / e e/ e sacroiliac joint (white arrows in Fig 3.7-22d) while a transverse CT cut
e/e
Comorbidities
• Hypercholesterolemia
: // t .m : / / .m
through the anterior pelvic ring revealed the left-sided pubic fracture
t
(Fig 3.7-22e). The fracture-dislocation of the sacroiliac joint was fixed
• Arterial hypertension
Treatment and outcome ht tps ht tps

with two iliosacral screws and the pubic ramus fracture with a retro-
grade transpubic screw. The AP x-ray of the pelvic ring after 3 years
showed complete healing of the anterior and posterior pelvic ring
The AP x-ray of the pelvis showed a left-sided displaced superior and (Fig 3.7-22f). Another inlet and another outlet view of the pelvis were
inferior pubic ramus fracture (Fig 3.7-22a). Pelvic inlet and outlet views obtained (Fig 3.7-22g–h).
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
a
htt ps: b c
htt ps:
e rs e r s
b o ok d
b
e
o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
f g h
Fig 3.7-22a–h Example of a displaced type III fracture in the posterior ilium.
k e rs b Pelvic inlet view.

ke rs
a AP pelvic x-ray of a left-sided displaced superior and inferior pubic ramus fracture.
eb oo c Pelvic outlet view.
e b oo b o o
e/e
d Transverse computed tomographic (CT) cut through the sacrum showing a fracture dislocation of the left sacroiliac joint (white arrows).
e / e /
e Transverse CT cut through the anterior pelvic ring showing the left-sided pubic fracture.
m
f AP x-ray of the pelvic ring after 3 years showing complete healing of the anterior and posterior pelvic ring.
m
g Pelvic inlet view.
/ /t . // t .
ps: ps:
h Pelvic outlet view.
352
htt htt
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Patient
. m e /
. m e/e
CASE 5
/ / t
An 84-year-old woman fell in a nursing home.
/ / t
The transverse computed tomographic (CT) cut through the pos-
Comorbidities
htt
• Type 2 diabetes mellitus
ps: htt ps:
terior pelvic ring showed the fracture starting near the sacroiliac joint
and the transverse CT cut through the ilium revealed the displace-
ment in the fracture site, corresponding to a fragility fracture of the
• Renal insufficiency pelvis type IIIa (Fig 3.7-23b–c). It was operatively stabilized with an
• Macular degeneration angular stable plate for the iliac fracture and a lag screw along the
iliac crest (Fig 3.7-23d). Inlet and outlet views of the pelvis were
e rs
r s
obtained (Fig 3.7-23e–f).
e
b o ok The AP x-ray of the pelvis showed a left-sided fracture through the
bo
ilium running from the inner curve to the iliac crest (white arrows) ok b o o
e/ e e/ e
and through the left superior and inferior pubic rami (Fig 3.7-23a).
e/e
: // t .m : / / t .m
ht tps ht tps
kea
r s b
k e r s c
b o o b o o b o o
e /e t . m e/e t . m e/e
/ / / /
htt ps: htt ps:
d e f
Fig 3.7-23a–f Example of a displaced type III fracture in the iliac wing.
e s through the left superior and inferior pubic rami.

e r s
a AP x-ray of the pelvis showing a left-sided fracture through the ilium running from the inner curve to the iliac crest (white arrows) and
r
b o ok b o ok
b Transverse computed tomographic (CT) cut through the posterior pelvic ring showing the fracture starting near to the sacroiliac joint.
c Transverse CT cut through the ilium showing the displacement in the fracture site. It concerns a fragility fracture of the pelvis type IIIa.
b o o
e/ e / e
d Operative stabilization with angular stable plate for the ilium fracture and lag screw along the iliac crest.
e Pelvic inlet view.
e e /e
f Pelvic outlet view.
://t . m : / / t . m
t t p s tps
4.4 h
Fragility fracture of the pelvis type IV
Fragility fractures of the pelvis type IV are displaced bilateral
ht
Fragility fracture of the pelvis type IVa has bilateral iliac
posterior injuries. The frequency of H-type sacral fractures fractures or bilateral sacroiliac disruptions (Fig 3.7-24).
(FFP type IVb), which is about 15%, is striking in the case
kers rs
series and was the starting point for the new classification [18]. Fragility fracture of the pelvis type IVb is an H-type sacral
o
This fracture morphology can be regarded as the extension of
ke
fracture, containing a bilateral vertical fracture through the
b o unilateral or bilateral nondisplaced vertical sacral alar fractures,

b oo
sacral ala with a horizontal component connecting them
b o o
e /e e e/e
seen in FFP type II lesions [17]. The horizontal component of (Fig 3.7-25).
e
the fracture is hardly visible on conventional x-rays. Looking
m / m
/ /t .
at the sagittal reconstructions of CT to detect or exclude this
t .
Fragility fracture of the pelvis type IVc is a combination of
//
s:
fracture is therefore strongly recommended (Fig 3.7-8).
ps:
different posterior instabilities (Fig 3.7-26).
http htt 353
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.7 Pelvic ring
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
ok ok
a b c
b o bo
Fig 3.7-24a–c Type IVa—bilateral iliac fractures or bilateral sacroiliac disruptions with anterior pelvic ring fracture.
b o o
e / e a Illustration of a type IVa fracture.
e/ e e/e
c Pelvic inlet view.
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e/e
a b c
e / e/
Fig 3.7.25a–c Type IVb—H-type sacral fracture with anterior pelvic ring fracture.
m m
a Illustration of a type IVb fracture.
/ / t . / /t .
ps: ps:
b Transverse computed tomographic (CT) cut.
c Sagittal computed tomographic cut.
htt htt
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
a b
://t . m c
Fig 3.7-26a–c Type IVc—combination of different posterior instabilities with anterior pelvic ring fracture.
: / / t . m
p s
a Illustration of a type IVc fracture.
t t tps
h
ht
k e rs
Fragility fractures of the pelvis possess the highest degree
ke rs
lumbosacral spine into the pelvis. Iliolumbar fixation can
eb oo of instability when there is dissociation between the lum-
e b oo
be performed on both sides separately; alternatively, a trans-
b o o
e/e
bosacral skeleton and the pelvic ring. Operative fixation verse rod connects the constructs of both sides. When the
e / restores stability and prevents further dislocation of the

m e / lumbopelvic fixation is combined with an iliosacral screw
m
/ /t .
lumbosacral spine. Operative stabilization connects the lum-
t
fixation, the construct is described as triangular fixation
// .
ps: ps:
bar spine to the posterior ilium to prevent intrusion of the (Case 6: Fig 3.7-27).
354
htt htt
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Patient
. m e /
. m e/e
CASE 6
/ / t
A 67-year-old woman with chronic pain in the posterior pelvis. She
/ / t
the fractures in the sacral ala (white arrows in Fig 3.7-27b). The

did not recall any specific trauma.
htt ps:
transverse CT cut through the anterior pelvic ring showed a right-
sided superior pubic ramus fracture (white arrow in Fig 3.7-27c).
• Rheumatoid arthritis A sagittal CT cut through the midsacrum revealed a horizontal sacral
• Spinal canal stenosis fracture between S1 and S2 with intrusion of the lumbosacral seg-
• Hypothyreosis ment into the small pelvis (white arrow in Fig 3.7-27d). There was
e rs
• Cardiac insufficiency
r s
an H-type fracture of the sacrum and a fracture of the anterior
e
b o ok • Vascular dementia
• Glaucoma
bo ok
pelvic ring, which corresponded with a fragility fracture of the pelvis
type IVb.
b o o
e/ e • Cataract
e/ e The patient was treated with bilateral iliolumbar fixation between
e/e
: // t .m / t .m
L4 and the posterior ilium. Additionally, an iliosacral screw was in-
: /
tps tps
A coronal computed tomographic (CT) cut through the sacrum serted in S1 on both sides. The fracture of the anterior pelvic ring
ht ht
displayed bilateral complete fractures of the sacral ala (white arrows was stabilized with a retrograde transpubic screw (Fig 3.7-27e).
in Fig 3.7-27a). Transverse CT cut through the sacrum confirmed Inlet and outlet views of the pelvis were obtained (Fig 3.7-27f–g).
e r s e r s
e /
t . m e/ t . m e/e
a
/ / b
/ /
htt ps: htt ps:
e rs e r s
b o ok c
b od ok e
b o o
e/ e e / e Fig 3.7-27a–g Example of a lumbopelvic fixation—a
e /e
://t . m sacral ala.
: / / t . m
67-year-old woman with bilateral complete fractures of the
t t p s tps
a Coronal computed tomographic (CT) cut through the
ht
sacrum showing bilateral complete fractures of the
h sacral ala (white arrows).

b Transverse CT cut through the sacrum confirming the
fractures in the sacral ala (white arrows).
c Transverse CT cut through the anterior pelvic ring
showing a right-sided superior pubic ramus fracture
kers rs (white arrow).

f g
o ke d A sagittal CT cut through the midsacrum revealing
oo o
a horizontal sacral fracture between S1 and S2 with
b o b intrusion of the lumbosacral segment into the small

b o
e /e /e e/e
pelvis (white arrow).
t . m e e AP x-ray of the pelvis 3 months after surgery.

f Pelvic inlet view.
t .m
/ / //
ps: ps:
g Pelvic outlet view.
htt htt 355
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.7 Pelvic ring
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
In the vast majority, posterior pelvic ring lesions are associ-
t .
• Physiotherapy starts with the patient still in bed. To pre-
m e/e
s: / / / /
ps:
ated with anterior pelvic ring lesions and vice versa. When pare the patient for out-of-bed mobilization, breathing
http htt
treating the posterior pelvic ring operatively, surgeons should therapy and mobilization of the extremities is performed.
also take fixation of the anterior pelvic ring into consider- Once adequate pain control is achieved, the patient will
ation. Sole stabilization of the posterior pelvic ring may not sit up. This is followed by standing and consecutively
restore adequate stability to the whole ring, with a higher trying to take first steps with the assistance of a physio-
risk of implant loosening or secondary fracture displacement therapist and a walking aid such as a rolling walking
e s
due to continuous and repetitive loading during mobiliza-
r
tion. Closing the whole ring gives the best support for a
er s
frame. The order is always written “weight bearing as
tolerated”, as this population is not able to successfully
b o ok quick postoperative pain relief and safe mobilization.
bo ok
observe partial weight bearing.
• Continuous x-ray controls during follow-up evaluate bone
b o o
e/ e e/ e
The anterior pelvic ring can be stabilized with an external healing and rule out further displacement with delayed
e/e
: // t .m
fixator or with different internal devices [20]. Some tech-
niques of application are percutaneous, others less invasive
: / /
are prone to secondary displacement due to pulling mus- .m
healing or nonunion. Especially bilateral anterior lesions
t
tps
and still others open. They use a bridging, positioning, or
ht
compression principle. The decision on which osteosynthe-
sis is the most appropriate depends on fracture type, extent ht tps
cle forces. It is recommended to take conventional pelvic
x-rays at 3, 6, and 12 weeks. Alternatively, a pelvic CT
control confirms bone healing (Case 7: Fig 3.7-28). Some
of displacement, and localization of instability. The different patients develop painful nonunions and need operative
techniques for anterior pelvis fixation, their indications, and fixation.
limitations will be described in topics 5.2.11–5.2.14 of this
e r s
chapter.
e r s
The patient decides how fast mobilization can take place
ook ok o
with regard to pain. It is expected that out-of-bed mobiliza-
e b e b o tion is possible within a few days after trauma. When mo-

b o
t . m e/ bilization is successful, discharge with further pain manage-

ment and physiotherapy can be planned.
t . m e/e
5.1 Nonoperative management
/ / / /
ps:
Successful nonoperative management of pelvic ring fractures
htt
in older patients requires optimal orthogeriatric comanage-
ment. Meticulous monitoring of pain levels and daily inter- htt ps:
In all patients with FFP, being treated nonoperatively or
operatively, the underlying bone disease must be diagnosed
and treated in accordance with established guidelines [21].
professional and interdisciplinary discussion of the treatment The multidisciplinary team should therefore include geri-
progress with appropriate adaptations can limit the func- atricians and specialists in bone metabolism, like endocri-
tional decline. Cornerstones of nonoperative treatment are: nologist and osteologist. Teriparatide can play an important
e rs e r s
role in accelerating bone healing of osteoporotic pelvic frac-
b o ok • Pain management with oral analgesics, typically routine
b o
acetominophen with additional opioid dosing. Often opi- ok
tures [22, 23] (see chapter 1.10 Osteoporosis).
b o o
e/ e / e
oids need to be given routinely for patients to be able to
e
be mobilized. Patients are at high risk for severe constipa-
e /e
://t . m
tion due to pain, immobility, and opioid therapy, and
: / / t . m
t t p s
need to be placed on routine laxatives and monitored for
tps
ht
effect. The pain from constipation can be confused with
h
pain related to the fracture (see chapter 1.12 Pain ma-
nagement).
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Patient
. m e/e
CASE 7
/ / t
A 75-year-old woman who was treated nonoperatively for a fragil-
: / / t
The fracture had healed. A small amount of callus was visible in
ity fracture of the pelvic ring type IIc lesion.
htt ps:
front of the anterior sacral cortex of the left sacral ala (white arrow
in Fig 3.7-28a). A coronal computed tomographic (CT) cut showed
the healed fracture with a small remaining fissure in the posterior
• Degenerative lumbar scoliosis part of the previous fracture line (white arrow in Fig 3.7-28b). A
transverse CT cut through the anterior pelvic ring showed perios-
teal callus bridging over the previous fracture site (white arrow in
e rs er s
Fig 3.7-28c). A transverse CT cut through the inferior pubic ramus
b o ok bo ok
showed bridging callus anteriorly and posteriorly (white arrow). The
patient was able to walk with full weight bearing and without walk-
b o o
e/ e e/ e ing aids (Fig 3.7-28d).
e/e
: // t .m : / / t .m
tps tps
Fig 3.7-28a–d Callus formation after
ht ht
nonoperative treatment of a fragility
fracture of the pelvis.
a Transverse computed tomograph-
ic (CT) cut through the sacrum
showing a healed fracture with a
small amount of callus in front of
e r s e r s the anterior sacral cortex of the

left sacral ala (white arrow).
ook ok
a b
b b o
b Coronal CT cut showing the
healed fracture with a small
b o o
e / e e/ e remaining fissure in the posterior
part of the previous fracture line
e/e
/ / t . m (white arrow).
/ /t . m
ps: ps:
c Transverse CT cut through the an-
terior pelvic ring showing a perios-
htt htt
teal callus bridge over the previous
fracture site (white arrow).
d Transverse CT cut through the
inferior pubic ramus showing
bridging callus anteriorly and
c d posteriorly (white arrow).
e rs e r s
b o ok 5.2 Operative treatment
b o ok
• Minimally invasive, percutaneous procedures are attrac-
b o o
e/ e e / e
Multiple techniques for reduction and fixation of posterior tive because they take less time, involve less blood loss,
e /e
://t . m
and anterior pelvic ring instabilities have been developed
for high-energy pelvic trauma. In adolescents and adults,
and allow for quick recovery.
: / / t .
• Lengthy and aggressive surgery with higher blood loss m
t t p s
ORIF is more often used than closed reduction and percu-
tps
and higher risk of infection, heterotopic ossification, and
h
taneous fixation. In contrast to FFP in older patients, resto-
ration of the anatomy is of utmost importance for regaining
an excellent long-term clinical function.
ht
thromboembolism should be avoided [24].
The type of stabilization depends on the individual anatomy

of the posterior pelvis, especially the morphology of the
The principles of operative treatment in fragility fracture sacrum, as well as the characteristics and localization of
k e rs
patients (see chapter 1.2 Principles of orthogeriatric surgical
e rs
instability (see topic 4 in this chapter).
k
oo oo o
care) apply also to pelvic ring injuries:
eb e b Topics 5.2.2–5.2.10 refer to fixation techniques for the pos-

b o
e /
t . m
storing stability for pain control and mobilization. /
• Precise anatomical reduction is less important than re-
e terior pelvic ring, while topics 5.2.11–5.2.14 refer to the
anterior pelvic ring.
t .m e/e
/ / //
htt ps: htt ps:
357
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.7 Pelvic ring
k e rs ke rs
e b oo e b oo b o o
e / 5.2.1 Timing and planning
t . m e / analyze the CT data thoroughly before surgery to avoid mal-
t . m e/e
s: / / / /
ps:
Patients with FFP are generally hemodynamically stable; position of implants [18, 25]. Especially in dysmorphic sacra,
http htt
there is usually no need for emergency fixation. Timing it is beneficial to use computer navigation for exact screw
depends more on the general condition of the patient and placement [26].
patient’s preference to reserve operative treatment for failed
nonoperative treatment. Preoperative planning must include Positioning
positioning of the patient, the choice of reduction maneuvers When positioning the patient, it is essential that:
e s
and instruments, the sequence of operative procedures, and
r
the type of implants that will be used. Preoperatively, the
er s
• The patient is placed with the injured side on the edge
b o ok bowels should be purged to assure good intraoperative vi-

sualization of bony landmarks with image intensification.
bo ok
of a radiolucent table enabling free orientation of the
drill.
b o o
e/ e e/
This is of special interest for all cases in which a percutane- e • A large skin area starting from the pubic symphysis and
e/e
ous procedure is planned.
: // t .m the umbilicus going posteriorly at the gluteal region is

draped.
: / / t .m
Indication
The indications include:ht tps
5.2.2 Iliosacral screw in supine position
neuvers are not necessary.
ht tps
• The lower extremities are not draped, as reduction ma-
Image intensification
• Sacroiliac dislocations High-quality image intensifier visualization of the injured
• Fracture dislocations (crescent fracture) pelvic side must be assured. Before starting the procedure,
e r s
• Nondisplaced or minimally displaced fractures of the sacral
e r s
a lateral x-ray of the lumbosacral junction is produced. In
ook ok o
ala or through the neuroforamina (Denis zones I and II) this x-ray, the ideal insertion point for iliosacral screw inser-
e b [16]. In the majority of FFPs, the sacral alar fracture is at
e b o tion in the body of S1 is identified. A small skin incision

b o
e / least one component of the injury.
t . m e/ allows penetration of the drill through the gluteal muscles.
t . m
Under image intensifier control, the tip of the drill is placed e/e
/ /
Preoperative computed tomographic evaluation
/ /
at the ideal insertion point on the outer cortex of the pos-
ps:
The pelvic ring is a complex 3-D structure and the morphol-
htt
ogy varies between individuals. The operative anatomy of
the posterior pelvic ring is especially variable. Corridors for htt ps:
terior ilium. With a hammer blow or a short drilling, the
drill tip perforates this outer cortex. The image intensifier
is now turned back for AP x-ray, inlet, and outlet views for
exact implant insertion are sometimes narrow or nonexistent. further drilling and screw insertion (Fig 3.7-29) [27].
For these reasons it is highly recommended that surgeons
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
kers kers
a b c d
Fig 3.7-29a–d Example of optimal placement of screws.
b o o o o
a Intraoperative lateral x-ray of the lumbosacral transition. The ideal entry portal is identified under image intensification with the drill bit
held in a Kocher clamp.
b b o o
e /e center of the S1 corridor.
t . e/e
b The drill bit has been drilled through the outer and inner table of the posterior ilium; its position is below the iliac cortical density in the
m t .m e/e
/
c Intraoperative pelvic inlet view shows the tip of the drill bit in line with the anterior third of the S1 sacral body.
/ //
ps: ps:
d Intraoperative outlet view. The tip of the drill bit is in line with the superior part of the S1 sacral body.
358
htt htt
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Screw fixation
t . m e /
t . m
Although low or no compression is achieved in the fracture e/e
s: / / / /
ps:
Depending on the diameter of the sacral corridor, insertion gap, iliosacral screw insertion in osteoporotic bone increas-
http htt
of one or two screws will be possible. Biomechanical stud- es local stiffness and diminishes pain (Case 8: Fig 3.7-30). But
ies have proven that stability of a sacroiliac fixation is sig- due to low anchorage in trabecular bone, there is a higher
nificantly higher with two screws [28, 29]. Screw purchase risk of secondary screw loosening. Changes in the screw
in FFP is significantly lower in older than in younger patients design may help achieve better anchorage.
due to lower trabecular density. A higher risk of implant
k e rs loosening indicates the need for regular x-ray controls. The

following technical tips are important:
er s
Perforated cannulated screws allow for cement augmenta-
tion. After screw insertion, a few cc of cement with a low
o o o ok
viscosity are applied to the cancellous bone around the tip
o o
e/eb b b
• Iliosacral screws are placed perpendicular to the plane of of the screw. The cement interdigitates with the trabecular
e/ e
instability, ie, the coronal plane for sacral alar fractures. bone and the pull-out force is much higher than without
e/e
: // t .m
• The screws to be used are 7.3 mm or 8 mm cannulated
screws with a long or continuous thread.
: / / .m
cement [30]. The cement must not leak into the fracture site,
t
the alar void, the sacral canal, or the canal of the sacral
tps
• The screws cross the midline and reach the opposite ala.
ht
This ensures that the thread of the screw is situated in
the sacral body, which has the highest trabecular den- ht tps
nerve roots of S1. Therefore, cement application has to be
done carefully, slowly, and under image intensifier control
[31].
sity (Denis zone III) [16]. Screw lengths have to be adapt-
ed accordingly [7, 29]. An alternative procedure is using nonperforated cannu-
• Washers help to avoid screw perforation through the lated iliosacral screws, turning them back for about 1 cm
e r s near cortex.
e r s
after complete insertion, filling up the canal of the screw
ook ok o
• Tightening the screws with a long thread will put some with liquid cement and finally reinserting the screws as
e b b
compression on the fracture site by direct pressure of the
e o before [30]. Recently, a combination of sacroplasty with
b o
e / e/
screw head with washer against the lateral cortex of the
m
posterior ilium. The surgeon feels increasing resistance
t .
cement-augmented iliosacral screw osteosynthesis has been
proposed [32].
t . m e/e
[29].
/ / / /
ps:
• In case a screw with continuous thread is used, it is suf-
htt
ficient to insert the screw until its head with washer
touches the lateral cortex of the posterior ilium. No com- htt ps:
Little is known in the literature about results and complica-
tions of cement augmentation. Although the first results
seem promising, critical analysis is still needed to recommend
pression is obtained; the screw has the function of a po- it as a standard procedure [33].
sitioning screw.
• In case two screws are inserted, their trajectory should
e rs be parallel or slightly converging. The tips of both screws

e r s
b o ok are then located in the body of S1 but behind each other.
b o
The second screw can also be placed in the body of S2, ok b o o
e/ e / e
but the sacral corridor of S2 is smaller than the one in
S1.
e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
359
rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
3.7 Pelvic ring
k e rs ke rs
e b oo e b oo b o o
e / Patient
. m e /
. m e/e
CASE 8
/ / t
An 82-year-old woman sustained a displaced superior pubic ramus
/ / t
A coronal computed tomographic cut through the sacrum showed
fracture after a fall at home.
Comorbidities htt ps: htt ps:

a complete fracture of the right sacral ala (white arrows). The lesion
corresponded with a fragility fracture of the pelvic ring type IIc. Non-
operative treatment was started, but operative therapy was performed
• No known comorbidities 2 weeks later because the patient had intense pain (Fig 3.7-30b).
Treatment and outcome Two iliosacral screws were inserted in S1 to stabilize the sacral alar
e rs The AP x-ray of the pelvis showed a displaced superior pubic ramus

r s
fracture and a retrograde transpubic screw to stabilize the pubic
e
b o ok fracture on the right side (Fig 3.7-30a).
bo ok
ramus fracture (Fig 3.7-30c). The AP x-ray at the 1-year follow-up
showed complete healing of the fracture (Fig 3.7-30d).
b o o
e/ e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
a
ke r s b
e r s
b o o b o ok b o o
e /e t . m e/ e
t . m e/e
/ / / /
htt ps: htt ps:
c d
Fig 3.7-30a–d Example of a percutaneous sacroiliac fixation.
e rs a AP pelvic x-ray of a displaced superior pubic ramus fracture on the right side.
e r s
ok ok
b Coronal computed tomographic cut through the sacrum showing a complete fracture of the right sacral ala (white arrows).
b o o
c Postoperative AP x-ray of the pelvis after insertion of two iliosacral screws in S1 for stabilization of the sacral alar fracture and a retro-
b b o o
e/ e e / e
grade transpubic screw for stabilization of the pubic ramus fracture.
d AP pelvic x-ray 1 year later showing complete healing of the fractures.
e /e
://t . m : / / t . m
t t p s tps
h
5.2.3 Iliosacral screws in prone position
The prone position has several advantages for iliosacral screw
osteosynthesis. The authors recommend using the prone
ht
• The distance from skin to bone becomes shorter, which
enhances precision of screw placement. In obese people,
this is of significant importance.
position whenever iliosacral screw fixation in supine posi- • The technique corresponds with the one described for
tion seems to be complicated or other surgeries have to be the supine position.
k e rs done in prone position. The main advantages of prone po-

ke rs
oo oo o
sition are: 5.2.4 Anterior plate fixation of the posterior ilium
eb e b A minority of patients with FFP have a fracture of the ilium.

