Orthopedic Considerations in the Older Adult

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Orthopedic Considerations in the Older Adult

• What to worry about in the old folks!!!

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Topics to cover and relate..

• Arthritis
• Osteoporosis disease and prevention
• Falls and prevention
• Types of Injuries

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The elderlya increasing concern

• Although the big surge in the elderly population
  is not expected until the baby boomers turn 65 in
  the next century, significant demographic shifts
  are already underway. In 1940 only 7 percent of
  Americans had a chance of living to age 90 in
  1980, it was 24 percent. In 1950 there were 4,475
  persons age 100 years or older by 1990, the
  number was 54,000.

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Osteoporosis
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Osteoporosis and the Orthopedic Surgeon

• First fracture may be warning sign
• Osteoporosis, or "porous bone" is a medical
  condition that weakens bone by making it more
  porous and less dense. Bone density is one of the
  factors that determine bone strength, so
  individuals with low bone density have a higher
  risk for fracture and refracture.

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Osteoporosis

• Disease of adolescence!!
• 35 and 50 years old
• You may have begun to gradually lose bone. At
  this stage in your life, getting enough calcium
  (1,000 mg each day) and exercise are crucial to
  keep bone loss to a minimum. Most women enter
  menopause between the ages of 42 and 55.

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OSTEOPOROSIS

• You should be getting 1,000 mg of calcium each
  day. If you rarely get out in the sun, vitamin D
  also may be recommended
• (2 Na free TUMS!)
• Try to walk, jog or perform a resistance
  workout for at least 20 minutes, three times a
  week.

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OSTEOPOROSIS

• Over 50 years old
• For women who have gone through menopause, they
  may be losing bone at a rate of 1 to 6 percent
  per year
• Adequate calcium intake and exercise still are
  important

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Men and Osteoporosis ? ?

• Men should also be concerned about osteoporosis.
  Approximately one in eight men will have an
  osteoporotic fracture. Men with a history of
  hypogonadism, thyroid dysfunction, long-term
  steroid therapy, high alcohol consumption or low
  physical activity are especially at risk.
  One-third of all hip fractures experienced by men
  are related to osteoporosis, and one-third of
  these men will die within the first year after
  the fracture.

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Osteoporosis and Fractures

• The risk of a serious fracture can double after a
  first fracture in certain high-risk groups.
  Additionally, many patients, particularly those
  who suffer hip fractures, are at high risk for
  premature death or loss of independence after the
  fracture.

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Osteoporosis and Fractures

• One out of four people who have an osteoporotic
  hip fracture will need long-term nursing home
  care.
• Half of those who experience osteoporotic hip
  fractures are unable to walk without assistance.
• Those who experience the trauma of an
  osteoporotic hip fracture have a 24 increased
  risk of dying within one year following the
  fracture

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Osteoporosis and Fractures

• Osteoporosis is a contributing factor in as many
  as 1.5 million fractures each year, including
• About 300,000 hip fractures
• About 700,000 vertebral (spine) fractures
• About 250,000 wrist fractures
• About 300,000 fractures at other sites

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Osteoporosis and Fractures

• Hispanic women may be among those at highest
  risk. Between 13 percent and 16 percent of
  Hispanic women have osteoporosis. As many as 49
  of Mexican-American women 50 years of age or
  older have low bone density.
• Although the rate of hip fractures is lower in
  Asian-American women, the rate of vertebral
  fractures is about equal between Asian-American
  and Caucasian women.
• About 10 percent of African-American women over
  50 have osteoporosis. An additional 30 percent
  have low bone density. Between 80 percent and 95
  percent of all fractures experienced by
  African-American women over age 64 are related to
  osteoporosis.

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Osteoporosis and Fractures

• . Make sure you get enough calcium and vitamin D
  in your diet. The National Academy of Sciences
  recommends 400 to 800 units of Vitamin D and
  1,000 to 1,500 mg of Calcium per day.
• How many Sodium free TUMS is that??

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Osteoporosis

• Participate in activities that will strengthen
  bone and muscle. Regular exercise is one of the
  best things you can do to prevent osteoporosis.
  Weight-bearing exercises like walking, jogging
  and tennis and low-impact exercise classes are
  best for building and maintaining strong bones.

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Osteoporosis

• Because falls are the most common cause of
  fractures, do some balance activities to reduce
  your risk.

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Fall Prevention

• If you have osteoporosis and you fall, you are
  likely to break a bone. Ten million people
  currently have osteoporosis another 34 million
  have low bone mass and therefore are at risk of
  developing the disease. More than 1.5 million
  Americans each year sustain a fracture related to
  osteoporosis.

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Steps to take
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Prevent Falls
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Orthopedic Surgery

• Hip fractures remain a major source of morbidity
  and mortality in the elderly, and their incidence
  is increasing as the population ages. Surgical
  management followed by early mobilization is the
  treatment of choice for most patients with hip
  fractures. However, all co morbid medical
  conditions, particularly cardiopulmonary and
  fluid-electrolyte imbalances, must be evaluated
  and stabilized prior to operative intervention

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Hip Fractures

• Non displaced femoral-neck fractures should be
  stabilized with multiple parallel lag screws or
  pins. The treatment of displaced femoral-neck
  fractures is based on the patient's age and
  activity level young active patients should
  undergo open reduction and internal fixation
  older, less active patients are usually treated
  with hemiarthroplasty, either uncemented or
  cemented. Regardless of treatment method, the
  goal is to return the patient to his or her
  prefracture level of function.

