1-21 Management of Osteoporotic Fractures

8/14/2019 1-21 Management of Osteoporotic Fractures

1/55

MANAGEMENT OF MANAGEMENT OF OSTEOPOROTIC OSTEOPOROTIC

FRACTURES FRACTURES

Prof DrProf Dr

Hazem Abd ElazeemHazem Abd ElazeemCairo University HospitalsCairo University Hospitals


2/55

EpidemiologyEpidemiology**1.51.5million osteoporosis-relatedmillion osteoporosis-related

fractures annuallyfractures annually**700,000700,000vertebral fracturesvertebral fractures

**300,000300,000hip fractureship fractures**250,000250,000distaldistal

forearm/wrist/Colles' fracturesforearm/wrist/Colles' fractures

**$13.3$13.3billion in direct costsbillion in direct costs

annuallyannually **Projected $240 billion annually inProjected $240 billion annually inosteoporosis costs by 2040osteoporosis costs by 2040


3/55

**33%33%of women >65 yearsof women >65 yearsof age have vertebralof age have vertebralfracturesfractures

**32%32%of women and 17% of of women and 17% of

men >90 years of agemen >90 years of age

have hip fractureshave hip fractures

**33%33%of men >80 years of of men >80 years of

age have osteoporosisage have osteoporosis


4/55

Special characters of FractureSpecial characters of Fracture

**Osteoporosis affects bone with high surface area so itOsteoporosis affects bone with high surface area so itaffects mostly cancellous boneaffects mostly cancellous bone

--Trabecular bone resorption 8% per yearTrabecular bone resorption 8% per year

--Cortical bone resorption 0.5% per yearCortical bone resorption 0.5% per year--Affects commonly metaphyseal partAffects commonly metaphyseal part

--Low energy have considerable effect in fracture causationLow energy have considerable effect in fracture causation**Falls from standing exceed femur strength by 50% in elderlyFalls from standing exceed femur strength by 50% in elderly


5/55


6/55

Age-related changesAge-related changes

After age 60, subperiostealarea slowly increases butmedullary cavity enlargesfaster, resulting in netdecrease of corticalthickness and mass


7/55

Different degrees of loss of trabecular bone architecture (osteopenia) at theproximal femur from normal to severe

osteoporosis (according to Singh(.


8/55

FRACTURESFRACTURES

**FRAGILITYFRAGILITYFRACTURESFRACTURES..

**MINOR TRAUMAMINOR TRAUMA..

COMMON SITESCOMMON SITES::**SpineSpine..--

--Proximal end of Proximal end of femurfemur..

--Distal end of radiusDistal end of radius.. --Proximal end of Proximal end of humerushumerus..


9/55

Management of FracturesManagement of Fractures

--Anatomic reductionAnatomic reduction--Stable internal fixationStable internal fixation

--Preservation of the blood supplyPreservation of the blood supplyusing atraumatic techniqueusing atraumatic technique--Avoid excessive periosteal strippingAvoid excessive periosteal stripping

--Utilize indirect reduction techniquesUtilize indirect reduction techniques--Early active mobilizationEarly active mobilization


10/55

**Important aspects of treatmentImportant aspects of treatment

--Replace anticipated deficits in calciumReplace anticipated deficits in calciumreservereserve

--Consider the help of pharmacologicalConsider the help of pharmacologicaltreatmenttreatment

--Rule out underlying metabolic boneRule out underlying metabolic bonediseasedisease


11/55

Fractures of the SpineFractures of the Spine

**Types of spinalTypes of spinalfracturefracture

--CompressionCompressionfracturesfractures

--Burst fracturesBurst fractures

**Rarely neurologicRarely neurologiccompromisecompromise

**Rarely unstableRarely unstable


12/55

**Indications of instabilityIndications of instability Neurologic deficitNeurologic deficit Kyphosis >30Kyphosis >30

Compression >50%Compression >50%

Translation >4 mmTranslation >4 mm Interspinous-process wideningInterspinous-process widening


13/55


14/55

Two types of back pain can beTwo types of back pain can bedistinguisheddistinguished::


