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Epidemiology, Diagnosis

Prevention and Management of
Osteoporotic Fractures
Kenneth A. Egol, MD
NYU-Hospital For Joint Diseases
Created March 2004; Revised May 2006

Background
• Osteoporosis -- a
decreased bone density
with normal bone
mineralization
– WHO Definition (1994)
• Bone Mineral Density ≥2.5
SD’s below the mean seen
in young normal subjects

– Incidence increases with
age
• 15% of white women age
50-59
• 70% of white women older
than age 80

Background
• Risk factors for osteoporosis




Female sex
European ancestry
Sedentary lifestyle
Multiple births
Excessive alcohol use

Background • Senile osteoporosis common – Some degree of osteopenia is found in virtually all healthy elderly patients • Treatable causes should be investigated – – – – – Nutritional deficiency Malabsorption syndromes Hyperparathyroidism Cushings disease Tumors .

3 million hip fractures will occur globally • Enormous cost to society .Background • The incidence of osteoporotic fractures is increasing – Estimated that half of all women and one-third of all men will sustain a fragility fracture during their lifetime • By 2050 --> 6.

Background • The most common fractures in the elderly osteoporotic patient include: – Hip Fractures • Femoral neck fractures • Intertrochanteric fractures • Subtrochanteric fractures – – – – Ankle fractures Proximal humerus fracture Distal radius fractures Vertebral compression fractures .

Background • Fractures in the elderly osteoporotic patient represent a challenge to the orthopaedic surgeon • The goal of treatment is to restore the pre-injury level of function • Fracture can render an elderly patient unable to function independently --requiring institutionalized care .

Background • Osteopenia complicates both fracture treatment and healing • Internal fixation compromised – Poor screw purchase – Increased risk of screw pull out – Augmentation with methylmethacrylate has been advocated • Increased risk of non-union – Bone augmentation (bone graft. substitutes) may be indicated .

Pre-injury Status • Medical History • Cognitive History • Functional History – Ambulatory status • • • • Community Ambulator Household Ambulator Non-Functional Ambulator Non-Ambulator – Living arrangements .

Pre-injury Status • Systemic disease – Pre-existing cardiac and pulmonary disease is common in the elderly – Diminishes patients ability to tolerate prolonged recumbency – Diabetes increases wound complications and infection – May delay fracture union .

not incapacitating – ASA IV.mild systemic disease – ASA III.normal healthy – ASA II.severe incapacitating disease – ASA V.Pre-injury Status • American Society of Anesthesiologists (ASA) Classification – ASA I.Severe systemic disease.moribund patient .

Pre-injury Status • Cognitive Status – Critical to outcome – Conditions may render patient unable to participate in rehabilitation • • • • Alzheimer’s CVA Parkinson's Senile dementia .

7 billion annually – 20% higher incidence in urban areas – 15% lifetime risk for white females who live to age 80 .000 in 1990 to 650.000 by 2040 – Cost approximately $8.Hip Fractures • General principles – With the aging of the American population the incidence of hip fractures is projected to increase from 250.

Hip Fractures • Epidemiology – Incidence increases after age 50 – Female: Male ratio is 2:1 – Femoral neck and intertrochanteric fractures seen with equal frequency .

Hip Fractures • Radiographic evaluation – Anterior-posterior view – Cross table lateral – Internal rotation view will help delineate fracture pattern .

Hip Fractures • Radiographic evaluation – Occult hip fracture • Technetium bone scanning is a sensitive indicator. but may take 2-3 days to become positive • Magnetic resonance imaging has been shown to be as sensitive as bone scanning and can be reliably performed within 24 hours .

UTI.Hip Fractures • Management – Prompt operative stabilization • Operative delay of > 24-48 hours increases one-year mortality rates • However. important to balance medical optimization and expeditious fixation – Early mobilization • Decrease incidence of decubiti. atelectasis/respiratory infections – DVT prophylaxis .