b o
e / • Due to gravity, the soft tissues of the buttocks fall down,
t . m
which makes it easier to access the posterior ilium. e / The fracture typically starts at the inner curve of the in-
nominate bone and runs laterally and proximally through
t .m e/e
/ / //
the ilium wing toward the iliac crest (Case 5: Fig 3.7-23) [34].
htt ps: htt ps:

rs
rs 26.07.18 10:29
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / The main steps are:
t . m e /
t .
the fracture. The screws must take the longest trajectory
m e/e
s: / / / /
ps:
through the bone possible. The proximal screws are di-
http htt
• The approach should occur via the first window of the rected parallel to the iliosacral joint and have a length of
ilioinguinal approach and exposes the iliosacral joint me- up to 70 mm, the distal screws are directed toward distal
dially and the iliopectineal eminence distally. and lateral, taking the longest trajectory in the iliac bone
• Debridement, reduction, and compression of the fracture above the acetabular cavity.
gap should be performed with the help of one or several • At the iliac crest, the fracture is stabilized with a long
e rs reduction forceps. More important than precise reduction

is creating sufficient stability.
er s
small fragment lag screw, which runs parallel to the iliac
crest between the inner and outer cortex. Alternatively,
b o ok • Fixation is done with a preshaped and twisted large frag-

ment angular stable plate along the pelvic brim. At least
bo ok
a small fragment bridging plate is placed on top of the
iliac crest (Fig 3.7-31).
b o o
e/ e two angular stable screws should be used at each side of
e/ e e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e b ook a b
e b o ok c
b o o
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
d e f g h
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
i
t t p s j k
tps
ht
Fig 3.7-31a–k Example of plate fixation.
h
a AP x-ray of the pelvis in a 78-year-old man with Alzheimer’s disease and recurrent falls. There is a fracture through the ilium starting at the inner
curve and running through the iliac wing towards the iliac crest (white arrow). There is also a fracture of the left superior and inferior pubic rami.
b Pelvic inlet view shows the fracture at the inner curve (white arrow).
c Pelvic outlet view shows the fracture at the iliac crest (white arrow).
d Transverse computed tomographic (CT) cut through the ilium shows the left-sided fracture.
k e rs
e Coronal CT cut confirming the iliac fracture near the sacroiliac joint.
ke rs
f Intraoperative alar x-ray of the left ilium showing the position of the angular stable plate.
eb oo g Intraoperative obturator x-ray of the left ilium.
b oo
h Intraoperative obturator x-ray of the obturator foramen showing the position of the retrograde transpubic screw.
e b o o
/ / e/e
i Postoperative AP x-ray of the pelvis with angular stable plate bridging the left ilium fracture, lag screw along the iliac crest and retrograde
e transpubic screw.
t . m e t .m
j Postoperative inlet view.
/ / //
ps: ps:
k Postoperative outlet view.
htt htt 361
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
3.7 Pelvic ring
k e rs ke rs
e b oo e b oo b o o
e / 5.2.5 Sacroplasty
t . m e /
t
• Most fractures of the posterior pelvic ring are combined
. m e/e
s: / / / /
ps:
This is a minimally invasive procedure to inject cement into with fractures of the anterior pelvis. Current literature
http htt
the fractured sacrum [35]. Multiple insertion points for the does not describe what happens with anterior instabilities
needle have been described in literature. It can be inserted: after sacroplasty.
• Some FFP fractures may evolve from a category of lower
• Directly behind the fracture zone to a category of higher instability. It is not clear which
• In the distal ala through thin soft tissues operative treatment should be performed in case of con-
e rs
• At the typical location used for iliosacral screw insertion
er s
tralateral or additional ipsilateral sacral fracture after
sacroplasty.
ok ok
[36]
b o According to the literature, pain intensity reduces signifi-

bo • Little is known about the long-term outcome after sacro-
plasty. The question which fracture types of FFP benefit
b o o
e/ e e/
cantly and mobilization can be started quickly. Indicatione the most from sacroplasty remains unsolved. In the au-
e/e
: // t .m
may be based on MRI findings only [37] or CT diagnostics
[31]. Clearly, the risk of leakage is much higher with cortical
thors’ opinions, only a minority of FFP are suitable for
this technique.
: / / t .m
technique are:
ht tps
fractures in place (Fig 3.7-32) [31, 37]. Concerns regarding this
ht tps
• The cement behaves as a foreign body between the frac-
ture fragments and may hinder bone healing.
• The fracture plane of the sacral ala is vertical. Vertical
e r s loading while standing and walking leads to shearing

e r s
ook ok o
forces that interfere with bone healing and may not be
e b neutralized by cement augmentation.

e b o b o
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
b
e rs e r s
b o ok b o ok Fig 3.7-32a–e An 87-year-old woman with a his-
b o o
e/ e e / e tory of pain in the posterior pelvic region without
memorable trauma.
e /e
a
://t . m c
: / / t .
a AP pelvic x-ray showing a right-sided superior
and inferior pubic ramus fracture (white
m
t t p s tps
arrow). Callus formation indicates that the
h ht
fractures are older.
b Coronal computed tomographic (CT) cut
through the sacrum showing a complete frac-
ture of the sacral ala near the sacroiliac joint
(white arrows).
c Transverse CT cut confirming the lateral sacral
k e rs ke rs alar fracture (white arrow).

d Postoperative AP pelvic x-ray after sacro-
eb oo e b oo plasty. Besides cement in the sacral ala, there

is cement in the sacroiliac joint.
b o o
e /
t . m e / e Lateral x-ray of the sacrum. There is cement
t .m
extravasation into several presacral veins and
e/e
/ / /
through the anterior cortex of the sacral ala
/
ps: ps:
d e (white arrows).
362
htt htt
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 5.2.6 Transiliac bars
t . m e / 5.2.7 Transsacral bars
t . m e/e
s: / / / /
ps:
Transiliac bars bridge the area of instability; in connection A threaded bar is inserted through the sacral corridor of S1
http htt
with an anterior stabilization, they act as a tension band [39, 40]. This is only possible if this corridor is available. This
[38]. Advantages of transiliac bars are: fixation stabilizes monolateral or bilateral nondisplaced or
minimally displaced fractures of the sacral ala or sacroiliac
• It is a less invasive technique. joint. The technique is demanding and preoperative plan-
• They offer high stability with compressive forces perpen- ning is of utmost importance. A small part of the Caucasian
e rs dicular to the fracture plane(s).

• Bilateral lesions can be treated with one fixation. A bi-
er s
but a larger part of the Asian population has dysmorphic
sacra, in which the transsacral corridor is too small or non-
b o ok lateral iliosacral screw osteosynthesis with four screws

in the sacral corridor S1 or two screws in S1 and two in
bo ok
existent [7].
b o o
e/ e e/
S2 will probably not provide similar enduring stability in e The procedure is performed through small skin incisions,
e/e
older patients.
: // t .m
• There is no penetration into the sacral bone with reduced
: / / .m
which are placed in line with the central axis of the trans-
t
sacral corridor of S1. Two incisions of 4–5 cm are sufficient.
ht tps
risk of damage to neural and vascular structures inside
the sacrum or just anterior to it.
ht tps
The horizontal direction of the transsacral bar is perpen-
dicular to the plane of the sacral fractures. Tightening of the
nuts and washers creates compression and enhances stabil-
Disadvantages include the prominent hardware that can be ity (Case 9: Fig 3.7-33). The stability of the construct does not
felt behind the sacrum and may disturb the patient while depend on the strength of the cancellous bone in the body
sitting. In the era of bridging plates and transsacral bars, of S1, as is the case with iliosacral screw osteosynthesis. The
e r s
transiliac bars are used less frequently.
e r s
stability depends on the strength of the external cortex of
ook ok o
the posterior iliac wing, against which the nuts and washers
e b Two incisions are made parallel and just lateral to the pos-
e b o are tightened. The few outcome data for this technique have
b o
e /
t . m
exposed. One fingerbreadth anterior to the crest, a hole of e/
terior iliac crests. The lateral cortex of the posterior ilium is been reported as positive [40, 41].
t . m e/e
/ /
6 mm is drilled through the posterior ilium. Through the
/ /
htt ps:
hole, a threaded 6 mm bar is passed in the coronal plane
behind the sacrum towards the opposite posterior ilium. A
similar hole is drilled and the bar pushed through this sec- htt ps:
ond hole. On both sides, nuts are placed over the ends of
the threaded bar. Washers are used to prevent perforation
of the nuts through the outer cortex. When tightening the
e rs
nuts, compression is created on the sacral fracture. A second
e r s
b o ok bar may be placed below the first bar using the same tech-
nique.
b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
Patient
p s tps
CASE 9
h t t
A 77-year-old woman with a left superior and inferior pubic ramus
fracture after a fall at home. ht
(Fig 3.7-33b). A transverse computed tomographic cut through the
sacrum showed a bilateral sacral alar fracture that was complete
on the right side and incomplete on the left side (white arrows).
Comorbidities These fractures corresponded with a fragility fracture of the pelvis
• Hypercholesterolemia type IIc (Fig 3.7-33c). The fractures were fixed operatively with a
k e rs
• Hypothyreosis
• Urinary incontinence
ke rs
transsacral bar and bilateral iliosacral screws. The pubic ramus frac-
ture was stabilized with a retrograde transpubic screw. The AP
eb oo e b oo
pelvic x-ray taken after 2 years showed complete healing of all
b o o
e/e
Treatment and outcome fractures. There was a slight loosening of the retrograde transpubic
e / e /
The AP x-ray of the pelvis showed a left superior and inferior pubic
m
screw (Fig 3.7-33d). Another inlet and outlet view of the pelvis was
m
/ /t .
ramus fracture (Fig 3.7-33a). An inlet x-ray of the pelvis was obtained taken (Fig 3.7-33e–f).
// t .
htt ps: htt ps:
363
rs
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/ / t . m // t . m
htt ps: htt ps:
3.7 Pelvic ring
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
ok ok
a b c
b o bo b o o
e/ e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
d e f
e r s e r s
Fig 3.7-33a–f A 77-year-old woman with a fracture of the superior and inferior pubic ramus.
ook ok
a AP pelvic x-ray of a left superior and inferior pubic ramus fracture.
b
b Pelvic inlet view.
b o
c Transverse computed tomographic cut through the sacrum showing a bilateral sacral alar fracture, complete on the right side and incom-
b o o
e / e plete on the left side (white arrows).
e/ e e/e
/ / t . m / /t . m
d AP pelvic x-ray after 2 years showing complete healing of all fractures but a slight loosening of the retrograde transpubic screw.
ps: ps:
htt htt
5.2.8 Bridging plate Bridging plate osteosynthesis can be done as a less invasive
A plate, which is curved at its ends, is used instead of a procedure. The incisions are similar to those for transiliac
e rs
transiliac bar. The plate lies posterior to the sacrum and is
r s
bar osteosynthesis. The soft tissues behind the sacrum and
e
b o ok contoured around the posterior iliac crests near the poste-
b o
rior iliac spines. To prevent placing uncomfortable hardware ok
between the posterior iliac crests are tunneled for plate po-
sitioning [43]. The plate takes the function of a tension band,
b o o
e/ e / e
just below the skin, an osteotomy of the posterior superior
e
iliac spines (PSISs) can be performed and a bone block the
but it does not create direct compression on the fracture
site. With this bridging osteosynthesis, bilateral sacral alar
e /e
://t . m
width of the plate removed. Once the plate has been in-
/ t
fractures are stabilized in one procedure. In case of unilat-
: / . m
t t p s
serted, the bone blocks are reinserted and fixed with a small
tps
eral fractures, the bridging plate can prevent development
ht
screw [42]. The plate can also be inserted more distally be- of a contralateral fracture. Combination of iliosacral screws
h
tween the notches just below the posterior inferior iliac
spines. This distal plate location has the advantage of the
with the posterior plate enhances stability. Specific angular
stable plate designs have been developed. They create a
implant being very close to the posterior cortex of the sa- higher stability than the nonangular stable fixation [44, 45].
crum. The plate ends are bowed and fitted against the pos-
k e rs
terior ilium. Long screws can be inserted through the two
marginal plate holes on each side. One screw goes in the
ke rs
eb oo anterior direction parallel to the sacroiliac joint, the other
e b oo b o o
e/e
screw in the superior direction parallel to the iliac crest.
e / m e / m
/ /t . // t .
htt ps: htt ps:
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 5.2.9 Transiliac internal fixator
t . m e /
t
and can have a length of 100 mm. The screw heads are
. m e/e
s: / / / /
ps:
A minimally invasive alternative to transiliac bars or bridg- connected with a rod of 5 or 6 mm diameter which is placed
http htt
ing plate osteosynthesis is the insertion of a transiliac inter- in a subcutaneous tunnel (Case 10: Fig 3.7-34) [46]. In a bio-
nal fixator. An osteotomy of the PSIS is performed, and a mechanical model with complete iliosacral disruption, sta-
bone block with the width of a pedicle screw head removed. bility is as high as anterior plate osteosynthesis of the sac-
The trajectory for a long pedicle screw is drilled. From the roiliac joint and iliosacral screw osteosynthesis [47]. The
PSIS, this trajectory passes above the greater sciatic notch experience with transiliac internal fixation of type C lesions
e s
and goes in the direction of the anterior inferior iliac spine.
r
The screw is located between the inner and outer cortex of
er s
in high-energy pelvic trauma is very good, but there are no
published data yet on this procedure in FFP.
b o ok the ilium. The pedicle screw has a diameter of up to 7 mm
bo ok b o o
e/ e e/ e e/e
Patient
: // t .m Treatment and outcome
: / / t .m
CASE 10
pelvic pain.
ht tps
An 86-year-old woman with a history of several falls and posterior
ht tps
A fracture of the anterior pelvic ring could not be identified (Fig
3.7-34a). A transverse computed tomographic (CT) cut through the
sacrum revealed a complete fracture of the left sacral ala (white
Comorbidities arrows). This lesion corresponded with a fragility fracture of the
• Cardiac insufficiency pelvis type IIa (Fig 3.7-34b). A coronal CT cut confirmed the complete
• Stenosis of the aortic valve fracture of the left sacral ala (Fig 3.7-34c). A posterior transiliac
e r s
• Peripheral arterial disease
r s
internal fixator was inserted (Fig 3.7-34d). An inlet and an outlet
e
ook ok o
• Renal insufficiency view of the pelvis were obtained (Fig 3.7-34e–f).
e b • Pneumonia
e b o b o
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
e rs
a b
e r s c
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
d e f
rs rs
Fig 3.7-34a–f An 86-year-old woman with several falls in the past and actual posterior pelvic pain.
k e a AP pelvic x-ray not showing a fracture of the anterior pelvic ring.
ke
b Transverse computed tomographic (CT) cut through the sacrum revealing a complete fracture of the left sacral ala (white arrows).
eb oo e b oo
c Coronal CT cut confirming the complete fracture of the left sacral ala.
b o o
e/e
d Postoperative AP pelvic x-ray showing the inserted posterior transiliac internal fixator.
e / e Pelvic inlet view.
m e / m
/ /t . // t .
htt ps: htt ps:
365
rs
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/ / t . m // t . m
htt ps: htt ps:
3.7 Pelvic ring
k e rs ke rs
e b oo e b oo b o o
e / 5.2.10 Lumbopelvic fixation
t . m e / 5.2.11 Supraacetabular external fixation
t . m e/e
s: / / / /
ps:
With this technique, a tight connection is created between From each side, one or two Schanz screws are inserted from
http htt
the lumbar spine and the posterior ilium. A vertical incision the anterior inferior iliac spine toward the PSIS (Fig 3.7-35).
above the sacrum going up to the level of L4 or L5 is need- The skin incisions run vertically from the anterior superior
ed. One pedicle screw is placed in the pedicle of L5 at the iliac spine (ASIS) downward. The trajectory through the
side of instability. In case of pronounced lordosis, the L4 soft tissues has to be prepared bluntly. Care has to be taken
pedicle is preferred so that a more vertically directed con- not to injure the lateral cutaneous femoral nerve, which
e s
struct is built. The second pedicle screw is inserted in the
r
posterior ilium as described in transiliac internal fixation.
er s
runs below the inguinal ligament just medial to the ASIS
towards distal and lateral. The screws have a length of up
b o ok A connection rod is inserted between and fixed to the ped-

icle screws. In case of an H-type sacral fracture, a bilateral
bo ok
to 100 mm. They are connected to each other and to the
other side with rods. The frame bridges the anterior pelvis
b o o
e/ e lumbopelvic fixation with transverse connection between
e/ e [51–53]. Biomechanical studies have proven that its stability
e/e
: // t .m
both rods is performed [48]. The procedure can be performed
percutaneously, but more intraoperative image intensifica-
is high enough to control disruptions of the anterior pelvic
: / / t .m
ring but not of the posterior pelvic ring [54]. If a posterior
ht tps
tion is needed for precise pedicle insertion. Lumbopelvic
fixation can be combined with a transverse fixation like
iliosacral screws or a transsacral bar. The construct then
should be considered as well.
ht tps
pelvic ring lesion has been identified, operative stabilization
looks triangular (Case 6: Fig 3.7-27) [49]. 5.2.12 Retrograde transpubic screw
The optimal indication for retrograde transpubic screw
The advantage of lumbopelvic fixation is its less invasive fixation is a superior pubic ramus fracture, which is situ-
e r s
procedure. The construct controls vertical instability. It is
e r s
ated above the obturator foramen or at the anterior rim of
ook ok o
especially recommended in H-type fractures to prevent fur- the acetabulum. Fractures which are situated more medi-
e b ther intrusion of the lumbosacral segment into the small

e b o ally, running within the pubic bone and near to the pubic
b o
e / pelvis. It is a bridging construct, which does not produce
t . m
fracture compression. Literature of lumbopelvic fixation e/ symphysis, cannot be bridged safely with a screw:
t . m e/e
/ /
focuses on the control of vertically unstable pelvic fractures
/ /
• The screw can be inserted with a percutaneous technique
htt ps:
or spondylolisthesis of the lumbosacral junction [48, 50].
Little is known about complications and results in FFP.
if the fracture is minimally displaced.
htt ps:
• Before starting surgery, the level and inclination of the
screw are identified under image intensifier control with
the help of a long K-wire or drill bit that is placed over
the skin of the lower abdomen and moved until it per-
fectly covers the trajectory of the screw in the superior
e rs e r s
pubic ramus. This line is marked.
b o ok b o ok
• A small skin incision is made near the pubic symphysis
following that line, and the trajectory to the anterior
b o o
e/ e e / e pubic bone is prepared.
• The 2.8 mm drill bit is held in 45° inclination to the
e /e
://t . m / t
frontal and sagittal planes. Under image intensification,
: / . m
t t p s tps
the location of the drill tip is adjusted until it lies pre-
ht
cisely in line with the optimal trajectory of the screw.
h The image intensifier is brought into the obturator-out-
let and iliac-inlet positions consecutively, while the drill
bit enters the canal and is moved cranially and laterally
a b through the superior pubic ramus [55]. Special attention
k e rs
Fig 3.7-35a–b Insertion point for supraacetabular external fixator
Schanz screw. Under image intensification, the corridor becomes
ke rs
is paid to avoid penetration of the drill bit into the ace-
tabulum. The drilling procedure is continued until the
oo oo o
visible in the obturator outlet views as a high triangle above the
eb acetabular cavity.
e b
tip of the drill bit reaches and perforates the posterolat-
b o
e/e
eral cortex of the iliac body.
e / a Image intensification with K-wire inside the triangle.
e /
b Image intensification of the contralateral side, also with K-wire
m
• The length of the trajectory in the bone may reach 130 mm
m
/t .
inside the triangle. The K-wires will consecutively be replaced
/ // t .
[56]. The most anterior part of the trajectory is overdrilled
ps: ps:
by Schanz screws. by 4.5 mm. A 7.2 mm cannulated screw of appropriate
366
htt htt
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
length is inserted over the 2.8 mm drill bit. The use of a
t . m
low variable screw directions [57, 58]. It is advisable to drill e/e
s: / / / /
ps:
washer is not absolutely necessary. The screw head lies long trajectories in the bone for the screws and use screws
http htt
in the thick tendinous attachment of the adductor mus- as long as possible to obtain good purchase and a high pull-
cles at the pubic bone (Case 3: Fig 3.7-18, Case 9: Fig 3.7-33). out force. Near the pubic symphysis, screw lengths of 60 mm
• The screw primarily splints the superior pubic ramus should be used. The infraacetabular corridor with the screw
fracture; it does not achieve strong compression [55]. passing lateral to the obturator foramen and medial to the
When the drill bit cannot pass the acetabulum without acetabulum going into the posterior column should be used,
e rs perforating the joint, a shorter screw must be chosen. It