15/55

Treatment of spinal fractureTreatment of spinal fracture

AnalgesicsAnalgesics

External bracing (JewettExternal bracing (Jewett,, Thoracolumbosacral orthosisThoracolumbosacral orthosis))

Activity modificationsActivity modifications

Maintain weight-bearing activitiesMaintain weight-bearing activities Identify underlying causeIdentify underlying cause


16/55

Hip FracturesHip Fractures

**25%25%of women >60of women >60years of age haveyears of age havehip fractureship fractures

**12%12%to 20% mortalityto 20% mortality**50%50%able to return toable to return to

independentindependentambulationambulation

**Incidence is clearlyIncidence is clearlyrelated torelated toosteoporosisosteoporosis


17/55

Femoral neck fractureFemoral neck fracture

**High incidence of High incidence of nonunion/ avascularnonunion/ avascularnecrosisnecrosis

**ClosedClosedreduction/pinningreduction/pinning

**14%14%nonunionnonunion**15%15%avascular necrosisavascular necrosis

andand

**Higher incidence of Higher incidence of failure infailure inosteoporosis due toosteoporosis due toloss of fixationloss of fixation


18/55

--ClosedClosedreduction withreduction with

internalinternalfixationfixation

--80%80%good orgood orexcellent resultsexcellent results

--RequiresRequiresanatomicanatomicreductionreduction


19/55

**HemiarthroplastyHemiarthroplastyindicationsindications

--Active householdActive householdor communityor communityambulatorsambulators

--Patients withPatients with

severesevereosteoporosisosteoporosis--If unable to obtainIf unable to obtain

stable reductionstable reduction

*h lH i h l


20/55

**Hemiarthroplasty vsHemiarthropl asty vs pinning pinning

**Study of 215 displacedStudy of 215 displacedfractures treated withfractures treated withclosed reduction withclosed reduction withinternal fixationinternal fixation

6363))29%29%((had died by 2 yearshad died by 2 years

Nonunion in 39 patients )18%Nonunion in 39 patients )18%((Avascular necrosis in 14Avascular necrosis in 14

patients )6.5%patients )6.5%((Only 36 )17%( requiredOnly 36 )17%( requiredreoperationreoperation


21/55

Intertrochanteric FracturesIntertrochanteric Fractures**Incidence of malunion andIncidence of malunion and

varus may be disablingvarus may be disabling**Avoid shorteningAvoid shortening&&

external rotation deformityexternal rotation deformity

**Implant considerationsImplant considerationsLoad bearing -- fixedLoad bearing -- fixed nail-nail-plate constructplate construct

Intermediate -- slidingIntermediate -- slidingnail-plate constructnail-plate construct

Load sharing --Load sharing --intramedullary nail-intramedullary nail-

screw constructscrew construct


22/55

**Medial displacement Medial displacement osteotomy osteotomy

--Puts fracture in most stablePuts fracture in most stableconfigurationconfiguration

--Less stress on implantLess stress on implant

--Results in shortened limbResults in shortened limband weak abductorsand weak abductors


23/55

Techniques to enhanceTechniq ues to enhancefixationfixation

**Screw must be centralScrew must be central

in head/neckin head/neck

**Must engageMust engagesubchondral bonesubchondral bonewithin 11 to 25 mmwithin 11 to 25 mmrangerange

--Valgus screw/plateValgus screw/plate140 is optimal140 is optimal


24/55

**PolymethylmethacrylPolymethylmethacrylate used to augmentate used to augmentfixation allows earlyfixation allows earlyweight bearingweight bearing

**Reduce posteromedialReduce posteromedial(lesser trochanter)(lesser trochanter)fragment to increasefragment to increasestrength of constructstrength of construct


25/55

Failures in Hip FracturesFailures in Hip Fractures

**Causes of Causes of redisplacement andredisplacement and

reoperationreoperation::

