This is prepared to present before doctors from different specialities. Hence here discussiuon comes only in a general practitioner's aspect. It is not going deep into the orthopaedic aspects
1. HIP FRACTURES IN ELDERLY
- not just a simple matter of fixation
Dr Arun Ravindran
SR/Orthopaedics
SNIMS
2. • Most commonly done Orthopaedic Surgery at
SNIMS – elderly hip fractures
3. • Osteoporosis (Silent killer)
• a major public health problem because of its
association with low-energy trauma or
fragility fractures
4. • Hip fracture has been recognized as the most
serious consequence of osteoporosis
because of its complications, which include…
chronic pain
Disability
diminished quality of life
premature death
5. • Rising life expectancy throughout the globe
• number of elderly individuals is increasing in every
geographical region
• incidence of hip fracture will rise from 1.66 million in
1990 to 6.26 million by 2050
6. • Osteoporotic hip fracture is an established
health problem in the West
• increasingly recognized as a growing problem
in Asia
7. • Most common cause = Osteoporosis
Age
Sex – high incidence in females
C/c medical conditions – thyroid disorders,
intestinal disorders, neurological conditions
Some medications
Nutritional problems
Physical inactivity
Tobacco and alcohol
12. Cognitive and neurological
complications
• 10% cases - mild problems after surgery
(inability to concentrate, write, read a book,
etc) but are able to overcome activities of
daily living
13. • Postoperative delirium –
• 13.5% to 33% of cases
Causes –
advanced age
history of cognitive impairment
history of alcohol abuse
preoperative medication (special attention to
unrecognized benzodiazepine use)
type of anesthetic used during surgery
infection
urinary retention and fluid or electrolyte disturbance
14. • Regional/Spinal anesthesia reduces the
incidence of delirium, compared to GA early
after surgery
• Supplemental oxygen (3-4 L/min) continually
till day 2 post-surgery, or while patient’s
oxygen saturation is not ≥ 95%
15. Cardiac complications
• 1-year recorded mortality exceeds 20% in
patients with hip fracture
• perioperative myocardial ischemia in aged
patients 35% to 42%
• heart failure and myocardial ischemia - causes
of mortality
20. Urinary tract complications
• Urinary retention, urinary infections and acute
kidney injuries
• intermittent catheterization immediately after
surgery OR catheter removed the morning after
surgery - lower rates of urinary retention
• Urinary catheters should be removed as soon as
possible
21. • UTI - Leading cause of nosocomial infection
• 12% to 61% of all patients with hip fractures
• important risk factor for delirium
• prolong the hospital stay for another 2-5 days
and even a higher mortality rate
23. Hematologic complications
• blood loss from a hip fracture – about 500 mL
• intraoperative causes - comprise fluid shifting
and significant blood loss during surgery
• Postoperative anemia - repeated phlebotomy
or hemodilutional anemia
24. • Perioperative anemia - adverse events
• related to other medical complications
• increased hospitalization duration, rate of
readmission and death
• Hb ≤ 10 g/dL at admission - increased
mortality at 30 d in patients with hip fractures
26. Presure sores
• Close to 35% of decubitus ulcers occur at the
conclusion of the first week of hospitalization
• Risk factors include age, malnutrition, history
of smoking and systemic illnesses
27. • Special beds
• aggressive skin care
• nursing focused on prevention
• good nutrition….
help prevent the evolution
to ulceration
28. Per and post operative
mortality
• Overall 1 year mortality rate that varies from
14% to 36% among patients aged 65 or above
• Mortality is significantly influenced by
preoperative cognitive state, medical
comorbidities and mobility
30. • patients treated non-
operatively have a
higher mortality rate
• Patients operated
within 48 h appear
to have a better
outcome than those
with a delayed
surgical intervention
31. • However, in medically unstable patients, a
delay of surgery does not result in a
statistically significant difference in mortality
compared to patients treated by early surgery
32. Anaesthetic complications of
hip fractures
• Arterial hypotension, defined as a
preoperative drop in mean arterial blood
pressure of more than 30%, or a presurgical
pressure reading of 60-70 mmHg
• Arterial hypotension has been reported in
15%-33% of patients during the first 20 min
after spinal anesthesia induction
33. • cognitive dysfunction during hospitalization –
decreased incidence with spinal anaesthesia
• recent meta-analyses recommend Spinal
anaesthesia as the technique of choice for hip
fracture repair, as long as it is not
contraindicated
34. Bone cement implantation syndrome
• Poorly understood syndrome
• hypoxia, hypotension, cardiac arrhythmias, lung
hypertension, decline in cardiac output
• reduced through…
modern cementing techniques
appropriate anesthesia interventions
adequate patient preparation
avoiding the use of cement altogether
50. Most frequently encountered
questions…!!!
