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1、Epidemiology,Diagnosis Prevention and Management of Osteoporotic FracturesKenneth A.Egol,MDNYU-Hospital For Joint DiseasesCreated March 2004;Revised May 2006BackgroundOsteoporosis-a decreased bone density with normal bone mineralizationWHO Definition(1994)Bone Mineral Density 2.5 SDs below the mean
2、seen in young normal subjectsIncidence increases with age15%of white women age 50-5970%of white women older than age 80BackgroundRisk factors for osteoporosisFemale sexEuropean ancestrySedentary lifestyleMultiple birthsExcessive alcohol useBackgroundSenile osteoporosis commonSome degree of osteopeni
3、a is found in virtually all healthy elderly patientsTreatable causes should be investigatedNutritional deficiencyMalabsorption syndromesHyperparathyroidismCushings diseaseTumorsBackgroundThe incidence of osteoporotic fractures is increasingEstimated that half of all women and one-third of all men wi
4、ll sustain a fragility fracture during their lifetimeBy 2050-6.3 million hip fractures will occur globallyEnormous cost to societyBackgroundThe most common fractures in the elderly osteoporotic patient include:Hip FracturesFemoral neck fracturesIntertrochanteric fracturesSubtrochanteric fracturesAnk
5、le fracturesProximal humerus fractureDistal radius fracturesVertebral compression fracturesBackgroundFractures in the elderly osteoporotic patient represent a challenge to the orthopaedic surgeonThe goal of treatment is to restore the pre-injury level of functionFracture can render an elderly patien
6、t unable to function independently-requiring institutionalized careBackground Osteopenia complicates both fracture treatment and healingInternal fixation compromisedPoor screw purchaseIncreased risk of screw pull outAugmentation with methylmethacrylate has been advocated Increased risk of non-unionB
7、one augmentation(bone graft,substitutes)may be indicatedPre-injury StatusMedical HistoryCognitive HistoryFunctional HistoryAmbulatory statusCommunity AmbulatorHousehold AmbulatorNon-Functional AmbulatorNon-AmbulatorLiving arrangementsPre-injury StatusSystemic diseasePre-existing cardiac and pulmonar
8、y disease is common in the elderlyDiminishes patients ability to tolerate prolonged recumbencyDiabetes increases wound complications and infectionMay delay fracture unionPre-injury StatusAmerican Society of Anesthesiologists(ASA)ClassificationASA I-normal healthyASA II-mild systemic diseaseASA III-S
9、evere systemic disease,not incapacitatingASA IV-severe incapacitating diseaseASA V-moribund patientPre-injury StatusCognitive StatusCritical to outcomeConditions may render patient unable to participate in rehabilitationAlzheimersCVA ParkinsonsSenile dementiaHip FracturesGeneral principlesWith the a
10、ging of the American population the incidence of hip fractures is projected to increase from 250,000 in 1990 to 650,000 by 2040Cost approximately$8.7 billion annually20%higher incidence in urban areas15%lifetime risk for white females who live to age 80Hip FracturesEpidemiologyIncidence increases af
11、ter age 50Female:Male ratio is 2:1Femoral neck and intertrochanteric fractures seen with equal frequencyHip FracturesRadiographic evaluationAnterior-posterior viewCross table lateralInternal rotation view will help delineate fracture patternHip FracturesRadiographic evaluationOccult hip fractureTech
12、netium bone scanning is a sensitive indicator,but may take 2-3 days to become positiveMagnetic resonance imaging has been shown to be as sensitive as bone scanning and can be reliably performed within 24 hoursHip FracturesManagementPrompt operative stabilizationOperative delay of 24-48 hours increas
13、es one-year mortality ratesHowever,important to balance medical optimization and expeditious fixationEarly mobilizationDecrease incidence of decubiti,UTI,atelectasis/respiratory infectionsDVT prophylaxisHip FracturesOutcomesFracture related outcomesHealingQuality of reductionFunctional outcomesAmbul
14、atory abilityMortality(25%at one year)Return to pre-fracture activities of daily livingHip FracturesFemoral neck fracturesIntracapsular locationVascular SupplyMedial and lateral circumflex vessels anastamose at the base of the neckblood supply predominately from ascending arteries(90%)Artery of liga
15、mentum teres(10%)Hip FracturesFemoral neck fracturesTreatmentNon-displaced/valgus impacted fracturesNon-operative 8-15%displacement rateOperative with cannulated screwsNon-union 5%and osteonecrosis is approximately 8%Hip FracturesFemoral neck fracturesDisplaced fractures should be treated operativel
16、yTreatment:Open vs.Closed Reduction and Internal fixation30%non-union and 25%-30%osteonecrosis rateNon-union requires reoperation 75%of the time while osteonecrosis leads to reoperation in 25%of casesHip FracturesFemoral neck fracturesTreatment:HemiarthroplastyUnipolar Vs BipolarCan lead to acetabul
17、ar erosion,dislocation,infectionHip FracturesFemoral neck fracturesTreatmentDisplaced fractures can be treated non-operatively in certain situationsDemented,non-ambulatory patientMobilize earlyAccept resulting non or malunionHip FracturesIntertrochanteric fracturesExtracapsular(well vascularized)Reg
