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Fragility Fractures & Orthogeriatric Care – Comprehensive Study Notes

Introduction

  • Life expectancy ↑ globally; by 2050 those ≥ 60 y will outnumber younger cohorts.
  • Fastest-growing subgroup: ≥ 80 y; > 10 % of hip-fracture pts in some nations are ≥ 90 y.
  • In many orthopaedic-trauma units, fragility-fracture pts ≈ 30 % of caseload.
  • Osteoporosis → chronic disease with intermittent acute episodes (fractures).
  • Two therapeutic pillars:
    • Orthogeriatric co-managed acute care (≈ 30–35 d incl. rehab).
    • Life-long secondary fracture prevention.

Terminology & Definitions

  • Fragility fracture (WHO 1998): “fracture caused by injury insufficient to break normal bone; consequence of ↓ compressive / torsional strength.”
    • Clinically: fracture after minimal trauma (e.g., fall from standing height).
  • Osteoporosis: “systemic skeletal disease characterized by low bone mass + microarchitectural deterioration ➔ ↑ fragility & fracture risk.”
  • Typical osteoporotic sites: hip, spine, distal radius, proximal humerus; any fracture > 50 y with low bone mass is osteoporotic.

Epidemiology

  • Global burden: osteoporotic fracture every 3 s.
  • Lifetime fracture risk at 50 y: women 40–50 %, men 13–22 %.
  • After 1 fracture, ≈ 50 % sustain another; risk ↑ exponentially with each event.

Hip

  • Incidence rises exponentially with age; ≈ 0.6 M / y EU, 0.3 M / y USA.
  • > 10-fold variation world-wide; by 2050 > 50 % of hip fractures will be in Asia.

Vertebra

  • Most common osteoporotic fracture; only ≈ 30 % are clinical (symptomatic).

Distal radius

  • Incidence peaks early post-menopause; plateaus mid-60s.
  • Lifetime risk at 50 y: women 20 %, men 5 %.

Proximal humerus

  • Lifetime risk at 50 y: women 13 %, men 4 %; overall age-adjusted incidence ≈ 50–60 % of hip-fracture rate.

Etiology & Pathophysiology

  • Bone strength = density + quality.
    • Density = g mineral / area; depends on peak mass & loss.
    • Quality = architecture, turnover, mineralization, micro-damage.
  • Fracture when applied load > strain tolerance; osteoporotic bone has lower threshold; in severe cases everyday loads suffice (e.g., spine).

Cortical bone changes

  • Endosteal resorption → thin cortex, ↑ medullary diameter; esp. women.
  • Age 30→80 y: elastic modulus –8 %, ultimate strength –11 %, toughness –34 %.
  • Tube-model bending stiffness: \frac\pi4 (R^4 - r^4)

Cancellous bone changes

  • ↓ trabecular thickness, number, connectivity; plates → rods (age 35 vs 73 micro-CT).
  • Mechanical usage (Wolff’s law) influences bone but exercise only small ↑ mass.

Clinical Impact on Fixation

  • ↓ cortical thickness → ↓ screw holding power; osteoporotic changes impair implant anchorage.

Measurement

  • DEXA = gold standard; osteoporosis if T-score ≤ –2.5 SD (young Caucasian female ref). Provides ≈ 70 % of strength info.
  • Indications: long-term steroids, early surgical menopause, risk factors (ETOH, smoking, BMI<18.5, FHx), baseline / f-u of therapy.
  • Acute fracture: estimate osteoporosis via x-ray, drilling “haptics”, age, sex, comorbidities.

Falls

  • Majority of fractures due to falls; prevention strategies: strength & balance training, home-hazard mods, vision, med review, pacing, cognitive-behavioural.
  • Risk factors overlap fracture risks: prior falls, weakness, gait, psychoactive / anticonvulsant / antihypertensive meds.

Other injury mechanisms

  • Increasing high-impact trauma in active retirees (stairs, driving, outdoor sports).

