Epidemiology, Diagnosis Prevention and Management of

Osteoporotic Fractures

Kenneth A. Egol, MD

NYU-Hospital For Joint Diseases

Created March 2004; Revised May 2006

Background• Osteoporosis -- a

decreased bone density with normal bone mineralization– WHO Definition (1994)

• Bone Mineral Density ≥2.5 SD’s below the mean seen in young normal subjects

– Incidence increases with age

• 15% of white women age 50-59

• 70% of white women older than age 80

Background

• Risk factors for osteoporosis– Female sex– European ancestry– Sedentary lifestyle– Multiple births– Excessive alcohol use

Background

• Senile osteoporosis common– Some degree of osteopenia is found in virtually all

healthy elderly patients

• Treatable causes should be investigated– Nutritional deficiency– Malabsorption syndromes– Hyperparathyroidism– Cushings disease– Tumors

Background• The incidence of osteoporotic fractures is

increasing– Estimated that half of all women and one-third of all

men will sustain a fragility fracture during their lifetime• By 2050 --> 6.3 million hip fractures will occur globally

• Enormous cost to society

Background• The most common fractures in the elderly

osteoporotic patient include:– Hip Fractures

• Femoral neck fractures• Intertrochanteric fractures• Subtrochanteric fractures

– Ankle fractures– Proximal humerus fracture– Distal radius fractures– Vertebral compression fractures

Background

• Fractures in the elderly osteoporotic patient represent a challenge to the orthopaedic surgeon

• The goal of treatment is to restore the pre-injury level of function

• Fracture can render an elderly patient unable to function independently --requiring institutionalized care

Background

• Osteopenia complicates both fracture treatment and healing

• Internal fixation compromised– Poor screw purchase– Increased risk of screw pull out– Augmentation with methylmethacrylate

has been advocated

• Increased risk of non-union– Bone augmentation (bone graft,

substitutes) may be indicated

Pre-injury Status

• Medical History

• Cognitive History

• Functional History– Ambulatory status

• Community Ambulator

• Household Ambulator

• Non-Functional Ambulator

• Non-Ambulator

– Living arrangements

Pre-injury Status

• Systemic disease– Pre-existing cardiac and pulmonary disease is

common in the elderly– Diminishes patients ability to tolerate

prolonged recumbency– Diabetes increases wound complications and

infection– May delay fracture union

Pre-injury Status

• American Society of Anesthesiologists (ASA) Classification– ASA I- normal healthy– ASA II- mild systemic disease– ASA III- Severe systemic disease, not

incapacitating– ASA IV- severe incapacitating disease– ASA V- moribund patient

Pre-injury Status

• Cognitive Status– Critical to outcome– Conditions may render patient unable to

participate in rehabilitation• Alzheimer’s• CVA• Parkinson's• Senile dementia

Hip Fractures

• General principles– With the aging of the American population the

incidence of hip fractures is projected to increase from 250,000 in 1990 to 650,000 by 2040

– Cost approximately $8.7 billion annually– 20% higher incidence in urban areas– 15% lifetime risk for white females who live to

age 80

Hip Fractures

• Epidemiology– Incidence increases after age 50– Female: Male ratio is 2:1– Femoral neck and intertrochanteric fractures

seen with equal frequency

Hip Fractures

• Radiographic evaluation– Anterior-posterior

view

– Cross table lateral

– Internal rotation view will help delineate fracture pattern

Hip Fractures

• Radiographic evaluation– Occult hip fracture

• Technetium bone scanning is a sensitive indicator, but may take 2-3 days to become positive

• Magnetic resonance imaging has been shown to be as sensitive as bone scanning and can be reliably performed within 24 hours

Hip Fractures• Management

– Prompt operative stabilization• Operative delay of > 24-48 hours increases one-year mortality

rates• However, important to balance medical optimization and

expeditious fixation

– Early mobilization• Decrease incidence of decubiti, UTI, atelectasis/respiratory

infections

– DVT prophylaxis

Hip Fractures

• Outcomes– Fracture related outcomes

• Healing

• Quality of reduction

– Functional outcomes• Ambulatory ability

• Mortality (25% at one year)

• Return to pre-fracture activities of daily living

Hip Fractures

• Femoral neck fractures– Intracapsular location– Vascular Supply

• Medial and lateral circumflex vessels anastamose at the base of the neck

• blood supply predominately from ascending arteries (90%)

• Artery of ligamentum teres (10%)