Hip Fractures • Outcomes – Fracture related outcomes • Healing • Quality of reduction – Functional outcomes • Ambulatory ability • Mortality (25% at one year) • Return to pre-fracture activities of daily living .

Hip Fractures • Femoral neck fractures – Intracapsular location – Vascular Supply • Medial and lateral circumflex vessels anastamose at the base of the neck • blood supply predominately from ascending arteries (90%) • Artery of ligamentum teres (10%) .

Hip Fractures • Femoral neck fractures • Treatment – Non-displaced/ valgus impacted fractures • Non-operative 8-15% displacement rate • Operative with cannulated screws • Non-union 5% and osteonecrosis is approximately 8% .

Closed Reduction and Internal fixation • 30% non-union and 25%-30% osteonecrosis rate • Non-union requires reoperation 75% of the time while osteonecrosis leads to reoperation in 25% of cases .Hip Fractures • Femoral neck fractures – Displaced fractures should be treated operatively – Treatment: Open vs.

dislocation. infection .Hip Fractures • Femoral neck fractures • Treatment: Hemiarthroplasty – Unipolar Vs Bipolar – Can lead to acetabular erosion.

non-ambulatory patient – Mobilize early • Accept resulting non or malunion .Hip Fractures • Femoral neck fractures • Treatment – Displaced fractures can be treated non -operatively in certain situations • Demented.

Hip Fractures • Intertrochanteric fractures – Extracapsular (well vascularized) – Region distal to the neck between the trochanters – Calcar femorale – Posteromedial cortex – Important muscular insertions .

Hip Fractures • Intertrochanteric fractures – Treatment • Usually treated surgically • Implant of choice is a hip compression screw that slides in a barrel attached to a sideplate • The implant allows for controlled impaction upon weightbearing .

Hip Fractures • Intertrochanteric fractures – Treatment • Primary prosthetic replacement can be considered • For cases with significant comminution .

Hip Fractures • Subtrochanteric Fractures – Begin at or below the level of the lesser trochanter – Typically higher energy injuries seen in younger patients – far less common in the elderly .

Hip Fractures • Subtrochanteric Fractures – Treatment • Intramedullary nail (high rates of union) • Plates and screws .

Ankle Fractures • Common injury in the elderly – Significant increase in the incidence and severity of ankle fractures over the last 20 years • Low energy injuries following twisting reflecting the relative strength of the ligaments compared to osteopenic bone .

Ankle Fractures • Epidemiology – Finnish Study (Kannus et al) • Three-fold increase in the number of ankle fractures among patients older than 70 years between 1970 and 2000 • Increase in the more severe Lauge-Hansen SE-4 fracture – In the United States. .3 per 1000 Medicare recipients • Figure that appears to be steadily rising. ankle fractures have been reported to occur in as many as 8.

Ankle Fractures • Presentation – – – – Follows twisting of foot relative to lower tibia Patients present unable to bear weight Ecchymosis. deformity Careful neurovascular exam must be performed .

Ankle Fractures • Radiographic evaluation – Ankle trauma series includes: • AP • Lateral • Mortise – Examine entire length of the fibula .

non-displaced malleolar fracture without evidence of disruption of syndesmotic ligaments treated non-operatively with full weight bearing – My utilize walking cast or cast brace .Ankle Fractures • Treatment – Isolated.

Ankle Fractures • Treatment – Unstable fracture patterns with bimalleolar involvement. or unimalleolar fractures with talar displacement must be reduced – Treatment closed requires a long leg cast to control rotation • may be a burden to an elderly patient .

Ankle Fractures • Treatment – Reductions that are unable to be attained closed require open reduction and internal fixation – The skin over the ankle is thin and prone to complication – Await resolution of edema to achieve a tension free closure .

Ankle Fractures • Treatment – Fixation may be suboptimal due to osteopenia • May have to alter standard operative techniques • Cement Augmentation – Reports in literature mixed • Early studies showed no difference in operative vs non-op treatment -.with operative groups having higher complication rates • More recent studies show improved outcomes in operatively treated group – Goal is return to pre-injury functional status .