will generate lower stability and have a higher risk of
er s
if possible. It can have a length of more than 100 mm and
has a very good holding power in the strong ischium (Case 11:
b o ok loosening.
bo ok
Fig 3.7-36) [59]. When the fracture is situated at the anterior
lip of the acetabulum, an infrapectineal plate can be used
b o o
e/ e When the superior pubic ramus fracture is displaced but
e/ e through a Stoppa approach. The plate is curved and runs
e/e
: // t .m
appropriate for retrograde transpubic screw fixation, closed
or open reduction can be done. The skin incision is the same,
: / / .m
from the posterosuperior margin of the pubic bone below
t
the pelvic brim toward the sacroiliac joint. Two or three
tps
but can be smaller than in the case of plate fixation. The
ht
displaced superior pubic ramus fracture is reduced by direct
means and the trajectory for the screw drilled under control ht tps
screws can be placed above the acetabulum, realizing a good
anchorage of the plate into the iliac body. Double plate
osteosynthesis may be considered in cases of chronic insta-
of finger touch and image intensification. bility, where a high stability over a long healing time is
necessary (Case 12: Fig 3.7-37).
5.2.13 Plate fixation
e r s
An infraumbilical midline incision or a Pfannenstiel skin
e r s
The approach is very well endured by older adults, as it uses
ook ok o
incision can be chosen. The linea alba is split above the anatomical layers without necessitating muscle or tendon
e b symphysis and the retropubic space exposed. The anterior

e b o detachment [60]. To date, the literature has not specifically
b o
e / e/
curve of the pelvic ring can be exposed further laterally
m
following the modified Stoppa approach. As the instability
t .
addressed plate fixation or retrograde transpubic screw
t . m
fixation in the anterior pelvis of a geriatric population. e/e
/ /
is not situated in the joint, but close to it, the plate will not
/ /
htt ps:
be placed strictly above the pubic symphysis but more toward
one side. Small fragment curved plates are used, which al-
htt ps:
CASE 11
e rs
A 75-year-old woman with a history of rheumatoid arthritis.
r s
There was bone resorption, bone defect, and instability of the pubic
e
b o ok
symphysis. Irregular bone architecture was visible at the right sacral
ala (Fig 3.7-36a). Pelvic inlet and outlet views were obtained (Fig
b o o
e/ e • Rheumatoid arthritis
• Hodgkin’s disease
e / e 3.7-36b–c). A transverse computed tomographic (CT) cut through
the sacrum showed a complete fracture of the right sacral ala with
e /e
• Sicca syndrome
://t . m : / / t . m
bone defect and connection with the sacroiliac joint (Fig 3.7-36d). A
• Aortic valve replacement
t t p s tps
coronal CT cut showed the irregular sacral alar fracture with callus
ht
• Chronic hepatic disease formation at the anterior sacral cortex (Fig 3.7-36e). A postoperative
h
• Total hip replacements
• Total knee replacement
coronal CT cut through the sacrum revealed that the posterior pelvic
ring fracture had been fixed with a transsacral bar and additional ilio-
sacral screw (Fig 3.7-36f). The instability of the pubic symphysis was
stabilized after debridement of the joint with a long curved plate. The
k e rs ke rs
marginal screws used the infraacetabular corridor. All other screws
used the longest possible bone trajectory (Fig 3.7-36g). Another inlet
eb oo e b oo
view of the pelvis and after 3 months another pelvic outlet view were
b o o
e/e
obtained (Fig 3.7-36h–i).
e / m e / m
/ /t . // t .
htt ps: htt ps:
367
rs
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/ / t . m // t . m
htt ps: htt ps:
3.7 Pelvic ring
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs
a b
er s c
b o ok bo ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
d e f
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
g
htt ps: h i
htt ps:
Fig 3.7-36a–i A 75-year-old woman with a history of rheumatoid arthritis.
a AP pelvic x-ray showing bone resorption, bone defect, and instability of the pubic symphysis. Irregular bone architecture is visible at the
right sacral ala.
b Pelvic inlet view.
e rs
c Pelvic outlet view.
e r s
ok ok
d Transverse computed tomographic (CT) cut through the sacrum showing a complete fracture of the right sacral ala with bone defect and
b o connection with the sacroiliac joint.
b o
e Coronal CT cut showing the irregular sacral alar fracture with callus formation at the anterior sacral cortex.
b o o
e/ e e / e
f Postoperative coronal CT cut through the sacrum showing the posterior pelvic ring fracture fixed with a transsacral bar and additional
e /e
iliosacral screw.
://t . m / t .
g X-ray showing the pubic symphysis stabilized with a long, curved plate. The marginal screws use the infraacetabular corridor. All other
: / m
h Pelvic inlet view.
t t p s
screws use the longest bone trajectory possible.
tps
i
h
Pelvic outlet view 3 months after surgery.
ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Patient
m e / m e/e
CASE 12
/ / t .
A 77-year-old woman with a history of corticosteroid use.
/ / t .
A coronal CT cut through the pubic symphysis showed a small bone
Comorbidities
• Hypothyreosis htt ps: htt ps:
defect and irregular margins (Fig 3.7-37c). The posterior instability
had been treated with a transsacral bar and additional iliosacral
screw. The anterior pubic instability had been treated with pubic
• Arterial hypertension debridement, tricortical bone grafting, and double plate osteosyn-
thesis, as bony fusion of the pubic symphysis was the therapeutic
Treatment and outcome goal and a longer healing time could be expected (Fig 3.7-37d). A
e rs
The AP x-ray of the pelvis showed instability of the pubic symphysis
r s
pelvic inlet view was obtained (Fig 3.7-37e). The pelvic outlet view
e
b o ok due to the vertical displacement of the left pubic bone (Fig 3.7-37a).
A transverse computed tomographic (CT) cut through the sacrum
bo ok
showed the long marginal screws of the superior plate using the
infraacetabular corridors into the ischium. The view was taken
b o o
e/ e e
showed a complete and older left sacral alar fracture (Fig 3.7-37b).
e/
3 months postoperatively (Fig 3.7-37f).
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a b c
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d e f
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Fig 3.7-37a–f A 77-year-old woman with an unstable pubic symphysis.
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a AP pelvic x-ray showing instability of the pubic symphysis due to the vertical displacement of the left pubic bone.
b o o
b Transverse computed tomographic (CT) cut through the sacrum showing a complete and older left sacral alar fracture.
b b o o
e/ e d Postoperative AP pelvic x-ray.
e / e
c Coronal CT cut through the pubic symphysis showing a small bone defect and irregular margins.
e /e
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f Pelvic outlet view showing the long marginal screws of the superior plate using the infraacetabular corridors into the ischium.
: m
t t p s tps
h
5.2.14 Internal fixator
ht
dominal aponeurotic fascia is carefully made between the two
The concept of the internal fixator is similar to that of the screw heads. A bent rod is inserted in this tunnel and locked
transiliac internal fixator on the posterior pelvis. It is a bridg- in both screw heads [61]. The stability of the construct is sim-
k e rs
ing osteosynthesis, which is spanned over the anterior pelvis
with the implants being inserted in a less invasive way. Two
ke rs
ilar to that of external fixation. As in anteroinferior external
fixation, care has to be taken not to injure the lateral cutane-
eb oo pedicle screws, ie, one left and one right, are inserted from
e b oo
ous femoral nerves during preparation of the corridors. When
b o o
e/e
the anterior inferior iliac spine toward the PSIS. The pathway the rod is inserted too deep, it may put direct pressure on the
e / e /
of the pedicle screws is the same as that of the Schanz screws
m
iliopsoas muscle and the femoral nerve. A case series with
m
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of the external fixator. The length of the screws is up to
t .
femoral nerve palsy has been described after anterior internal
//
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100 mm. A subcutaneous tunnel anterior to the lower ab- fixation of the pelvic ring [62, 63].
htt htt 369
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3.7 Pelvic ring
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As the implants are located close to the inguinal region and 5.4.1 Nonunion after nonoperative treatment
t . m e/e
s: / / / /
ps:
subcutaneously, implant removal must be considered in pa- Nonunion is the end result of a failed healing process:
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tients with complaints of the prominent hardware.
• The fracture site represents a high-stress riser along the
5.3 Aftercare otherwise stiff pelvic ring. This stress riser impedes heal-
Regardless of the treatment, patients with FFP should receive ing of a usually benign fracture. The situation is often
appropriate analgesia and be mobilized as soon as possible underdiagnosed.
e s
[64] (see chapter 1.12 Pain management). Non-weight bear-
r
ing is associated with functional decline, complications, and
er s
• Long-standing complaints vary from disabling pain dur-
ing standing and walking to severe immobilizing pain.
b o ok poor outcomes, and patients should be motivated and sup-

ported to move and walk as much as possible.
bo ok
• Operative treatment with restoration of pelvic stability
is the only option with a high success rate.
b o o
e/ e e/ e • The type of fixation and the invasiveness of surgery de-
e/e
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Close clinical supervision is needed to identify patients who
are not doing well and express continuing or increasing pain nonunion, and the amount of displacement.
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pend on the degree of instability, the localization of the
t
tps
during mobilization [24]. A possible increase of instability
ht
must be ruled out with new conventional pelvic x-rays and
CT scans. ht tps
In the posterior pelvic ring, iliosacral screw fixation with or
without cement augmentation and transsacral bar osteo-
synthesis are techniques of choice for nonunions of the
Patients with FFP type II lesions, who have been treated sacral ala and the iliosacral joint. They create interfragmen-
operatively, and patients with FFP type III and type IV le- tary compression, which is perpendicular to the fracture
e r s
sions need longer support and rehabilitation. Short transfers,
e r s
gap. Open debridement of the nonunion is not needed. In
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eg, from the bed to a chair or from the bed to the toilet, are pure iliosacral instabilities, a debridement of the joint is
e b b
allowed immediately. If the patient allows, walking with a
e o combined with an anterior plate fixation. In case of fractures
b o
e / e/
rolling walking frame is started. This recommendation has
m
not been proven by clinical studies but is meant to prevent
t .
of the ilium, the technique of osteosynthesis will be the
same as in acute lesions. An angular stable plate osteosyn-
t . m e/e
/ /
postoperative immobilization with its known complications. thesis provides enough stability for healing.
/ /
ps:
Radiological studies after 3, 6, and 12 weeks confirm stabil-
htt
ity and ongoing fracture healing.
htt ps:
In anterior pelvic nonunions, high stability is needed for
the time of healing. In contrast with the posterior pelvic
5.4 Nonunion ring, the bone mass is thin and the corridors for strong im-
Nonunion of acute fractures or secondary fatigue fractures plant fixation small. Exposure of the nonunion, debridement,
can occur in the anterior and posterior pelvic ring. With a and plate fixation are recommended. As in acute lesions,
e rs
fracture at one site, the pelvic ring gets more susceptible to
r s
the plate screws should have the longest trajectory possible
e
b o ok fatigue-type fractures at other sites. The FFP then changes
b o
from a type of lower instability to one of higher instability. ok
in the bone. In case of bone defect, cancellous bone grafting
is performed to fill the gap. When a pubic symphysis dias-
b o o
e/ e / e
This especially happens in patients who undergo a long pe-
e
riod of nonoperative treatment despite continuing com-
tasis with bone defect due to chronic instability is present,
a tricortical bone graft is taken from the iliac crest and placed
e /e
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plaints. The pelvic ring gradually and progressively fails
/ t
in the defect. The pubic symphysis with tricortical graft is
: / . m
t t p s
which finally renders the patient bedridden. Signs of chron-
tps
stabilized with a double plate osteosynthesis. The first plate
ht
ic instability can be observed on conventional x-rays and is placed superiorly and the second anteriorly (see Case 11:
h
CT scans. Due to continuous motion and wear, bone frag-
ments resorb. Larger fracture gaps and bone defects become
Fig 3.7-36 , Case 12: Fig 3.7-37).
visible. In areas with high load, bone resorption is combined

with densification of the margins (see Fig 3.7-9, Fig 3.7-10,
k e rs
Fig 3.7-11). At the same time, callus is visible as an attempt
of fracture healing. The clinical and radiological picture is
ke rs
eb oo that of a nonunion, sometimes stiff, sometimes mobile, but
e b oo b o o
e/e
always painful. These situations have to be distinguished
e / m e /
from nonunion after operative treatment, which is the con-
m
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sequence of inadequate fixation, implant loosening, and
/ / // t .
ps: ps:
secondary displacement.
370
htt htt
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rs 26.07.18 10:30
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htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 5.4.2 Nonunion after operative treatment
t . m e /
t . m
fixation is always necessary. The most stable osteosynthesis e/e
s: / / / /
ps:
When operative treatment fails, the reasons for failure have is chosen and the nonunion put under compression. Bone
http htt
to be identified. In addition to metabolic and nutritional grafting is more often needed as in nonunion after nonop-
contributors to poor bone quality (see chapter 1.10 Osteo- erative treatment. While iliosacral screw osteosynthesis and
porosis), typical mechanical reasons for failure include in- transsacral bar osteosynthesis are the fixations of choice in
adequate stability due to inappropriate fixation, inadequate the posterior pelvis, it is plate osteosynthesis in the ante-
implants, or low strength of fixation in osteoporotic bone. rior pelvic ring. In all cases of nonunion, an anabolic ther-
e s
Depending on the specific problem, implant removal is
r
needed or stability of osteosynthesis enhanced. Internal
er s
apy with teriparatide is strongly recommended to boost
fracture healing [22, 23].
b o ok bo ok b o o
e/ e e/ e e/e
6 References
: // t .m 10. Lau TW, Leung F. Occult posterior

: / / t .m
19. Wagner D, Kamer L, Rommens PM,
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ht ht
Hessmann MH. Management of acute with osteoporotic pubic rami fractures. to investigate the anatomy of the
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e r s [Fractures of the sacrum caused by

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ook ok
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comparison of sacroiliac screw
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/ / //
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:
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://t . m Indikationen und Technik

[Lumbopelvic stabilization for bilateral
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2009 Jul;43(3):245–252. supraacetabular external fixation for “Anterior subcutaneous pelvic internal
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oo oo o
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/ /t . // t .
htt ps: htt ps:
rs
rs 26.07.18 10:30
/ / t . m // t . m
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k e rs ke rs
e b oo e b oo b o o
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t . m e /
t . m e/e
3.8 Acetabulum / / / /
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e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e second period (2005–2006) [3]. Ferguson et al [4] observed
e/e
: // t .m
The treatment of geriatric acetabular fractures (GAFs) pres-
: / / t .m
a 2.4-fold increase of the acetabular fracture incidence in
patients > 60 between 1980 and 2007 and Sullivan [5] re-
reasons:
ht tps
ents a challenge for orthopedic surgeons for the following
ht tps
ported an 67% increase of GAF between 1998 and 2010. It
is reasonable to assume that this trend will continue during
the next few decades. While the overall majority of patients
• Despite an increasing incidence over the last few decades, with acetabular fractures are male, women are more fre-
GAF are infrequent injuries and overall personal experi- quently represented in the geriatric group [3].
ence of the treating surgeon is usually low.
e r s
• There are important treatment differences with regard
e r s
Acetabular fractures in younger patients usually result from
ook ok o
to fracture type, degree of instability, and accompanying high-energy trauma and frequently occur in polytraumatized
e b injuries such as femoral head impaction, preexisting os-

e b o patients. In older adults, acetabular fractures typically result
b o
e / patients.
t . e/
teoarthritis, comorbidities and functional demands of the
m
from ground level-level falls and are either isolated injuries
t . m
or combined with other osteoporotic fractures such as prox- e/e
/ /
• Treatment options range from nonoperative treatment
/ /
imal humeral or distal radial fractures. The fracture type is
nal fixation and arthroplasty. ps:

to internal fixation and hip arthroplasty and even inter-
htt
• Internal fixation and hip arthroplasty are performed us- htt ps:
mainly determined by the position of the hip joint during
trauma. In younger patients, the so-called “dashboard mech-
anism” is a characteristic injury mechanism with the knee
ing different approaches, techniques, and implants de- and hip joint in flexion and load transmission via the femo-
pending on the surgeon’s preferences and abilities. ral shaft. This results in a posterior fracture dislocation with
• There is a lack of controlled studies comparing different the involvement of the posterior wall and/or column (“pos-
e rs treatment options. Most studies typically describe case

r s
terior dislocation”). In geriatric patients, the hip joint is usu-
e
b o ok series limited by small sample sizes and lack of appropri-
ate comparison groups.
b o ok
ally in extension during the fall on the involved side with
load transmission via the greater trochanter and the femoral
b o o
e/ e e / e neck (Fig 3.8-1). Given the anteversion of the femoral neck,
the anterior column and/or wall as well as the quadrilat-
e /e
2 Epidemiology and etiology
://t . m / t .
eral plate are generally involved in GAF with medial protru-
: / m
t t p s tps
sion of the femoral head (“central dislocation”) [2, 3, 6].
ht
The incidence of GAF have shown a marked increase during
h
the last two decades [1]. An overall increase in life expectancy
as well as a higher activity level of octogenarians may ac-
count for these findings. In 2005, Cornell [2] predicted that
Fig 3.8-1 Typical mecha-
geriatric patients may soon be the most typical age group nism of injury of acetabular
k e rs
to present with acetabular fractures. Ochs reported an in-
crease in the mean age of patients with acetabular fractures
ke rs fractures in geriatric patients
is load transmission via the
eb oo from 43.0 (± 19.1) years in the period from 1991–1993 to
e b oo greater trochanter, involve-

ment of the anterior column
b o o
e/e
52.7 (± 19.8) years between 2005–2006 [3]. While the group
e / of patients aged between 20–30 years were the most frequent

m e / and the quadrilateral plate
m
due to the anteversion of
/ /t .
age group in the first study period (1991–1993), the group
/ t .
the femoral neck (central
/
ps: ps:
between 60–70 years represented the peak age group in the dislocation).
htt htt 373
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
3.8 Acetabulum
k e rs ke rs
e b oo e b oo b o o
e / 3 Diagnostics
t . m e / 3.2.2 Computed tomographic scan
t . m e/e
s: / / / /
ps:
Computed tomography (CT) is the gold standard for the
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3.1 Clinical evaluation evaluation of acetabular fractures, and multiplanar CT re-
In GAF, individual goals of treatment and the approach constructions are mandatory for understanding the exact
largely depend on patient-related factors, so the clinical acetabular fracture pattern [8, 9]. CT imaging of the pelvis
evaluation must extend beyond the routine history and allows for proper assessment of the following parameters:
physical examination. The following patient-related factors
k e rs should be thoroughly assessed before treatment options are

considered:
er s
• Detailed fracture line characteristics and type of
acetabular fracture (Case 1: Fig 3.8-2)
o o o ok
• Extent of anterior and posterior wall comminution
o o
e/eb b b
• Preinjury ambulatory status and/or marginal impaction
• Functional demands
e/ e • Impaction of the weight-bearing acetabular dome and
e/e
•
• Medical comorbidities
: // t .m
Independence in activities of daily living
• Articular surface congruity
: / / .m
of the femoral head (Case 3: Fig 3.8-4, Case 5: Fig 3.8-6)
t
•
•
•
Cognitive status
Bone quality
ht tps
Preexisting osteoarthritis of the affected hip
(Case 3: Fig 3.8-4)
• Intraarticular bony fragments ht tps
• Subtle subluxation/medialization of the femoral head
• Concomitant injuries, especially those with an impact

on postoperative mobilization plans Furthermore, modern CT permits manual multiplanar 2-D
reconstruction in any arbitrary plane. Additional manual
e r s
The optimal treatment strategy for an individual patient
e r s
reconstructions complement the information gained from
ook ok o
must be chosen considering factors related to both fracture standard axial, coronal, and sagittal planes.
e b and patient to provide the best possible clinical outcome.

e b o b o
e / e/
The primary goals in the treatment of GAF are prompt and
m
adequate single-staged treatment (“single-shot surgery”)
t .
3.2.3 Three-dimensional reconstruction
Three-dimensional surface-rendered CT images from dif-
t . m e/e
/ /
allowing for early mobilization and avoiding morbidity and
: / /
ferent regions are of great help for enhancing the surgeon’s
revision surgery.
h t p s
mortality associated with prolonged bed rest and subsequent
t htt ps:
understanding of the acetabular fracture and spatial rela-
tionship of fracture fragments as well as for planning the
operative approach. Three-dimensional CT allows for sub-
3.2 Imaging traction of the femoral head and enables the surgeon to
3.2.1 Plain x-rays view the complex 3-D anatomy of the fractured acetabulum
The three standard acetabular views include the AP view of from any perspective, including the intraoperative view.
e rs
the pelvis, the obturator oblique view (with the pelvis ro-
r s
Furthermore, 3-D CT helps to improve the accuracy and
e
b o ok tated 45° towards the uninjured side) and the iliac oblique
b o
view (with the pelvis rotated 45° towards the injured side). ok
interobserver reliability of acetabular fracture classification
especially in surgeons with limited experience [10, 11]. Three-
b o o
e/ e / e
According to the authors’ experience, however, AP views
e
of the pelvis with an initial CT scan are sufficient to rule out
dimensional CT images complement the 2-D images, as the
latter more accurately depict fracture details such as mar-
e /e
://t . m
medialization of the femoral head in GAF. Impaction of the
/
ginal and acetabular dome impaction, column comminution,
: / t . m
t t p s
subchondral bone of the superomedial acetabular dome may
tps
small intraarticular fragments and subtle fracture lines.
ht
be visible as a double arc on plain radiographs (“gull sign”)
h
(Case 3: Fig 3.8-4, Case 5: Fig 3.8-6) and is associated with a
poor prognosis after nonoperative treatment or internal
3.2.4 Magnetic resonance imaging
In general, magnetic resonance imaging (MRI) is of limited
fixation [7]. value in the routine assessment of GAF. High-resolution
MRI allows for imaging of the acetabular labrum and carti-
k e rs ke rs
lage. In geriatric patients MRI may be helpful to rule out
occult acetabular, femoral head or femoral neck fractures,
eb oo e b oo
which may not be visible on x-rays or CT scans.
b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
t . m e /
t . m
A characteristic fracture type in geriatric patients is the an- e/e
s: / / / /
ps:
terior column with posterior hemitransverse fracture (Case 1:
http htt
4.1 Classification of Letournel and Judet Fig 3.8-2, Case 3: Fig 3.8-4, Case 5: Fig 3.8-6, Case 6: Fig 3.8-7,
The classification system of Letournel and Judet is the most Case 8: Fig 3.8-9).
In these fractures the anterior column is
widely used and represents an anatomical and radiographic often multifragmentary or comminuted (Case 5: Fig 3.8-6),
description of acetabular fracture patterns [12]. This system while the posterior hemitransverse fracture is simple and
divides acetabular fractures into two groups, ie, basic and as- frequently undisplaced (Case 1: Fig 3.8-2). The quadrilateral
e s
sociated fractures, with five fracture subtypes in each group.
r
Basic fracture patterns include posterior wall fractures, pos-
er s
plate is generally in osseous continuity with the posterior
column (Case 5: Fig 3.8-6). Due to the medial protrusion of
b o ok terior column fractures, anterior wall fractures, anterior col-

umn fractures, and transverse fractures. Associated fracture
bo ok
the femoral head with medialization of the quadrilateral
plate, the posterior column is typically internally rotated.
b o o
e/ e e/
patterns include T-shaped fractures, posterior column with e This mechanism is comparable to the opening of a swinging
e/e
: // t .m
posterior wall fractures, transverse with posterior wall frac-
tures, anterior column with posterior hemitransverse fractures
: / / .m
door by the femoral head and is called “open door injury”
t
by the authors in analogy to the “open book injury” of the
ht tps
and two-column fractures. While the AO/OTA or Tile clas-
sification of pelvic ring injuries is limited in its use for the
assessment of geriatric pelvic ring injuries (see chapter 3.7
pelvic ring.
ht tps
Pelvic ring), the commonly used classification systems for 5 Decision making
acetabular fractures (Letournel and AO/OTA classifications)
are valuable for the assessment of GAF as well. The distribu- 5.1 General remarks
ke r s
tion of acetabular fracture patterns in older adults differs sig-
e r s
In younger patients, we strive for fracture healing in an
b o o nificantly from younger patients, with fracture types involv-

ing the anterior column being much more common (Fig 3.8-1).
b o ok
anatomical position. Thus, displaced fractures generally re-
quire open reduction and internal fixation. The overall goals
b o o
e /e 4.2
m
AO/OTA Fracture and Dislocation Classification
t . e/ e in the treatment of GAF are as follows:
t . m e/e
/ /
The alphanumeric AO/OTA classification of acetabular frac-
/ /
• Rapid restoration of the hip function by an adequate
ps:
tures is based on the classification of Letournel and Judet,
htt
but includes additional modifiers, making it more complex
and less commonly used in daily practice. The AO/OTA clas- htt ps:
single-staged treatment (single-shot surgery) to allow for
early mobilization with weight bearing as tolerated
• Avoidance of the morbidity and mortality associated with
sification distinguishes between type A (partial articular bed rest and/or revision surgery [13, 14]
fractures with one column involved: A1, posterior wall; A2,
posterior column; A3, anterior wall or anterior column), Treatment options for GAF include:
e rs
type B (a portion of the acetabular articular surface is in
e r s
b o ok osseous continuity with the iliac bone: B1, transverse; B2,
b o
T-shaped; B3, anterior column and posterior hemitransverse)
•
• ok
Nonoperative treatment (Case 1: Fig 3.8-2, Case 2: Fig 3.8-3)
Internal fixation (Case 4: Fig 3.8-5)
b o o
e/ e e / e
and type C (fracture patterns with no osseous continuity
between the acetabular articular surface and the iliac bone:
•
•
Hip arthroplasty (Case 3: Fig 3.8-4, Case 5: Fig 3.8-6)
e
Combinations of internal fixation and arthroplasty (Case 6: /e
://t
different subtypes of two-column fractures).
. m Fig 3.8-7, Case 7: Fig 3.8-8)
: / / t . m
t t p s tps
ht
4.3 Typical fracture types in geriatric patients The exact roles of the different treatment strategies have not
h
Geriatric acetabular fractures show less variation than ac-
etabular fractures in younger patients due to more uniform
yet been clearly defined as there is a paucity of adequately
powered randomized or other prospective studies. Param-
injury mechanisms. The incidence of anterior column and eters which need to be addressed during decision making
wall fractures as well as anterior column with posterior include fracture type, age, comorbidities, activity level, os-
k e rs
hemitransverse fractures is significantly higher in these pa-
tients than in younger populations [4]. Additionally, radio-
ke rs
teoporosis, and preexisting osteoarthritis. Orthogeriatric
comanagement is necessary for optimal practice. Generally,
eb oo graphic findings associated with poor outcome, such as
e b oo
the delay between trauma and operative intervention should
b o o
e/e
superomedial dome impaction (gull sign) (Case 3: Fig 3.8-4, be minimized. The operative treatment of GAF, however,
e / e
Case 5: Fig 3.8-6), comminution, and marginal impaction in
m / requires special skills and an appropriate level of experience.