The Fragility-Fracture Patient

  • Definition: low-energy trauma fracture + age ≥ 70–80 y with reduced general health (≥ 2 comorbidities, cognitive / functional disability, frailty, sarcopenia).
  • ISS>15: mortality rises sharply beyond 64 y, further beyond 89 y.

Comorbidities (assess via Charlson, CIRS)

  • Common: cardiac dz, dementia, renal dysfunction (40 % hip pts CKD), pulmonary dz, HTN, DM, malignancy.
  • Polypharmacy → ↑ ADRs; high prevalence anticoagulants.

Active conditions needing stabilization (< 72 h limit)

  • Decomp HF, acute MI/angina, stroke, infection/sepsis, severe hypo-/hypertension, GI bleed, rhabdomyolysis, AKI.

Functional Disabilities & Frailty

  • Geriatric assessment guides goals; upper limbs often needed for ambulation → NWB unrealistic.
  • Frailty = ↓ reserve across systems; prevalence high; goal “do no harm”.
  • Sarcopenia: loss muscle mass/strength (5–13 % age 60–70; 11–50 % > 80). Bed rest → 0.5 % mass & 4 % strength loss/day.

Facilities Requirements

  • Obstacle-free rooms, handrails, low beds, large clocks, good lighting, therapy room on ward, delirium-preventive design.

Orthogeriatric Comanagement

Comorbidity Construct

  • Index disease ↔ comorbidities + age, sex, individual attributes determine complexity.

Goal Setting

  • Short-term & long-term functional targets; revise as course evolves.

Team & Roles

  • Co-ownership: surgeons, geriatricians, anesthesiologists equal partners.

Orthopaedic Trauma Surgeon

  • Decide need for geriatric facility, initiate team, imaging, plan surgery enabling immediate full weight bearing, manage pain, abx, anticoag, rehab plan, ward rounds.

Geriatrician / Medical Lead

  • Early ED involvement; full medical work-up, cognitive assessment (AMTS), fluid, med optimization, delirium prevention, osteoporosis Rx, fall-risk plan.

Anesthesiologist

  • Early nerve-block analgesia, clearance, choose GA vs neuraxial, immediate postop care.

Nursing

  • Continuous assessment (falls, pressure, nutrition, infection), catheter management, walking-aid training, discharge planning.

Physio / OT / Speech / Social / Dietitian / Case-manager / Pharmacist / Psychiatrist & other specialists – detailed tasks enumerated.

Guidelines & Protocols

  • IOF/AO “Guide to Improving Care”, BOA/BGS Blue Book; use checklists, pathways, audits.

Fast-Track & Urgent Surgery

  • ED stay ≤ 2 h; OR capacity dedicated; time-to-knife good comanagement KPI.

Lifelong Assistance Topics

  • Walking aids, home adaptation, secondary prevention, exercise, nutrition, end-of-life planning (esp. dementia pts; 90 % < 1 y survival in nursing home).

Principles of Medical Treatment

Pre-op Optimization Steps

  • Hydration, Hb/coag/glucose control, BP, COPD bronchodilators, dysrhythmia control, warming, delirium vigilance, skin checks.

Delay to Surgery

  • Local guidelines + multidisciplinary consensus minimize delays (> 72 h ➔ complications ↑).

Fluids / Electrolytes

  • Use isotonic only; monitor Na/K; avoid diuretics misuse; prevent delirium.

Pain Management

  • Early, adequate analgesia ↓ delirium 35 %.
  • Avoid NSAIDs; IV agents: paracetamol, metamizole, (di)hydromorphine, morphine, piritamide. Convert to oral early.
  • Opioids: low doses, caution in CKD, delirium risk.
  • Regional anesthesia: femoral nerve block, 3-in-1 etc. reduce opiates & pulm complications.

Fracture Immobilisation Pre-op

  • Pillow/foam splint legs; traction rarely indicated (no evidence of benefit; painful, costly).

