骨質(zhì)疏松性骨折課件

BackgroundRiskfactorsforosteoporosisFemalesexEuropeanancestrySedentarylifestyleMultiplebirthsExcessivealcoholuseBackgroundRiskfactorsforost1BackgroundSenileosteoporosiscommonSomedegreeofosteopeniaisfoundinvirtuallyallhealthyelderlypatientsTreatablecausesshouldbeinvestigatedNutritionaldeficiencyMalabsorptionsyndromesHyperparathyroidismCushingsdiseaseTumorsBackgroundSenileosteoporosis2Background TheincidenceofosteoporoticfracturesisincreasingEstimatedthathalfofallwomenandone-thirdofallmenwillsustainafragilityfractureduringtheirlifetimeBy2050-->6.3millionhipfractureswilloccurgloballyEnormouscosttosocietyBackground Theincidenceofos3BackgroundThemostcommonfracturesintheelderlyosteoporoticpatientinclude:HipFracturesFemoralneckfracturesIntertrochantericfracturesSubtrochantericfracturesAnklefracturesProximalhumerusfractureDistalradiusfracturesVertebralcompressionfracturesBackgroundThemostcommonfrac4BackgroundFracturesintheelderlyosteoporoticpatientrepresentachallengetotheorthopaedicsurgeonThegoaloftreatmentistorestorethepre-injuryleveloffunctionFracturecanrenderanelderlypatientunabletofunctionindependently--requiringinstitutionalizedcareBackgroundFracturesintheeld5BackgroundOsteopeniacomplicatesbothfracturetreatmentandhealingInternalfixationcompromisedPoorscrewpurchaseIncreasedriskofscrewpulloutAugmentationwithmethylmethacrylatehasbeenadvocatedIncreasedriskofnon-unionBoneaugmentation(bonegraft,substitutes)maybeindicatedBackgroundOsteopeniacomplica6Pre-injuryStatusMedicalHistoryCognitiveHistoryFunctionalHistoryAmbulatorystatusCommunityAmbulatorHouseholdAmbulatorNon-FunctionalAmbulatorNon-AmbulatorLivingarrangementsPre-injuryStatusMedicalHisto7Pre-injuryStatusSystemicdiseasePre-existingcardiacandpulmonarydiseaseiscommonintheelderlyDiminishespatientsabilitytotolerateprolongedrecumbencyDiabetesincreaseswoundcomplicationsandinfectionMaydelayfractureunionPre-injuryStatusSystemicdise8Pre-injuryStatus AmericanSocietyofAnesthesiologists(ASA)ClassificationASAI-normalhealthyASAII-mildsystemicdiseaseASAIII-Severesystemicdisease,notincapacitatingASAIV-severeincapacitatingdiseaseASAV-moribundpatientPre-injuryStatus AmericanSoc9Pre-injuryStatusCognitiveStatusCriticaltooutcomeConditionsmayrenderpatientunabletoparticipateinrehabilitationAlzheimer’sCVAParkinson'sSeniledementiaPre-injuryStatusCognitiveSta10HipFracturesGeneralprinciplesWiththeagingoftheAmericanpopulationtheincidenceofhipfracturesisprojectedtoincreasefrom250,000in1990to650,000by2040Costapproximately$8.7billionannually20%higherincidenceinurbanareas15%lifetimeriskforwhitefemaleswholivetoage80HipFracturesGeneralprinciple11HipFracturesEpidemiologyIncidenceincreasesafterage50Female:Maleratiois2:1FemoralneckandintertrochantericfracturesseenwithequalfrequencyHipFracturesEpidemiology12HipFracturesRadiographicevaluationAnterior-posteriorviewCrosstablelateralInternalrotationviewwillhelpdelineatefracturepatternHipFracturesRadiographiceval13HipFracturesRadiographicevaluationOcculthipfractureTechnetiumbonescanningisasensitiveindicator,butmaytake2-3daystobecomepositiveMagneticresonanceimaginghasbeenshowntobeassensitiveasbonescanningandcanbereliablyperformedwithin24hoursHipFracturesRadiographiceval14HipFracturesManagementPromptoperativestabilizationOperativedelayof>24-48hoursincreasesone-yearmortalityratesHowever,importanttobalancemedicaloptimizationandexpeditiousfixationEarlymobilizationDecreaseincidenceofdecubiti,UTI,atelectasis/respiratoryinfectionsDVTprophylaxisHipFracturesManagement15HipFracturesOutcomesFracturerelatedoutcomesHealingQualityofreductionFunctionaloutcomesAmbulatoryabilityMortality(25%atoneyear)Returntopre-fractureactivitiesofdailylivingHipFracturesOutcomes16ClosedReductionandInternalfixationCalcium/VitaminDSupplementationIntheUnitedStates,anklefractureshavebeenreportedtooccurinasmanyas8.SubtrochantericFractures112/100,000inmenTypicallyhigherenergyinjuriesseeninyoungerpatientsDVTprophylaxisFemoralneckfracturesKyphosisandscoliosismaydevelopRadiographicevaluationProximalHumerusPreventionandTreatmentofBoneFragilitypoorresultsareassociatedwithrotatorcufftears,malunion,nonunionAnkleFracturesMortality(25%atoneyear)VertebralCompressionFracturesLockedplatingversusprostheticreplacementPoorscrewpurchaseTendertopalpationASAV-moribundpatientHipFracturesFemoralneckfracturesIntracapsularlocationVascularSupplyMedialandlateralcircumflexvesselsanastamoseatthebaseoftheneckbloodsupplypredominatelyfromascendingarteries(90%)Arteryofligamentumteres(10%)ClosedReductionandInternal17HipFracturesFemoralneckfracturesTreatmentNon-displaced/valgusimpactedfracturesNon-operative8-15%displacementrateOperativewithcannulatedscrewsNon-union5%andosteonecrosisisapproximately8%HipFracturesFemoralneckfrac18HipFracturesFemoralneckfracturesDisplacedfracturesshouldbetreatedoperativelyTreatment:Openvs.ClosedReductionandInternalfixation30%non-unionand25%-30%osteonecrosisrateNon-unionrequiresreoperation75%ofthetimewhileosteonecrosisleadstoreoperationin25%ofcasesHipFracturesFemoralneckfrac19HipFracturesFemoralneckfracturesTreatment:HemiarthroplastyUnipolarVsBipolarCanleadtoacetabularerosion,dislocation,infectionHipFracturesFemoralneckfrac20HipFracturesFemoralneckfracturesTreatmentDisplacedfracturescanbetreatednon-operativelyincertainsituationsDemented,non-ambulatorypatientMobilizeearlyAcceptresultingnonormalunionHipFracturesFemoralneckfrac21HipFracturesIntertrochantericfracturesExtracapsular(wellvascularized)RegiondistaltotheneckbetweenthetrochantersCalcarfemoralePosteromedialcortexImportantmuscularinsertionsHipFracturesIntertrochanteric22HipFracturesIntertrochantericfracturesTreatmentUsuallytreatedsurgicallyImplantofchoiceisahipcompressionscrewthatslidesinabarrelattachedtoasideplateTheimplantallowsforcontrolledimpactionuponweightbearingHipFracturesIntertrochanteric23HipFracturesIntertrochantericfracturesTreatmentPrimaryprostheticreplacementcanbeconsideredForcaseswithsignificantcomminutionHipFracturesIntertrochanteric24HipFracturesSubtrochantericFracturesBeginatorbelowthelevelofthelessertrochanterTypicallyhigherenergyinjuriesseeninyoungerpatientsfarlesscommonintheelderlyHipFracturesSubtrochantericF25HipFracturesSubtrochantericFracturesTreatmentIntramedullarynail(highratesofunion)PlatesandscrewsHipFracturesSubtrochantericF26HipFracturesThegoaloftreatmentistorestorethepre-injuryleveloffunctionProgressiveambulationshouldbestartedearlyEstimatedthathalfofallwomenandone-thirdofallmenwillsustainafragilityfractureduringtheirlifetimeIfacceptablereductionisnotattainedopenreductionshouldbeundertakenProximalHumerusProximalHumerusVertebralCompressionFracturesHipFracturesHipFracturesDisplacedfracturesshouldbetreatedoperativelyMortality(25%atoneyear)Prostheticreplacementcanbeexpectedtoresultinrelativelypainfreeshoulders30%non-unionand25%-30%osteonecrosisrateQuestions/Comments117/100,000MayhavetoalterstandardoperativetechniquesCushingsdiseaseDVTprophylaxisPre-injuryStatusAnkleFracturesCommoninjuryintheelderlySignificantincreaseintheincidenceandseverityofanklefracturesoverthelast20years

LowenergyinjuriesfollowingtwistingreflectingtherelativestrengthoftheligamentscomparedtoosteopenicboneHipFracturesAnkleFracturesCo27AnkleFracturesEpidemiologyFinnishStudy(Kannusetal)Three-foldincreaseinthenumberofanklefracturesamongpatientsolderthan70yearsbetween1970and2000IncreaseinthemoresevereLauge-HansenSE-4fractureIntheUnitedStates,anklefractureshavebeenreportedtooccurinasmanyas8.3per1000MedicarerecipientsFigurethatappearstobesteadilyrising.AnkleFracturesEpidemiology28AnkleFracturesPresentationFollowstwistingoffootrelativetolowertibiaPatientspresentunabletobearweightEcchymosis,deformityCarefulneurovascularexammustbeperformedAnkleFracturesPresentation29AnkleFracturesRadiographicevaluationAnkletraumaseriesincludes:APLateralMortiseExamineentirelengthofthefibulaAnkleFracturesRadiographicev30AnkleFracturesTreatmentIsolated,non-displacedmalleolarfracturewithoutevidenceofdisruptionofsyndesmoticligamentstreatednon-operativelywithfullweightbearingMyutilizewalkingcastorcastbraceAnkleFracturesTreatment31AnkleFracturesTreatmentUnstablefracturepatternswithbimalleolarinvolvement,orunimalleolarfractureswithtalardisplacementmustbereducedTreatmentclosedrequiresalonglegcasttocontrolrotationmaybeaburdentoanelderlypatientAnkleFracturesTreatment32AnkleFracturesTreatmentReductionsthatareunabletobeattainedclosedrequireopenreductionandinternalfixationTheskinovertheankleisthinandpronetocomplicationAwaitresolutionofedematoachieveatensionfreeclosureAnkleFracturesTreatment33AnkleFracturesTreatmentFixationmaybesuboptimalduetoosteopeniaMayhavetoalterstandardoperativetechniquesCementAugmentationReportsinliteraturemixedEarlystudiesshowednodifferenceinoperativevsnon-optreatment--withoperativegroupshavinghighercomplicationratesMorerecentstudiesshowimprovedoutcomesinoperativelytreatedgroupGoalisreturntopre-injuryfunctionalstatusAnkleFracturesTreatment34ProximalHumerusBackgroundVerycommonfractureseeningeriatricpopulations112/100,000inmen439/100,000inwomenResultoflowenergytraumaGoalistorestorepainfreerangeofshouldermotionProximalHumerusBackground35ProximalHumerusEpidemiologyIncidencerisesdramaticallybeyondthefifthdecadeinwomen71%ofallproximalhumerusfracturesoccurinpatientsolderthan60AssociatedwithfrailfemalesPoorneuromuscularcontrolDecreasedbonemineraldensityProximalHumerusEpidemiology36Alzheimer’sAnkleFractures112/100,000inmenVertebralCompressionFracturesProximalHumerusLivingarrangementsPreventionandTreatmentofBoneFragilityRecombinantformulationofparathyroidhormoneCrosstablelateralMorecommonthanhipfracturesNumberofelderlyisincreasingallwillhavetoworktogetherindifficulteconomictimesDisplacedfracturesshouldbereducedwithrestorationofradiallength,inclinationandtiltPre-injuryStatusThegoaloftreatmentistorestorethepre-injuryleveloffunctionAwaitresolutionofedematoachieveatensionfreeclosureProlongedbedrestshouldbeavoidedCanleadtoacetabularerosion,dislocation,infectionImportantmuscularinsertionsDiminishespatientsabilitytotolerateprolongedrecumbencyOsteopeniacomplicatesbothfracturetreatmentandhealingProximalHumerusBackgroundArticulateswiththeglenoidportionofthescapulatoformtheshoulderjointFourpartsCombinationofbony,muscular,capsularandligamentousstructuresmaintainsshoulderstabilityStatusoftherotatorcuffiskeyAlzheimer’sProximalHumerusBac37ProximalHumerusRadiographicevaluationAPScapulaYAxillaryCTscancanbehelpfulProximalHumerusRadiographice38ProximalHumerusTreatmentMinimallydisplaced(onepartfractures)usuallystabilizedbysurroundingsofttissues Nonoperative:91%goodtoexcellentresultsProximalHumerusTreatment39ProximalHumerusTreatmentIsolatedlessertuberosityfracturesrequireoperativefixationonlyifthefragmentcontainsalargearticularportionorlimitsinternalrotationIsolatedgreatertuberosityassociatedwithlongitudinalcufftearsandrequireORIFProximalHumerusTreatment40ProximalHumerusTreatmentDisplacedsurgicalneckfracturescanbetreatedclosedbyreductionunderanesthesiawithX-rayguidanceAnatomicneckfracturesarerarebuthaveahighrateofosteonecrosisIfacceptablereductionisnotattainedopenreductionshouldbeundertakenProximalHumerusTreatment41ProximalHumerusTreatmentClosedtreatmentof3and4partfractureshaveyieldedpoorresultsFailureoffixationisaprobleminosteopenicboneLockedplatingversusprostheticreplacementProximalHumerusTreatment42ProximalHumerusTreatmentRegardlessoftreatmentallrequireprolonged,supervisedrehabilitationprogrampoorresultsareassociatedwithrotatorcufftears,malunion,nonunionProstheticreplacementcanbeexpectedtoresultinrelativelypainfreeshouldersFunctionalrecoveryandROMvariableProximalHumerusTreatment43DistalRadiusBackgroundVerycommonfractureintheelderlyResultfromlowenergyinjuriesIncidenceincreaseswithage,particularlyinwomenAssociatedwithdementia,pooreyesightandadecreaseincoordinationDistalRadiusBackground44DistalRadiusEpidemiologyIncreasinginincidenceEspeciallyinwomenPeakincidenceinfemales60-70Lifetimeriskis15%Mostfrequentcause:fallonoutstretchedarmDecreasedbonemineraldensityisafactorDistalRadiusEpidemiology45DistalRadiusRadiographicevaluationPALateralObliqueContralateralwristImportanttoevaluatedeformity,ulnarvarianceDistalRadiusRadiographiceval46ImportantmuscularinsertionsHipFracturesVertebralcompressionfracturesVertebralCompressionFracturesInhibitsboneresorptionbyreducingosteoclastrecruitmentandactivityPreventionandTreatmentofBoneFragilitybloodsupplypredominatelyfromascendingarteries(90%)ASAV-moribundpatientCriticaltooutcome112/100,000inmenSomedegreeofosteopeniaisfoundinvirtuallyallhealthyelderlypatientsContralateralwristInhibitsboneresorptionbyinhibitingosteoclastactivityIncidenceincreasesafterage50112/100,000inmen7billionannuallyMayhavetoalterstandardoperativetechniquesSenileosteoporosiscommonHipFracturesCalcitononinDistalRadiusTreatmentNon-displacedfracturesmaybeimmobilizedfor6-8weeksMetacarpal-phalangealandinterphalangealjointmotionmustbestartedearlyImportantmuscularinsertionsD47DistalRadiusTreatmentDisplacedfracturesshouldbereducedwithrestorationofradiallength,inclinationandtiltUsuallyaccomplishedwithlongitudinaltractionunderhematomablockIfsatisfactoryreductionisobtainedtreatmentinalongarmorshortarmcastisundertakenNostatisticaldifferenceinmethodWeeklyradiographsarerequiredDistalRadiusTreatment48DistalRadiusTreatment:OperativeifacceptablereductionnotobtainedregionalorgeneralanesthesiaMethodsORIFClosedreductionandpercutaneouspinningwithexternalfixationBonegraftingfordorsalcomminutionDistalRadiusTreatment:Operat49DistalRadiusTreatmentResultsarevariableanddependonfracturetypeandreductionachievedMinimallydisplacedandfracturesinwhichastablereductionhasbeenachievedresultingoodfunctionaloutcomesDistalRadiusTreatment50DistalRadiusTreatmentDisplacedfracturestreatedsurgicallyproducegoodtoexcellentresults70-90%Functionallimitsincludepain,stiffnessanddecreasedgripDistalRadiusTreatment51VertebralCompressionFracturesBackgroundNearlyallpost-menopausalwomenoverage70havesustainedavertebralcompressionfractureUsuallyoccurbetweenT8andL2KyphosisandscoliosismaydevelopmarkersforosteoporosisVertebralCompressionFracture52VertebralCompressionFracturesEpidemiologyMorecommonthanhipfractures117/100,000TwiceascommoninfemalesLifetimeriskina50yearoldwhitefemaleis32%VertebralCompressionFracture53VertebralCompressionFracturesBackgroundPresentwithacutebackpainTendertopalpationNeurologicdeficitisrarePatternsBiconcave(upperlumbar)Anteriorwedge(thoracic)Symmetriccompression(T-Ljunction)VertebralCompressionFracture54VertebralCompressionFracturesRadiographicevaluationAPandlateralradiographsofthespineSymptomaticvertebrae1/3heightofadjacentBonescancandifferentiateoldfromnewfracturesVertebralCompressionFracture55VertebralCompressionFracturesTreatmentSimpleosteoporoticvertebralcompressionfracturesaretreatednon-operativelyandsymptomaticallyProlongedbedrestshouldbeavoidedProgressiveambulationshouldbestartedearlyBackexercisesshouldbestartedafterafewweeksVertebralCompressionFracture56SubtrochantericfracturesOcculthipfractureClosedReductionandInternalfixationHipFracturesHipFracturesMorecommonthanhipfracturesOcculthipfractureBoneformedwhileonbisphosphonatetherapyishistologicallynormalSignificantincreaseintheincidenceandseverityofanklefracturesoverthelast20yearsQuestions/CommentsIfyouwouldliketovolunteerasanauthorfortheResidentSlideProjectorrecommendupdatestoanyofthefollowingslides,pleasesendane-mailtoKyphosisandscoliosismaydevelopBonegraftingfordorsalcomminutionASAIV-severeincapacitatingdisease117/100,000HipFracturesCalcium/VitaminDSupplementsPreventionandTreatmentofBoneFragilityProximalHumerusTeriparatide(Forteo)VertebralCompressionFracturesTreatmentAcorsetmaybehelpfulMostfractureshealuneventfullyKyphoplastyanoptionSubtrochantericfracturesVerte57PreventionStrategiesfocusoncontrollingfactorsthatpredisposetofractureFallpreventionPreventionStrategiesfocuson58PreventionMultidisciplinaryprogramsMedicaladjustmentBehaviormodificationExerciseclassesControversialPreventionMultidisciplinarypr59PreventionandTreatmentofBoneFragilityWellestablishedlinkbetweendecreasingbonemassandriskoffractureTreatmentofosteoporosisEstrogenCalcium/VitaminDSupplementsCalcitononinBisphosphonatesTeriparatide(Forteo)PreventionandTreatmentofBo60PreventionandTreatmentofBoneFragilityEstrogen2-3%bonelosswithmenopauseUnopposedorcombinedtherapyhasbeenshowntoreducehipfractureincidenceinwomenaged65-74by40-60%(Hendersonetal.1988)RiskofbreastandendometrialcancerincreasedinunopposedtherapyPreventionandTreatmentofBo61PreventionandTreatmentofBoneFragilityFosmaxShowntoincreasethebonedensityinfemoralneckinpostmenopausalwomenwithosteoporosis(Liebermanetal.NEJM1995)Reducedhipfracturerateby50%inwomenwhohadsustainedapreviousvertebralfracture.(Blacketal.Lancet1996)PreventionandTreatmentofBo62PreventionandTreatmentofBoneFragilityCalcium/VitaminDSupplementationRecommendedformostmenandwomen>50yearsCalciumAge<50--1,000mg/dayAge>50--1,200mg/dayVitaminDAge51-70--400IU/dayAge>70--600IU/dayCombiningVitaminDandcalciumsupplementationhasbeenshowntoincreasebonemineraldensityandreducetheriskoffracturePreventionandTreatmentofBo63PreventionandTreatmentofBoneFragilityCalcitoninInhibitsboneresorptionbyinhibitingosteoclastactivityApprovedfortreatmentofosteoporosisinwomenwhohavebeenpost-menopausalfor>5yearsDailyintranasalsprayof200IUTrialdemonstrated33%reductionofvertebralcompressionfractureswithdailytherapy(ChesnutAmJMed2000)NoeffectonhipfracturesdemonstratedPreventionandTreatmentofBo64PreventionandTreatmentofBoneFragilityBisphosphonatesInhibitsboneresorptionbyreducingosteoclastrecruitmentandactivityBoneformedwhileonbisphosphonatetherapyishistologicallynormalAvailableformulationsAlendronateRisendronateIbandronateStrongestevidenceforrapidfractureriskreductionDecreasingtheincidenceofbothvertebralandnonvertebralfracturesPreventionandTreatmentofBo65PreventionandTreatmentofBoneFragilityTeriparatide(Forteo)RecombinantformulationofparathyroidhormoneStimulatestheformationofnewbonebyincreasingthenumberandactivityofosteoblastsOncedailysubcutaneousinjectionof20gStudyof1637post-menopausalwomen65%reductionintheincidenceofnewvertebralfractures53%reductionintheincidenceofnewnonvertebralfracturesPreventionandTreatmentofBo66ConclusionsPreventionismultifacetedCostcontainmentalsoajointeffortbetweenorthopaedists,primarycarephysicians,PTandsocialworkFunctionaloutcomeismaximizedbyearlyfixationandmobilizationinoperativecasesNumberofelderlyisincreasingallwillhavetoworktogetherindifficulteconomictimesReturntoGeneral/PrinciplesIndexE-mailOTAaboutQuestions/CommentsIfyouwouldliketovolunteerasanauthorfortheResidentSlideProjectorrecommendupdatestoanyofthefollowingslides,pleasesendane-mailtoConclusionsPreventionismulti67Background TheincidenceofosteoporoticfracturesisincreasingEstimatedthathalfofallwomenandone-thirdofallmenwillsustainafragilityfractureduringtheirlifetimeBy2050-->6.3millionhipfractureswilloccurgloballyEnormouscosttosocietyBackground Theincidenceofos68Pre-injuryStatusSystemicdiseasePre-existingcardiacandpulmonarydiseaseiscommonintheelderlyDiminishespatients