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EpidemiologyEpidemiology
**1.51.5million osteoporosis-relatedmillion osteoporosis-relatedfractures annuallyfractures annually
**700,000700,000vertebral fracturesvertebral fractures
**300,000300,000hip fractureship fractures
**250,000250,000distaldistalforearm/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 in
osteoporosis costs by 2040osteoporosis costs by 2040
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**33%33%of women >65 yearsof women >65 yearsof age have vertebralof age have vertebralfracturesfractures
**32%32%of women and 17% ofof women and 17% of
men >90 years of agemen >90 years of age
have hip fractureshave hip fractures
**33%33%of men >80 years ofof men >80 years ofage have osteoporosisage have osteoporosis
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Special characters of FractureSpecial characters of Fracture
**Osteoporosis affects bone with high surface area so itOsteoporosis affects bone with high surface area so it
affects 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
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Age-related changesAge-related changes
After age 60, subperiostealarea slowly increases butmedullary cavity enlargesfaster, resulting in netdecrease of corticalthickness and mass
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FRACTURESFRACTURES
**FRAGILITYFRAGILITYFRACTURESFRACTURES..
**MINOR TRAUMAMINOR TRAUMA..
COMMON SITESCOMMON SITES:*:*SpineSpine.-.-
--Proximal end ofProximal end offemurfemur..
--Distal end of radiusDistal end of radius..--Proximal end ofProximal end of
humerushumerus..
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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
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Fractures of the SpineFractures of the Spine
**Types of spinalTypes of spinalfracturefracture
--CompressionCompressionfracturesfractures
--Burst fracturesBurst fractures
**Rarely neurologicRarely neurologiccompromisecompromise
**Rarely unstableRarely unstable
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**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
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Two types of back pain can beTwo types of back pain can be
distinguisheddistinguished::
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Hip FracturesHip Fractures
**25%25%of women >60of women >60years of age haveyears of age have
hip fractureship fractures
**12%12%to 20% mortalityto 20% mortality
**50%50%able to return toable to return to
independentindependent
ambulationambulation
**Incidence is clearlyIncidence is clearly
related torelated to
osteoporosisosteoporosis
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--ClosedClosed
reduction withreduction with
internalinternalfixationfixation
--80%80%good orgood or
excellent resultsexcellent results
--RequiresRequires
anatomicanatomic
reductionreduction
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**HemiarthroplastyHemiarthroplasty
indicationsindications
--Active householdActive household
or communityor community
ambulatorsambulators
--Patients withPatients with
severesevereosteoporosisosteoporosis
--If unable to obtainIf unable to obtain
stable reductionstable reduction
**H i th l tH i th l
t
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**Hemiarthroplasty vsHemiarthroplasty vspinningpinning
**Study of 215 displacedStudy of 215 displacedfractures treated withfractures treated withclosed reduction withclosed reduction with
internal 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%( required
reoperationreoperation
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Intertrochanteric FracturesIntertrochanteric Fractures
**Incidence of malunion andIncidence of malunion andvarus may be disablingvarus may be disabling
**Avoid shorteningAvoid shortening&&
external rotation deformityexternal rotation deformity
**Implant considerationsImplant considerationsLoad bearing -- fixedLoad bearing -- fixednail-nail-plate constructplate construct
Intermediate -- slidingIntermediate -- sliding
nail-plate constructnail-plate construct
Load sharing --Load sharing --
intramedullary nail-intramedullary nail-
screw constructscrew construct
**M di l di lM di l di l t
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**Medial displacementMedial displacementosteotomyosteotomy
--Puts fracture in most stablePuts fracture in most stableconfigurationconfiguration
--Less stress on implantLess stress on implant
--Results in shortened limbResults in shortened limb
and weak abductorsand weak abductors
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Techniques toTechniques toenhance fixationenhance fixation
**Screw must be centralScrew must be central
in head/neckin head/neck
**Must engageMust engagesubchondral bonesubchondral bonewithin 11 to 25 mmwithin 11 to 25 mm
rangerange
--Valgus screw/plateValgus screw/plate140 is optimal140 is optimal
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**PolymethylmethacrylPolymethylmethacryl
ate used to augmentate used to augment
fixation allows earlyfixation allows early
weight bearingweight bearing
**Reduce posteromedialReduce posteromedial
(lesser trochanter)(lesser trochanter)fragment to increasefragment to increase
strength of constructstrength of construct
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Failures in Hip FracturesFailures in Hip Fractures
**Causes ofCauses of
redisplacement andredisplacement and
reoperationreoperation::
--OsteoporosisOsteoporosis--Fracture displacementFracture displacement
--Collapse of femoralCollapse of femoral
headhead
--Bone mineral contentBone mineral content
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Supracondylar interlocking nailSupracondylar interlocking nail
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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 pain
subsidessubsides
--Full passive range of motionFull passive range of motionencouraged by 3 to 4encouraged by 3 to 4
weeks, active range ofweeks, active range of
motion at 5 to 6 weeksmotion at 5 to 6 weeks
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Surgical optionsSurgical 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 with
HemiarthroplastyHemiarthroplasty
--Repair rotator cuffRepair rotator cuff
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Colles' FractureColles' Fracture
**Involves dorsalInvolves dorsal
displacement of thedisplacement of the
radiusradius
**May or may not involveMay or may not involve
the ulnathe ulna
**Often results in an ulnarOften results in an ulnar
styloid fracturestyloid fracture
**Fractures intra- and/orFractures intra- and/or
extra-articularextra-articular
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Closed reduction and castingClosed reduction and casting
Adequate reductionAdequate reductionNeutral 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
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**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 plastermostlymostlydeformity recurrencedeformity recurrence
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**PercutaneousPercutaneous
pinning fixation pinning fixation
--Unstable, severelyUnstable, severelycomminutedcomminuted
fracturesfractures
--80%80%to 90% goodto 90% good
or excellentor excellent
results inresults in
functionalfunctionaloutcomeoutcome
--15%15%to 60%to 60%
complication ratecomplication rate
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**Open reduction withOpen reduction with
internal fixationinternal fixation
--Reserved for grossly displacedReserved for grossly displaced
intra-articular fracturesintra-articular fractures
--Augment with bone graftAugment with bone graft
--Research into injection ofResearch into injection of
hydroxyapatite to augmenthydroxyapatite to augment
fracturefracture
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Osteoporotic Fracture ManagementOsteoporotic Fracture Management
SummarySummary
Prevention better thanPrevention better than
treatmenttreatmentOperative treatment use isOperative treatment use is
common but is difficultcommon but is difficult
**Internal fixationInternal fixation
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*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
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