Anticoagulation Management

  • Clopidogrel: do NOT delay hip surgery; halt peri-op unless recent coronary stent; neuraxial contra w/ dual therapy.
  • VKA: reverse to INR ≤ 1.5–1.8 with 2.5–10 mg IV vit K; check INR 4–6 h.
  • DOACs: stop; monitor (aPTT, anti-Xa, PT, ROTEM). Neuraxial after > 24 h off drug. Antidotes: idarucizumab (dabigatran), andexanet alfa (Xa inhibitors). PCC/FFP etc. for bleeding.

Postoperative Management

Delirium & Dementia

  • Up to 60 % peri-op hip-fx pts delirious; mortality up to 30 %.
  • Features: altered consciousness/attention, cognitive change, acute/fluctuating, medical etiology.
  • Risk factors list (age, brain dz, metabolic, organ failure, meds, restraints, pain, etc.).

Prevention

  • Early fluids, O2, warmth, analgesia, review meds, manage bowel/bladder, nutrition, mobilize early, environmental orientation, sleep aids.

Management

  • Treat underlying cause; symptom control (low-dose haloperidol reduced severity/duration). Use low beds, family contact.

Transfusion Thresholds

  • Indicated: Hb ≤ 6 g/dL (3.7 mmol/L) or Hb 8–10 g/dL (5.0–6.2 mmol/L) with hypoxia signs.
  • NOT indicated: Hb > 10 g/dL (≥ 6.2 mmol/L).

Thromboprophylaxis

  • LMWH pre- or post-op depending on timing/neuraxial; continue until mobile; consider 35-d hip-fx extension case-by-case.

Malnutrition

  • Diagnose via wt loss (> 5 %/3 mo), BMI<20, albumin<3.5 g/dL, MNA.
  • Calorie 1500–2000 kcal/day; protein 0.9–1.1 g/kg; fluid 1.5–2 L/d.
  • Early oral supplements ↓ mortality & complications.

Rehabilitation

  • Acute geriatric rehab units improve mobility, QoL, ↓ readmissions, depression & falls.

Secondary Fracture Prevention

Fall Prevention

  • 1/3 ≥ 65 y fall annually; 5–6 % cause fracture. Ask about past falls; address home, meds, vision, balance, shoes, CVS issues.

Vitamin D & Calcium

  • Aim 25-OH-D > 32 ng/mL; deficiency < 10 ng/mL.
  • D3 1200–2000 IU/d + Ca 500–1000 mg/d orally.

Osteoporosis Pharmacotherapy

  • Oral bisphosphonates (alendronate, risedronate) start ≥ 3 wk post-op (Fx protection after ≥ 6 mo). Compliance poor; reinforce.
  • IV zoledronic acid 5 mg yearly ≥ 3 wk post-op; immediate protection, assured compliance, .
  • Refracture on BP or severe osteoporosis: consider anabolic \text{teriparatide}.
  • CI in CKD: use denosumab 60 mg SC q6 mo.
  • Communicate plan in writing to GP & patient.

Force Reduction Devices

  • Hip protectors in institutions – modest benefit; compli­ance issue.
  • Soft flooring halves fall impact forces.

Anesthesia Considerations

  • Risk stratify via surgery type, duration, anticoag, delirium risk, neuraxial feasibility.
  • Neuraxial: ↓ delirium, VTE, MI trend; ↑ intra-op hypotension; CI critical AS, clopidogrel.
  • GA: ↓ hypotension, but resp dz + GA ↑ morbidity; hydrate pre-op.

Principles of Surgical Treatment

Timing

  • Operate within 24–48 h; > 72 h delay ➔ ↑ complications & mortality.

Soft-Tissue Concerns

  • Thin, fragile skin; risk pressure sores, degloving (case Fig 4.8-7).
  • Vascular changes (arterial insuff, venous stasis) → healing issues.

Bone Quality & Deformation

  • Osteoporotic bone thin cortices; bisphosphonate-related thick brittle cortex (atypical fractures).
  • Geriatric femoral bowing (varus, antecurvatum) challenges nail/plate fit.

