Approach to fractures

1. Approach to fracture
management in elderly
Supervised by : Dr Zaid Alshemmari
By Ameedaldeen Adnan
Ali Hussein khadhim

2. Objectives
1. Know the importance of fracture in elderly
2. Risk factor that contribute to these fractures
3. Common fracture in elderly
4. How you can manage these fractures
5. Impact of fracture of their life

3. introduction
 Older adults, adults 65 years and older, have both an
increased rate of trauma and an increased predisposition
to injury from even minimal force. This makes older
adults a high-risk population for traumatic fracture from
high- or low-impact mechanisms.
 One of the most common changes is their bones undergo
several changes decrease in bone density, also known as
osteoporosis.
 Also due to other physiologic changes of ageing as well as
common comorbidities, Difficulties with gait, vision, and
proprioception contribute to falls.

4. introduction
 Multiple medical conditions also increase the risk of
fracture. Any condition requiring chronic glucocorticoid
use, such as inflammatory bowel disease, celiac disease,
chronic obstructive pulmonary disease, and rheumatoid
arthritis, decreases BMD.
 treatment of low bone mineral density (BMD) has been
shown to significantly reduce fracture rates.
 The most common fractures in older adults are vertebral
fractures from compression or trauma, followed by hip
and distal radius fractures.

5. 75 years female present with back pain after falling.

6. Vertebral fracture
 Spinal fractures in the elderly are the most common
manifestation of osteoporosis and often occur from low
energy mechanism or even in the absence of trauma.
 Cervical spine fractures are quite common, especially at C2.
 Compression fracture of the vertebral body is common,
especially in elderly.
 A compression fracture : is defined as a collapsing in vertebral
bone in the spine and decreased in height at least 15-20 % as a
result of pressure or degeneration of the spinal bones.
 Osteoporosis is the underlying cause of many lumbar
fractures, especially in postmenopausal women. Osteoporotic
spinal fractures are unique in that they may occur without
apparent trauma. However, a thorough diagnostic workup is
always required to rule out spinal malignancy.

7. Vertebral fracture
 Etiology
 1.Trauma
 2.Osteoporosis/Osteopenia (bone density loss)
 3.Osteomyelitis (Bone infection)
 4.Pathologic Fractures (Primary or Metastatic Tumors)
 5.Prolonged use of corticosteroids
 Clinical features
 compression fracture should be suspected in any patient older than
50 years with acute onset of sudden low back pain.
 Midline back pain is the hallmark symptom of lumbar compression
fractures. The pain is axial, no radiating, aching, or stabbing in
quality and may be severe and disabling. The location of the pain
corresponds to the fracture site. In elderly patients with severe
osteoporosis, there may be no pain at all as the fracture occurs
spontaneously.

8. investigation
 Perform a complete blood cell count with differential,
prostate-specific antigen testing and ESR.
 Radiography is the standard imaging study for spine fractures.
Anteroposterior and lateral views
 Computed tomography (CT) scanning is an invaluable tool to
evaluate the complexity of fractures seen on radiographs
Magnetic resonance imaging (MRI) is required when the
patient describes lower extremity motor or sensory loss.
Radicular pain is another indication for MRI. Also, when canal
compromise is suspected.
 When malignancy is strongly suspected, a vertebral biopsy is
indicated.

9. treatment
 In the past, treatment options for lumbar fractures were quite
limited, with bracing and rest prescribed most often. While
many patients improved with this regimen.
 some did not and were left with chronic, disabling pain so they
may need surgery vertebroplasty and kyphoplasty.
 Vertebroplasty involves injecting a form of cement polymer
into the fractured vertebral body. Kyphoplasty is similar to
vertebroplasty, except a balloon is used to expand the volume
of the fractured segment prior to introducing the cement
polymer.
 Elderly patients with osteoporotic compression fractures are
often treated with TLSO bracing and rehabilitation. To facilitate
progress in the rehabilitation program

10. complications
 Early mobilization is extremely important to decrease the
frequency of secondary medical complications. Complications
can occur in young adults and in elderly patients.
 Osteoporotic lumbar fractures
 Many of these patients have comorbid medical illnesses such
as heart disease, lung disease, or diabetes. Often, a period of
bed rest can worsen these and other conditions.
 Other common complications that can occur during bed rest
include pneumonia, deep vein thrombosis, pulmonary
embolism, skin breakdown, and gastric ulceration.
 Prolonged bed rest in an elderly individual can worsen
underlying osteoporosis and increase the risk of additional
fractures.

11. complications
 Pathologic fractures
 All patients with compression fractures require a
thorough examination to make certain the fracture is not
a secondary manifestation of a systemic illness.
 Traumatic injuries
 As in nontraumatic injuries, early mobilization is
important in patients with traumatic injuries, to prevent
secondary complications
 These patients can also have neurologic injury affecting
the bowel and bladder, in addition to the complications
listed above. Therefore, programs for catheterization and
bowel evacuation are required.