m
/ /t .
posterior wall fractures and femoral head impactions are
t .
A delay until operative treatment may be justified if no ex-
//
ps: ps:
more commonly seen in geriatric patients [4]. perienced surgeon is immediately available [13, 14].
htt htt 375
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
3.8 Acetabulum
k e rs ke rs
e b oo e b oo b o o
e / 5.2
t . m
Nonoperative versus operative treatment e / A 2-stage procedure with initial internal fixation and sec-
t . m e/e
s: / / / /
ps:
The appraisal of joint instability, rather than joint congru- ondary hip arthroplasty after osseous consolidation of the
http htt
ency in younger patients, represents an important factor in fracture in the situation of symptomatic posttraumatic os-
the decision-making process. Instability is often positively teoarthritis is a standard procedure in the treatment of ac-
correlated with pain and the inability to ambulate. In unclear etabular fractures in nongeriatric patients. In geriatric pa-
situations, an attempt to mobilize the patient with adequate tients, however, the concept of single-shot surgery, ie, a
pain management and close monitoring is often made. Fail- single operative intervention in the first days after trauma
e s
ure makes a strong case for operative stabilization (Case 3:
r
Fig 3.8-4).
er s
as a definitive solution, should be applied in order to reduce
the number of operative interventions and the overall re-
b o ok b
For the assessment of fracture stability, it is more importanto ok
habilitation time. Accordingly, primary hip arthroplasty is
an enticing concept for the treatment of geriatric acetabular
b o o
e/ e e/
to assess the acetabular columns rather than the acetabulare fractures. The major challenge of primary total hip arthro-
e/e
: // t .m
walls. While displaced acetabular walls need operative in-
tervention in young patients, this may not be true for geri-
plasty (THA) is the fixation of the cup in the fractured ac-
: /
etabulum. Revision cups and acetabular reinforcement rings
/ t .m
ht tps
atric patients. A displacement of a few millimeters may be
tolerated if the femoral head remains centered during weight
bearing (Case 1: Fig 3.8-2). Regular follow-up x-rays are there-
quired.
ht tps
and combinations with internal fixation are frequently re-
fore necessary in these cases in order to detect additional Primary arthroplasty may be considered in the following
displacement (Case 3: Fig 3.8-4). A displacement of only a few situations:
millimeters of the acetabular columns is relevant and indi-
e r s
cates a higher degree of instability. These fractures typically
e r s
• Fragile patients with limited mobility (Case 3: Fig 3.8-4)
ook ok o
require operative treatment (Case 7: Fig 3.8-8). Nondisplaced • Comminuted fractures (Case 5: Fig 3.8-6)
e b fractures of the columns as well as nondisplaced transverse

e b o • Impaction zones of the acetabular dome (gull sign)
b o
e / e/
or hemitransverse fractures may be treated nonoperatively
m
with weight bearing as tolerated (Case 1: Fig 3.8-2, Case 2:
t .
(Case 3: Fig 3.8-4, Case 5: Fig 3.8-6)
• Severe osteoporosis (Case 8: Fig 3.8-9)
t . m e/e
/ /
Fig 3.8-3). Operative treatment is usually indicated in fractures • Preexisting osteoarthritis (Case 7: Fig 3.8-8)
/ /
ps:
with subluxation or dislocation of the hip joint, even in
htt
patients in a poor general condition, in order to facilitate
nursing care and mobilization (Case 3: Fig 3.8-4, Case 5:
• Fractures that would require extensive surgery or
combined approaches (Case 5: Fig 3.8-6)
htt ps:
• Acetabular fractures after femoral hemiarthroplasty
Fig 3.8-6). Nonoperative treatment of unstable fractures with (Case 8: Fig 3.8-9)
prolonged bed rest or skeletal traction leads to poor func- • Periprosthetic acetabular fractures (Case 9: Fig 3.8-10)
tional results and complications due to immobilization and
e rs
should be avoided in the treatment of GAF [15].
e r s
b o ok 5.3 Internal fixation versus arthroplasty
b o
6
ok Therapeutic options
b o o
e/ e / e
Due to a lack of adequate trial data, the decision to employ
e
internal fixation or arthroplasty mainly depends on the sur-
6.1 Nonoperative treatment
Nonoperative treatment includes weight bearing as tolerated,
e /e
://t . m
geon's preference, experience, and personal skills [16-18].
/
using walking aids, and pain medication (Case 1: Fig 3.8-2,
: / t . m
t t p s
New prosthetic fixation concepts for the acetabular compo-
tps
Case 2: Fig 3.8-3). Nonsteroidal antiinflammatory drugs are
ht
nents, such as angular stable reinforcement rings (Case 3: often avoided in geriatric patients because of their renal,
h
Fig 3.8-4, Case 5: Fig 3.8-6, Case 8: Fig 3.8-9), and their further
development will increase the relevance of primary arthro-
gastric, and cardiac toxicity. Regular x-ray follow-ups are
mandatory in order to rule out secondary displacement. In
plasty for GAF. cases of worsening medial protrusion of the femoral head
and/or increasing pain during mobilization, operative in-
k e rs ke rs
tervention may be considered (Case 3: Fig 3.8-4).
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Nonoperative treatment
. m e /
. m e/e
CASE 1
/ / t / / t
Patient
htt ps:
A 76-year-old cooperative male patient living with his wife and able
to ambulate independently. He sustained a ground-level fall while
Comorbidities
• Carotid artery stenosis
• No history of cardiac disease htt ps:
walking onto his right hip. The initial x-ray showed a minimally • Osteoporosis (first diagnosed during the treatment of the
displaced fracture without medial protrusion of the femoral head acetabular fracture)
and preexisting radiological signs of hip osteoarthritis. The patient • Vitamin D deficiency 25-hydroxyvitamin D3: 9.2 ng/mL
e rs
had no relevant hip pain before trauma (Fig 3.8-2a). The computed
r s
(23 nmol/L)
e
b o ok tomographic scan showed an anterior column with incomplete pos-
terior hemitransverse fracture without articular displacement or
bo ok
Fracture type
b o o
e / e subluxation (Fig 3.8-2b–f).
e/ e Anterior column with incomplete posterior hemitransverse fracture
(AO/OTA 62B3), no articular displacement, and no medial protru-
e/e
: // t .m sion of the femoral head (Fig 3.8-2a-f).
: / / t .m
ht tps Treatment and outcome
ht tps
Pain management and mobilization were started on the first day after
admission. Weight bearing was performed as tolerated by the patient
using crutches. Full weight bearing (FWB) was achieved on the fifth
day with subsequent discharge after an x-ray follow-up. Vitamin D
e r s e r s
was given orally. At the final follow-up after 12 months, the patient
ook ok
had no relevant hip pain with complete functional recovery. X-ray
b b o follow-up showed mild radiologic progression of the osteoarthritis of
b o o
e / e e/ e the hip but no medial protrusion of the femoral head (Fig 3.8-2g).
e/e
a
/ / t . m Discussion
/ /t . m
s: ps:
In stable fractures without displacement of the columns and without
http htt
medial protrusion of the femoral head, nonoperative treatment is
a viable option even in the presence of displacement of the ace-
tabular walls of a few millimeters. Geriatric patients are typically not
able to perform partial weight bearing due to frailty, weakness, and
preexisting gait disorders. Accordingly, weight bearing should be
b
e rs e r s
performed as tolerated by the patient using walking aids. Full weight
bearing should not be prohibited. Regular follow-up x-rays are
b o ok b o ok
important in the first few weeks. In this case, FWB was achieved on
day 5.
b o o
e/ e e
e / e e /e
://t . m : / / t . m
c
t t p s tps
h ht
k e rsd f g
ke rs
eb oo Fig 3.8-2a–g A 76-year-old man after a fall.
e b oo b o o
/ / e/e
a X-ray showing a minimally displaced acetabular fracture, no medial protrusion of the femoral head, and preexisting signs of hip osteoarthritis.
e m e m
b–f Computed tomographic scan with coronal and 3-D reconstructions showing anterior column with incomplete posterior hemitransverse
t . t .
/
fracture, no articular displacement, no medial protrusion of the femoral head.
/ //
ps: ps:
g X-ray after 12 months showing mild radiological progression of the osteoarthritis, no medial protrusion of the femoral head, functional recovery.
htt htt 377
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
3.8 Acetabulum
k e rs ke rs
e b oo e b oo b o o
e / m
Secondary arthroplasty after nonoperative treatment
. e /
. m e/e
CASE 2
/ / t / / t
Patient
htt ps:
A 79-year-old cooperative female patient was living with her husband
and able to ambulate independently. She fell onto her right hip
Discussion
htt ps:
This case is similar to the case in Case 1: Fig 3.8-2. Rapid mobiliza-
tion and early discharge from hospital after nonoperative treatment
while hiking. The initial x-ray showed a consolidated fracture of the was feasible with an uneventful course during the first 6 months.
anterior pelvic ring and hip osteoarthritis. The patient had no relevant There was no prolonged period of immobilization and pain, which
hip pain before the trauma. While the fracture was not visible on is a major goal in geriatric fracture treatment. Total hip arthroplasty
e rs x-ray, the computed tomographic scan showed a nondisplaced

r s
(THA) after osseous consolidation of the fracture without acetabu-
e
b o ok transverse fracture of the right acetabulum (Fig 3.8-3a–b).
bo ok
lar deformity supersedes the need for a revision cup or an acetab-
ular reinforcement ring and enables the use of a cementless press-
b o o
e/ e Comorbidities
• Insulin-dependent diabetes mellitus
e/ e fit cup. The long-term survival rate of patients with secondary THA
after consolidated minimally or nondisplaced acetabular fractures
e/e
/ t .m
• Osteoporosis that was first diagnosed after an anterior pelvic ring
: / / t .m
is expected to be comparable with the survival rate of patients with
: /
tps tps
fracture and treated with vitamin D3 and calcium primary THA due to osteoarthritis of the hip or THA after femoral
ht ht
• No history of cardiac disease neck fractures [19, 20]. Indications for early operative treatment are
impaired mobilization due to severe pain and increasing displace-
Fracture type ment of the fracture. An additional indication for an early THA is
Nondisplaced transverse fracture (AO/OTA 62B1), no articular step- persistent pain in the first 6 months after trauma, while patients
off, and no medial protrusion of the femoral head (Fig 3.8-3a–b). with an interim pain-free period may be treated with secondary THA
e r s e r s
as shown in the case above.
ook ok
b
Nonoperative treatment as described in case 1 was performed with
b o b o o
e / e e/ e
discharge after 7 days. Alendronate (70 mg once a week) was added
to her basic osteoporosis treatment. There was an uneventful further
e/e
t . m
course with full functional recovery by 6 months and minimal need
/ / / /t . m
ps: ps:
for ongoing pain medication. The patient resumed hiking and performed
htt htt
all activities of daily living by herself. Subsequently, however, the
patient developed increasing pain in the right hip. An x-ray after
10 months showed progression of the hip osteoarthritis (Fig 3.8-3c).
Total hip arthroplasty was performed after 12 months with an unce-
mented press-fit cup. The further course was uneventful (Fig 3.8-3d).
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs a b c
ke rs d
eb oo Fig 3.8-3a–d A 79-year-old woman after a fall on her hip.
e b oo b o o
/ / e/e
a X-ray showing hip osteoarthritis but no visible fracture.
e m e
b Computed tomographic scan with transverse reconstruction showing a nondisplaced transverse fracture of the right acetabulum.
t . t .m
/
c X-ray after 10 months showing the healed fracture and radiological progression of hip osteoarthritis.
/ //
ps: ps:
d Total hip arthroplasty with uncemented press-fit cup.
378
htt htt
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / m
Primary arthroplasty after nonoperative treatment
. e /
. m e/e
CASE 3
/ / t / / t
Patient
htt ps:
An 81-year-old female patient with severe dementia, living in a
nursing home, with very limited mobility and using a walking frame.
Discussion
htt ps:
At this point, operative repair remains controversial in patients with
She was found lying on the floor of the nursing home. The patient significantly poor functional status. Typically, such cases are discussed
was not able to describe the injury. The initial x-ray showed an an- and decided by an interdisciplinary team. Due to her decreased life
terior column fracture with superomedial dome impaction (gull sign) expectancy, limited general mobility, and the presence of a radio-
e rs
(Fig 3.8-4a). The computed tomographic scan revealed an addi-
r s
graphic feature indicating poor outcome after internal fixation (gull
e
b o ok tional undisplaced posterior hemitransverse fracture (Fig 3.8-4b–d).
bo ok
sign), total hip arthroplasty was performed. Osseous continuity be-
tween the supraacetabular bone and the sacroiliac joint is manda-
b o o
e/ e Comorbidities
• Severe dementia
e/ e tory to use this type of reinforcement ring without additional inter-
nal fixation of the acetabular columns. The fractured acetabulum is
e/e
• Cervical carcinoma
: // t .m / t .m
simply bridged. In fractures with extensions to the iliac crest and to
: /
tps tps
• Severe osteoporosis (receiving drug therapy) the supracetabular bone, additional internal fixation may be consid-
ht ht
• Congestive heart failure ered (Case 6: Fig 3.8-7, Case 7: Fig 3.8-8). The major advantage of
this type of reinforcement ring is the use of multiple locking screws
Fracture type in different directions for better screw purchase in osteoporotic
Anterior column with undisplaced posterior hemitransverse fracture bone. While techniques for fixation of revision cups and reinforce-
(AO/OTA 62B3) and superomedial dome impaction (gull sign) ment rings are in general similar for the treatment of acetabular
e r s
(Fig 3.8-4a–d).
r s
fractures and acetabular bone defects, there is one major difference,
e
ook ok
ie, bone defects need to be bridged permanently, while acetabular
b
b o fractures heal within a few weeks resulting in an overall increased
b o o
e / e Due to her poor general condition and increased operative risks,
nonoperative treatment with pain management and mobilization
e/ e stability and decreased load to the implant.
e/e
t . m
was initially conducted. However, the patient complained of increas-
/ / / /t . m
ps: ps:
ing pain in the first days of attempts to mobilize her. An x-ray obtained
htt htt
on day 7 revealed increasing displacement and medial protrusion
of the femoral head (Fig 3.8-4e). Primary hip arthoplasty with no
additional internal fixation was performed on day 11 via a lateral
approach in a lateral decubitus position using an angular stable
reinforcement ring with a cemented polyethylene cup. This type of
e s
cup was used due to her low demand, her sarcopenia, and her
r
dementia in order to reduce the risk of hip dislocation. The reinforce-
e r s
b o ok ment ring was fixed to the supraacetabular bone using multiple
b o
small-fragment locking screws. Bone graft from the femoral head ok b o o
e/ e e / e
was used to fill the fracture gaps and to avoid cement penetrating
e /e
://t . m
into the lesser pelvis. No attempt was made to reduce the medial
wall. The postoperative mobilization included full weight bearing
: / / t . m
t p s
with a walking frame. Wound drainage during the fourth postop-
t tps
h
erative week was successfully managed with a single soft-tissue
revision and antibiotic treatment for 6 weeks. The x-rays at 3 months
showed a healed acetabular fracture without signs of component
ht
loosening (Fig 3.8-4f). The patient continued to reside in the nurs-
ing home, reached her former level of mobility, and did not have
k e rs
residual hip pain.
a
ke rs
eb oo e b oo
Fig 3.8-4a–f An 81-year-old woman after a fall.
b o o
/ / e/e
a X-ray showing an anterior column fracture and superomedial
e t . m e dome impaction (gull sign).
t .m
/ / //
htt ps: htt ps:
379
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
3.8 Acetabulum
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok b c
bo
d
ok b o o
e/ e e/ e e/e
: // t .m : / / t .m
ht tps ht tps
e r s e r s
e b ook e f
e b o ok b o o
/ e/ e/e
Fig 3.8-4a–f (cont) An 81-year-old woman after a fall.
e b–d C omputed tomographic scan with transverse, coronal, and sagittal reconstructions showing no relevant medial protrusion of the femoral
t . m
head, mild gull sign, and incomplete posterior hemitransverse fracture.
t . m
/ / / /
ps: ps:
e X-ray after 7 days showing increasing displacement and medial protrusion of the femoral head.
f X-ray after 3 months showing healed acetabular fracture without signs of component loosening.
htt htt
6.2 Internal fixation for direct reduction and fixation of the quadrilateral plate,
Internal fixation of GAF follows similar principles used for which is crucial to restore the buttress function of the me-
e rs
internal fixation of younger patients in terms of reduction
r s
dial wall [21, 22]. The Stoppa approach may be combined
e
b o ok and fixation techniques. There are, however, some differ-
b o
ences. The workhorse anterior approaches are the ilioingui- ok
with the lateral window of the ilioinguinal approach (Oler-
ud window) to stabilize high anterior column fractures and
b o o
e/ e / e
nal and the Stoppa approaches, while the Kocher-Langen-
e
beck approach is the standard posterior approach. Combined
fractures of the iliac crest (Case 4: Fig 3.8-5). Alternatively,
the quadrilateral plate may be addressed through the two
e /e
://t . m
and extensive approaches should be avoided (Case 4: Fig
/
lateral windows of the ilioinguinal approach and fixed with
: / t . m
t t p s
3.8-5). Given the higher incidence of anterior column frac-
tps
long cortical screws [23]. Conventional pelvic reconstruction
ht
tures and medial protrusion of the femoral head, anterior plates may be used for fixation, while future developments
h
approaches are more frequently used in geriatric patients.
The Stoppa approach as an “intrapelvic approach” allows
will allow the use of angular stable and anatomically pre-
shaped plates.
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:30
t t p s t t ps
h h
k e rs k e rs
eb oo / e b oo / e b
Internal fixation
. me . me
CASE 4
s: / / t s: / / t
Patient
h t t p
A 76-year-old cooperative male patient. He was very active and in
good general health. An x-ray of the hip obtained two years previ-
Discussion
h t t p
This is not a typical geriatric fracture despite the patient’s age for
the following reasons. First, there was a higher-energy trauma. Sec-
ously after a simple fall showed joint space narrowing (Fig 3.8-5a). ond, the patient was very active with no relevant comorbidities or
The patient, however, did not complain about hip pain at that time. osteoporosis. Third, this fracture type typically results from high-
Subsequently, he had a fall from an approximately 3-meter high tree energy trauma in nongeriatric patients, while anterior column with
ke rs
and sustained a two-column fracture of the left acetabulum
r s
posterior hemitransverse fractures are more common in geriatric
e
o o (Fig 3.8-5b-c).
o ok
patients. Accordingly, internal fixation was performed via an ante-
eb b eb
rior approach and primary hip arthroplasty was not considered.
Comorbidities
e/ e /
Primary arthroplasty in two-column fractures without additional in-
e
.m .m
• Benign prostatic hypertrophy ternal fixation is not advisable in general, as these fracture types are
: // t / /t
defined by an osseous separation of the two columns from the ili-
:
tps s
Fracture type ac bone, which impedes fixation of the acetabular component. In
http
Downloaded by: University of Ottawa. Copyrighted material.

ht
High two-column fracture of the left acetabulum (AO/OTA 62C1) younger patients, however, the posterior wall fragment may have
(Fig 3.8-5b-c). been addressed directly via a posterior approach in order to prevent
or at least delay symptomatic posttraumatic osteoarthritis. In this
Treatment and outcome case, secondary arthroplasty was considered to be necessary given
Internal fixation via a midline Stoppa approach with an additional the radiological finding of osteoarthritis already present prior to the
r s
iliac window was performed. The posterior column was indirectly
e r s
injury (Fig 3.8-5a). Fortunately, at 3 years the clinical result was
e
ook ok
reduced and fixed with a lag screw crossing both columns from satisfactory and secondary THA was not needed.
eb e b o
anterior to posterior [24]. A posterior approach was not used. Partial
e b
e/ /
weight bearing using crutches was advised for 6 weeks. An x-ray
me
follow-up after 3 years showed osseous consolidation of the fracture
/ t . m
and only mild progression of the hip osteoarthritis (Fig 3.8-5d). The
/ / / t .
ps: tps :
patient was satisfied with the functional result. There was no need
htt ht
for secondary total hip arthroplasty (THA) at this point.
e rs e r s
ok ok
eb o / e b o / e b
: / / t . me : / / t . me
a
ht tps b
ht tps
Fig 3.8-5a–d A 76-year-old man with a
two-column fracture of the left acetabulum.
a X-ray 2 years before trauma showing
mild signs of hip osteoarthritis.
b Computed tomographic scan with 3-D
reconstruction (view from anterior)
k e rs ke rs showing a two-column fracture of the

left acetabulum.
eb oo /e b oo c Computed tomographic scan with 3-D

reconstruction (view from posterior)
/e b
me me
showing a two-column fracture of the
left acetabulum.
c
: / /t . d
/ t.
d X-ray after 3 years showing mild
: /
tps s
progression of the hip osteoarthritis.
ht h t t p
381
/ / t . m // t . m
htt ps: htt ps:
3.8 Acetabulum
k e rs ke rs
e b oo e b oo b o o
e / 6.3 Arthroplasty
t . m e / 20, 25–28]. However, there is a lack of randomized or pro-
t . m e/e
s: / / / /
ps:
The major challenge of primary hip arthroplasty is the fix- spective studies, and the level of evidence is low. Recent
http htt
ation of the cup in the fractured acetabulum. Revision cups developments include reinforcement rings with angular
(Case 7: Fig 3.8-8, Case 9: Fig 3.8-10) and acetabular reinforce- stable fixation of the ring in the supraacetabular bone using
ment rings (Case 3: Fig 3.8-4, Case 5: Fig 3.8-6, Case 8: Fig 3.8-9) multiple locking screws (Case 3: Fig 3.8-4, Case 5: Fig 3.8-6,
often need to be employed. These implants were mainly Case 6: Fig 3.8-7, Case 8: Fig 3.8-9). These rings were primarily
developed for the treatment of acetabular bone defects and developed for the treatment of GAF in osteoporotic bone
e rs cup loosening in revision hip arthroplasty and were later

adopted for the treatment of GAF. There are several reports
er s
without additional internal fixation of the fractures. The
first results in a series of 30 patients showed promising results
b o ok describing primary hip arthroplasty using different approach-

es and implant types and in a small number of patients [16,
bo ok
with no implant-related failures (publication in progress).
b o o
e/ e e/ e e/e
: // t .m : / / t .m
Primary arthroplasty
ht tps ht tps
CASE 5

An 81-year-old cooperative female patient. After a stroke in 2006, With relevant displacement of the posterior column and the quad-
she recovered sufficiently and was able to walk short distances rilateral plate and medial protrusion of the femoral head, operative
without walking aids. She had a fall while walking on the street treatment was indicated after initial closed reduction and traction.
e r s and sustained an acetabular fracture on the left side. The trauma

e r s
The surgery was performed on the third day after trauma, using an
ook ok o
x-ray showed medial protrusion of the femoral head (central dis- angular stable reinforcement ring (Fig 3.8-4f) with a cemented poly-
e b location) (Fig 3.8-1) and a superomedial dome impaction (gull

e b o ethylene cup via a lateral approach. There was no attempt to reduce
b o
e / e/
sign) (Fig 3.8-6a). Three-dimensional reconstructions showed a
m
multifragmentary fracture of the anterior column (Fig 3.8-6b) and
t .
the quadrilateral plate (Fig 3.8-6d). One year postoperatively, the
fracture had healed and there was no component loosening
t . m e/e
/ /
a simple fracture of the posterior column with the quadrilateral
/ /
(Fig 3.8-6e). The patient had reached her previous activity level.
Comorbidities
ps:
plate in osseous continuity with the posterior column (Fig 3.8-6c).
htt Discussion
htt ps:
This case shows a typical geriatric acetabular fracture pattern, ie, an
• Ischemic heart disease anterior column with posterior hemitransverse fracture. The fracture
• Prior stroke in 2006 with incomplete functional recovery of the anterior column is multifragmentary while the posterior hemi-
• Depression transverse fracture is simple. The quadrilateral plate is in osseous
e rs e r s
continuity with the posterior column, which is internally rotated
b o ok Fracture type
b o
Anterior column with posterior hemitransverse fracture (AO/OTA ok
(open door injury). There is a superomedial dome impaction (gull
sign), which is a poor prognostic parameter after internal fixation.
b o o
e/ e / e
62B3) and superomedial dome impaction (gull sign) (Fig 3.8-6a-c).
e
Accordingly, primary total hip arthroplasty was performed via a
single approach with an uneventful postoperative course and func-
e /e
://t . m tional recovery.
: / / t . m
t t p s tps
h ht
Fig 3.8-6a–e An 81-year-old woman with
k e rs ke rs an acetabular fracture on her left side.

a X-ray showing medial protrusion of the
eb oo e b oo femoral head and superomedial dome

impression.
b o o
e /
t . m e / b Computed tomographic scan with
t .m
3-D reconstruction (view from oblique
e/e
/ / /
anterior) showing multifragmentary
/
ps: ps:
a b fracture of the anterior column.
382
htt htt
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok c d
bo ok e
b o o
e/ e e
Fig 3.8-6a–e (cont) An 81-year-old woman with an acetabular fracture on her left side.
e/
c Computed tomographic scan with 3-D reconstruction (view from posterior) showing a simple hemitransverse fracture of the posterior
e/e
// t .m
column, quadrilateral plate in osseous continuity with the posterior column.
/ / t .m
d Postoperative x-ray showing total hip arthroplasty using an angular stable reinforcement ring with a cemented polyethylene cup via a
: :
tps tps
lateral approach.
ht ht
e X-ray after 1 year showing healed acetabular fracture without signs of component loosening.
6.4 Internal fixation and arthroplasty fixation of both columns in combined procedures. Internal
e r s
If primary hip arthroplasty is deemed to be the best treat-
r s
fixation in these cases may be performed via either an an-
e
ook ok
ment option for GAF, additional internal fixation may be terior (Case 6: Fig 3.8-7) or posterior (Case 7: Fig 3.8-8) approach.
b
considered. Internal fixation allows for an easier fixation of
b o The latter approach allows for fixation and arthroplasty via
b o o
e / e revision cups and reinforcement rings by reducing major
e/
displacement and adding stability to the acetabular columns.e the same approach with an overall reduced operation time
and blood loss. Some case reports in the literature describe
e/e
t . m
A perfectly anatomical reduction is not essential. The ace-
/ / t . m
combined procedures of internal fixation and arthroplasty,
/ /
ps: ps:
tabular walls do not need to be addressed in combined pro- but the overall quality of evidence for this combination is
htt htt
cedures. Additionally, it is not necessary to perform internal low [2, 28–30].
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
383
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
3.8 Acetabulum
k e rs ke rs
e b oo e b oo b o o
e /
t . m
Internal fixation via an anterior approach and primary e /
t . m e/e
/ /
CASE 6
arthroplasty
ps: / ps: /
Patient
htt
An 83-year-old cooperative female patient, who was living alone
htt
Primary arthroplasty was considered as the better treatment option
and did not use any walking aids, sustained a fall in a bus due to compared to internal fixation due to the age of the patient and the
an unexpected emergency braking. The trauma x-ray (Fig 3.8-7a) multifragmentary fracture pattern. In order to address the fracture
e rs and computed tomographic scan (Fig 3.8-7b) showed a multifrag-

mentary anterior column fracture with an additional simple poste-
er s
extension to the iliac crest, plate fixation of the anterior column was
performed via a midline Stoppa approach in supine position followed
b o ok rior hemitransverse fracture. Additionally, there was a fracture exten-

sion to the iliac crest (arrow in Fig 3.8-7b).
bo ok
by total hip arthroplasty via a lateral approach in lateral decubitus
position using an angular stable reinforcement ring. The subsequent
b o o
e/ e e/ e course was uneventful. The fracture healed, there was no component
e/e
Comorbidities
• Hypertension
: // t .m again.
: / / .m
loosening (Fig 3.8-7c). The patient was able to walk independently
t
Fracture type
tps
• No history of cardiopulmonary events
ht Discussion
ht tps
In the first step of the decision-making process, operative treatment
Anterior column with posterior hemitransverse fracture (AO/OTA was deemed to be the best treatment option for this patient due
62B3) and fracture extension to the iliac crest (Fig 3.8-7a-b). to the multifragmentary fracture pattern and the medial protrusion
of the femoral head. In a second step, arthroplasty was favored as
e r s e r s
described above. The decision for an additional internal fixation was
ook ok o
made due to the fracture extension to the iliac crest. The plate
e b e b o bridges the anterior column but does not address the quadrilateral
b o
e /
t . m e/ plate. The sole use of a revision cup or a reinforcement ring would
t . m
not have bridged the fracture extension. The major disadvantage is e/e
/ / / /
the need for two approaches with additional operative time and
htt ps: ps:

blood loss, which ideally should be minimized in geriatric patients.
htt
e rs a
e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
kers rs
b c
o ke
oo o
Fig 3.8-7a–c An 83-year-old woman with a multifragmentary anterior column fracture.
b o b
a X-ray showing a multifragmentary anterior column fracture with medial protrusion of the femoral head.
b o
e /e /e e/e
b Computed tomographic scan with 3-D reconstruction (view from lateral oblique) showing a multifragmentary anterior column fracture
t . m e
with a simple posterior hemitransverse fracture and fracture extension to the iliac crest (arrow).
t .m
/ /
c X-ray after osseous healing: plate fixation of the anterior column via a midline Stoppa approach in supine position followed by total hip
/ /
ps: ps:
arthroplasty via a lateral approach in lateral decubitus position using an angular stable reinforcement ring.
384
htt htt
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ /
CASE 7
arthroplasty
ps: /
Internal fixation via a posterior approach and primary
ps: /
Patient htt
A 78-year-old male patient who was able to walk independently
Fracture type htt
Incomplete low two-column fracture (AO/OTA 62C2), major dis-
sustained a simple fall while walking. The initial x-ray (Fig 3.8-8a) placement of the posterior column (Fig 3.8-8a), and fracture exten-
and computed tomographic scan (Fig 3.8-8b–c) showed an incom- sion to the supraacetabular region (arrows in Fig 3.8-8b–c).
e rs
plete low two-column fracture with displacement of the posterior
er s
b o ok column and a fracture extension to the supraacetabular region (arrows
bo
in Fig 3.8-8b–c). Additionally, there were signs of preexisting osteo- ok
Primary arthroplasty was considered as the better treatment option
b o o
e/ e e/ e
arthritis (ie, narrowing of the joint space and subchondral bone cysts). than internal fixation mainly because of the preexisting and symp-
tomatic osteoarthritis. In order to address the fracture extension to
e/e
Comorbidities
: // t .m / t .m
the supraacetabular bone, open reduction and plate fixation of the
: /
tps tps
• Hypertension posterior column was performed via a Kocher-Langenbeck approach
ht ht
• Vitamin D deficiency (25-hydroxyvitamin D3: 8.4 ng/mL in a lateral decubitus position followed by total hip arthroplasty
[21 nmol/L]) using the same approach. A cementless revision cup was used. The
• Anticoagulation for atrial fibrillation further course was uneventful (Fig 3.8-8d).
Discussion
e r s e r s
This case is similar to the one in Case 6: Fig 3.8-7. The major dis-
ook ok
placement of the posterior column and the fracture extension, how-
b b o ever, can be addressed via a posterior approach. Arthroplasty was
b o o
e / e e/ e performed using the same approach, which eliminated the need
for a second approach and reduced the overall operative time. The
e/e
/ / t . m / /t . m
fracture pattern is not multifragmentary as in Case 6: Fig 3.8-7 due
ps: ps:
to the better bone quality in this case. Accordingly, a revision cup
htt htt
with conventional screws was used.
e rs e r s
b o ok b o ok b o o
e/ e a
e / e b c
e /e
://t . m : / / t . m
t t p s tps
h ht
Fig 3.8-8a–d A 78-year-old man with a low two-column fracture
after a fall.
k e rs ke rs
a X-ray showing an incomplete two-column fracture and major
displacement of the posterior column.
eb oo e b oo
b–c Computed tomographic scan with coronal reconstructions show-
ing fracture extension in the supraacetabular region (arrows).
b o o
e /
t . m e / d X-ray after 6 weeks showing open reduction and plate fixation
t .m
of the posterior column via a Kocher-Langenbeck approach
e/e
/ / /
with total hip arthroplasty using a cementless revision cup via
/
ps: ps:
d the same approach.
htt htt 385
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
3.8 Acetabulum
k e rs ke rs
e b oo e b oo b o o
e /
t . m
Acetabular fracture after femoral hemiarthroplasty e /
t . m e/e
/ /
CASE 8
ps: / ps: /
htt htt
Patient Fracture type
An 88-year-old female nursing home resident who required a walk- Anterior column with posterior hemitransverse fracture (AO/OTA
ing frame for ambulation sustained a femoral neck fracture 8 years 62B3) and no femoral component loosening or periprosthetic
previously, which was treated with femoral hemiarthroplasty. She femoral fracture (Fig 3.8-9a–b).
had a ground-level fall in the nursing home and sustained an ante-
k e rs rior column with posterior hemitransverse fracture of the right

acetabulum (Fig 3.8-9a–b). There was no femoral component loos-
er s
The initial treatment included closed reduction and the application
o o ening of the prosthesis or additional femoral periprosthetic fracture.

o ok
of traction (Fig 3.8-9c). Surgery was performed via a lateral approach
o o
e/eb b b
using an angular stable reinforcement ring with a cemented poly-
Comorbidities
e/ e ethylene cup. There was no reduction or internal fixation of the
e/e
• Diabetes mellitus
• Renal insufficiency
: // t .m : / / .m
acetabular fracture. Bone grafting to fill the fracture gap was not
t
performed, as there was no femoral head available. The further
• Peripheral neuropathy
ht
• Congestive heart failure
• Osteoporosis
tps ht tps
course was uneventful. The patient returned to the nursing home
and reached her former mobility level again. An x-ray follow-up after
2 years showed no component loosening and osseous consolidation
• Atrial fibrillation of the fracture despite the lack of bone grafting (Fig 3.8-9d).
Discussion
ke r s e r s
Internal fixation of acetabular fractures after femoral hemiarthro-
b o o b o ok
plasty is not advisable in general. In this case, an angular stable
reinforcement ring with a cemented cup was used due to the
b o o
e /e t . m e/ e frailty of the patient and the poor bone quality. The fracture was not
t . m
further addressed but healed. The operative procedure took ap- e/e
/ / / /
proximately 1 hour and allowed for immediate postoperative full
htt ps: management.

htt ps:
weight bearing, both of which are major goals in geriatric fracture
e rs a
e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
kers kers
b c d
b o o b o o
Fig 3.8-9a–d An 88-year-old woman with an anterior column fracture after a fall.
a X-ray showing an acetabular fracture after femoral hemiarthoplasty.
b o o
e /e e/e
b Computed tomographic scan with 3-D reconstruction (view from anterior oblique) showing the anterior column with posterior
hemitransverse fracture, no femoral component loosening or periprosthetic femoral fracture.
m m e/e
c
/t .
X-ray after closed reduction and the application of traction.
/ // t .
ps: ps:
d X-ray after 2 years showing no component loosening and osseous consolidation of the fracture.
386
htt htt
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Periprosthetic acetabular fracture
t . m e /
t . m e/e
/ /
CASE 9
ps: / ps: /
htt htt
Patient Discussion
A 71-year-old cooperative female patient able to ambulate indepen- There is no alternative option to revision arthroplasty in this case.
dently. Total hip arthroplasty was performed 2 years before due to In order to facilitate cup fixation in the presence of a transverse
hip osteoarthritis via a minimally invasive anterior approach. She had fracture, a posterior approach was applied, the posterior column
a simple fall on her left hip and sustained a periprosthetic transverse was stabilized, and a revision cup was inserted through the same
e s
fracture of the acetabulum with cup loosening (Fig 3.8-10a). There
r
was no loosening of the shaft or periprosthetic femoral fracture.
er s
approach. Due to her younger age, good health status, and better
bone quality (Case 8: Fig 3.8-9), a revision cup with conventional
bo ok
screws was used.
b o o
e/ e • Hypertension
e/ e e/e
[17 nmol/L])
: // t .m
• Vitamin D deficiency (25-hydroxyvitamin D3: 6.8 ng/mL
: / / t .m
Fracture type
ht tps
Periprosthetic transverse fracture with cup loosening ht tps
(AO/OTA 62B1) (Fig 3.8-10a).
e r s
Surgery was performed via a posterior Kocher-Langenbeck approach.
e r s
ook ok o
In a first step, the cup was removed via a posterior arthrotomy. Then
e b b o
the posterior column was reduced and fixed with a pelvic reconstruc-
e b o
e / e/
tion plate. The quadrilateral plate was not addressed. A cementless
m
revision cup was used. The further course was uneventful as the
t . t . m e/e
/ /
x-ray after 6 weeks shows (Fig 3.8-10b).
/ /
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
e/e
a b
e / m e /
Fig 3.8-10a–b A 71-year-old woman after a fall on her left hip.
m
/t .
a X-ray showing periprosthetic transverse fracture with cup loosening.
/ // t .
ps: ps:
b X-ray after 6 weeks showing posterior approach and plate fixation of the posterior column as well as cementless revision cup.
htt htt 387
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
3.8 Acetabulum
k e rs ke rs
e b oo e b oo b o o
e / 7 References
t . m e /
t . m e/e
/ / / /
htt ps:
1. Mears DC. Surgical treatment of
acetabular fractures in elderly
patients with osteoporotic bone.
11. Garrett J, Halvorson J, Carroll E, et al.
Value of 3-D CT in classifying
acetabular fractures during orthopedic
htt ps:
24. Gansslen A, Krettek C. Osteosynthese
von Zwei-Pfeiler-Frakturen des
Azetabulums über den ilioinguinalen
J Am Acad Orthop Surg. residency training. Orthopedics. Zugang [Internal fixation of acetabular
1999 Mar–Apr;7(2):128–141. 2012 May;35(5):e615–e620. both-column fractures via the
2. Cornell CN. Management of acetabular 12. Letournel E. Acetabulum fractures: ilioinguinal approach]. Oper Orthop
fractures in the elderly patient. classification and management. Clin Traumatol. 2009 Sep;21(3):270–282.
e rs HSS J. 2005 Sep;1(1):25–30.

3. Ochs BG, Marintschev I, Hoyer H, et al.
r s
Orthop Relat Res. 1980 Sep(151):81–106.
e
13. Moed BR, WillsonCarr SE, Watson JT.
German.
25. Romness DW, Lewallen DG. Total hip
b o ok Changes in the treatment of acetabular

fractures over 15 years: Analysis of
bo ok
Results of operative treatment of
fractures of the posterior wall of the
arthroplasty after fracture of the
acetabulum. Long-term results. J Bone
b o o
e/ e 1266 cases treated by the German
Pelvic Multicentre Study Group (DAO/
e/ e
acetabulum. J Bone Joint Surg Am.
2002 May;84-A(5):752–758.
Joint Surg Br. 1990 Sep;72(5):761–764.
26. Hoellen IP, Mentzel M, Bischoff M,
e/e
.m .m
DGU). Injury. 2010 Aug;41(8):839–851. 14. Mears DC, Velyvis JH, Chang CP. et al. Acetabulumfraktur beim alten
: // t
4. Ferguson TA, Patel R, Bhandari M, et al.
Fractures of the acetabulum in patients
Displaced acetabular fractures managed
operatively: indicators of outcome.
: / / t
Menschen. Primäre endoprothetische
Versorgung [Acetabular fractures
tps tps
aged 60 years and older: an Clin Orthop Relat Res. in elderly persons. Primary
ht ht
epidemiological and radiological study. 2003 Feb(407):173–186. endoprosthetic treatment]. Orthopade.
J Bone Joint Surg Br. 15. Spencer RF. Acetabular fractures in 1997 Apr;26(4):348–353. German.
2010 Feb;92(2):250–257. older patients. J Bone Joint Surg Br. 27. Borens O, Wettstein M, Garofalo R,
5. Sullivan MP, Baldwin KD, Donegan DJ, 1989 Nov;71(5):774–776. et al. Die Behandlung von
et al. Geriatric fractures about the hip: 16. Ward AJ, Chesser TJ. The role of acute Acetabulumfrakturen bei geriatrischen
divergent patterns in the proximal total hip arthroplasty in the treatment Patienten mittels modifizierter
e r s femur, acetabulum, and pelvis.

Orthopedics. 2014 Mar;37(3):151–157.
of acetabular fractures. Injury.
2010 Aug;41(8):777–779.
e r s Kabelcerclage und primärer
Hüfttotalprothese. Erste Ergebnisse
ook ok
6. Hessmann MH, Nijs S, Rommens PM. 17. Gary JL, VanHal M, Gibbons SD, et al. [Treatment of acetabular fractures in
b
Acetabulumfrakturen im Alter.
Ergebnisse eines differenzierten
b o
Functional outcomes in elderly patients
with acetabular fractures treated with
the elderly with primary total hip
arthroplasty and modified cerclage.
b o o
e / e Behandlungskonzeptes [Acetabular
fractures in the elderly. Results of a
e/ e
minimally invasive reduction and
percutaneous fixation. J Orthop Trauma.
Early results]. Unfallchirurg.
2004 Nov;107(11):1050–1056. German.
e/e
sophisticated treatment concept].
/ / t . m 2012 May;26(5):278–283.
t . m
28. Rickman M, Young J, Trompeter A, et al.
/ /
ps: ps:
Unfallchirurg. 18. Li YL, Tang YY. Displaced acetabular Managing acetabular fractures in the
2002 Oct;105(10):893–900. German. fractures in the elderly: results after elderly with fixation and primary
htt htt
7. Anglen JO, Burd TA, Hendricks KJ, et al. open reduction and internal fixation. arthroplasty: aiming for early
The “Gull Sign”: a harbinger of failure Injury. 2014 Dec;45(12):1908–1913. weightbearing. Clin Orthop Relat Res.
for internal fixation of geriatric 19. Toro JB, Hierholzer C, Helfet DL. 2014 Nov;472(11):3375–3382.
acetabular fractures. J Orthop Trauma. Acetabular fractures in the elderly. 29. Guerado E, Cano JR, Cruz E. Surgical
2003 Oct;17(9):625–634. Bull Hosp Jt Dis. 2004;62(1-2):53–57. technique: intraacetabular
8. Ohashi K, El-Khoury GY, Abu-Zahra KW, 20. Makridis KG, Obakponovwe O, Bobak P, osteosynthesis with arthroplasty for
et al. Interobserver agreement for et al. Total hip arthroplasty after acetabular fracture in the octogenarian.
e rs Letournel acetabular fracture

r
acetabular fracture: incidence of
e s Injury. 2012 Apr;43(4):509–512.
ok ok
classification with multidetector CT: are complications, reoperation rates and 30. Saxer F, Studer P, Jakob M. Offene
b o
standard Judet radiographs necessary?
Radiology. 2006 Nov;241(2):386–391.
functional outcomes: evidence today.
b o
J Arthroplasty.
Stabilisierung und Endoprothetik bei
geriatrischen Patienten mit
b o o
e/ e 9. O’Toole RV, Cox G, Shanmuganathan K,
et al. Evaluation of computed
e / e
2014 Oct;29(10):1983–1990.
21. Hirvensalo E, Lindahl J, Bostman O.
acetabulären Frakturen [Open
stabilization and primary hip
e /e
tomography for determining the
diagnosis of acetabular fractures.
://t . m A new approach to the internal fixation

of unstable pelvic fractures. Clin Orthop
/ / t .
arthroplasty in geriatric patients with
acetabular fractures: combination of
: m
J Orthop Trauma.
2010 May;24(5):284–290.
t t p s Relat Res. 1993 Dec(297):28–32.