Proximal Humerus • Background – – – – – Very common fracture seen in geriatric populations 112/100.000 in women Result of low energy trauma Goal is to restore pain free range of shoulder motion .000 in men 439/100.

Proximal Humerus • Epidemiology – Incidence rises dramatically beyond the fifth decade in women – 71% of all proximal humerus fractures occur in patients older than 60 – Associated with • frail females • Poor neuromuscular control • Decreased bone mineral density .

Proximal Humerus • Background – Articulates with the glenoid portion of the scapula to form the shoulder joint – Four parts – Combination of bony. capsular and ligamentous structures maintains shoulder stability – Status of the rotator cuff is key . muscular.

Proximal Humerus • Radiographic evaluation – – – – AP Scapula Y Axillary CT scan can be helpful .

Proximal Humerus • Treatment – Minimally displaced (one part fractures) usually stabilized by surrounding soft tissues • Non operative: 91% good to excellent results .

Proximal Humerus • Treatment – Isolated lesser tuberosity fractures require operative fixation only if the fragment contains a large articular portion or limits internal rotation – Isolated greater tuberosity associated with longitudinal cuff tears and require ORIF .

Proximal Humerus • Treatment – Displaced surgical neck fractures can be treated closed by reduction under anesthesia with Xray guidance • Anatomic neck fractures are rare but have a high rate of osteonecrosis – If acceptable reduction is not attained open reduction should be undertaken .

Proximal Humerus • Treatment – Closed treatment of 3 and 4 part fractures have yielded poor results – Failure of fixation is a problem in osteopenic bone • Locked plating versus prosthetic replacement .

malunion. nonunion – Prosthetic replacement can be expected to result in relatively pain free shoulders – Functional recovery and ROM variable .Proximal Humerus • Treatment – Regardless of treatment all require prolonged. supervised rehabilitation program – poor results are associated with rotator cuff tears.

Distal Radius • Background – Very common fracture in the elderly – Result from low energy injuries – Incidence increases with age. poor eyesight and a decrease in coordination . particularly in women – Associated with dementia.

Distal Radius • Epidemiology – Increasing in incidence • Especially in women – – – – Peak incidence in females 60-70 Lifetime risk is 15% Most frequent cause: fall on outstretched arm Decreased bone mineral density is a factor .

Distal Radius • Radiographic evaluation – – – – PA Lateral Oblique Contralateral wrist • Important to evaluate deformity. ulnar variance .

Distal Radius • Treatment – Non-displaced fractures may be immobilized for 6-8 weeks – Metacarpal-phalangeal and interphalangeal joint motion must be started early .

Distal Radius • Treatment – Displaced fractures should be reduced with restoration of radial length. inclination and tilt • Usually accomplished with longitudinal traction under hematoma block – If satisfactory reduction is obtained treatment in a long arm or short arm cast is undertaken • No statistical difference in method – Weekly radiographs are required .

Distal Radius • Treatment: Operative – if acceptable reduction not obtained – regional or general anesthesia – Methods • ORIF • Closed reduction and percutaneous pinning with external fixation – Bone grafting for dorsal comminution .

Distal Radius • Treatment – Results are variable and depend on fracture type and reduction achieved – Minimally displaced and fractures in which a stable reduction has been achieved result in good functional outcomes .

Distal Radius • Treatment – Displaced fractures treated surgically produce good to excellent results 70-90% – Functional limits include pain. stiffness and decreased grip .

Vertebral Compression Fractures • Background – Nearly all post-menopausal women over age 70 have sustained a vertebral compression fracture – Usually occur between T8 and L2 – Kyphosis and scoliosis may develop • markers for osteoporosis .

000 Twice as common in females Lifetime risk in a 50 year old white female is 32% .Vertebral Compression Fractures • Epidemiology – – – – More common than hip fractures 117/100.