12. 60 years female Presents to the emergency
department after a fall.

14. LOW-ENERGY DORSALLY DISPLACED FRACTURES
(‘COLLES’ FRACTURE’)
 Define as a transverse fracture of the radius just above
the wrist, with dorsal displacement of the distal fragment
 Clinical features
 We can recognize the most common fracture pattern by
the ‘dinner-fork’ deformity.
 In patients with less deformity may have pain on
movement, swelling, ecchymoses, tenderness.

15. Treatment
 UNDISPLACED FRACTURES (minimally displaced)
 dorsal splint for a day or two until the swelling resolved,
then the cast is completed for 5 weeks.
 An X-ray is taken at 10–14 day to exclude slippingn
 DISPLACED FRACTURES
 Displaced fractures must be reduced under anaesthesia
 If it is satisfactory, a dorsal plaster slab is applied,
extending from just below the elbow to the metacarpal
necks. The position is then checked by X-ray. It is held in
position by a crepe bandage.

16. Treatment
 IMPACTED OR FRAGMENTED LOW-ENERGY DISTAL
RADIUS FRACTURES
 With substantial impaction or fragmentation in
osteoporotic bone, manipulation and plaster
immobilization alone may be insufficient. The fracture can
sometimes be reduced and held with percutaneous wires
or a volar locking plate

17.  Complications of distal radius fractures:
 EARLY
1. Circulatory problems
2. Nerve injury
3. Complex regional pain syndrome (CRPS)
4. Associated injuries of the carpus
5. Redisplacement
 LATE
1. Malunion
2. Delayed union and non-union
3. Tendon rupture
4. Carpal instability
5. Secondary osteoarthritis

18. Fracture neck of femur
The fracture usually results from a fall directly onto the
greater trochanter.
In younger individuals,the usual cause is a fall from a height
or a blow sustained in a road accident; these patients often
have multiple injuries and in 20% there is an associated
fracture of the femoral shaft.
However, this injury is most commonly seen in elderly
osteoporotic people; here less force is required – perhaps no
more than catching a toe in the carpet and twisting the hip
into external rotation.

19. Garden’s classification
Stage I is an incomplete impacted
fracture.
Stage II is a complete but undisplaced
fracture .
Stage III is a complete fracture with
moderate displacement
Stage IV is a severely displaced
fracture.
Left untreated, a benign-looking Stage I
fracture may rapidly disintegrate to
Stage IV.
With displaced fractures there is an
increased risk of damage to the
femoral head blood supply and thus a
significant incidence of avascular
necrosis.

20. Special features
There is usually a history of a fall, followed by pain
in the hip. If the fracture is displaced, the patient
lies with the limb in lateral rotation and the leg
looks short.
X-rays
Two questions must be answered:
is there a fracture ?
is it displaced?
Usually the break is obvious, but an impacted
fracture can be missed by the unwary.
Displacement is judged by the abnormal shape of
the bone images and the degree of mismatch
of the trabecular lines in the femoral head and
neck and the innominate (supraacetabular) bone.
This assessment is important because impacted or
undisplaced fractures do well after internal fixation,
whereas displaced fractures have a high rate of
nonunion and avascular necrosis.

21. Treatment
Operative treatment is almost mandatory. Why ?
 Displaced fractures will not unite without internal fixation, and in any case
elderly people should be
got up and kept active without delay if pulmonary complications and bed sores are
to be prevented.
 Impacted fractures can be left to unite, but there is always a risk that they may
become displaced, even
while lying in bed, so fixation is safer.
When should the operation be performed?
young patients operation is urgent: interruption of the blood supply will produce
irreversible cellular changes after 12 hours and the way to prevent this is to obtain
accurate reduction and internal fixation as soon as possible.
In older patients also the delay of treatment carries a high risk of
complications.especially in the very elderly, who are often ill .

22. What if operation is considered too dangerous?
Lying in bed on traction may be even more dangerous! And leaving the fracture
untreated too painful. The patient least fit for operation may need it most.
Prophylaxis against thromboembolism is very important .
The principles are accurate reduction, secure fixation and early activity. Under
anaesthesia the fracture is manipulated and reduction is checked by x-ray. If it is
satisfactory, the fracture is securely fixed with cannulated screws, or with a sliding
(‘dynamic’) compression screw which attaches to the femoral shaft. Impacted
fractures can be fixed as they lie.
What if the fracture cannot be accurately reduced?
In patients over 60 years old partial or total hip replacement should be seriously
considered.
In patients under 60 years it is worth trying open reduction rather than replace the
joint.
From the first day the patient should sit up in bed or in a chair. Walking with
crutches is encouraged as soon as possible.