22. Laflamme GY, Hebert-Davies J, Unfallchirurg.
tps
minimally invasive techniques].
h
10. Hufner T, Pohlemann T, Gänsslen A,
et al. Die Wertigkeit der CT zur
Klassifikation und
Entscheidungsfindung nach
Rouleau D, et al. Internal fixation of
osteopenic acetabular fractures
involving the quadrilateral plate. Injury.
2011 Oct;42(10):1130–1134.
ht
2011 Dec;114(12):1122–1127. German.
Acetabulumfrakturen. Eine 23. Culemann U, Holstein JH, Kohler D,

systematische Analyse [The value of CT et al. Different stabilisation techniques
k e rs in classification and decision making in

acetabulum fractures. A systematic
e rs
for typical acetabular fractures in the
elderly– a biomechanical assessment.
k
oo oo o
analysis]. Unfallchirurg. 1999 Injury. 2010 Apr;41(4):405–410.
eb
Feb;102(2):124–131. German.
e b b o
e /
t . m e /
t .m e/e
/ / //
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rs
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/ / t . m // t . m
htt ps: htt ps:
Simon C Mears, Stephen L Kates
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
3.9 Femoral neck / / / /
htt ps:
htt ps:
e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e • The team also includes the emergency department team,
e/e
: // t .m
Femoral neck fracture is a common injury in older adults,
: / / t .m
medical doctors, anesthesiologists, nurses, therapists, and
hospital administrators. All must be fully committed to
ht tps
which typically requires both hospitalization and surgery.
Successful management of the femoral neck fracture patient
requires an understanding of the basic geriatric principles, ht tps
early surgery and mobilization to achieve the best results.
The goal of this chapter is to present the basics of femoral

ie, early operative intervention, managing the osteoporotic neck fracture management using case presentations.
bone, and avoiding adverse events including reoperation,
and how to apply them:
e r s 2
e r s
Epidemiology and etiology
ook ok o
• Nearly all femoral neck fractures require surgery to return
e b b o
patients as close as possible to their former level of func-
e
Hip fractures are a common injury and femoral neck fractures
b o
e / tion.
m e/
• Better outcomes occur when surgery is performed rap-
t .
represent about half of these fractures [4, 5]. The prevalence
t . m
of femoral neck fracture is increasing worldwide as a result e/e
/ /
idly after the injury. Earlier surgery has been shown to
/ /
of the aging population. If osteoporosis is effectively treated,
htt ps:
reduce the risk of mortality and morbidity even when
factors such as patient comorbidities are controlled. Sur-
gery within 12 hours of the injury may give the best htt ps:
the incidence of fractures can be reduced [5].
Femoral neck fractures are usually the result of falls on

results. mechanically weakened bone. Osteoporosis results in bones
• Most femoral neck fractures are unstable fractures; ar- with thinner cortices and reduced quantity and quality of
throplasty allows for immediate weight bearing. cancellous bone. Osteoporotic bones are wider in diameter
e rs
• A truly nondisplaced or stable impacted fracture may be
r s
and more susceptible to fracture. Osteoporotic patients also
e
b o ok treated with internal fixation techniques.
b o
• Displaced and angulated fractures are best treated with ok
tend to fall more frequently due to poor balance, sarcopenia,
visual problems, and comorbid conditions [6]. The rise in
b o o
e/ e / e
arthroplasty. Internal fixation of displaced fractures leads
e
to an unacceptable rate of reoperation (ie, about 40%)
frequency of falls increases the likelihood of a catastrophic
fall with fracture. Femoral neck fractures often occur in
e /e
[1–3].
://t . m / t .
patients with multiple comorbidities. They are more com-
: / m
t t p s
• Arthroplasty technique is dependent on patient factors
tps
mon in women than men, although men experience high-
ht
and surgeon factors. Infirm patients do well with hemi- er complication rates after a fracture than women.
h
arthroplasty, while active, cognitively intact patients do
better with total hip arthroplasty (THA).
• The ideal stem and cup design characteristics are un- 3 Diagnostics
known. However, a higher rate of periprosthetic fractures
kers rs
occurs after uncemented stem fixation. Preoperative evaluation should be streamlined and standard-
o
• The goal of surgery is immediate full weight bearing and
ke
ized. Emergency department physicians should quickly
b o mobilization. Early rehabilitation allows for maximal re-

b oo
evaluate for fracture using plain x-rays and rapidly assess
b o o
e /e e e/e
turn of function. the patient and consult the orthopedic surgeon and medical
m e /
• Early surgery requires a coordinated approach to care specialist. Standardization of orders and protocols should
m
/ /t .
with medical and orthopedic services working together
t .
allow for quick admission and limited medical testing with
//
ps: ps:
for optimal outcomes. a goal of early surgery [7].
htt htt 389
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
3.9 Femoral neck
k e rs ke rs
e b oo e b oo b o o
e / 3.1 Clinical evaluation
t . m e / valgus-impacted fractures with no displacement on the lat-
t . m e/e
s: / / / /
ps:
Patients with femoral neck fractures typically present with eral view. Displaced fractures are any fracture with displace-
http htt
acute hip pain after injury and are unable to bear weight ment on lateral x-rays and/or varus displacement.
on the injured extremity. Physical examination findings
typically demonstrate pain with hip motion. With a displaced
fracture, the leg will be shortened and externally rotated. 5 Decision making
Nondisplaced fractures may present without shortening and
k e rs the practitioner needs to have a low threshold for imaging

to rule out fracture. Patients are often not reliable regarding
5.1
er s
Operative versus nonoperative
Most patients with femoral neck fractures are treated op-
o o their history of injury. They may be able to lift their leg and
o ok
eratively. A minority may be considered for nonoperative
o o
e/eb b b
even walk around. If they have a nondisplaced femoral neck treatment [12]. Generally, this applies to a patient who can-
e/ e
fracture, the fracture can displace in the next week or two. not tolerate any type of surgery or is truly at the end of life.
e/e
: // t .m
For information regarding medical assessments and optimi-
zation for surgery, see chapter 1.4 Preoperative risk assess-
Some patients with dementia may have severe contractures
: / / t
that would make operative repair almost impossible. In these .m
ment and preparation.
3.2 Imaging ht tps ht tps

cases, patients may be mobilized as tolerated, and pain con-
trol and pressure sore prevention efforts are of utmost im-
portance. A palliative care consult is often useful and con-
An AP pelvis and AP and lateral views of the affected hip sideration should be given to hospice care.
should be performed. A true AP view is needed to visualize
the entire femoral neck. Rotated or oblique views may fail 5.2 Fixation versus arthroplasty
e r s
to visualize the fracture. A pelvis view is helpful to look for
k e r s
5.2.1 Stable fractures
b o o associated injuries or prior surgical implants. It is also used

for preoperative planning. Care should be taken to place
b o ok
Nondisplaced fractures are often considered for internal
fixation (Case 1: Fig 3.9-1) [13]. It is critical that the fracture
b o o
e /e m e/ e
the uninjured leg in a neutral position while imaging. If the
x-rays are normal and examination of the hip produces pain,
t .
is “truly stable”. Any displacement on the lateral view gen-
erally means instability. Fixation may be performed with
t . m e/e
/ /
a fracture is still likely. Further imaging is then required to
/ /
cannulated screws or with a sliding hip screw using standard
rule out fracture.
htt ps:
Magnetic resonance imaging is the best test to look for bone
image intensification on a fracture table.
htt ps:
For positioning of cannulated screws, three screws are com-
edema, nondisplaced or stress fractures [8]. A computed monly used and an inverted triangle formation had been
tomographic (CT) scan with thin cuts through the femoral shown to lead to fewer nonunions [14]. This has also been
neck is the second best test. This will diagnose most, but not shown to be more stable. It is essential to keep the lateral
e rs
all femoral neck fractures. It is also the most appropriate to
r s
screw entry point above the level of the lesser trochanter
e
b o ok evaluate nonunions after fixation attempts.
b o ok
[15]. Multiple entry holes should also be avoided to prevent
creation of a stress riser and subsequent subtrochanteric
b o o
e/ e 4 Classification
e / e femoral fracture [16].
e /e
://t . m / t
The use of arthroplasty for the treatment of stable fractures
: / . m
t t p s
Femoral neck fracture classifications include many different
tps
is controversial. Arthroplasty has some advantages. It pres-
ht
systems of varying complexity [9]. The most commonly used ents no significant risk for poor healing, the development
h
is the Garden system that uses AP hip x-rays and classifies
femoral neck fractures into four types. Types 1 and 2 are
of avascular necrosis, or nonunion or malunion of the frac-
ture. Patients treated with arthroplasty have fewer reop-
nondisplaced or minimally displaced and types 3 and 4 are erations, less pain, and higher quality of life than patients
displaced. Discrimination between type 1 and 2 fractures or treated with fixation [17]. The surgery, however, has risk
k e rs
type 3 and 4 fractures limited by high interobserver vari-
ability [10]. Because of this, fractures are termed stable or
ke rs
associated with arthroplasty and leads to slightly higher
blood loss [18]. Further studies are required to determine
eb oo unstable. In nondisplaced fractures it is important to evalu-
e b oo
the best treatment for stable femoral neck fractures.
b o o
e/e
ate the lateral view as well as the AP view. Displacement
e / m e /
on the lateral view alone may lead to a higher rate of failure
m
t .
with internal fixation [11]. Stable fractures are either non-
/ / // t .
ps: ps:
displaced or detectable only by advanced imaging or are
390
htt htt
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / Stable fracture treated with screw fixation
. m e /
. m e/e
CASE 1
/ / t / / t
Patient
htt ps:
A 93-year-old woman sustained a low-energy fall. She lived with
her granddaughter at home and could ambulate independently. htt ps:
room to assess stability with range of motion of the hip. This does
require extra operating time as this must be done prior to position-
ing the patient for either internal fixation or hemiarthroplasty. Two
Comorbidities image intensifiers can also help in positioning the screws during
• Hypertension surgery.
e rs
• Mild cognitive dysfunction
er s
bo ok
If internal fixation is chosen, various options exist. It is unclear if
screw fixation or sliding hip screw with side plate is the best option
b o o
e / e e/ e
The patient’s x-rays in the emergency department revealed a right-
sided valgus-impacted femoral neck fracture (Fig 3.9-1a). This ap-
[20]. Currently, the results of the trial by fixation using alternative
implants for the treatment of hip fractures investigators, which seeks
e/e
/ t .m
peared well aligned on the lateral view (Fig 3.9-1b). She underwent
: / / t .m
to answer this question, are nearing publication [21]. Arthroplasty,
: /
tps tps
screw fixation in situ, which was found to be stable under image while a longer surgery, may provide better results long term with
ht ht
intensification (Fig 3.9-1c–d). She was mobilized and allowed to less reoperations and higher patient satisfaction [18]. Another con-
bear weight, and the fracture showed evidence of radiographic and troversial topic within this case is the prevention of second osteo-
clinical healing at 3 months (Fig 3.9-1e). porotic fractures. The rate of a second fracture is particularly high
in female patients with advanced age and multiple comorbidities
Nine months later she had a similar fall and sustained a similar [22]. The exact pharmacological treatment of osteoporosis in geri-
e r sinjury on the contralateral side (Fig 3.9-1f), despite the use of intra-
r s
atric patients or near the end of life is controversial. Treatments that
e
ook ok
venous bisphosphonate therapy to manage osteoporosis after the take time to work may not be worthwhile. Bisphosphonate therapy
b b o
first fracture. This was also treated with screw fixation (Fig 3.9-1g). is thought to be cost-effective in patients up to age of 90 years [23].
b o o
e / e e/ e
Her second fracture also went on to uneventful healing (Fig 3.9-1h). Fall prevention strategies and supplementation with calcium and
vitamin D are worthwhile. Patients with femoral neck fractures should
e/e
Discussion
/ / t . m t . m
be assessed and treated for osteoporosis after fracture. Despite
/ /
ps: ps:
This patient sustained sequential bilateral stable femoral neck frac- treatment with intravenous bisphosphonate, this patient sustained
htt htt
tures. Both were treated successfully with internal fixation. The pa- a second fragility fracture.
tient was allowed to bear weight as tolerated after both surgeries,
which was crucial for early rehabilitation and return to function. Key points
• Stable femoral neck fractures with no displacement or with
Operative fixation options here included the use of internal fixation stable valgus impaction can be treated with internal fixation.
e s
or arthroplasty. Unstable fracture patterns have more reoperations
r
when internal fixation is used than stable fracture patterns. Determi-
e r s
• Screws should be carefully positioned in an inverted triangle to
give the best chance of fracture healing with internal fixation.
b o ok nation of the stability of the fracture can be assessed using x-rays
b o
with AP and lateral views. There may be a role for the use of com- ok
• If the fracture is noted to be unstable on evaluation with image
intensifier, strong consideration should be given for arthroplasty
b o o
e/ e e / e
puted tomographic scanning to help in this determination [19]. An- rather than internal fixation.
e /e
://t . m
other possible option is to use image intensification in the operating
: / / t . m
t t p s tps
h ht
Fig 3.9-1a–h A 93-year-old
independent woman after
k e rs ke rs several falls.
a AP injury x-ray of the
eb oo e b oo pelvis showing a valgus-

impacted right femoral
b o o
e /
t . m e / neck fracture.
t .m
b The lateral view showing
e/e
/ / /
good alignment of the
/
ps: ps:
a b neck and head.
htt htt 391
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
3.9 Femoral neck
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
ps: ps:
Fig 3.9-1a–h (cont) A 93-year-old
htt htt
independent woman after several falls.
c AP view of the hip with image in-
tensification showing the position
of the guide wires in the femoral
head across the fracture.
d The intraoperative lateral view
under image intensification show-
e rs er s ing the alignment of the guide
ok ok
wires in the lateral plane.
b o bo e AP x-ray of the hip showing the
b o o
e/ e c d
e/ e e fracture fixation at 3 months after

the injury. The fracture position is
e/e
: // t .m / / t .m
unchanged and there is no change
in the position of the screws.
:
tps tps
f Coronal computed tomographic
ht ht
scan of the hip showing the con-
tralateral fracture with a very simi-
lar pattern to the initial fracture.
g AP intraoperative view with
image intensification showing
excellent positioning of the guide
e r s e r s wires for the screw fixation.

h Both fractures seemed to be
ook ok o
radiographically healed and in
e b e b o excellent alignment 3 months

b o
e/e
f g h
e / m e/
after the second fracture.
m
/ / t . / /t .
htt
5.2.2 Unstable fractures
ps:
Most femoral neck fractures are displaced and are best treat-
htt ps:
malunion, shortening, or avascular necrosis [1–3]. (Case 2:
Fig 3.9-2). A treatment algorithm or femoral neck fracture
ed with arthroplasty. In several studies, internal fixation treatment is seen in Fig 3.9-3.
had a significantly higher reoperation rate for nonunion,
e rs e r s
o ok Unstable fracture treated with fixation
o ok o o
CASE 2
e/ e b Patient
e / e b e /e b
://t . m
A 72-year-old woman with a history of stroke and left-sided weak-
ness. Twenty years earlier, she had sustained a distal femoral frac-
: / / t .
unstable at the time of fixation and a derotation pin was placed
during insertion of the hip screw. The pin was removed after screw m
t t p s
ture treated with a retrograde nail. She was minimally ambulatory
tps
placement. The bone quality was extremely poor. After surgery, the
h
getting from bed to chair and always used a walker. The patient fell
from a seated position and sustained a displaced femoral neck
fracture with x-rays demonstrating a low femoral neck fracture
ht
patient had increasing pain and at 2 weeks the fracture fixation was
seen to have slipped with migration of the screw (Fig 3.9-2d). Two
weeks later the screw had cut out through the head and pain was
(Fig 3.9-2a). The intramedullary rod extended to below the lesser worse (Fig 3.9-2e).
trochanter. After discussion with the patient and family the decision
k e rswas made to attempt fracture fixation, as arthroplasty would have

e rs
The patient wanted to try to walk again and elected to have the
k
b o o required removal of the nail.
b oo
hardware removed with conversion to a hip arthroplasty. During
surgery the hip screw was removed and the hip was found to be
b o o
e /e stiff. The nail was then removed. The bone of the distal femur had
e/e
/ /t . m
Fracture fixation was performed using a 4-hole sliding hip screw
with side plate to overlap the nail (Fig 3.9-2b–c). The fracture was
// t m
grown in to the nail, and some of the intramedullary bone of the
.
distal femur came out with the nail, weakening the distal bone.
htt ps: htt ps:

rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
During further hip exposure the distal femur fractured (Fig 3.9–2f).
t . m
Another option for difficult cases with poor bone is the use of cement e/e
s: / / / /
ps:
The intraoperative decision was made to treat the distal femoral augmentation. This is not approved for use by the Food and Drug
http htt
fracture with a long locking plate and the femoral head was removed Administration in the United States but is commonly used in Europe
(Fig 3.9-2g). The distal femoral fracture healed and the patient went [24]. Cement is carefully placed within the femoral head prior to
on to use a motorized wheelchair for ambulation. At 3 months after placement of the hip screw. Great care must be taken to prevent
surgery, the hip was much less painful and she was satisfied with cement from entering the joint and if penetration of the femoral
the result (Fig 3.9-2h–i). head has occurred with the guide wire, cement should not be used.
e rs
Discussion
e
Key pointsr s
b o ok Decision making is important in the minimally ambulatory patient.
bo
In this situation arthroplasty was fraught with difficulty with the in ok
Unstable fractures have a high rate of failure with internal fixation.
Some patients with complex problems and minimal ambulation
b o o
e/ e e/
situ hardware and the extremely poor bone stock. Removal of thee may be better treated with hip resection or nonoperative treatment.
e/e
: // t .m
retrograde femoral nail was difficult, and the unstable nature of the
fracture made fixation challenging. While the sliding hip screw was
: / / .m
Older adults with hip fractures have little reserve, and very little
t
margin exists for both operative and medical errors. The best results
ht tps
placed with a low tip-apex distance, the bone quality was so poor
that fixation was not sufficient. Perhaps initial hip resection or non-
operative care would have led to the same results but with much
morbidity, and mortality.
ht tps
should be achieved in the first surgery to prevent complications,
less morbidity than the two operations that were performed.
e r s e r s
e /
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
a b c
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
d
h
e f g h
ht i
Fig 3.9-2a–i A 72-year-old woman with an unstable fracture.
a Injury AP x-ray showing a low femoral neck fracture.
k e rs
c Lateral x-ray showing that the reduction was not completely anatomical.
ke rs
b AP x-ray showing a 2-hole sliding hip screw with side plate placed above the existing retrograde nail.
eb oo b oo
d At 2 weeks after surgery the hip screw had migrated superiorly into the femoral head.
e At 4 weeks the fixation has completely failed and the head screw had penetrated the femoral head.
e b o o
e / g
e /
f Intraoperative image intensification showing an AP view of the distal femur. The fracture line is visible at the supracondylar level.
m
Intraoperative x-ray showing plate fixation of the femur.
t . t .m e/e
/
h Three months after surgery, an AP x-ray shows healing at the fracture site.
/ //
ps: ps:
i AP view of the hip showing the femoral head resection and the plate extending up to the proximal femur.
htt htt 393
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
3.9 Femoral neck
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
s: / / Femoral neck fracture
/ /
http Fit for surgery
Most patients htt ps:
End of life
Nonoperative care
Displaced Nondisplaced
e rs er s Gentle mobilization
b o ok Community ambulator
o
Minimal ambulator
b ok Internal fixation
b o o
e / e Total hip arthroplasty
e/ e Hemiarthoplasty Consider arthroplasty
e/e
.m .m
Fig 3.9-3 An algorithm for treatment of femoral neck fractures [25].
: // t : / / t
5.2.3 Timing
ht tps
Timing of treatment is critical for the best outcomes. There ht tps
UK from 10.9% to 8.5% (for more information on hip frac-
ture audit, see chapter 2.9 Use of registry data to improve
is debate about the best time to fix hip fractures but clearly, care) [27]. There is some data that extremely rapid repair,
early surgery is better. Longer delays give the patients more ie, less than 12 hours, may have the best results [28, 29].
days in pain, are expensive, and lead to higher morbidity
e r s and mortality rates. The American Academy for Orthopae-

e r s
5.2.4 Hemiarthroplasty or total arthroplasty
ook ok o
dic Surgery’s (AAOS) Hip Fracture Clinical Practice Guidelines With arthroplasty, there are several decisions to make. One
e b give a moderate recommendation for surgery within 48 hours

e b o is whether to perform partial or THA. As a rule, age greater
b o
e / [26]. By implementation of a hip fracture audit including a
m e/
requirement for hip fracture repair within 36 hours of frac-
t .
than 80 years, low functional status, and multiple comor-
bidities all support hemiarthroplasty (Case 3: Fig 3.9-4).
t . m e/e
/ /
ture, mortality rates have been reduced nationwide in the
/ /
htt ps: htt ps:
Cemented hemiarthroplasty
CASE 3
Patient
e rs An 83-year-old man with a history of Parkinson's disease and mul-

r s
after surgery, his pain was greatly improved. The x-rays showed his
e
b o ok tiple comorbidities. He had sustained a previous hip fracture on the
b o
contralateral side 2 years before. He had a fall 8 weeks back and ok
hemiarthroplasty to be in good position (Fig 3.9-4d–e).
b o o
e/ e / e
was in the emergency department with knee pain. The x-rays of the
e
knee at that time did not reveal any acute injury (Fig 3.9-4a). He
At this point the family found it difficult to come in for follow-up and
requested that he should only return to the clinic if he had a problem
e /e
://t . m
was having difficulty walking and was transferred to a nursing home. with the hip.
: / / t . m
t t p s
His pain continued until he became unable to transfer himself inde-
tps
ht
pendently. He was found to have knee pain with hip motion, and Discussion
h
x-rays revealed a nonunion of a femoral neck fracture (Fig 3.9-4b–c). On initial presentation to the emergency department, the diagnosis
of femoral neck fracture was missed. The patient complained of
Comorbidities knee pain, and the knee x-rays were negative. Hip pain often refers
• Multiple comorbidities including deafness and blindness to the knee and any older patient with a fall should be thoroughly
k e rs Treatment and outcome