--OsteoporosisOsteoporosis--Fracture displacementFracture displacement

--Collapse of femoralCollapse of femoralheadhead

--Bone mineral contentBone mineral content


26/55

SUPRACONDYLAR FRACTURE OFSUPRACONDYLAR FRACTURE OFFEMURFEMUR


27/55

Supracondylar interlocking nailSupracondylar interlocking nail


28/55

Proximal Humerus FractureProximal Humerus Fracture

**5%5%of osteoporotic fracturesof osteoporotic fractures**80%80%nondisplacednondisplaced

--Nondisplaced fractures --Nondisplaced fractures --

immobilization in sling andimmobilization in sling andearly motion as painearly motion as painsubsidessubsides

--Full passive range of motionFull passive range of motionencouraged by 3 to 4encouraged by 3 to 4weeks, active range of weeks, active range of

motion at 5 to 6 weeksmotion at 5 to 6 weeks


29/55

Surgical optionsSurg ical options

--Closed reduction, percutaneous pinningClosed reduction, percutaneous pinning

--Pinning less effective in poor bone qualityPinning less effective in poor bone quality--Greater tuberosity fracture needs reductionGreater tuberosity fracture needs reduction

and possibly rotator cuff repairand possibly rotator cuff repair--Comminuted fracturesComminuted fractures

--Open reduction with internal fixation usingOpen reduction with internal fixation usingscrews and tension band wiring if possiblescrews and tension band wiring if possible

--33or 4 part fractures should be treated withor 4 part fractures should be treated withHemiarthroplastyHemiarthroplasty

--Repair rotator cuff Repair rotator cuff


30/55

Colles' FractureColles' Fracture

**Involves dorsalInvolves dorsaldisplacement of thedisplacement of theradiusradius

**May or may not involveMay or may not involvethe ulnathe ulna

**Often results in an ulnarOften results in an ulnarstyloid fracturestyloid fracture

**Fractures intra- and/orFractures intra- and/orextra-articularextra-articular


31/55

Closed reduction and castingClosed reduction and casting

Adequate reductionAdequate reduction Neutral angulationNeutral angulation

No radial shorteningNo radial shortening

All types of deformity betterAll types of deformity better tolerated in elderly so usetolerated in elderly so use

judgmentjudgment


32/55

**Long arm cast 2 to 4 weeksLong arm cast 2 to 4 weeks

**Short arm cast another 4 to 6Short arm cast another 4 to 6

weeksweeks **Incidence of reflexIncidence of reflex

sympathetic dystrophysympathetic dystrophy,, stiffness, malunionstiffness, malunion

--52%52%complicationcomplicationrate with plasterrate with plaster mostlymostlydeformity recurrencedeformity recurrence


33/55


34/55


35/55

Osteoporotic Fracture ManagementOsteoporotic Fracture Management

SummarySummaryPrevention better thanPrevention better thantreatmenttreatmentOperative treatment use isOperative treatment use is

common but is difficultcommon but is difficult

**I t l fi tiInternal fi ation


36/55

**Internal fixationInternal fixation--Standard indicationsStandard indications

--Use wide perchase screws ( cancellousUse wide perchase screws ( cancellous))--Augmentation with polymethyl-Augmentation with polymethyl-

methacrylate or hydroxyapatitemethacrylate or hydroxyapatite--Structural grafting or bone substituteStructural grafting or bone substitute

--Polysegmental fixationPolysegmental fixation--Less of reduction or fixation or of correctionLess of reduction or fixation or of correction

is expectedis expected

--Postoperative plaster or bracing is betterPostoperative plaster or bracing is better--Maximize preoperative medical treatmentMaximize preoperative medical treatment

--Consider discharge program & careConsider discharge program & care


37/55

Pharmacologic managementPharmacologic management

48%48%reduction in incidence of fracturesreduction in incidence of fractures----Calcium and vitamin DCalcium and vitamin D

Hormone replacement therapyHormone replacement therapy--

Augmentation agentsAugmentation agents----CalcitoninCalcitonin

--AlendronateAlendronate

--PamidronatePamidronate


38/55

Wh tWh tWh tWh t


39/55

WhatWhat

after theafter thefirstfirstfracturefracture??

WhatWhat

after theafter thefirstfirstfracturefracture??

