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
SDs 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

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 --> 6.3 million hip fractures will occur globally
Enormous cost to society

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

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

Pre-injury Status
Cognitive Status
Critical to outcome
Conditions may render patient unable to
participate in rehabilitation

Alzheimers
CVA
Parkinson's
Senile dementia

Hip Fractures
General principles
With the aging of the American population the
incidence of hip fractures is projected to
increase from 250,000 in 1990 to 650,000 by
2040
Cost approximately $8.7 billion annually
20% higher incidence in urban areas
15% lifetime risk for white females who live to
age 80

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

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, UTI, 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%

Hip Fractures
Femoral neck fractures
Displaced fractures should be treated operatively
Treatment: Open vs. 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
Treatment: Hemiarthroplasty
Unipolar Vs Bipolar
Can lead to acetabular erosion, dislocation,
infection

Hip Fractures
Femoral neck fractures
Treatment
Displaced fractures can be treated non
-operatively in certain situations
Demented, non-ambulatory patient

Mobilize early
Accept resulting non or malunion

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, ankle fractures have been reported to

occur in as many as 8.3 per 1000 Medicare recipients
Figure that appears to be steadily rising.

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

Ankle Fractures
Treatment
Isolated, 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
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 men
439/100,000 in women
Result of low energy trauma
Goal is to restore pain free range of shoulder motion

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, muscular, capsular and
ligamentous structures maintains shoulder
stability
Status of the rotator cuff is key

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

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

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

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

Vertebral Compression Fractures

Epidemiology

More common than hip fractures

117/100,000
Twice as common in females
Lifetime risk in a 50 year old white female is
32%

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

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. NEJM 1995)
Reduced hip fracture rate by 50% in women
who had sustained a previous vertebral fracture.
(Black et al. Lancet 1996)

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 -- 1,200 mg/day
Vitamin D
Age 51-70 -- 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

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

Conclusions
Prevention is multifaceted
Cost containment also a joint effort between
orthopaedists, primary care physicians, 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
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