Any conservative options??
Will surgery be a success??
Are we giving more pain to the patient by
operating??
What we are gaining by operating a very old
person of low life expecxtancy??
51. If not operating………
Severe pain
Not able to sit up or turn to either side
Bed sore
DVT, pulmonary embolism
Pneumonia……..
52. After fixation of fracture…
• Pain relief
• Bring back to previous
ambulatory status
• Even in a bed ridden patient
– surgery allows better
general care
53. When to operate???
• Within 48 hrs !!!
• Lesser mortality and morbidity for cases
operated within 48 hours
54. Post op period… What we do???
• make patient sit on the first post operative day
• Standing / walker aided ambulation on 2nd day
55. Prevention of Hip fractures in elderly
• Healthy lifestyle choices in early adulthood
build a higher peak bone mass
reduce your risk of osteoporosis in later years
• The same measures may lower your risk of
falls and improve your overall health if you
adopt them at any age
56. • Get enough calcium and vitamin D.
How Much Calcium Do You Need?
Women
Age 50 & younger - 1,000 mg daily
Age 51 & older - 1,200 mg daily
Men
Age 70 & younger - 1,000 mg daily
Age 71 & older - 1,200 mg daily
57. How Much Vitamin D Do You Need?
• Women and Men
• Under age 50 - 400-800 IU daily
• Age 50 and older - 800-1,000 IU daily
58. • Exercise to strengthen bones and improve
balance
• Weight-bearing exercises, such as walking,
help you maintain peak bone density for more
years
59. • Exercise also increases your overall strength,
making you less likely to fall
• Balance training reduce risk of falls, since
balance tends to deteriorate with age
60. • Avoid smoking or excessive drinking
• alcohol - impair balance - likely to fall
• Assess your home for hazards.
Remove throw rugs, keep electrical
cords against the wall, and clear
excess furniture and anything else
that could trip you
61. • Make sure every room and
passageway is well-lit
• Check your eyes. Have an eye
exam every other year, or more
often if you have diabetes or an
eye disease.
62. • Watch your medications.
Feeling weak and dizzy - side
effects of many medications
• Stand up slowly. Getting up too
quickly can cause your blood
pressure to drop and make you
feel wobbly.
• Use a walking stick or walker
63. • Hand rails and grab bars
• Avoid loose clothings
64. • Make it non slip – non slip mats
• Live on one level
• Move carefully
66. Who all to be screened??? (NOF, US)
• Anyone with a fragility fracture
• All women age 65 and older
• Postmenopausal younger than 65 with risk
factors
• Men over 50 with risk factors
67. • Non pharmacological management
Nutrition – Calcium , protein rich food
Exercise – regular aerobic/moderate weight
bearing exercises
Avoid smoking and alcohol
68. Pharmacologic Treatment
• Calcium & Vit D supplements
• Bisphosphonates
Alendronate 70 mg / month
Risedronate 35 mg/ week
Ibandronate 150 mg / month
Zolendronate - once an year
• Oestrogen – blocks Osteoclastic action
• SERM
• Calcitonin – nasal spray – 200 IU
• Teriparatide – s/c - anabolic effect on trabecular bone
• Fluoride and Strontium – under clinical trial
• Denosumab – s/c every 6 months
69. To conclude….
• Incidence of Elderly Hip fractures is rising
• Major cause is Osteoporosis
• Complication rates are very high compared to
other fractures in the same age group
70. • Most of the cases are treated Surgically
• Surgery to be performed preferably within 48
hrs
• Early mobilisation and ambulation improves
the quality of life and reduce mortality rates
71. • Methods to prevent fall should be taken
• Adopt healthy lifestyles
• Regular exercises according to the age have
important role in maintaining bone density
and muscle power
• Create awareness about Osteoporosis
screening and treatment