ke rs
evaluated. Any pain on hip examination requires an x-ray to rule out
hip fracture. In this case, treatment was delayed by several weeks
eb oo He was admitted from the emergency department and evaluated
e b oo
and this resulted in further deconditioning and worsened func-
b o o
e/e
by the medical service. He was believed to be medically optimized tional status for the patient.
e / m e /
for surgery, and cemented hemiarthroplasty was performed using a
m
/ /t .
posterior approach the following day. After surgery he struggled to
t .
The patient had multiple comorbidities but was ambulatory prior to
//
s:
regain function due to overall weakness and poor mobility. Six weeks
ps:
the injury. Cemented hemiarthroplasty allowed for immediate weight
394
http htt
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e / Key points
t . m e/e
s: / / / /
ps:
bearing and reduced risks of periprosthetic fracture. Despite the Clinical and radiographic examinations after a fall in an older patient
http htt
length of time until fracture fixation, no arthritic changes were seen needs to include examination of the hip. Hip pain may radiate to
on the acetabular side of the hip allowing for hemiarthroplasty. If the knee and confuse the evaluation, resulting in a missed diagno-
degenerative changes were seen, total hip arthroplasty (THA) should sis. Cemented hemiarthroplasty is an excellent treatment option for
be considered. With the history of Parkinson's disease, an antero- the medically complex and minimally active patient.
lateral operative approach could be considered to reduce the risk
k e rs of hip instability.
er s
Patients who are active and cognitively intact have more pain from
hemiarthroplasty than with THA (Case 4: Fig 3.9-5) [30, 31]. How-
o o o ok
ever, THA has a higher rate of dislocation than hemiarthroplasty.
o o
e/eb b b
With partial hip replacement, no functional differences have been
e/ e found between a unipolar and a bipolar prosthesis [32]. To try to

e/e
: // t .m : / / t .m
reduce dislocation after THA, some authors have utilized a constrained
liner or a dual mobility head. The dual mobility head has a small
ht tps ht tps
metal head inside of a large polyethylene head. This articulates with
a metal acetabular shell. Good results have been shown with both
approaches although long-term results are unknown [33–35].
e r s e r s
e / a b
t . m e/ t . m e/e
/ / / /
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
c
://t . m d
: / / t . m
t t p s tps
h ht
Fig 3.9-4a–e An 83-year-old male patient with Parkinson's disease.
a AP x-ray of the knee taken at the initial injury revealing no
fracture. Unfortunately, the hip injury was missed as the pain
radiated from the hip to the knee.
k e rs ke rs
b AP x-ray of the hip revealing an unstable chronic femoral neck
fracture.
eb oo e b oo
c Lateral x-ray showing the displaced fracture.
d AP pelvis x-ray at 6 weeks after surgery showing a cemented
b o o
e /
t . m e / hemiarthroplasty on the right side. The left side had a previ-
t .m
ous intertrochanteric fracture that has healed with cephalo
e/e
/ / medullary fixation.
//
ps: ps:
e e The lateral x-ray showing good alignment of the femoral stem.
htt htt 395
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
3.9 Femoral neck
k e rs ke rs
e b oo e b oo b o o
e / Total hip arthroplasty
. m e /
. m e/e
CASE 4
/ / t / / t
Patient
htt ps:
A 66-year-old healthy woman fell from a standing position and sus-
tained a displaced femoral neck fracture (Fig 3.9-5a–b). She was htt ps:
tions. This may present a dilemma over a weekend if a surgeon
who routinely performs THA is not available. The risks of operative
living with her husband, ambulated independently, and enjoyed delay must then be weighed against the potential upside of total
gardening and walking. versus hemiarthroplasty.
k e rs Treatment and outcome

r s
This patient underwent ultra-early fracture repair. Two studies [36,
e
o o She was admitted to the hospital, medically assessed, and optimized
for surgery. She underwent total hip arthroplasty (THA) with an
o ok
37] have shown that ultra-early surgery (< 12 hours from admission)
may give better results. This patient was treated with a quick mo-
o o
e/eb e/ e b e/eb
anterior approach. The patient was mobilized that evening and al- bilization protocol that is often used for total joint replacement
lowed to bear weight as tolerated. The following day, physical ther- patients with hip arthritis. The patient was in good physical shape
/ t .m
apy was initiated and she was able to ambulate about 30 meters.
: / / t .m
and had excellent family support. This allowed for early and safe
: /
tps tps
She met criteria for hospital discharge and went home with her hospital discharge.
ht ht
family. She did well after surgery and followed a self-directed exercise
program. At the 1-month follow-up, she was not using an ambula- Key points
tory aid and had little pain. The x-rays showed her uncemented hip • Total hip arthroplasty should be utilized in patients with displaced
replacement in excellent position and alignment (Fig 3.9-5c–d). femoral neck fracture and high prefracture activity levels.
• Ultra-early surgery (ie, < 12 hours) may lessen operative morbid-
e r s Discussion
r s
ity and mortality.
e
ook ok
The active patient with a displaced femoral neck fracture should be • Rapid recovery protocols can be implemented in active patients
b
considered for THA. Total hip arthroplasty has been shown to have
b o with hip fracture.
b o o
e / e e/ e
less pain and fewer reoperations in active patients. Total replace-
ment does have a higher dislocation rate than hemiarthroplasty and
• At the follow-up, this patient should be assessed and treated for
her osteoporosis. This will help to reduce the risk of subsequent
e/e
t . m
the surgeon should be skilled in arthroplasty to prevent complica-
/ / fractures as she ages.
/ /t . m
htt ps: htt ps:
e rs e r s
b o ok b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
a
h c
ht
d
k e rs ke rs
Fig 3.9-5a–d Active 66-year-old woman falling from standing height.
eb oo e b oo
a Injury AP pelvis x-ray showing a displaced left femoral neck fracture. Bone
quality appears to be good.
b o o
e /
t . m e /b The lateral x-ray showing the displaced and unstable fracture.
t .m
c AP pelvis x-ray at 1 month after surgery showing the uncemented implants in
e/e
/ / good position that appear to be incorporating.
//
ps: ps:
b d The lateral view showing appropriate anteversion of the cup.
396
htt htt
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 5.2.5 Operative approach
t . m e /
t . m
Early surgery is essential to early rehabilitation. Rehabilita- e/e
s: / / / /
ps:
Each approach (ie, anterior, anterolateral, or posterior) has tion should be started as soon as possible with an order for
http htt
risks and benefits. An elevated risk of hip dislocation is as- weight bearing as tolerated. With fast recovery protocols,
sociated with THA for fracture [38]. It has been suggested patients may be mobilized on the day of surgery. Getting
that an anterolateral approach is better, as the risk of dislo- up to the side of the bed or to a chair will begin this process.
cation is lower for both hemiarthroplasty [39–41] and THA Continued mobilization and physical therapy will allow the
[42]. This should be strongly considered in patients with patient to continue the process of rehabilitation. Many pa-
e s
neuromuscular disorders or Parkinson's disease, who may
r
be more susceptible to postoperative dislocation. Minimal-
er s
tients are functionally impaired before surgery and may be
debilitated. This reduces the likelihood of a return to inde-
b o ok ly invasive approaches for hip replacement have not been

associated with differences in 1-year outcomes [43]. Mini-
bo ok
pendent living after fracture. For more details, see chapters
1.8 Postoperative surgical management and 1.9 Postacute
b o o
e/ e e/ e
mally invasive techniques should only be used by surgeons care.
e/e
with extensive arthroplasty experience.
: // t .m : / / t .m
5.2.6 Type of prosthesis
ht tps
Use of uncemented femoral prostheses is associated with a
higher rate of periprosthetic fractures than use of cemented
7 Operative complications
ht tps
Short-term or long-term operative complications impact the
devices [44–47]. These studies have led to AAOS guideline outcomes of older fragility fracture patients (FFPs) dramat-
recommendations for the use of cemented femoral stems ically and often result in a much worse outcome than in
[26]. Good results have also been shown even in very osteo- those with a successful index surgery. This is mainly due to
e r s
porotic femora with several types of uncemented stem de-
e r s
the frailty and limited compensatory capacity, ie, reserves,
ook ok o
signs including tapered flat, tapered, rectangular, and fully of FFPs. Avoiding complications by any means has a high
e b coated designs. Cemented designs are associated with a low

e b o priority. In case of a complication, a targeted and timely
b o
e / e/
but real rate of acute intraoperative hypotension and mor-
m
tality [48]. Cementation should be performed carefully with-
t .
intervention is mandatory to avoid further unnecessary de-
t . m
viations. These situations require excellent co-management e/e
out overpressurization.
/ / and communication within the team.
/ /
6 htt
Therapeutic options
ps: 7.1
htt
Failure of screw fixation ps:
Early or late failure of internal fixation is a common com-
plication after treatment of femoral neck fractures. Early
6.1 Initial treatment failure is from loss of fixation or nonunion. Late failure may
A standardized pathway for admission will help get the pa- be from aseptic necrosis, osteoarthritis, or malunion. Treat-
e rs
tient to an appropriate floor bed and off of the hard stretch-
r s
ment of failure is typically managed with conversion to a
e
b o ok er in the chaotic environment of the emergency department.
b o
The iliac fascia or femoral nerve blocks are helpful to allevi- ok
hip replacement. This may be a hemiarthroplasty or a THA.
Decision making is based on the status of the acetabular
b o o
e/ e / e
ate pain and to minimize the risk of delirium [49]. No ben-
e
efit has been found with the use of skin or boot traction and
cartilage and the patient activity level (Case 5: Fig 3.9-6).
e /e
://t . m
this can lead to skin problems or pressure ulceration [50].
/ t .
The screw holes may weaken the greater trochanter and
: / m
t t p s tps
care should be taken not to break the trochanter. The fem-
ht
6.2 Rehabilitation oral head should be dislocated first prior to removal of the
h
Maintaining mobility and preparing for rehabilitation of the
patient starts on presentation to the emergency department.
screw fixation to help prevent intraoperative fracture. The
stem should be checked with an intraoperative x-ray to
Adequate pain control will allow less narcotic pain medicine. assure that it is not incorrectly placed through the screw
Nerve blocks given in the emergency department decrease holes and not down the shaft of the femur. If a cemented
k e rs
pain and may allow for the patient to be comfortable or to
even sit up in the preoperative period.
ke rs
stem is used, the cement may flow out of the screw holes
and these should be manually plugged during cementation.
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
397
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
3.9 Femoral neck
k e rs ke rs
e b oo e b oo b o o
e / m
Conversion to total hip arthroplasty after screw failure—
. e /
. m e/e
CASE 5
late periprosthetic fracture

/ / t / / t
Patient
htt ps:
A 77-year-old woman with Parkinson's disease presented with a htt ps:
Hip replacement: A fully coated stem was used due to the patient’s
previous hip fracture treated with screw fixation 2 years prior. She osteoporotic femoral bone quality. Another option could have been
had developed progressive hip pain and difficulty walking. Her a cemented stem. It is possible that a cemented device would have
examination revealed a hip with painful range of motion and an produced less of a stress riser at the tip of the stem. However, a fall
e rs antalgic gait. Her Parkinson's disease was managed with medica-

r s
may result in a periprosthetic fracture with any stem design.
e
b o ok tions and she was living at home using a walker for ambulation.
bo ok
Fracture fixation: While an open approach was used for fracture
b o o
e / e Treatment and outcome
e/ e
The x-rays revealed failure of screw fixation with a collapse of the
fixation, with current plate design and locking attachment plates for
condylar plates, it is possible to use a smaller approach and still
e/e
/ t .m
femoral head and secondary arthritic change of the hip joint. From
: / / t .m
achieve excellent fracture fixation. The placement of screws should
: /
tps tps
the AP and lateral views the three screws had not been inserted also be considered. If locking screws are placed just distal to the
ht ht
in an inverted triangle configuration (Fig 3.9-6a–b). Her bone qual- fracture, a cortical screw will give a less rigid construct. Proximally,
ity was thought to be poor with a stovepipe-shaped femur and locking attachment plates now available may offer improved screw
thinning of cortices on both the AP and lateral views. She chose to fixation around the stem. For more details on periprosthetic fixation,
undergo hip replacement and an uncemented fully coated pros- see chapter 3.13 Periprosthetic fractures around the hip.
thesis was used due to her poor bone quality. She recovered well
r s
from surgery but had a fall 2 months later and sustained a peri-
ke
Key points
e r s
ok
prosthetic femoral fracture at the tip of the prosthesis (Fig 3.9-6c). • Internal fixation has a higher failure rate and need for reoperation
b o o The prosthesis appeared to be well fixed. This was treated with
b o than arthroplasty. Arthroplasty should be favored over internal
b o o
e /e e e/e
plate fixation using unicortical screws and cables proximally. Three fixation in older patients with displaced femoral neck fractures.
t . m
to be callus at the fracture site (Fig 3.9-6d–e). e/
months after surgery she was bearing weight and there appeared • Uncemented implants have a higher rate of periprosthetic frac-
tures than cemented implants.
t . m
/ / / /
ps: ps:
• Careful thought to implant construct and screw position should
htt htt
Discussion be given in the case of osteoporotic patients with periprosthetic
Fracture fixation: It is unknown if the femoral neck fracture was fractures.
displaced or nondisplaced at the time of the original surgery. Initial
hemiarthroplasty, while a larger procedure, would have prevented
the osteonecrosis of the femoral head that occurred. Even if fracture
e rs fixation was used, a better pattern of screw placement may have

given better fixation but may not have prevented aseptic necrosis
e r s
b o ok of the femoral head.
b o ok b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht Fig 3.9-6a–e A 77-year-
old woman with poor bone
quality.
a AP x-ray showing col-
lapse of the femoral
k e rs ke rs head after screw fixa-

tion of a femoral neck
eb oo e b oo fracture.
b Lateral x-ray showing
b o o
e /
t . m e / the three screws used
t .m
in a vertical alignment,
e/e
/ / /
not in an inverted
/
ps: ps:
a b triangle.
398
htt htt
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
Fig 3.9-6a–e (cont) A 77-year-old
woman with poor bone quality.
e rs er s c Injury x-ray showing the total hip
ok ok
arthroplasty with well-fixed stem
b o bo and a fracture at the tip of the

stem.
b o o
e/ e e/ e d AP x-ray at 3 months showing
e/e
.m .m
the plate construct with callus
: // t / t
formation at the fracture site.
: /
tps tps
e Lateral x-ray at 3 months after
c d e fracture.
ht ht
7.2 Failure of hemiarthroplasty 7.4 Periprosthetic fracture
Hemiarthroplasty has been shown to have excellent implant A common complication of hip replacement surgery is peri-
e r s
longevity in hip fracture patients [51]. Implants may fail from
e r s
prosthetic fracture. This may occur during surgery or later
ook ok o
erosion of the acetabular cartilage. Risk factors include preex- from subsequent trauma. Intraoperative fractures typically
e b isting osteoarthritis, damage to the labrum during placement

e b o occur with uncemented components during final component
b o
e / tion of the wrong size femoral head may cause premature
t . e/
of the replacement, or high activity level of the patient. Selec-
m
impaction. Treatment is with cerclage wires or cables of the
t . m
proximal femur. Often the same implant can be used. If the e/e
/ /
cartilage wear. Typically these patients present with activity-
/ /
fracture results in an unstable femoral implant situation,
ps:
related groin pain. The x-rays will show narrowing of the
htt
acetabular cartilage. Treatment of acetabular erosion is best
accomplished with conversion to a THA. Another cause of htt ps:
conversion to a more distally fixed femoral component is
very successful [55]. Later periprosthetic fractures are man-
aged using the Vancouver algorithm [56]. If the component
failure is polyethylene wear within a bipolar hemiarthroplas- is loose, then it must be revised to a revision implant. If the
ty. This may lead to osteolysis similar to that seen in THA [52]. component is stable, internal fixation is the preferred treat-
ment. For more detailed information, see chapter 3.13
e rs
7.3 ailure of total arthroplasty—intraoperative
F
r s
Periprosthetic fractures around the hip.
e
b o ok acetabular failure
b o
Placement of the acetabular component can be challenging ok b o o
e/ e / e
in very osteoporotic bone. There is a tendency for rapid ad-
e
vancement of the reamer after it goes through the cartilage.
e /e
://t . m
This can lead to over medialization of the cup. Even worse
: / / t . m
t t p s
is if this over reaming is eccentric and the posterior wall is
tps
ht
weakened or removed. This eliminates that ability to get a
h
press fit. The surgeon has several options if this occurs. One
is placement of a cemented acetabular component. Another
is the use of an augment either autograft from the existing
femoral head or the use of a metal augment [53]. This can
k e rs
reconstruct the posterior/superior wall and enable the sur-
geon to establish a press fit of the cup. The final option is the
ke rs
eb oo use of a cage construct [54]. These are complex techniques
e b oo b o o
e/e
that require an experienced hip surgeon. If an unexperienced
e / m e
surgeon sees that a stable cup cannot be placed, the best/ m
t .
option may be to close the patient without implant place-
/ / // t .
ps: ps:
ment and immediate referral to a revision hip expert.
htt htt 399
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
3.9 Femoral neck
k e rs ke rs
e b oo e b oo b o o
e / 7.5 Dislocation
t . m e / Treatment for component malalignment is correction of the
t . m e/e
s: / / / /
ps:
Dislocation is more common with a THA than with hemi- incorrect implant positioning. The femoral component should
http htt
arthroplasty when used for femoral neck fracture. The rate be in anteversion and the acetabular component with cor-
of dislocation in one study was 8.1% [38]. It is unclear why rect anteversion and abduction angle using the safe zone.
the rate of dislocation is higher when a THA is used for a Most commonly, the dislocation is posterior with deep flex-
fracture as opposed to osteoarthritis but it is thought to be ion but anterior dislocation may occur if components are
due to lack of capsular contracture in the fracture patient. too anteverted. If implant position is correct and dislocation
e s
It also may result from patients with cognitive impairment
r
in the perioperative period, a common problem in FFPs. The considered.
er s
still occurs then the use of a constrained liner should be
b o ok type of approach is also thought to play a role, with antero-

lateral approaches more stable than posterior approaches
bo ok
Technical tips to avoid dislocation:
b o o
e/ e e/ e
[25]. Dislocation is often the result of incorrect component
e/e
: // t .m
placement. Careful attention needs to be made to both ac-
etabular and femoral component orientation.
• Use a more stable approach for patients prone to disloca-
tion; anterior lateral is the preferred approach.
: / / t .m
s tps
http
• Take care not to damage the labrum on approach to leave
With a hemiarthroplasty, this is most commonly incorrect
anteversion of the femoral component. This may depend
on the approach [57]. With a posterior approach, retrover-
ht
its suction fit effect on the prosthetic head.
• Make sure that the femoral implant is placed in antever-
sion and is not retroverted.
sion will lead to posterior dislocation. With an anterior or
anterolateral approach, excessive anteversion may lead to 7.6 Prosthetic joint infection
e r s
anterior hip dislocation. The appropriate amount of antever-
k e r s
Infection is the second most common major complication
b o o sion is felt to be about 20° [58]. This can be treated with
b
revision of the femoral implant and correction of the mal-
o ok
after arthroplasty for hip fracture [59] and problematic for
the debilitated FFP. The rate of infection is thought to be
b o o
e /e dislocation will still occur.
t . m e/ e
rotation. If the implant is retained and converted to a THA, higher after arthroplasty for a diagnosis of fracture compared
to osteoarthritis [60].
t . m e/e
/ / / /
ps:
Another cause for dislocation of hemiarthroplasty is the lack
htt
of a true “suction fit” of the head in the acetabulum. This
can result from: htt ps:
Deep periprosthetic infection should be promptly recognized
and treated. Clinical findings may be a painful arthroplasty,
wound redness, or drainage. Diagnosis is with arthrocente-
sis and culture. Options for treatment include surgical de-
• Retained bony or cement fragments in the acetabulum bridement and antibiotics or removal of implants and either
and/or damage to the labrum of the hip during exposure. a 1- or 2-stage approach to treatment [61]. Suppressive treat-
e rs The solution is to be certain the acetabulum is free of

r s
ment with antibiotics alone works poorly. Treatment is dif-
e
b o ok debris and soft tissue prior to reduction.
b o
• A lack of a hemispherical acetabulum due to deformity, ok
ficult and should be tailored to the patient, especially in the
very old and fragile patient [61, 62]. The most moribund
b o o
e/ e / e
arthritis, or an inverted flap of capsule retained in the
e
acetabulum when the head is reduced. In case of a non-
patients may be treated with implant removal alone and
permanent resection arthroplasty (Case 6: Fig 3.9-7).
e /e
://t . m
hemispherical acetabulum, the surgeon needs to convert
: / / t . m
to THA.
t t p s tps
ht
• An inappropriately sized head, ie, too large or too small.
h
Obviously, it is essential to achieve a correct head size
based on measurement of the extracted head and trial
reduction of the trial implant in the acetabulum.
k e rs ke rs
eb oo e b oo b o o
e /
t . m e /
t .m e/e
/ / //
htt ps: htt ps:
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / m
Infected and dislocated bipolar hemiarthroplasty
. e /
. m e/e
CASE 6
/ / t / / t
Patient
htt ps:
An 84-year-old woman with dementia sustained a displaced femo-
ral neck fracture.
Discussion
htt ps:
The patient was initially treated with hemiarthroplasty, however, her
implants were poorly placed. Retroversion of the femoral stem led
to posterior hip dislocation. This was then treated with conversion
Treatment and outcome to a constrained THA without correction of the femoral component
She was treated at another hospital with hemiarthroplasty. Two malposition. The same forces producing the dislocation of her hemi-
e rs
weeks after surgery, she dislocated her hip while sitting up. The hip
r s
arthroplasty occurred and the implant fractured through her pelvis.
e
b o ok was managed with closed reduction, but she subsequently dislo-
cated it two more times. She underwent revision surgery to a total
bo ok
Revision surgery for a dislocating hemiarthroplasty is difficult and a
thorough evaluation of the stem should be performed. A well ce-
b o o
e/ e ral stem was retained.
e/ e
hip arthroplasty (THA) using a constrained liner. The original femo- mented stem can be revised by recementing a smaller stem into
the existing cement mantle with correct anteversion. With multiple
e/e
: // t .m : / / t .m
surgeries and infection, this patient’s delirium worsened. Ultimate-
tps tps
Subsequently, she dislocated the THA when getting up. The x-rays ly, this led to long-term nursing home placement. Complications
ht ht
revealed that the cup had fractured through the acetabulum and and reoperations must be avoided to give good results in the older
the constrained liner was intact (Fig 3.9-7a–b). She was transferred adult population.
into a tertiary referral center for further care. At that time, she was
found to be draining serosanguinous fluid from her hip incision. She Treatment of an infected total hip prosthesis in the debilitated hip
was acutely delirious on admission, experienced severe hip pain, fracture patient is challenging. In this case, due to her poor func-
e r s
and was unable to ambulate. Before these events, she had been
r s
tional status, a permanent resection arthroplasty was chosen. In a
e
ook ok
living at home. more active patient, a 2-stage approach with reimplantation could
b b o have been considered.
b o o
e / e e/ e
After discussion with her caregivers, the best option was thought to
be treatment of her hip infection with removal of all hip implants Key points
e/e
t . m
and debridement. During surgery it was found that the screws in
/ / t . m
• The femoral stem must be placed with correct anteversion to
/ /
ps: ps:
her cup had pulled through the entire posterior acetabulum giving prevent hip dislocation.
htt htt
a larger posterior wall/column fracture (Fig 3.9-7c–d). The stem was • Constrained implants play a role in instability treatment only
removed and found to have been placed in retroversion. A nonar- when the implant position is correct. Their use can almost always
ticulating spacer was placed and she was treated with intravenous be avoided.
antibiotics. Cultures did not grow an organism. After surgery her • All efforts must be made to avoid reoperation in the femoral
delirium worsened and she became highly agitated. Geriatric con- neck fracture patient; “single-shot surgery” is best.
e s
sultation was requested for pharmacological treatment of her de-
r
lirium/dementia. She required one further surgical debridement to
e r s
• Treatment of infection after femoral neck repair is challenging
and often requires implant removal.
b o ok get the wound to heal.
b o ok
In a healthier patient, the implants may be directly revised or an
b o o
e/ e e / e
After a long hospital course, her delirium persisted and she was antibiotic-impregnated cement spacer may be placed. A course of
e /e
://t . m
placed in long-term care at a nursing home. At the 6-week follow-up
she was found to be comfortable and had no desire to ambulate.
: / / t . m
6 weeks of pathogen-specific intravenous antibiotics is used after
implant removal. If the infection appears to be eradicated the spac-
t t p s
She was not considered a good candidate for reimplantation surgery.
tps
er may be removed and a second hip replacement placed. Surgical
h ht
treatment is required in all deep prosthetic joint infections. Pros-
thetic joint infections should never be treated with antibiotics alone.
It is mandatory to comanage these patients with an infectious disease
physician. The orthopedic surgeon should not attempt to manage
these patients alone.
k e rs ke rs
eb oo e b oo b o o
e /
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t .m e/e
/ / //
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401
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3.9 Femoral neck
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
b
k e rs er s
o o o ok o o
e/eb t .m e/ e b
t .m e/eb
: // : / /
a
ht tps ht tps
e r s e r s
e /
t . m e/d
t . m e/e
/ / / /
ps: ps:
Fig 3.9-7a–d An 84-year-old woman with dementia and hip infection and
dislocation.
htt htt
a AP x-ray showing an uncemented total hip with constrained liner. The cup
had pulled out of the acetabulum and the head had remained within the
constrained liner.
b Lateral x-ray showing the hip replacement.
c A 3-D computed tomographic (CT) scan showing the transverse portion
of the fracture created by the cup pulling though the bone.
e rs
c
r s
d A 3-D CT showing the posterior wall injury. The cup pulled through the
e
ok ok
entire posterior wall of the acetabulum.
b o b o b o o
e/ e e / e e /e
://t . m : / / t . m
t t p s tps
h ht
k e rs ke rs
eb oo e b oo b o o
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t .m e/e
/ / //
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rs
rs 26.07.18 10:30
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htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 8 References
t . m e /
t . m e/e
/ / / /
htt ps:
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ps:
22. Moll MA, Bachmann LM, Joeris A, et al.
htt
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e rs et al. Internal fixation versus cemented