Vertebral Compression Fractures • Background – Present with acute back pain – Tender to palpation – Neurologic deficit is rare • Patterns – Biconcave (upper lumbar) – Anterior wedge (thoracic) – Symmetric compression (T-L junction) .

Vertebral Compression Fractures • Radiographic evaluation – AP and lateral radiographs of the spine – Symptomatic vertebrae 1/3 height of adjacent – Bone scan can differentiate old from new fractures .

Vertebral Compression Fractures
• Treatment
– Simple osteoporotic vertebral compression
fractures are treated non-operatively and
symptomatically
– Prolonged bedrest should be avoided
– Progressive ambulation should be started early
– Back exercises should be started after a few
weeks

Vertebral Compression Fractures
• Treatment
– A corset may be helpful
– Most fractures heal uneventfully
– Kyphoplasty an option

Prevention
• Strategies focus on controlling factors that
predispose to fracture
• Fall prevention

Prevention • Multidisciplinary programs – – – – Medical adjustment Behavior modification Exercise classes Controversial .

Prevention and Treatment of Bone Fragility • Well established link between decreasing bone mass and risk of fracture • Treatment of osteoporosis – – – – – Estrogen Calcium/Vitamin D Supplements Calcitononin Bisphosphonates Teriparatide (Forteo) .

Prevention and Treatment of Bone Fragility • Estrogen – 2-3% bone loss with menopause – Unopposed or combined therapy has been shown to reduce hip fracture incidence in women aged 65-74 by 40-60% (Henderson et al. 1988) – Risk of breast and endometrial cancer increased in unopposed therapy .

Lancet 1996) . NEJM 1995) – Reduced hip fracture rate by 50% in women who had sustained a previous vertebral fracture.Prevention and Treatment of Bone Fragility • Fosmax – Shown to increase the bone density in femoral neck in post menopausal women with osteoporosis (Lieberman et al. (Black et al.

400 IU/day – Age >70 -.600 IU/day • Combining Vitamin D and calcium supplementation has been shown to increase bone mineral density and reduce the risk of fracture .200 mg/day • Vitamin D – Age 51-70 -.Prevention and Treatment of Bone Fragility • Calcium/Vitamin D Supplementation – Recommended for most men and women >50 years • Calcium – Age <50 -.1.000 mg/day – Age >50 -.1.

Prevention and Treatment of Bone Fragility • Calcitonin – Inhibits bone resorption by inhibiting osteoclast activity – Approved for treatment of osteoporosis in women who have been post-menopausal for > 5 years • Daily intranasal spray of 200 IU – Trial demonstrated 33% reduction of vertebral compression fractures with daily therapy (Chesnut Am J Med 2000) • No effect on hip fractures demonstrated .

Prevention and Treatment of Bone Fragility • Bisphosphonates – Inhibits bone resorption by reducing osteoclast recruitment and activity – Bone formed while on bisphosphonate therapy is histologically normal – Available formulations • Alendronate • Risendronate • Ibandronate • Strongest evidence for rapid fracture risk reduction – Decreasing the incidence of both vertebral and nonvertebral fractures .

Prevention and Treatment of Bone Fragility • Teriparatide (Forteo) – Recombinant formulation of parathyroid hormone – Stimulates the formation of new bone by increasing the number and activity of osteoblasts – Once daily subcutaneous injection of 20 g • Study of 1637 post-menopausal women – 65% reduction in the incidence of new vertebral fractures – 53% reduction in the incidence of new nonvertebral fractures .

please send an email to ota@aaos. primary care physicians.Conclusions • Prevention is multifaceted • Cost containment also a joint effort between orthopaedists.org E-mail OTA about Questions/Comments Return to  General/Principles  Index . PT and social work • Functional outcome is maximized by early fixation and mobilization in operative cases • Number of elderly is increasing all will have to work together in difficult economic times If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides.