Geriatric fracture

BY- DR. CHIRAG PATIL
M.D.S in Oral & Maxillofacial Surgery

 Introduction
 Geriatrics
 Incidence
 Aging
 Soft tissue changes
 Physiologic changes
 Anatomic changes in maxilla and
mandible
 Blood supply
 Age changes in mandible
 Osteoporosis
 Role of Vitamin D
 Maxillary sinus (Pneumatization)
 Classification
 Treatment
 Summary

 Dictionaries define 'geriatric' as 'pertaining to old people’
 The World Health Organization (1963) has defined 'middle-age' as
being 45-59 years, ‘Elderly' as being 60-74 years and the ‘Aged' as
over 75 years of age
 Most developed countries have accepted the chronological age of 65
years as a definition of 'elderly' or older person.

 A study by Ferrera et al in 2000, 94% of the
reported injury in the geriatric population was due
to falls, motor vehicle crashes and pedestrian
related accidents
Ferrera PC et al Outcomes of admitted geriatric trauma victims AM J emerge med. 2000 Sep;18(5):575-80

 Age and sex of the patients :-
Subhashraj and Ravindran. Maxillofacial intervention in trauma patients. Indian J Dent Res, 19(2), 2008
Age-group Percentage
60-65 40
66-70 22.1
71-75 12.4
76-80 16.8
>81 8.7

Site of injury Percentage
Soft tissue injury 46
Maxillary fractures 9
Mandibular fractures 15
Zygomatic complex 12
Nasal bone fractures 8
Cranial bone fractures 5
Dentoalveolar fractures 5
• Site of injury

Cause of injury
Cause of injury Percentage
Road traffic accidents 60.5
Fall 15.1
Assault 13.5
Others 10.8

 Makinodan described aging as “ an inherent progressive
impairment of function with passage of time ,which cannot be
averted and which causes individuals to become more
vulnerable to death ‘.
 Biologic aging involves both general and specific organ
system changes that are predictive of failing health .

 As the age advances skin shows generalized thinning in the epidermis and there is
less function in skin appendages.
 A thickness of the dermis decreases as a result loss of elastic and collagen fibers .
 A decreases in the hyaluronic acid production leading to a low water binding
capacity . As skin becomes grossly thinner , underlying blood vessels are more
readily visible .
 Due to thinning of epidermis and dermis makes the skin more vulnerable to injury
because of inadequate cushioning to withstand external physical trauma .

 Alveolar bone relies on the presence of the existing dentition as the dentition is
lost there is resorption of the alveolar process.
 Biomechanical forces serves as control mechanism and are responsible for bone
remodeling.
 The concept holds that tension forces result in bone deposition and pressure
forces result in bone resorption .

 Manson and lucas shown that generalized
remodeling occurs at much higher rate in alveolar
bone than in adjacent corpus of mandible
 Tallgren also noted that alveolar resorption is
approximately four times greater in mandible than
in maxilla .

 According to Bradley 1970 angiographic studies on the mandible of cadavers
, he suggested that inferior alveolar nerve and vessels greatly reduced in size
.
 The position of inferior alveolar nerve lies on the superior aspect of residual
ridge .

 Decreased vascularity & oxygen tension
 Blood supply to mandible changes from
centrifugal to centripetal force as age advances
 Cohen in 1960 also suggested that stripping of
periosteum in edentulous mandible in open
reduction may compromise the blood supply and
increase the incidence of non union across the
fracture site .
 Bradley 1975 advocated that supra periosteal
dissection should be done with wire or plates
placed over the periosteum when open reduction
is necessary in edentulous mandible
Bradley JC: A radiological investigation into the age changes of the inferior dental artery. Br J Oral Surg 13: 82 (1975)

AT BIRTH ADULT OLD AGE
Mental Foramen Near the lower border Midway between
upper & lower border
Near the upper border
Angle of mandible Obtuse 180 Right angle Obtuse 140
Coronoid & condylar
processes
Coronoid is larger &
above condyle
Condyle is above the
coronoid
Condyle is above the
coronoid but in
extreme old age- bent
backwards
Mandibular canal Runs above the
mylohyoid line
Runs parallel to
mylohyoid line
Runs close to the
upper border
Symphysis menti Present two halves
united fibrous tissue
Represented by faint
ridge only in upper
part
Not recognizable or
absent
AGE CHANGES IN MANDIBLE

 A Major global health problem. (WHO estimate
>200 mill)
 Definition: progressive systemic skeletal disease
characterized by low bone mass and
microarchitecture deterioration of bone tissue,
leading to enhanced bone fragility and a
consequent increase in fracture risk.
 Age, generic and lifestyle variables (i.e., nutrition,
exercise, smoking), chronic disease, known to be
associated with rapid bone loss.
 Women affected more than men
 Consequences:
 Bone fragility
 increased risk of fractures

 It helps to prevent osteoporosis
 Post menopausal female
 Daily requirement of vitamin D at least 800 IU/day
should be consider in patient above 6o years .
 Swiss survey has shown that ‘‘osteoporosis remains
under-diagnosed and undertreated in patients aged
50 years and older presenting with a fragility
fracture.’’ Meta-analyses indicate that vitamin D
should always be given together with calcium.