Prof. Hazem Abdel AzeemProf. Hazem Abdel AzeemProfessor of OrthopedicsProfessor of Orthopedics

Cairo University, Egypt Cairo University, Egypt


40/55


41/55

First Fractures Increase RiskFirst Fractures Increase Risk


42/55

First Fractures Increase Risk First Fractures Increase Risk for Subsequent Fracturesfor Subsequent Fractures

Klotzbuecher et al. J Bone Miner Res 2000; 15 (4): 721-39

WristWrist VertVert HipHip AllAll PooledPooled

WristWrist 3.33.3))22 5.35.3((

1.71.7))1.41.4--2.12.1((

1.91.9))1.61.6 2.22.2((

2.42.4))1.71.7 3.43.4((

2.02.0))1.71.7 2.42.4((

VertVert 1.41.4))22 5.35.3((

4.44.4))3.63.6 5.45.4((

2.32.3))2.02.0 2.82.8((

1.81.8))1.71.7 1.91.9((

1.91.9))1.71.7 2.32.3((

OtherOther 1.81.8))22 5.35.3((

1.91.9))1.31.3 2.82.8((

2.02.0))1.71.7 2.32.3((

1.91.9))1.31.3 2.72.7((

1.91.9))1.71.7 2.22.2((

HipHip 2.52.5))1.81.8 3.53.5((

2.32.3))1.51.5 3.73.7((

1.91.9 2.42.4))1.91.9--3.23.2((

Subsequent Fracture

P

riorFracture


43/55

Osteoporosis Goes Unrecognized InOsteoporosis Goes Unrecognized Ina Clinical Settinga Clinical Setting

0

20

40

60

80

100

120

140

P a

t i e n

t s ( n )

Fractureidentifiedby studyradiologists

Fracturenoted inradiologyreport

Fracturenoted inmedicalrecord

Receivedosteoporosistreatment

132

65

23 25

n=934

Only 19% of women with a fracture received treatment Only 19% of women with a fracture received treatment


44/55

Are Physicians Missing anAre Physicians Missing an

OpportunityOpportunity??

Freedman KB et al., J. Bone & Joint Surg 2000; 82-A: 1063-70

1162 1162 W with a distal radial fracture, > 55 W with a distal radial fracture, > 55

yrsyrs

) ) 60%60%>>7474yrsyrs ( (3333((2.8%2.8%))had a bone density scanhad a bone density scan

266266((22.9%22.9%))were treated with at least 1were treated with at least 1

medicationmedication

173173((16.2%16.2%))of 1069 women filledof 1069 women filled

prescriptions in response to fractureprescriptions in response to fracture

883883) ) 76%76% ( (received neither a BMD /received neither a BMD /

treatment for osteoporosistreatment for osteoporosis


45/55


46/55

(A). The patient was revised with a 19.5-mm extensively porous coated cobalt-chromium alloy stem (B). At the 20-month follow-up, there was extensive thinning of the proximal cortical bone, but the patient was asymptomatic (C). Adapted from Sumner DR, Turner TM. Total hip revision surgery. New York: Raven Press, 1995.


47/55

The 7 Zones of GruenThe 7 Zones of Gruen

h f


48/55

The 7 Zones of GruenThe 7 Zones of Gruen(Further Analysis(Further Analysis))


49/55


50/55

Example of DensitometryExample of Densitometry


51/55


52/55


53/55


54/55

NormalNormal

ModerateModerateOsteoporosiOsteoporosi

ss

SevereSevereOsteoporosisOsteoporosis

Decrease in trabecular thickness ismore pronounced for non load-

bearing horizontal trabeculae.

Decrease in connections betweenhorizontal trabeculae

Decrease in trabecular strengthand increased susceptibility tofracture from gravity and physicalactivity.

Why Is It Important to ExamineWhy Is It Important to ExamineTrabecular ConnectivityTrabecular Connectivity??

Mosekilde L. Calcified Tissue Inter. 53(Suppl 1): S121-S126. 1993


55/55

1-21 Management of Osteoporotic Fractures

Documents

Transcript of 1-21 Management of Osteoporotic Fractures