骨质疏松性骨折ppt课件

Epidemiology,Diagnosis Prevention and Management of Osteoporotic FracturesKenneth A.Egol,MDNYU-Hospital For Joint DiseasesCreated March 2019;Revised May 2019Background 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 80Background Risk factors for osteoporosis Female sex European ancestry Sedentary lifestyle Multiple births Excessive alcohol useBackground 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 TumorsBackground 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 societyBackground 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 fracturesBackground 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 careBackground 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 indicatedPre-injury Status Medical History Cognitive History Functional History Ambulatory status Community Ambulator Household Ambulator Non-Functional Ambulator Non-Ambulator Living arrangementsPre-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 unionPre-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 patientPre-injury Status Cognitive Status Critical to outcome Conditions may render patient unable to participate in rehabilitation Alzheimers CVA Parkinsons Senile dementiaHip 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 80Hip Fractures Epidemiology Incidence increases after age 50 Female:Male ratio is 2:1 Femoral neck and intertrochanteric fractures seen with equal frequencyHip Fractures Radiographic evaluation Anterior-posterior view Cross table lateral Internal rotation view will help delineate fracture patternHip 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 hoursHip 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 prophylaxisHip 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 livingHip 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 casesHip Fractures Femoral neck fractures Treatment:Hemiarthroplasty Unipolar Vs Bipolar Can lead to acetabular erosion,dislocation,infectionHip 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 malunionHip Fractures Intertrochanteric fractures Extracapsular(well vascularized)Region distal to the neck between the trochanters Calcar femorale Posteromedial cortex Important muscular insertionsHip 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 weightbearingHip Fractures Intertrochanteric fractures Treatment Primary prosthetic replacement can be considered For cases with significant comminutionHip 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 elderlyHip Fractures Subtrochanteric Fractures Treatment Intramedullary nail(high rates of union)Plates and screwsAnkle 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 boneAnkle 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 performedAnkle Fractures Radiographic evaluation Ankle trauma series includes:AP Lateral Mortise Examine entire length of the fibulaAnkle 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 braceAnkle 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 patientAnkle 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 closureAnkle 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 statusProximal 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 motionProximal 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 densityProximal 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 keyProximal Humerus Radiographic evaluation AP Scapula Y Axillary CT scan can be helpfulProximal Humerus Treatment Minimally displaced(one part fractures)usually stabilized by surrounding soft tissues Non operative:91%good to excellent resultsProximal 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 X-ray 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 replacementProximal 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 variableDistal 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 coordinationDistal 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 factorDistal Radius Radiographic evaluation PA Lateral Oblique Contralateral wrist Important to evaluate deformity,ulnar varianceDistal Radius Treatment Non-displaced fractures may be immobilized for 6-8 weeks Metacarpal-phalangeal and interphalangeal joint motion must be started earlyDistal 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 requiredDistal 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 outcomesDistal Radius Treatment Displaced fractures treated surgically produce good to excellent results 70-90%Functional limits include pain,stiffness and decreased gripVertebral 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 osteoporosisVertebral 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 fracturesVertebral 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 weeksVertebral Compression Fractures Treatment A corset may be helpful Most fractures heal uneventfully Kyphoplasty an optionPrevention Strategies focus on controlling factors that predispose to fracture Fall preventionPrevention Multidisciplinary programs Medical adjustment Behavior modification Exercise classes ControversialPrevention 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 therapyPrevention 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 2019)Reduced hip fracture rate by 50%in women who had sustained a previous vertebral fracture.(Black et al.Lancet 2019)Prevention and Treatment of Bone Fragility Calcium/Vitamin D Supplementation Recommended for most men and women 50 years Calcium 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 fracturePrevention 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 demonstratedPrevention 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 fracturesPrevention 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 fracturesConclusions 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 timesIf you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides,please send an to otaaaos.org