 The National Osteoporosis Guideline Group (NOGG) —
 1000 mg of calcium, 800 U of vitamin D, and 1 g/kg body weight of
protein as a general measure for osteoporosis prevention
Geriatric Orthopaedic Surgery & Rehabilitation 2(3) Daniel Eschle et al Andre´ G et al . Aeschlimann, et al

 As maxillary alveolar bone is lost, the distance
between the maxillary sinus floor and the residual
ridge decreases, and the ratio of sinus space to bone
increases.
 The lateral wall of the maxillary sinus is often thin, and
the combination of these factors can produce a
severely comminuted fracture, or "eggshell,' fracture

 Physiologic process.
 Pneumatization is the enlargement of
the sinus by resorption of alveolar
bone
 A thin cortex remains over the alveolar
ridge to maintain a normal contour
 Continuous process persisting
throughout life.

Luhr HG, Reidick T, Merten HA: Results of treatment of fractures of the atrophic edentulous mandible by compression plating: A retrospective evaluation of 84 consecutive
cases’ Oral Maxillofacial Surg 54: 250 (1996).
 Luhr et. al. 1996
CLASS %
Class I
Moderate atrophy
Height 16 to 20mm
30
Class II
Significant atrophy
Height 11 to 15 mm
39
Class III
Extreme atrophy
Height 10mm or less
31

 Seshul et al. 1978.
 Bilateral body fracture of mandible
 Fracture create extreme downward &
backward angulation of anterior part of
mandible due to mylohyoid and digastric
muscle.
 Extreme displacement lead to respiratory
distress

Methods of immobilization
1. Direct osteosynthesis
a) Supra periosteal / Sub periosteal
b) Bone plates (Lateral bone / Inferior bone plating)
c) Pencile bone plate
d) Transosseous wiring
e) Circumferential wiring or straps
f) Transfixation with Kirschner wires
g) Fixation using cortico-cancellous bone graft with or without titanium /
resorbable mesh
h) Lag screws
1. Indirect skeletal fixation
a) Pin fixation
b) Bone clamps
2. Intermaxillary fixation using Gunning type of splints

 1.SUPRA PERIOSTEAL / SUB PERIOSTEAL
 Fracture of the mandible are exposed in a subperiosteal
plane to facilitate reduction.
 Bradley 1975 supraperiosteal dissection in atrophic
mandibular fracture, to preserve the tenuous blood
supply.
 If not exposed subperiosteally, fragments ends
cannot be visualized accurately, result in malreduction
 Application of internal fixation devices would be difficult
in supraperiosteal dissection
 Difficulty in supraperiosteal dissection when attempting
to add autogenous bone at the time of fracture repair
Edward Ellis et Al Treatment Protocol for Fractures of the Atrophic Mandible J Oral Maxillofac Surg 66:421-435, 2008

 It is particularly used for displaced fractured of edentulous
mandible
 Fracture stabilized by immobilization of jaw
 Efficient and easy to use
 less likely to result in periosteal stripping than a larger plate
 Both compression and non compression require adequate
blood supply to achieve uncomplicated bony union
(Rhinelander 1974)
 Plates should be applies with the intervening layer of attached
periosteum (Bradley 1975)
 Do not need as much bone density as a reconstruction plate
 Preferred method of fixation for edentulous mandibular body
fracture
 Inability of the plates to withstand maxillomandibular forces.
Matthew J.Madsen et al Management of Atrophic Mandible Fractures Oral Maxillofacial Surg Clin N Am 21 (2009) 175–183

 The 2.4-mm reconstruction plate is strong enough to overcome
the functional load as well as to counteract the masticatory
forces
 provide primary stability
 ADVANTAGES
o Good visualization for plate adaptation
o Decreases the rate of postoperative infection and failure
o Patient may continue to wear a prosthesis, which can further
stabilize the fracture.

 DISADVANTAGES
o Screws in these large plates may cause another
fracture upon placement
o Screws can fail by stripping the bone
o Inflammation
o Bony necrosis
o Injury to the inferior alveolar nerve

 A monocortical 2.0 mm titanium, 8 or 10-hole hardware
 The two proximal holes are spherical sliding holes that
allow minor compression even with monocortical screws
 Treatment of atrophic mandibular fractures, by an intra-
oral approach
 patients with mandibular heights ranging from ‘‘10 mm
or less’’ to 20 mm
 Carries properties of a miniplate with an improved
stability
Henrique do Couto de Oliveira et al Treatment of Atrophic Mandibular Fractures with the Pencilboneplate: Report of 2 Cases Oral and
Maxillofacial Surgeons of India 2012

 Many simple edentulous fractures can be satisfactorily
immobilized by direct Trans osseous wires
 Transosseous wiring donot provide rigid
osteosynthesis and supplementary fixation may
required
 Less periosteal stripping is required which may be
advantageous when dealing with very thin mandible
 When neurovascular bundle crosses the fracture site
its easier to avoid damage with use of transosseous
wiring than a screwed plate
 Wiring techniques continue to provide a simple and
reliable alternative as unavailability of miniaturized
plates universally
KILLEY’S Fractures of the mandible. Peter Banks. 4th ed

 ADVANTAGES
o Cheap
o Easy to use
o Biologically well tolerated
o Minimum specialized equipment is required
 DISADVANTAGES
o Does not provide three-dimensional stability.
o Micromovement of fracture
o Delayed healing

 Circumferential wiring or straps in
oblique fractures of the edentulous
mandible can be most effectively and
simply immobilized by circumferential
wires,
 Williams (1985) has described the
use of miniaturized circumferential
nylon straps as a useful alternative to
wire.
Williams .J LI., Nylon circumferential straps, in maxillofacial injuries Edinburgh, Churchill Livingston, 332 (1985).

 Direct wiring across the fracture line.
 The transfixing wires is passed first into the proximal
or distal segment and drilled down the center of the
mandible to emerge through the cortex and skin,
 The wire end attached to the drill will eventually come
to lie opposite the fracture at which point the inserting
drill is detached and the direction of the wire reversed
so that it is made to pass back down the other
fragment transfixing the fracture
(Mc dowell et al,1954,Vero1968)
 It is not possible in ultra thin mandible due to risk of
inferior alveolar nerve
McDowell ,F, Barrett Brown,J.,Fryer,MP.et al., surgery of face, mouth and jaws .st Louis, mosby, 52-55, 71-72.

 In 1973 Obsweger and Sailer suggested pimary
bone grafting as a method of satabilizing and
augmenting fracture of the body of ultrathin
edentulous mandible
 Wood et al 1979, a 5 cm length of rib is obtained as
an autogeneous graft rib is spilt and the two pieces
are placed on each side of fracture in an manner of
first-aid splint applied to a limb lased together by
series of circumferential wire sandwiching the
fracture bone between them.
 Iliac bone can be employed similarly (James, 1976)
Obwegeser HL, Sailer HF: Another way of treating fractures of the atrophic edentulous mandible. J Maxillofac Surg 1: 213 (1973)
Woods WR, Hiatt WR, Borrks RL: A technique for simultaneous fracture repair and augmentation of the atrophic edentulous mandible. J Oral
Surg 37: 131 (1974).

 A titanium mesh crib with a simultaneous iliac crest,
anterior tibial, rib, or calvarial bone graft is another
approach to augmenting the edentulous ridge and
stabilizing the fracture.
 Rate of bony union without complications is 70%;
 Bone grafts similarly held securely with the mesh
 DISADVANTAGES
 Increased risk for infection
 Intraoral wound dehiscence

 To rebuild the ridge in the site of atrophy using autogenous bone grafts.
 The mesh is contoured to encompass the defect and then is secured by 1.5-mm
screws
 ADVANTAGES
o It maintains the shape and location of the graft during the consolidation phase
 It does not require a second surgery to remove the material
 Follow the contour of the mandible

 The decreased surface area of bone, we do not
advocate the use of a lag screw to fix and
compress the bone fragments on either side of the
fracture in an atrophic edentulous mandible.
 This technique is primarily reserved for the
oblique, horizontally directed angle fracture or for
parasymphyseal fractures in mandibles that have
adequate height.

 A system of bone pins join together by rods &
universal joints can be used in edentulous fracture
 The method is used where there is extensive
comminution of a long segments particularly if it
involve symphysis
 Bone clamps such as the Brenthurst splint are
theoretically of use to immobilized the fracture in a
thin dentulous mandible avoiding direct surgical
exposure of the fracture site
KILLEY’S Fractures of the mandible. Peter Banks. 4th ed

 ADVANTAGES
o Bedside management
o No maxillomandibular fixation needed
o Cannot tolerate an extensive open operation
 DISADVANTAGES
o Good quality of mandibular bone
o Non rigid fixation
o Damage to inferior alveolar nerve
o Unwillingness

 Described by Thomas Bryan Gunning in 1866
 He used splint for the edentulous mandible consisted a
type of removable monobloc resembling two bite blocks
joined together
 Form of modified denture with bite blocks in place of
molar teeth and space in incisal area facilitating feeding
 Immobilization carried out by attaching upper splint to
maxilla by per alveolar wire and lower splint to
mandibular body by circumferential wire
 Properly constructed gunning type splints should hold the
jaws in a slight over closed relationship.
Gunning, T.B., The treatment of fractures of the lower jaw by interdental splints, N.Y.MED.J., 3: 433 (1866).

 The only disadvantage is that it will be difficult to take an adequate
impression when the mandible is badly fractured and the alveolar ridge
distorted by displacement of the fragments,
 After the splints have been attached to each jaw they are connected by
elastic bands or wire loops utilizing the hooks on the buccal surfaces of
each splint and intermaxillary fixation is established
 4-6 weeks of fixation
 Complications:
 Infection
 Food stagnation
 Poor oral hygiene
 Candida induced stomatitis
 Poor control of mobile fracture

 Closed reduction technique
 Patient denture used to stabilized mandibular fracture
 ADVANTAGES
o Stabilization in three planes (i.e- superior, buccal, lingual)
o Stabilization of lateral displacement
o Arch bar can be used to maxillomandibular fixation
 DISADVANTAGES
o Nonrigid fixation
o Compliance issue
o Poorly tolerated by patient
o Poorly adaptation of denture

Pathological fractures of the mandible - F. Gerhards, H.-D.
Kuffner, W. Wagner. Int. J. Oral maxillofac. Surg. 1998,
27.186-190.
 Fifty percent of the fractures had an inflammatory cause
 Severe atrophy of edentulous mandibles
 Benign tumours and cysts
 Primary or secondary malignancies
 Regardless of the cause, the majority of the fractures
occurred in the body of the mandible

 Infection
 Malunion
 Non- union
 Removal of loose hardware
 Osteoporosis
 Delayed healing

 Prophylactic use of antibiotics (when the potential for
infection is increased)
 Longer maintaining of sutures in place (wound healing is
delayed)
 Excision of ragged wound edges (vascularity is reduced)
 Rigid fixation for bone fractures (to achieve primary bone
healing when open reduction is indicated)
 Prolonged period of immobilization (when closed reduction
is indicated)
WOUND MANAGEMENT IN THE
ELDERLY
Gersein AD, Philips TJ. Rogers GS, et al: Wound healing and aging. Dermatol Clin 1993;11:749
43

Franciosi et al. Treatment of Edentulous Mandibular
Fractures with RIF. Craniomaxillofacial Trauma and
Reconstruction Vol. 7. No. 1/2014

Franciosi et al. Treatment of Edentulous Mandibular Fractures with RIF . Craniomaxillofacial Trauma and Reconstruction Vol. 7
No. 1/2014

 KILLEY’S Fractures of the mandible. Peter Banks. 4th ed
 FONSECA. Oral and maxillofacial Surgery . Vol 3. Trauma
 Edward Ellis et Al Treatment Protocol for Fractures of the Atrophic Mandible J Oral Maxillofac Surg 66:421-435, 2008
 Matthew J.Madsen et al Management of Atrophic Mandible Fractures Oral Maxillofacial Surg Clin N Am 21 (2009) 175–183
 Subhashraj and Ravindran. Maxillofacial intervention in trauma patients. Indian J Dent Res, 19(2), 2008
 Bradley JC: A radiological investigation into the age changes of the inferior dental artery. Br J Oral Surg 13: 82 (1975).
 Geriatric Orthopaedic Surgery & Rehabilitation 2(3) Daniel Eschle et al Andre´ G et al . Aeschlimann, et al
 Luhr HG, Reidick T, Merten HA: Results of treatment of fractures of the atrophic edentulous mandible by compression plating: A
retrospective evaluation of 84 consecutive cases’ Oral Maxillofacial Surg 54: 250 (1996).
 Williams .J LI., Nylon circumferential straps, in maxillofacial injuries Edinburgh, Churchill Livingston, 332 (1985).
 McDowell ,F, Barrett Brown,J.,Fryer,MP.et al., surgery of face, mouth and jaws .st Louis, mosby, 52-55, 71-72
 Obwegeser HL, Sailer HF: Another way of treating fractures of the atrophic edentulous mandible. J Maxillofac Surg 1: 213 (1973)
 Woods WR, Hiatt WR, Borrks RL: A technique for simultaneous fracture repair and augmentation of the atrophic edentulous mandible. J
Oral Surg : 131 (1974).
 Gunning, T.B., The treatment of fractures of the lower jaw by interdental splints, N.Y.MED.J., : 433 (1866).
 Gersein AD, Philips TJ. Rogers GS, et al: Wound healing and aging. Dermatol Clin 1993;11:749
 Franciosi et al. Treatment of Edentulous Mandibular Fractures with RIF. Craniomaxillofacial Trauma and Reconstruction Vol. 7 No. 1/2014

Geriatric fracture

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