18、ion distal to the neck between the trochantersCalcar femoralePosteromedial cortexImportant muscular insertionsHip FracturesIntertrochanteric fracturesTreatmentUsually treated surgicallyImplant of choice is a hip compression screw that slides in a barrel attached to a sideplateThe implant allows for
19、controlled impaction upon weightbearingHip FracturesIntertrochanteric fracturesTreatmentPrimary prosthetic replacement can be considered For cases with significant comminutionHip FracturesSubtrochanteric FracturesBegin at or below the level of the lesser trochanterTypically higher energy injuries se
20、en in younger patientsfar less common in the elderlyHip FracturesSubtrochanteric FracturesTreatmentIntramedullary nail(high rates of union)Plates and screwsAnkle FracturesCommon injury in the elderlySignificant increase in the incidence and severity of ankle fractures over the last 20 years Low ener
21、gy injuries following twisting reflecting the relative strength of the ligaments compared to osteopenic boneAnkle FracturesEpidemiologyFinnish Study(Kannus et al)Three-fold increase in the number of ankle fractures among patients older than 70 years between 1970 and 2000Increase in the more severe L
22、auge-Hansen SE-4 fractureIn the United States,ankle fractures have been reported to occur in as many as 8.3 per 1000 Medicare recipientsFigure that appears to be steadily rising.Ankle FracturesPresentationFollows twisting of foot relative to lower tibiaPatients present unable to bear weightEcchymosi
23、s,deformityCareful neurovascular exam must be performedAnkle FracturesRadiographic evaluationAnkle trauma series includes:APLateralMortiseExamine entire length of the fibulaAnkle FracturesTreatmentIsolated,non-displaced malleolar fracture without evidence of disruption of syndesmotic ligaments treat
24、ed non-operatively with full weight bearingMy utilize walking cast or cast braceAnkle FracturesTreatmentUnstable fracture patterns with bimalleolar involvement,or unimalleolar fractures with talar displacement must be reducedTreatment closed requires a long leg cast to control rotationmay be a burde
25、n to an elderly patientAnkle FracturesTreatmentReductions that are unable to be attained closed require open reduction and internal fixationThe skin over the ankle is thin and prone to complicationAwait resolution of edema to achieve a tension free closureAnkle FracturesTreatmentFixation may be subo
26、ptimal due to osteopeniaMay have to alter standard operative techniquesCement AugmentationReports in literature mixedEarly studies showed no difference in operative vs non-op treatment-with operative groups having higher complication ratesMore recent studies show improved outcomes in operatively tre
27、ated groupGoal is return to pre-injury functional statusProximal HumerusBackgroundVery common fracture seen in geriatric populations112/100,000 in men439/100,000 in womenResult of low energy traumaGoal is to restore pain free range of shoulder motionProximal HumerusEpidemiologyIncidence rises dramat
28、ically beyond the fifth decade in women71%of all proximal humerus fractures occur in patients older than 60Associated with frail femalesPoor neuromuscular controlDecreased bone mineral densityProximal HumerusBackgroundArticulates with the glenoid portion of the scapula to form the shoulder jointFour
29、 partsCombination of bony,muscular,capsular and ligamentous structures maintains shoulder stabilityStatus of the rotator cuff is keyProximal HumerusRadiographic evaluationAPScapula YAxillaryCT scan can be helpfulProximal HumerusTreatmentMinimally displaced(one part fractures)usually stabilized by su
30、rrounding soft tissues Non operative:91%good to excellent resultsProximal HumerusTreatmentIsolated lesser tuberosity fractures require operative fixation only if the fragment contains a large articular portion or limits internal rotationIsolated greater tuberosity associated with longitudinal cuff t
31、ears and require ORIF Proximal HumerusTreatmentDisplaced surgical neck fractures can be treated closed by reduction under anesthesia with X-ray guidanceAnatomic neck fractures are rare but have a high rate of osteonecrosisIf acceptable reduction is not attained open reduction should be undertaken Pr
32、oximal HumerusTreatmentClosed treatment of 3 and 4 part fractures have yielded poor resultsFailure of fixation is a problem in osteopenic boneLocked plating versus prosthetic replacementProximal HumerusTreatmentRegardless of treatment all require prolonged,supervised rehabilitation programpoor resul
33、ts are associated with rotator cuff tears,malunion,nonunionProsthetic replacement can be expected to result in relatively pain free shouldersFunctional recovery and ROM variableDistal RadiusBackgroundVery common fracture in the elderlyResult from low energy injuriesIncidence increases with age,parti