Atypical Femoral Fracture (AFF)

  • Transverse, thick cortex, lateral beaking; minimal trauma; prodromal pain; assoc. long-term BPs, Asian ethnicity, sclerotic mets DDx.

Indications for (Non)Operative Management

  • Surgically treat nearly all femoral & displaced tibial-shaft Fx.
  • Ankle fixation may benefit ambulators; foot Fx often non-op.
  • Upper-extremity: many proximal humerus, olecranon, distal radius managed non-op with acceptable function; but casts → dependency; choose op if it meaningfully improves ADLs & allows WB.
  • Non-op palliation for pre-terminal, bedridden pts (6–10 %).

Weight Bearing

  • Immediate WBAT crucial: prevents muscle loss, realistic (pts cannot do PWB), promotes healing, no ↑ loss fixation.

Fixation Techniques & Principles

  • Prefer relative stability & load-sharing.
  • Intramedullary > extramedullary where possible.
  • Use long plates, skip holes near Fx, ≥ 3–4 bicortical locking screws/fragment.
  • Splint whole bone to avoid stress risers (e.g., long nails, plates bridging prosthesis).
  • Locking plates/screws, variable-angle, angular-stable nails; blades condense bone.
  • Alignment: avoid varus; precise reduction essential.
  • Controlled impaction (DHS sliding) benefits.
  • Augmentation:
    • PMMA injected via perforated blades/screws or into voids (vertebro-, kypho-, tibial plateau).
    • Check with dye test to avoid joint perforation.
  • Biological adjuncts:
    • Autograft limited quality/quantity.
    • Allograft struts/void fillers (prox humerus, tibia, periprosth femur).
  • MIS benefits: less soft-tissue stripping, blood loss.
  • Positioning: pressure-relief, supine preferred for anesthetic care.
  • Joint replacement: hemi/THA for displaced femoral-neck; consideration at proximal humerus, distal humerus (elbow arthroplasty).

Outcomes

Healing

  • Healing stages normal but slower; stem-cell number & responsiveness ↓; implant failure risk ↑.

Mortality

  • Hip-fx 1-y mortality 12–35 %; higher in men, ↑ with age, comorbidities, low pre-fx function, low BMD.

Orthogeriatric Care Impact

  • Comanagement ↓ in-hospital & long-term mortality, LOS, readmissions, delirium, bleeding, infection; meta-analysis supports shared-care model benefits.

Example Case Highlights (summaries)

  • Fig 4.8-1 series: 88 y female – multiple sequential fragility fractures (hip → tibia → humerus → periprosthetic), illustrates chronic nature; teriparatide administered; spine fracture 3 y earlier no secondary prevention.
  • Fig 4.8-2: World hip-fracture rates – >10× variation; map underscores demographic influence.
  • Fig 4.8-3/4: Histology & micro-CT show cortical thinning and trabecular rodification with age.
  • Fig 4.8-5: UK trauma bank – probability of death vs age, ISS>15.
  • Fig 4.8-7: Degloving injury from gentle traction in 88 y woman; warns about skin fragility.
  • Fig 4.8-8/9/10/11/12/13/14: Surgical pitfalls & solutions—iatrogenic comminution, clamp caution, long-bone protection, cement augmentation, structural allograft.

Ethical & Practical Considerations

  • End-of-life discussions necessary for dementia pts (90 % survive < 1 y in LTC after admission).
  • Treatment aims shift from full activity restoration to functional independence consistent with patient goals.
  • System efficiency: fragility-fx pts often low priority—must correct.

Key Equations & Numerical References

  • Bending stiffness: EI = \frac\pi4 (R^4 - r^4) E$$ (E = modulus, R = outer radius, r = inner).
  • Muscle loss bed rest: 0.5 % mass & 4 % strength per day.
  • Risk stats, incidence figures, thresholds (Hb, vitamin D, supplementation doses) as listed above.