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Hip Fractures Mortality and Outcomes

• Mortality rates in the first year following a
  broken hip are around 25, and the rates are
  highest in older populations. The cause of
  mortality following a hip fracture is often due
  to blood clots, pneumonia, or infection.
  Furthermore, only about 25 of patients who
  sustain a broken hip return to their pre-injury
  level of activity.

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Hip Fractures Mortality and Outcomes

• Most important factor was the mental acuity of
  the patient prior to and after the fracture. (hip
  fractures VA Hospital Study)

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Femoral Neck Fractures

• Garden Classification
• 1-2 Non Displaced
• 3-4 Displaced
• Disruption of blood flow with resulting avascular
  necrosis
• Internal Fixation vs Arthroplasty

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Femoral Neck FracturesGarden Classification
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Femoral Neck Fractures

• Difficult to see non displaced fractures
• May need bone scan or CT or MRI to diagnose
• Low velocity falls
• May be diagnosed late
• May turn nondisplaced into a displaced fx

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Femoral Neck Fractures
Bone scan
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Femoral Neck Fractures
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Femoral Neck Fx ORIF vs. Arthroplasty
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Femoral Neck Fx Protocol

• High index of suspicion
• Xray ap/lat and cross table lat of femoral neck
• Exam is not always helpful
• Need further studies MRI CT or bone scan
• When in doubt, act like its broken!!!!

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Femoral Neck vs. Intertrochanteric Fractures
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Percutaneous pinning of femoral neck fractures
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Pelvic Fractures the great pretender!!!!
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Colles Fracture (Colles fracture?)

• Colles Fracture
• Most common upper extremity fx in the elderly
• Wet leaves, snow, throw rug, tripped over a
  pet.
• Hyper extension deformation force to the wrist

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Comminuted Distal Radius Fracture

• Silver fork deformity

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Comminuted Distal Radius Fracture
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CompressionFracturesThoracic and Lumbar
Can any of you tell me whether this is Lumbar or
Thoracic??
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Back and Spine

• Back or spine injuries are the most prevalent
  musculoskeletal impairments
• Difficult to diagnose masquerade as cardiac or
  gastric or pulmonary discomfort in the elderly

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Dowagers Hump
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Compression Fractures

• Burst type
• Cord impingement
• Usually from activity or a fall
• Usually higher velocity injury

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Compression Fracture

• Wedge pattern
• Much more common
• Function of osteoporosis an lack of structural
  support
• Look for other causes!!!!! METASTASIS INFECTION

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MRI of Compression Fracture
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May need bone scan for diagnosis
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Kyphoplasty
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Kyphoplasty

• Early results show kyphoplasty is a safe and
  effective method of vertebral reconstruction and
  stabilization in the treatment of osteoporotic
  VCFs. Like all surgeries, kyphoplasty does have
  risks.
• Complications may require additional treatments.
  These may be medications or surgery. Kyphoplasty
  is associated with excellent pain relief due to
  the vertebral body collapse. Well over 95 percent
  of patients rate their treatment a success. They
  are able to return to all of their pre-VCF
  function.

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More Kyphoplasty.

• Occasionally, patients complain of persistent
  pain after kyphoplasty. This may be due to
  irritation of tissues involved in the procedure
  itself. It is more likely due to the underlying
  arthritis and degeneration of the spine.
• Restoring vertebral body height and size is best
  accomplished when kyphoplasty is performed soon
  after the VCFs happen.

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Kyphoplasty..

• After kyphoplasty, severe osteoporosis may cause
  other fractures at other levels in some patients.
  
• There is a small risk of the bone cement leaking
  from within the boundaries of the vertebral body.
  In most cases, this rare event (occurrence less
  than 10 percent) does not cause any problems.

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Kyphoplasty.

• In very rare circumstances the cement may
  irritate or damage the spinal cord or nerves.
  This can cause pain, altered sensation, or even,
  very rarely, paralysis (estimated risk is less
  than 1 in 10,000). Should the cement leak
  further, more significant surgery may be needed
  to stop the irritation of the nerves or spinal
  cord.
• There is also a very small chance of the cement
  traveling to lungs.

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Humeral Neck Fractures

• Very common fracture in the osteoporotic bone of
  the humeral neck
• Can come in different types and requires
  different treatments
• Non displaced early AROM/PROM

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Humeral Neck Fractures

• Lack of healing secondary to loss of blood supply
• Bag o Bones TX vs.
• Humeral arthroplasy

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Treatment of Humeral Neck Fractures
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Hip and Knee Arthritis

• Arthritis or chronic joint symptoms affect nearly
  70 million Americans (about 1 in 3 adults),
  making it one of the most prevalent diseases in
  the United States.
• By 2020, an estimated 12 million Americans will
  be limited in daily activities because of
  arthritis.

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Arthritis and the elderly

• Arthritis is the leading chronic condition
  reported by the elderly.

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Knee and Hip Arthritis

• In 2002, more than 557,000 hip or knee
  replacement surgeries were performed

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Knee Arthritis

• Conservative treatment options
• NSAIDS CANE VISCOELASTIC TX
• Surgery
• Realignment
• Arthroscopic
• Replacement

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Knee Arthroplasty
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Other Orthopedic Considerations

• Medical history is terrible/Compliance is
  difficult
• Skin problems, IV Access
• DVT, Pressure sores
• Lack of stamina or will (therapeutic inertiato
  return to health)
• Lack of ability or willingness to cooperate
• Depressed Immune system
• Lack of Cardiac and other systems reserve
• Wound healing and Nitrogen balance

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TO CLOSE..

• Dont fall down or trip over preventable causes
  without taking your calcium and exercising with
  weak bones and no therapeutic inertia and break
  your hip or knee or shoulder or wrist while
  having arthritis.
• AND FINALLY.

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Have a milkshake!!!!
Thank you