11.Osteoporosis

8/9/2019 11.Osteoporosis

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Epidemiology, DiagnosisPrevention and Management of

Osteoporotic Fractures

Kenneth A. Egol, MDN !"#ospital For $oint Diseases

%reated March &''() *evised May &''+



Background• Osteoporosis -- a

decreased bone densitywith normal bonemineralization

– WHO Definition ( !!"#• Bone $ineral Density %&')D*s below the mean seenin young normal sub+ects

– ,ncidence increases withage

• of white women age.- !

• /. of white women olderthan age 0.



Background

• 1isk factors for osteo2orosis – 3emale se4 – 5uro2ean ancestry – )edentary lifestyle – $ulti2le births – 54cessi6e alcohol use



Background

• )enile osteo2orosis common – )ome degree of osteo2enia is found in 6irtually all

healthy elderly 2atients

• 7reatable causes should be in6estigated – 8utritional deficiency – $alabsor2tion syndromes

– Hy2er2arathyroidism – 9ushings disease – 7umors



Background• 7he incidence of osteo2orotic fractures is

increasing – 5stimated that half of all women and one-third of all

men will sustain a fragility fracture during their lifetime

• By &. . --: ;'< million hi2 fractures will occur globally• 5normous cost to society



Background

• 7he most common fractures in the elderlyosteo2orotic 2atient include= – Hi2 3ractures

• 3emoral neck fractures• ,ntertrochanteric fractures• )ubtrochanteric fractures

– >nkle fractures

– ?ro4imal humerus fracture – Distal radius fractures – @ertebral com2ression fractures



Background

• 3ractures in the elderlyosteo2orotic 2atientre2resent a challenge tothe ortho2aedic surgeon

• 7he goal of treatment is torestore the 2re-in+ury le6elof function

• 3racture can render anelderly 2atient unable tofunction inde2endently--reAuiringinstitutionalized care



Background

• Osteo2enia com2licates bothfracture treatment and healing

• ,nternal fi4ation com2romised – ?oor screw 2urchase – ,ncreased risk of screw 2ull out – >ugmentation with methylmethacrylate

has been ad6ocated• ,ncreased risk of non-union

– Bone augmentation (bone graftsubstitutes# may be indicated



?re-in+ury )tatus

• $edical History• 9ogniti6e History• 3unctional History

– >mbulatory status• 9ommunity >mbulator • Household >mbulator • 8on-3unctional >mbulator • 8on->mbulator

– Ci6ing arrangements



?re-in+ury )tatus

• )ystemic disease – ?re-e4isting cardiac and 2ulmonary disease is

common in the elderly – Diminishes 2atients ability to tolerate

2rolonged recumbency – Diabetes increases wound com2lications and

infection – $ay delay fracture union



?re-in+ury )tatus

• >merican )ociety of >nesthesiologists(>)># 9lassification – >)> ,- normal healthy – >)> ,,- mild systemic disease – >)> ,,,- )e6ere systemic disease not

inca2acitating – >)> ,@- se6ere inca2acitating disease – >)> @- moribund 2atient



?re-in+ury )tatus

• 9ogniti6e )tatus – 9ritical to outcome – 9onditions may render 2atient unable to

2artici2ate in rehabilitation• >lzheimer*s• 9@>• ?arkinson s

• )enile dementia



Hi2 3ractures

• Eeneral 2rinci2les – With the aging of the >merican 2o2ulation the

incidence of hi2 fractures is 2ro+ected toincrease from & . ... in !!. to ; . ... by&.".

– 9ost a22ro4imately F0'/ billion annually

– &. higher incidence in urban areas – lifetime risk for white females who li6e to

age 0.



Hi2 3ractures

• 52idemiology – ,ncidence increases after age . – 3emale= $ale ratio is &=

– 3emoral neck and intertrochanteric fracturesseen with eAual freAuency



Hi2 3ractures

• 1adiogra2hice6aluation – >nterior-2osterior 6iew –

9ross table lateral – ,nternal rotation 6iewwill hel2 delineatefracture 2attern



Hi2 3ractures

• 1adiogra2hic e6aluation – Occult hi2 fracture

• 7echnetium bone scanning is a sensiti6e indicator

but may take &-< days to become 2ositi6e• $agnetic resonance imaging has been shown to be

as sensiti6e as bone scanning and can be reliably 2erformed within &" hours



Hi2 3ractures

• $anagement – ?rom2t o2erati6e stabilization

• O2erati6e delay of : &"-"0 hours increases one-year mortalityrates

• Howe6er im2ortant to balance medical o2timization ande42editious fi4ation

– 5arly mobilization• Decrease incidence of decubiti G7, atelectasis res2iratory

infections

– D@7 2ro2hyla4is



Hi2 3ractures

• Outcomes – 3racture related outcomes

• Healing• Iuality of reduction

– 3unctional outcomes

• >mbulatory ability• $ortality (& at one year#• 1eturn to 2re-fracture acti6ities of daily li6ing



Hi2 3ractures

• 3emoral neck fractures – ,ntraca2sular location – @ascular )u22ly

• $edial and lateral circumfle4 6essels anastamose atthe base of the neck

• blood su22ly 2redominately from ascending arteries(!. #

• >rtery of ligamentum teres ( . #



Hi2 3ractures

• 3emoral neck fractures• 7reatment

– 8on-dis2laced 6algus im2acted fractures

• 8on-o2erati6e 0- dis2lacement rate• O2erati6e with cannulated screws• 8on-union and osteonecrosis is a22ro4imately

0



Hi2 3ractures

• 3emoral neck fractures – Dis2laced fractures should be treated o2erati6ely

– 7reatment= O2en 6s' 9losed 1eduction and ,nternalfi4ation

• <. non-union and & -<. osteonecrosis rate• 8on-union reAuires reo2eration / of the time while

osteonecrosis leads to reo2eration in & of cases



Hi2 3ractures

• 3emoral neck fractures• 7reatment= Hemiarthro2lasty

– Gni2olar @s Bi2olar

– 9an lead to acetabular erosion dislocationinfection



Hi2 3ractures

• 3emoral neck fractures• 7reatment

– Dis2laced fractures can be treated non-o2erati6ely in certain situations

• Demented non-ambulatory 2atient

– $obilize early• >cce2t resulting non or malunion



Hi2 3ractures

• ,ntertrochanteric fractures – 54traca2sular (well 6ascularized#

– 1egion distal to the neck between thetrochanters

– 9alcar femorale

– ?osteromedial corte4 – ,m2ortant muscular insertions



Hi2 3ractures

• ,ntertrochanteric fractures – 7reatment

• Gsually treated surgically• ,m2lant of choice is a hi2 com2ression screw that

slides in a barrel attached to a side2late• 7he im2lant allows for controlled im2action u2on

weightbearing



Hi2 3ractures

• ,ntertrochanteric fractures – 7reatment

• ?rimary 2rosthetic

re2lacement can beconsidered

• 3or cases with significantcomminution



Hi2 3ractures

• )ubtrochanteric 3ractures – Begin at or below the le6el

of the lesser trochanter – 7y2ically higher energyin+uries seen in younger

2atients

– far less common in theelderly



Hi2 3ractures

• )ubtrochanteric 3ractures – 7reatment

• ,ntramedullary nail (high rates ofunion#

• ?lates and screws



>nkle 3ractures

• 9ommon in+ury in the elderly – )ignificant increase in the

incidence and se6erity ofankle fractures o6er the last&. years

• Cow energy in+uries

following twisting reflectingthe relati6e strength of theligaments com2ared toosteo2enic bone



>nkle 3ractures

• 52idemiology – 3innish )tudy (Jannus et al#

• 7hree-fold increase in the number of ankle fracturesamong 2atients older than /. years between !/. and&...

• ,ncrease in the more se6ere Cauge-Hansen )5-" fracture – ,n the Gnited )tates ankle fractures ha6e been re2orted to

occur in as many as 0'< 2er ... $edicare reci2ients• 3igure that a22ears to be steadily rising'



>nkle 3ractures

• ?resentation – 3ollows twisting of foot relati6e to lower tibia – ?atients 2resent unable to bear weight

– 5cchymosis deformity – 9areful neuro6ascular e4am must be 2erformed



>nkle 3ractures

• 1adiogra2hic e6aluation – >nkle trauma series

includes=• >?• Cateral• $ortise

– 54amine entire length ofthe fibula



>nkle 3ractures•

7reatment – ,solated non-dis2laced malleolar fracturewithout e6idence of disru2tion of syndesmoticligaments treated non-o2erati6ely with full

weight bearing – $y utilize walking cast or cast brace



>nkle 3ractures

• 7reatment – Gnstable fracture 2atterns with bimalleolar

in6ol6ement or unimalleolar fractures withtalar dis2lacement must be reduced

– 7reatment closed reAuires a long leg cast tocontrol rotation

• may be a burden to an elderly 2atient



>nkle 3ractures

• 7reatment – 1eductions that are unable to

be attained closed reAuire

o2en reduction and internalfi4ation – 7he skin o6er the ankle is thin

and 2rone to com2lication – >wait resolution of edema to

achie6e a tension free closure



>nkle 3ractures

• 7reatment – 3i4ation may be subo2timal due to osteo2enia

• $ay ha6e to alter standard o2erati6e techniAues

• 9ement >ugmentation – 1e2orts in literature mi4ed

• 5arly studies showed no difference in o2erati6e 6s non-o2treatment -- with o2erati6e grou2s ha6ing higher com2licationrates

• $ore recent studies show im2ro6ed outcomes in o2erati6elytreated grou2

– Eoal is return to 2re-in+ury functional status



?ro4imal Humerus

• Background – @ery common fracture seen in geriatric 2o2ulations – & .. ... in men

– "<! .. ... in women – 1esult of low energy trauma – Eoal is to restore 2ain free range of shoulder motion



?ro4imal Humerus

• 52idemiology – ,ncidence rises dramatically beyond the fifth

decade in women – / of all 2ro4imal humerus fractures occur in

2atients older than ;. – >ssociated with

• frail females

• ?oor neuromuscular control• Decreased bone mineral density



?ro4imal Humerus

• Background – >rticulates with the glenoid 2ortion of the

sca2ula to form the shoulder +oint – 3our 2arts – 9ombination of bony muscular ca2sular and

ligamentous structures maintains shoulderstability – )tatus of the rotator cuff is key



?ro4imal Humerus•

1adiogra2hic e6aluation – >? – )ca2ula K – >4illary – 97 scan can be hel2ful



?ro4imal Humerus

• 7reatment – $inimally dis2laced (one 2art fractures#

usually stabilized by surrounding soft tissues• 8on o2erati6e= ! good to e4cellent results



?ro4imal Humerus

• 7reatment – ,solated lesser tuberosity fractures reAuire

o2erati6e fi4ation only if the fragment containsa large articular 2ortion or limits internalrotation

– ,solated greater tuberosity associated withlongitudinal cuff tears and reAuire O1,3



?ro4imal Humerus

• 7reatment – Dis2laced surgical neck fractures can be treated

closed by reduction under anesthesia with L-ray guidance

• >natomic neck fractures are rare but ha6e a highrate of osteonecrosis

– ,f acce2table reduction is not attained o2enreduction should be undertaken



?ro4imal Humerus• 7reatment

– 9losed treatment of < and " 2art fractures ha6eyielded 2oor results

– 3ailure of fi4ation is a 2roblem in osteo2enic

bone• Cocked 2lating 6ersus 2rosthetic re2lacement



?ro4imal Humerus

• 7reatment – 1egardless of treatment all reAuire 2rolonged

su2er6ised rehabilitation 2rogram – 2oor results are associated with rotator cuff tears

malunion nonunion – ?rosthetic re2lacement can be e42ected to result in

relati6ely 2ain free shoulders

– 3unctional reco6ery and 1O$ 6ariable



Distal 1adius

• Background – @ery common fracturein the elderly

– 1esult from low energy

in+uries – ,ncidence increases

with age 2articularlyin women

– >ssociated withdementia 2ooreyesight and a decreasein coordination



Distal 1adius

• 52idemiology

– ,ncreasing in incidence• 5s2ecially in women

– ?eak incidence in females ;.-/.

– Cifetime risk is – $ost freAuent cause= fall on outstretched arm – Decreased bone mineral density is a factor



Distal 1adius

• 1adiogra2hic e6aluation – ?>

– Cateral – ObliAue – Contralateral wrist

• ,m2ortant to e6aluate deformity ulnar 6ariance



Distal 1adius

• 7reatment – 8on-dis2laced fractures may be immobilized

for ;-0 weeks – $etacar2al-2halangeal and inter2halangeal

+oint motion must be started early



Distal 1adius• 7reatment

– Dis2laced fractures should be reduced withrestoration of radial length inclination and tilt

• Gsually accom2lished with longitudinal tractionunder hematoma block

– ,f satisfactory reduction is obtained treatment ina long arm or short arm cast is undertaken

• 8o statistical difference in method

– Weekly radiogra2hs are reAuired



Distal 1adius

• 7reatment= O2erati6e – if acce2table reduction not obtained

– regional or general anesthesia – $ethods

• O1,3

• 9losed reduction and 2ercutaneous 2inning withe4ternal fi4ation

– Bone grafting for dorsal comminution



Distal 1adius

• 7reatment – 1esults are 6ariable and de2end on fracturety2e and reduction achie6ed

– $inimally dis2laced and fractures in which astable reduction has been achie6ed result ingood functional outcomes



Distal 1adius

• 7reatment – Dis2laced fractures treated surgically 2roduce

good to e4cellent results /.-!.

– 3unctional limits include 2ain stiffness anddecreased gri2



@ertebral 9om2ression 3ractures

• Background – 8early all 2ost-meno2ausal women o6er age /.

ha6e sustained a 6ertebral com2ression fracture

– Gsually occur between 70 and C& – Jy2hosis and scoliosis may de6elo2

• markers for osteo2orosis




• 52idemiology – $ore common than hi2 fractures

– / .. ... – 7wice as common in females – Cifetime risk in a . year old white female is

<&




• Background – ?resent with acute back 2ain – 7ender to 2al2ation

– 8eurologic deficit is rare• ?atterns

– Biconca6e (u22er lumbar# – >nterior wedge (thoracic# – )ymmetric com2ression (7-C

+unction#




• 1adiogra2hice6aluation – >? and lateral

radiogra2hs of thes2ine

– )ym2tomatic 6ertebrae< height of ad+acent

– Bone scan candifferentiate old fromnew fractures




• 7reatment – )im2le osteo2orotic 6ertebral com2ression

fractures are treated non-o2erati6ely andsym2tomatically

– ?rolonged bedrest should be a6oided – ?rogressi6e ambulation should be started early – Back e4ercises should be started after a few

weeks




• 7reatment – > corset may be hel2ful

– $ost fractures heal une6entfully – Jy2ho2lasty an o2tion



?re6ention

• )trategies focus on controlling factors that 2redis2ose to fracture

• 3all 2re6ention



?re6ention

• $ultidisci2linary 2rograms – $edical ad+ustment

– Beha6ior modification – 54ercise classes – 9ontro6ersial



?re6ention and 7reatment of

Bone 3ragility• Well established link between decreasing

bone mass and risk of fracture

• 7reatment of osteo2orosis – 5strogen – 9alcium @itamin D )u22lements – 9alcitononin – Bis2hos2honates – 7eri2aratide (3orteo#




Bone 3ragility• 5strogen

– &-< bone loss with meno2ause

– Gno22osed or combined thera2y has beenshown to reduce hi2 fracture incidence inwomen aged ; -/" by ".-;. (Henderson etal' !00#

– 1isk of breast and endometrial cancer increasedin uno22osed thera2y




Bone 3ragility• 3osma4

– )hown to increase the bone density in femoral

neck in 2ost meno2ausal women withosteo2orosis (Cieberman et al' 85M$ !! #

– 1educed hi2 fracture rate by . in womenwho had sustained a 2re6ious 6ertebral fracture'(Black et al' Cancet !!;#




?re6ention and 7reatment ofBone 3ragility

• 9alcium @itamin D )u22lementation – 1ecommended for most men and women : . years

• 9alcium

– >ge N . -- ... mg day – >ge : . -- &.. mg day

• @itamin D – >ge -/. -- ".. ,G day

– >ge :/. -- ;.. ,G day• 9ombining @itamin D and calcium su22lementation

has been shown to increase bone mineral density andreduce the risk of fracture





• 9alcitonin – ,nhibits bone resor2tion by inhibiting osteoclast acti6ity – >22ro6ed for treatment of osteo2orosis in women who ha6e

been 2ost-meno2ausal for : years• Daily intranasal s2ray of &.. ,G – 7rial demonstrated << reduction of 6ertebral com2ression

fractures with daily thera2y (9hesnut Am J Med &...#• 8o effect on hi2 fractures demonstrated





• Bis2hos2honates – ,nhibits bone resor2tion by reducing osteoclast recruitment

and acti6ity – Bone formed while on bis2hos2honate thera2y is

histologically normal – >6ailable formulations

• >lendronate•

1isendronate• ,bandronate

• )trongest e6idence for ra2id fracture risk reduction – Decreasing the incidence of both 6ertebral and non6ertebral

fractures





• 7eri2aratide (3orteo# – 1ecombinant formulation of

2arathyroid hormone – )timulates the formation of new

bone by increasing the numberand acti6ity of osteoblasts – Once daily subcutaneous

in+ection of &. µ g• )tudy of ;</ 2ost-meno2ausal

women – ; reduction in the incidence of

new 6ertebral fractures – < reduction in the incidence of

new non6ertebral fractures



9onclusions

• ?re6ention is multifaceted• 9ost containment also a +oint effort between

ortho2aedists 2rimary care 2hysicians ?7 andsocial work • 3unctional outcome is ma4imized by early

fi4ation and mobilization in o2erati6e cases• 8umber of elderly is increasing all will ha6e to

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11.Osteoporosis

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