23. Dynamic hip screw Total hip replacement

24. Complications
1/ General complications
There is a high incidence of general complications in these elderly patients.
Thromboembolism, pneumonia and bed sores are constant dangers.
2/ Avascular necrosis.
3/ Non-union
4/ Osteoarthritis
Subarticular bone necrosis or femoral head collapse may lead, after several years, to
secondary osteoarthritis. If the symptoms warrant it, the joint should be replaced.

25. Intertrochanteric Fractures
As with femoral neck fractures, these injuries are common in elderly, osteoporotic
women.
However, in sharp contrast to the intracapsular neck fractures, the extracapsular
intertrochanteric fractures usually unite quite easily and seldom cause avascular
necrosis.
Intertrochanteric fractures can be classified according to the degree of
comminution, and thus the degree of instability . ( Kyle classification )

26. Clinical features
Following a fall the patient is in pain
and unable to stand. The limb is
shortened and lies in external rotation
more than with a neck femur . Swelling
and ecchymosis over the greater
trochanter may be seen later .
X-rays
The fracture usually runs diagonally
from the greater to the lesser
trochanter; it may be comminuted and
severely displaced, but in some cases
the crack can hardly be seen

27. Treatment
These fractures are almost always treated by early internal fixation –
not because they fail to unite with conservative treatment (they unite
quite readily). but
(1) to obtain the best possible position .
(2) to get the patient up and walking as soon as possible.
The common type of intertrochanteric fracture
can be reduced under x-ray control and then fixed with a compression
screw and plate. The patient is allowed to weightbear early, using
crutches until the fracture has united (8–12 weeks).
Severely comminuted and ‘reverse’ fractures are unstable and require
more complex fixation, similar to the devices used for subtrochanteric
fractures .

28. Complications
1/ General complications
Early complications are the same as with femoral neck fractures, reflecting the fact that
most of these patients are in poor health.
2/ Failure of fixation
 Screws may cut out of the osteoporotic bone.
 Reduction is poor.
 Fixation device is incorrectly positioned.
reduction and fixation may have to be re-done.
3/ Malunion
Varus and external rotation deformities are common. Fortunately they are seldom severe
and rarely interfere with function.

29. Subtrochanteric hip fractures
These fractures occur between the inferior margin of the lesser trochanter and
5 cm below this point, 10-30 ٪of hip fractures .
Subtrochanteric fractures have several features which make them interesting
(and challenging to treat)
1/ Blood loss is greater than with femoral neck or trochanteric fractures – the
region is covered with anastomosing branches of the medial and lateral
circumflex femoral arteries which come off the profunda femoris trunk.
2/ There may be subtle extensions of the fracture into the intertrochanteric
region, which may affect choice of treatment.
3/ The proximal part is abducted and externally rotated by the gluteal muscles,
and flexed by the psoas. The shaft of the femur has to be brought into a
position to match the proximal part or else a malunion is created by internal
fixation .

30. Classification
Russel-Taylor classification
used to differentiate between fractures that
would amenable to an intramedullary nail
(type I) and those that required some form of
a lateral fixed angle device (type II)
Type 1: Fractures not involving the piriformis
fossa of the femur. Subdivided into:
Type 1-A: Fractures that extend below the
lesser trochanter of the femur; and
Type 1-B: Fractures that involve the lesser
trochanter of the femur.
Type 2: Fractures that do involve the
piriformis fossa of the femur. Subdivided into:
Type 2-A: Fracture patterns with a stable
medial buttress; and
Type 2-B: Fracture patterns with no medial
femoral cortex stability

31. Diagnosis
Simple X-rays (anteroposterior
and lateral) of the hip diagnose
fracture in the majority of cases.In
subtrochanteric fractures, the
fracture is through or below the
lesser trochanter. It may be
transverse, oblique or spiral, and it
is frequently comminuted. upper
fragment is flexed and appears
short; the shaft is adducted and is
displaced proximally.

32. Treatment
A subtrochanteric fracture can be
corrected and aligned with non-operative
and operative methods.
 Skeletal traction may be applied under
local anesthesia to :
1/Stabilize and prepare elderly patient
with multiple medical problems for
surgery.
2/decrease blood loss.
 Surgery is usually the main treatment
for subtrochanteric fractures.(open or
close reduction with internal fixation).
Surgical options include external fixation,
intramedullary fixation or by using 95°
plates and DHS.

33. Complications
 Early
These patients, most of whom are elderly, are prone to general complications
such as deep vein thrombosis, pulmonary embolism, pneumonia ,bed sores .
 Late
1) varus and malunion or nonUnion .
2) most common complications Limp or limited hip rotation due to malunion .
3) Nail or screw fixation failure
4) Wound infection