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er
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s
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different ages and levels of life
ok ok
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: /
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/ t fractures treated with three cannulated
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: / t
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ook ok
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Co-managed care for fragility hip for displaced femoral neck fracture ultra-early surgery in hip fracture
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e rs Sensitivity and specificity of CT- and

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ok ok
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e e
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/ Prospective randomized controlled trial

et al. A randomised controlled trial
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e /e
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://t . m comparing dynamic hip screw and

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subcapital hip fractures. ANZ J Surg.
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t s
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p
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t
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ht
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independent patients with a displaced
et al. A new measurement for posterior comparing sliding hip screws and intracapsular fracture of the femoral
tilt predicts reoperation in undisplaced cancellous screws on revision surgery neck. A randomized, controlled trial.
rs rs
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k e patients treated by internal fixation and
ke
treatment of femoral neck fractures.
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oo oo o
followed for 1 year. Acta Orthop.
eb
2009 Jun;80(3):303–307. 2014 Jun 26;15:219.
e b
Unipolar or bipolar hemiarthroplasty
for femoral neck fractures in the
b o
/ / e/e
elderly? Clin Orthop Relat Res.
e t . m e 2003 Sep;(414):259–265.
t .m
/ / //
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403
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k e rs ke rs
e b oo e b oo b o o
e / 33. Hernigou P, Filippini P, Flouzat-
t . m e /
43. Imamura M, Munro NA, Zhu S, et al.
. m
53. Nehme A, Lewallen DG, Hanssen AD.
t e/e
/ /
Lachaniette CH, et al. Constrained liner
:
Single mini-incision total hip
/ /
Modular porous metal augments for
s ps:
in neurologic or cognitively impaired replacement for the management of treatment of severe acetabular bone
ht t
Clin Orthop Relat Res. p
patients undergoing primary THA.
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arthritic disease of the hip:
a systematic review and meta-analysis
of randomized controlled trials.
htt
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et al. Do dual-mobility cups reduce the 2012 Oct 17;94(20):1897–1905. Role of cages in revision arthroplasty of
risk of dislocation in total hip 44. Langslet E, Frihagen F, Opland V, et al. the acetabulum. J Bone Joint Surg Am.
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e rs femur in patients aged older than

75 years? J Arthroplasty.
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b o ok 2016 Jun;31(6):1256–1260.
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bo ok
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b o o
e/ e Dual mobility cups hip arthroplasty
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: // t
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tps tps
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ke r s
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High dislocation cumulative risk in 48. Gjertsen JE, Lie SA, Vinje T, et al. More et al. Higher risk of reoperation for
THA versus hemiarthroplasty for
/ / t . m re-operations after uncemented than bipolar and uncemented
/ /t . m
ps: ps:
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2011 Nov;469(11):3148–3153. treatment of displaced fractures of the 2012 Oct;83(5):459–466.
htt htt
39. Rogmark C, Fenstad AM, femoral neck: an observational study of 60. S assoon A, D’Apuzzo M, Sems S, et al.
Leonardsson O, et al. Posterior 11,116 hemiarthroplasties from a Total hip arthroplasty for femoral neck
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hemiarthroplasties in elderly hip 49. Mouzopoulos G, Vasiliadis G, disposition to an elective patient
fracture patients. Acta Orthop. Lasanianos N, et al. Fascia iliaca block population. J Arthroplasty.
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e rs
40. Biber R, Brem M, Singler K, et al.
r
risk for delirium: a randomized
e s 61. Kapadia BH, Berg RA, Daley JA, et al.
ok ok
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b o
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Traumatol. 2009 Sep;10(3):127–133.
b o
50. Handoll HH, Queally JM, Parker MJ.
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62. De Angelis G, Mutters NT, Minkley L,
b o o
e/ e and four consecutive cases. Int Orthop.
2012 Nov;36(11):2219–2223.
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et al. Prosthetic joint infections in the
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://t
et al. Reduced dislocation rate after hip
. m 2011 Dec 07(12):CD000168.
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2015 Dec;43(6):629–637.
: / / t . m
t p s
arthroplasty for femoral neck fractures
when changing from posterolateral to
t
et al. Cemented bipolar
hemiarthroplasty provides definitive
tps
h
anterolateral approach. Acta Orthop.
2010 Oct;81(5):583–587.
42. Hailer NP, Weiss RJ, Stark A, et al. The
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52. Coleman SH, Bansal M, Cornell CN,
ht
total hip arthroplasty depends on et al. Failure of bipolar
surgical approach, femoral head size, hemiarthroplasty: a retrospective
k e rs sex, and primary diagnosis. An analysis

of 78,098 operations in the Swedish
e rs
review of 31 consecutive bipolar
prostheses converted to total hip
k
oo oo o
Hip Arthroplasty Register. Acta Orthop. arthroplasty. Am J Orthop (Belle Mead
eb
2012 Oct;83(5):442–448. NJ). 2001 Apr;30(4):313–319.
e b b o
e /
t . m e /
t .m e/e
/ / //
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rs
rs 26.07.18 10:30
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htt ps: htt ps:
k e rs ke rs
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t . m e /
t . m e/e
/
/ / /
htt ps:
htt ps:
e rs er s
b o ok bo ok b o o
e/ e 1 Introduction
e/ e • In stable urban populations, hip fracture rates remain
e/e
: // t .m
Trochanteric femoral fractures are the most frequent and
: / / t .m
constant or have decreased, perhaps due to the influence
of factors such as birth cohort effects, improvements in
tps
typical major injuries in fragility fracture patients (FFPs).
ht
These fractures are mainly caused by a simple fall onto the
hip [1]. In a number of cases the fracture is just the tip of ht tps
bone mineral density, body mass index, osteoporosis
medication use, and/or lifestyle interventions such as
smoking cessation, improvement in nutritional status,
the iceberg due to the patient’s comorbid conditions such and fall prevention [3].
as cardiovascular diseases or sarcopenia. In order to allow • In western nations, 10–20% of previously independent
a remobilization, most of these patients have to undergo hip fracture patients need to move to a nursing home for
e r s
surgical repair with the following major treatment goals:
e r s
long-term care following hip fracture [5].
e b ook • Operative fixation as early as possible, with active rever-

e b o ok b o o
e / sal of anticoagulation if necessary
t . m
• Expedited, stepwise mobilization with weight bearing ase/ 3 Diagnostics
t . m e/e
/ /
tolerated (WBAT), starting the day of, or first day after, 3.1 Clinical evaluation
/ /
surgery
htt ps:
To reduce complications in these fragile patients, we propose htt ps:
Precise preoperative patient assessment with a detailed re-
view of the medical history is essential. Clinical examination
should assess blood loss, evaluate the vascular, muscular,
the use of standardized procedures for fracture treatment. and neurological status of the extremity, and identify soft-
tissue injuries or any infections (eg, chest infection). The
preoperative evaluation should be done in a comanaged
e rs
2 Epidemiology and etiology
r s
system together with a physician with experience in geri-
e
b o ok o
The expected increase in these fractures is predominantly
b ok
atrics and perioperative medical care, and is described in
detail in chapter 2.4 Elements of an orthogeriatric comana-
b o o
e/ e / e
due to demographic changes of our aging population with
e
a high prevalence of osteopenia and osteoporosis:
ged program.
e /e
://t . m 3.2 Imaging
: / / t . m
s
• The worldwide incidence of hip fractures was estimated
t t p
3.2.1 Plain x-rays
tps
ht
to be 1.7 million per year in 1990 and is expected to Two plain views and a pelvic view are the minimum set of
h
increase to 6.3 million per year in 2050 [2].
• There are wide variations in hip fracture rates worldwide,
radiographic images to understand the fracture, plan the
surgery, and select the implant.
with a positive correlation between rates of urbanization
and hip fractures [3]. 3.2.2 Computed tomographic scan
kers rs
• The 1-year mortality after hip fracture is substantially Computed tomographic (CT) scans are helpful to assess more
o
higher in men (9.4–37.1%) than women (8.2–12.4%)
ke
bony and soft-tissue details [6].
b o [4].
b oo b o o
e /e t . m e /e
t .m e/e
/ / //
htt ps: htt ps:
405
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
t . m e / screw (DHS) was tolerated better by young patients with
t . m e/e
s: / / / /
ps:
stable fractures while IM devices such as the proximal fem-
http htt
The AO/OTA Fracture and Dislocation Classification is rec- oral nail antirotation (PFNA) had better outcomes with os-
ommended for trochanteric and subtrochanteric fractures teoporotic patients, weak bone mass, and reverse oblique
and will be used in this chapter [7]. Pertrochanteric fractures fractures [10]. Furthermore, IM fixation can be minimally
are the most common variant and run from proximal-lateral invasive, which appears to benefit older trauma patients.
to distal-medial (AO/OTA Fracture and Dislocation Classi-
k e rs fication A1, A2). Intertrochanteric or reverse obliquity frac-

tures run from medial-proximal to lateral-distal (AO/OTA
er s
A study investigating markers of muscle damage (serum
creatine phosphokinase) associated with the surgical ap-
o o A3) [1]. Subtrochanteric fractures are located approximate-

o ok
proach revealed that intertrochanteric fractures stabilized
o o
e/eb b b
ly 5 cm distal from the lesser trochanter [1]. by a DHS experienced greater soft-tissue injury when com-
e/ e pared to patients whose fracture was stabilized by a nail [11].

e/e
5 Decision making
: // t .m : /
More studies have compared outcome parameters of intra-
/ t .m
ht tps
The major goals for the treatment of trochanteric fractures
are:
versus extramedullary fixation:
ht tps
• Reduced blood loss and costs were observed in a com-
parative analysis from France in patients being treated
• Single-shot surgery—this means that revision or addi- with a DHS [12].
tional surgeries should be avoided as they are known to • Operative time appears to be longer in the DHS group,
e r s worsen the overall outcome.

e r s
the surgical incision needs to be bigger and convalescence
ook ok o
• Minimal surgical exposure—FFPs are prone to surgical to early full weight bearing (FWB) was achieved at a
e b site infections and extended approaches prolong the re-

e b o later stage in patients being treated with a DHS [13].
b o
e / mobilization phase.
m e/
• Immediate mobilization and WBAT—mobilization is one
t .
• A relevant disadvantage of extramedullary fixation with
a DHS appears to be the higher risk of femoral neck short-
t . m e/e
/ /
essential issue in older adults to prevent complications;
/
ening. However, radiographic findings which favor IM
/
htt
bearing restrictions. ps:
in addition, many are not able to comply with weight-
htt
comes as shown in a comparative study [14]. ps:
fixation did not correlate with improved functional out-
• The additional use of a trochanteric stabilizing plate and

5.1 Operative versus nonoperative management a tension band wire with the DHS may be required when
Given the high tensile forces acting on the trochanteric area the greater trochanter is affected. However, additional
of the proximal femur [8] and the overall complication rates implant stabilization of the greater trochanter can be
e rs
with bed rest and immobility, treatment should almost al- bulky.
e r s
b o ok ways be operative. Nonoperative management is associated
b o
with higher mortality and serious functional loss [9]. For ok
• It has been proposed to use a sliding hip screw in stable
fractures with intact lesser trochanter and lateral wall of
b o o
e/ e / e
these reasons operative fracture fixation is generally recom-
e
mended in almost all geriatric patients, including bedridden
the greater trochanter and to prefer intramedullary sys-
tems in all other cases.
e /e
://t . m
patients, to facilitate nursing care, positioning, and pain
: / / t . m
relief.
t t p s tps
Intramedullary nailing seems to be less invasive than DHS
ht
placement. In a randomized study of 186 fractures treated
5.2 h
Intramedullary versus extramedullary device
Extramedullary and intramedullary (IM) fixation devices
by gamma nail or dynamic hip screw, gamma nails were
implanted with significantly shorter operation times, small-
are available for hip fracture fixation. Correct identification er incisions, and less intraoperative blood loss. The gamma
of the fracture pattern should influence the choice of implant nail group had a shorter convalescence and earlier FWB,
k e rs
as recommended by the American Academy of Orthopaedic
Surgeons and should be based on a cost-effective implant
ke rs
but there was no significant difference in mortality at
6 months, postoperative mobility, or hip function at review
eb oo selection.
e b oo
[13].
b o o
e /
t . m e /
There is limited evidence for superiority of either implant
based upon randomized trials, and the discussions remain
t .m e/e
/ / //
ps: ps:
controversial. Recent studies reported that the dynamic hip
406
htt htt
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e / 5.3 Blade versus screw
t . m e /
t . m
with arthroplasty, significantly lower than the complication e/e
s: / / / /
ps:
Biomechanically, a helical blade improves rotational stabil- rate of 20.7% reported with cephalomedullary nailing. In
http htt
ity of the construct [15] by compacting the bone around the this study, no significant difference was noted between the
implant and provides additional purchase in less dense bone groups with regard to blood loss, operative time, hospitaliza-
[16] (see topic 7.2 in this chapter). tion time, discharge destination to rehabilitation, or clinical
outcome [19].
5.4 Fixation versus joint replacement
k e rs The mainstay of treatment of pertrochanteric fractures is

internal fixation [17]. Yet, optimal treatment of unstable
er s
Acute prosthetic replacement may be considered but has
not yielded broader acceptance and is generally more re-
o o trochanteric fractures is controversial due to the variation

o ok
served for revision surgeries [20].
o o
e/eb b b
of available implants and no clear evidence-based guidelines.
Potential complications associated with osteosynthesis of
e/ e In severe ipsilateral arthritis of the hip, avascular necrosis of
e/e
: // t .m
proximal femoral fractures include cut-out of the screw or
blade (see topic 7.1 in this chapter), loss of reduction, and
: / / .m
the femoral head (Case 1: Fig 3.10-1), and in selected unstable
t
pertrochanteric fractures, arthroplasty may be a reasonable
nonunion.
ht tps
An investigation of 91 patients treated with a cemented
option for primary treatment.
ht tps
hemiarthroplasty for an unstable pertrochanteric fracture
described an operative revision rate of 3.3% and a 30-day
mortality of 5.5%. The authors concluded that hemiarthro-
e r s
plasty was a safe treatment strategy for unstable trochan-
e r s
ook ok o
teric fractures in older adults and allows early FWB [18]. A
e b recent age-, gender-, and fracture type-matched case-con-

e b o b o
e / trolled study conducted by Fichman et al [19] revealed a
m
major complication rate of 3.4% in fracture patients treated
t . e/ t . m e/e
/ / / /
Patient htt ps: Key points htt ps:
CASE 1
An 80-year-old woman had severe hip pain after a fall on her right • Total or hemiarthroplasty is an option in case of preexisting ar-
hip. Until her fall, the patient was mobile, walking with crutches, and thritis in hip fracture patients.
managed her daily living independently. • Reconstruction of the greater trochanter may be crucial to main-
e rs e r s
tain function of the affected hip [21].
b o
• Chronic obstructive pulmonary disease with a history of gluco- ok b o o
e/ e corticoid therapy
• Persistent nicotine use (30 pack years)
e / e e /e
• Hypertension
://t . m : / / t . m
t t p s tps
ht
h
Primary hemiarthroplasty was performed because of the advanced
degree of destruction of the hip joint; the refixation of the greater
trochanter was challenging (Fig 3.10-1a–d). Yet, reconstruction of
the greater trochanter was crucial to maintain function of the af-
k e rs
fected hip [21]. Reconstruction with cerclage wires or a trochanter
stabilizing plate would have been desirable, and total arthroplasty
ke rs
eb oo surgery may have been favorable due to the massive arthritic de-
e b oo b o o
e/e
struction of the acetabular component.
e / m e / m
/ /t . // t .
htt ps: htt ps:
407
rs
rs 26.07.18 10:30
/ / t . m // t . m
htt ps: htt ps:
k e rs ke rs
e b oo e b oo b o o
e /
t . m e /
t . m e/e
/ / / /
htt ps: htt ps:
e rs er s
b o ok bo ok b o o
e/ e e/ e e/e
a
: // t .m b
: / / t .m
ht tps ht tps
e r s e r s
e /
t . m e/ Fig 3.10-1a–d Unstable pertrochanteric fracture
. m
(AO/OTA 31A2.2) with ipsilateral avascular necrosis of the
t e/e
/ / / /
ps: ps:
femoral head.
a–b Preoperative AP (a) and lateral (b) x-rays.
htt htt
c–d Postoperative x-rays following primary treatment with
c d a cemented long-stem hemiprosthesis.
5.5
k e rs ugmented fixation versus nonaugmented

A
fixation
e r s
Biomechanical findings related to the standardized augmen-
tation of the PFNA:
b o o Polymethylmethacrylate (PMMA) has been used success-
b o
fully to augment different implants in fixation of osteopo- ok
1. Better anchorage of the blade in osteoporotic bone is the
b o o
e/e e / e
rotic fractures [22, 23]. Treatment of trochanteric fractures

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t t p s t t ps

b o b o Check hazards and legal restrictions on www.aofoundation.org/legal

e b The care of the young male high-energy trauma patient

b o ok courses were launched in Rochester, NY, USA, in 2006 un-

e r sin this emerging field. From an educational and clinical

e b designed for clinicians to share current experiences, learn

The impact of the dramatic demographic shift of the world’s

e r s from the AO Education Institute for their guidance and

e rs overall layout of this book and for taking in the many

Michael Blauth, MD Stephen L Kates, MD Joseph A Nicholas, MD,

e rs Professor and Director

b o o Department for Geriatrics

er s 1111 Amsterdam Ave

b o Clemens Hengg, PD Dr med

: // t Univ.-Klinik für Unfallchirurgie

Alexander Hofmann, Dr med

Marco Keller, Dr med

b o ok Austria 130, Dongduk-ro, Jung-gu

/ /t . m 6020 Innsbruck Germany

er s Florida Atlantic University

b o Staffordshire ST4 6GQ

: // t Director, Department of Orthopaedic Surgery

b o Associate Professor of Medicine

/ / t . m Giulio Pioli, MD, PhD

. me Vice-Chair, Department of Internal Medicine,

Carl Neuerburg, PD Dr med

eb 81377 Munich 5020 Salzburg

e b APL  abductor pollicis longus

eb oo CAM  Confusion Assessment Method

e / CCI  Charlson Comorbidity Index

metabolic equivalentht tps

HBR  home-based rehabilitation MGF  mechano growth factor

eb oo LAP  locking attachment plate

e / LBQ  local bone quality

htt htt XIII

weight bearing as tolerated ht tps

e b PTS  postthrombotic syndrome

regional anesthesia htt ps:

e / TEA  total elbow arthroplasty

e r sregularly reviewed and updated by the book editors. This

o o o 1.3 P rinciples of orthogeriatric anesthesia

1.6 A nticoagulation in the perioperative setting

b o o b o 1.8 Postoperative surgical management

t . me/ e 1 Michael Blauth, Peter Brink

1.9 Postacute care

1.11 S arcopenia, malnutrition, frailty, and falls

://t . m 1.14 D elirium

 vercoming barriers to implementation

3.2 H umeral shaft ht t p 191

of a care model Clemens Hengg, Vajara Phiphobmongkol 243

k e rs 2.3 C linical practice guidelines

o o 2.4 Elements of an orthogeriatric comanaged program

s 3.6 D istal forearm

ke r s Stephen L Kates, Joseph A Nicholas

2.8 F racture liaison service and improving treatment

b o Simon C Mears, Stephen L Kates 389

3.13 Periprosthetic fractures around the hip

3.15 P roximal tibia

h t Björn-Christian Link, Philippe Posso, Reto Babst

Christian CMA Donken, Michael HJ Verhofstad 535

3.18 A typical fractures

b o ok 1.2 Principles of orthogeriatric surgical care

e r s 1.6 Anticoagulation in the perioperative setting

e b APL abductor pollicis longus

eb oo CAM Confusion Assessment Method

e / CCI Charlson Comorbidity Index

HBR home-based rehabilitation MGF mechano growth factor

eb oo LAP locking attachment plate

e / LBQ local bone quality

e b PTS postthrombotic syndrome

e / TEA total elbow arthroplasty

o o o 1.3 P rinciples of orthogeriatric anesthesia

1.6 A nticoagulation in the perioperative setting

b o o b o 1.8 Postoperative surgical management

1.9 Postacute care

1.11 S arcopenia, malnutrition, frailty, and falls

://t . m 1.14 D elirium

vercoming barriers to implementation

3.2 H umeral shaft ht t p 191

k e rs 2.3 C linical practice guidelines

o o 2.4 Elements of an orthogeriatric comanaged program

s 3.6 D istal forearm

2.8 F racture liaison service and improving treatment

3.13 Periprosthetic fractures around the hip

3.15 P roximal tibia

3.18 A typical fractures

b o ok 1.2 Principles of orthogeriatric surgical care

e r s 1.6 Anticoagulation in the perioperative setting

b 1.7 Postoperative medical management

b o ok 2.5 G et the patient moving as soon as possible

b o ok 2.7 any surgeons, internists, and specialists do not

k e rs ke rs b–c After 10 days close

k e b–c Open reduction, fixation with cerclage wires and revision

k e a An 82-year-old man with a proximal femoral fracture (31A2).