34、cularly in womenAssociated with dementia,poor eyesight and a decrease in coordinationDistal RadiusEpidemiologyIncreasing in incidenceEspecially in womenPeak incidence in females 60-70Lifetime risk is 15%Most frequent cause:fall on outstretched armDecreased bone mineral density is a factorDistal Radi
35、usRadiographic evaluationPALateralObliqueContralateral wristImportant to evaluate deformity,ulnar varianceDistal RadiusTreatmentNon-displaced fractures may be immobilized for 6-8 weeksMetacarpal-phalangeal and interphalangeal joint motion must be started earlyDistal RadiusTreatmentDisplaced fracture
36、s should be reduced with restoration of radial length,inclination and tiltUsually accomplished with longitudinal traction under hematoma blockIf satisfactory reduction is obtained treatment in a long arm or short arm cast is undertakenNo statistical difference in methodWeekly radiographs are require
37、dDistal RadiusTreatment:Operativeif acceptable reduction not obtainedregional or general anesthesiaMethodsORIFClosed reduction and percutaneous pinning with external fixationBone grafting for dorsal comminution Distal RadiusTreatmentResults are variable and depend on fracture type and reduction achi
38、evedMinimally displaced and fractures in which a stable reduction has been achieved result in good functional outcomesDistal RadiusTreatmentDisplaced fractures treated surgically produce good to excellent results 70-90%Functional limits include pain,stiffness and decreased gripVertebral Compression
39、FracturesBackgroundNearly all post-menopausal women over age 70 have sustained a vertebral compression fractureUsually occur between T8 and L2Kyphosis and scoliosis may developmarkers for osteoporosisVertebral Compression FracturesEpidemiologyMore common than hip fractures117/100,000Twice as common
40、in femalesLifetime risk in a 50 year old white female is 32%Vertebral Compression FracturesBackgroundPresent with acute back painTender to palpationNeurologic deficit is rarePatternsBiconcave(upper lumbar)Anterior wedge(thoracic)Symmetric compression(T-L junction)Vertebral Compression FracturesRadio
41、graphic evaluationAP and lateral radiographs of the spineSymptomatic vertebrae 1/3 height of adjacent Bone scan can differentiate old from new fracturesVertebral Compression FracturesTreatmentSimple osteoporotic vertebral compression fractures are treated non-operatively and symptomaticallyProlonged
42、 bedrest should be avoidedProgressive ambulation should be started earlyBack exercises should be started after a few weeksVertebral Compression FracturesTreatmentA corset may be helpfulMost fractures heal uneventfullyKyphoplasty an optionPreventionStrategies focus on controlling factors that predisp
43、ose to fractureFall preventionPreventionMultidisciplinary programsMedical adjustmentBehavior modificationExercise classesControversialPrevention and Treatment of Bone FragilityWell established link between decreasing bone mass and risk of fractureTreatment of osteoporosisEstrogenCalcium/Vitamin D Su
44、pplementsCalcitononinBisphosphonatesTeriparatide(Forteo)Prevention and Treatment of Bone FragilityEstrogen2-3%bone loss with menopauseUnopposed or combined therapy has been shown to reduce hip fracture incidence in women aged 65-74 by 40-60%(Henderson et al.1988)Risk of breast and endometrial cancer
45、 increased in unopposed therapyPrevention and Treatment of Bone FragilityFosmaxShown to increase the bone density in femoral neck in post menopausal women with osteoporosis(Lieberman et al.NEJM 1995)Reduced hip fracture rate by 50%in women who had sustained a previous vertebral fracture.(Black et al
46、.Lancet 1996)Prevention and Treatment of Bone FragilityCalcium/Vitamin D SupplementationRecommended for most men and women 50 yearsCalcium Age 50-1,200 mg/dayVitamin DAge 51-70-400 IU/dayAge 70-600 IU/dayCombining Vitamin D and calcium supplementation has been shown to increase bone mineral density
47、and reduce the risk of fracturePrevention and Treatment of Bone FragilityCalcitoninInhibits bone resorption by inhibiting osteoclast activityApproved for treatment of osteoporosis in women who have been post-menopausal for 5 yearsDaily intranasal spray of 200 IUTrial demonstrated 33%reduction of ver
48、tebral compression fractures with daily therapy(Chesnut Am J Med 2000)No effect on hip fractures demonstratedPrevention and Treatment of Bone FragilityBisphosphonatesInhibits bone resorption by reducing osteoclast recruitment and activityBone formed while on bisphosphonate therapy is histologically
49、normalAvailable formulationsAlendronateRisendronateIbandronateStrongest evidence for rapid fracture risk reductionDecreasing the incidence of both vertebral and nonvertebral fracturesPrevention and Treatment of Bone FragilityTeriparatide(Forteo)Recombinant formulation of parathyroid hormoneStimulate
50、s the formation of new bone by increasing the number and activity of osteoblastsOnce daily subcutaneous injection of 20 gStudy of 1637 post-menopausal women 65%reduction in the incidence of new vertebral fractures53%reduction in the incidence of new nonvertebral fracturesConclusionsPrevention is mul