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Geriatric fracture casemultiple osteoporotic fractures
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Fully mobile without help prior to the accident. Medical history. Bronchial ... No pain, independently mobile with a walking stick, lives in residential home ... – PowerPoint PPT presentation
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Title: Geriatric fracture casemultiple osteoporotic fractures
1
Geriatric fracture casemultiple osteoporotic
fractures
- case-based interactive lecture/moderated
interactive session
Christian Kammerlander, Medical University
Innsbruck, AUTobias Roth, Medical University
Innsbruck, AU
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86-year-old female
- Stumbled on a carpet at home
- Arrived at emergency department at 0457 am
- Lives alone
- Pain in right shoulder, wrist, and hip
- Fully mobile without help prior to the accident
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Medical history
- Bronchial asthma, severe COPD
- CHD and peripheral arteriosclerosis
- Cardiac insufficiency NYHA IIIII
- Diabetes mellitus II (dietary)
- Arterial hypertension
- Osteoporosis without prior fractures
- Amaurosis left eye
- Hospitalized because of exacerbated COPD with
pneumonia 2 weeks before
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DEXA T-score
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Examination
- 153 cm, 50 kg
- Blood pressure 140/90, heart rate 100, rhythmic
- Dehydration
- Dyspnea due to severe COPD, oxygen needed (4
l/min) - Awake, fully oriented, good mental condition
- Malalignment of right wrist, swelling at right
shoulder, pain in right hip - No palpable pulses on both feet, sufficient
capillary perfusion
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Medication
- Fenoterol hydrobromide and ipratropium bromide as
aerosol - Fluticasone propionate and salmeterol xinafoate
as aerosol - Theophylline
- Acetylsalicylic acid
- Furosemide
- Pantoprazole
- Strontium ranelate, calcium, and vitamin D
3 drugs for COPD
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Medication
- Fenoterol hydrobromide and ipratropium bromide as
aerosol - Fluticasone propionate and salmeterol xinafoate
as aerosol - Theophylline
- Acetylsalicylic acid
- Furosemide
- Pantoprazole
- Strontium ranelate, calcium, and vitamin D
coronary heart disease
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Medication
- Fenoterol hydrobromide and ipratropium bromide as
aerosol - Fluticasone propionate and salmeterol xinafoate
as aerosol - Theophylline
- Acetylsalicylic acid
- Furosemide
- Pantoprazole
- Strontium ranelate, calcium, and vitamin D
heart insufficiencycontributes to dehydration
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Medication
- Fenoterol hydrobromide and ipratropium bromide as
aerosol - Fluticasone propionate and salmeterol xinafoate
as aerosol - Theophylline
- Acetylsalicylic acid
- Furosemide
- Pantoprazole
- Strontium ranelate, calcium, and vitamin D
stomach protection
10
Medication
- Fenoterol hydrobromide and ipratropium bromide as
aerosol - Fluticasone propionate and salmeterol xinafoate
as aerosol - Theophylline
- Acetylsalicylic acid
- Furosemide
- Pantoprazole
- Strontium ranelate, calcium, and vitamin D
osteoporosis medication
11
Preoperative examinations
- X-rays, CT scan of shoulder
- Thoracic x-ray
- ECG (normal rhythm)
- Laboratory tests (normal parameters of kidney and
liver function, hematocrit 42) - Seen by internal specialist(high risk for
surgery because of COPD, but no absolute
contraindication) - Seen by anesthesiologist
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Chest x-ray and ECG
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Situation
- Three osteoporotic fractures on the right side
- Medically complex geriatric patient
- High risk for anesthesia
- Cleared for surgery within 6 hours
- Patient gives written consent for surgical
treatment
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What would you do?
- Humeral head fracture
- Conservative treatment?
- Closed reduction and K-wires?
- ORIF?
- Intramedullary nailing?
- Distal radial fracture
- Conservative treatment?
- Closed reduction and K-wires?
- ORIF?
- External fixator?
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What would you do?
- Pertrochanteric femoral fracture
- Cannulated screws?
- Dynamic hip screw (DHS)?
- Intramedullary nailing?
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Treatment
- Distal radial fractureconservative treatment
closed reduction, cast - Immediate surgical treatment of
- Humerus closed reduction and pin fixation,
humerus block - Proximal femur PFNa
- Spinal anesthesia combined with plexus anesthesia
and ketamine
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Postoperative course
- Sitting mobilization poor due to severe COPD with
need for oxygen, CPAP therapy - Pain medication
- paracetamole iv
- morphine sc
- Enoxaparine sc
- Hematocrit 25 on 2nd day 4 blood units
- Sacral decubitus ulcer
- Urinary tract infection ? ciprofloxacine
conserves the kidney (diabetes,
dehydration)morphine helps against dyspnea
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Postoperative course
- Pneumonia on 3rd day ? switch to
piperacillin/tazobactame
- Discharge to rehabilitation center on day 15,
improved general condition - Still severe pain in the right shoulder
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Further course
- Start with full weight-bearing mobilization at
the rehabilitation center - Shortening of K-wires (plexus anesthesia) and
removing cast after 6 weeks - After 8 weeks in rehabilitation center discharge
to a nursing home - Suffers from depression due to loss of
independence
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Outcome after another 3 months
- No pain, independently mobile with a walking
stick, lives in residential home - Daily walks outside
- Still suffering from depression
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