Hip Fractures

• Femoral neck fractures

• Treatment– Non-displaced/ valgus impacted fractures

• Non-operative 8-15% displacement rate

• Operative with cannulated screws

• Non-union 5% and osteonecrosis is approximately 8%

Hip Fractures

• Femoral neck fractures– Displaced fractures should be treated operatively– Treatment: Open vs. Closed Reduction and Internal

fixation• 30% non-union and 25%-30% osteonecrosis rate

• Non-union requires reoperation 75% of the time while osteonecrosis leads to reoperation in 25% of cases

Hip Fractures• Femoral neck fractures

• Treatment: Hemiarthroplasty– Unipolar Vs Bipolar– Can lead to acetabular erosion, dislocation,

infection

Hip Fractures

• Femoral neck fractures

• Treatment– Displaced fractures can be treated non -

operatively in certain situations• Demented, non-ambulatory patient

– Mobilize early• Accept resulting non or malunion

Hip Fractures

• Intertrochanteric fractures– Extracapsular (well vascularized)– Region distal to the neck between the

trochanters– Calcar femorale– Posteromedial cortex– Important muscular insertions

Hip Fractures

• Intertrochanteric fractures– Treatment

• Usually treated surgically

• Implant of choice is a hip compression screw that slides in a barrel attached to a sideplate

• The implant allows for controlled impaction upon weightbearing

Hip Fractures

• Intertrochanteric fractures– Treatment

• Primary prosthetic replacement can be considered

• For cases with significant comminution

Hip Fractures

• Subtrochanteric Fractures– Begin at or below the level

of the lesser trochanter

– Typically higher energy injuries seen in younger patients

– far less common in the elderly

Hip Fractures

• Subtrochanteric Fractures– Treatment

• Intramedullary nail (high rates of union)

• Plates and screws

Ankle Fractures

• Common injury in the elderly– Significant increase in the

incidence and severity of ankle fractures over the last 20 years

• Low energy injuries following twisting reflecting the relative strength of the ligaments compared to osteopenic bone

Ankle Fractures

• Epidemiology– Finnish Study (Kannus et al)

• Three-fold increase in the number of ankle fractures among patients older than 70 years between 1970 and 2000

• Increase in the more severe Lauge-Hansen SE-4 fracture

– In the United States, ankle fractures have been reported to occur in as many as 8.3 per 1000 Medicare recipients

• Figure that appears to be steadily rising.

Ankle Fractures• Presentation

– Follows twisting of foot relative to lower tibia– Patients present unable to bear weight– Ecchymosis, deformity– Careful neurovascular exam must be performed

Ankle Fractures

• Radiographic evaluation– Ankle trauma series

includes:• AP

• Lateral

• Mortise

– Examine entire length of the fibula

Ankle Fractures• Treatment

– Isolated, non-displaced malleolar fracture without evidence of disruption of syndesmotic ligaments treated non-operatively with full weight bearing

– My utilize walking cast or cast brace

Ankle Fractures

• Treatment– Unstable fracture patterns with bimalleolar

involvement, or unimalleolar fractures with talar displacement must be reduced

– Treatment closed requires a long leg cast to control rotation

• may be a burden to an elderly patient

Ankle Fractures

• Treatment– Reductions that are unable to

be attained closed require open reduction and internal fixation

– The skin over the ankle is thin and prone to complication

– Await resolution of edema to achieve a tension free closure

Ankle Fractures

• Treatment– Fixation may be suboptimal due to osteopenia

• May have to alter standard operative techniques• Cement Augmentation

– Reports in literature mixed• Early studies showed no difference in operative vs non-op

treatment -- with operative groups having higher complication rates

• More recent studies show improved outcomes in operatively treated group

– Goal is return to pre-injury functional status

Proximal Humerus

• Background– Very common fracture seen in geriatric populations– 112/100,000 in men– 439/100,000 in women– Result of low energy trauma– Goal is to restore pain free range of shoulder motion

Proximal Humerus• Epidemiology

– Incidence rises dramatically beyond the fifth decade in women

– 71% of all proximal humerus fractures occur in patients older than 60

– Associated with • frail females• Poor neuromuscular control• Decreased bone mineral density

Proximal Humerus

• Background– Articulates with the glenoid portion of the

scapula to form the shoulder joint– Four parts– Combination of bony, muscular, capsular and

ligamentous structures maintains shoulder stability

– Status of the rotator cuff is key

Proximal Humerus• Radiographic evaluation

– AP– Scapula Y– Axillary– CT scan can be helpful

Proximal Humerus

• Treatment– Minimally displaced (one part fractures)

usually stabilized by surrounding soft tissues

• Non operative: 91% good to excellent results

Proximal Humerus

• Treatment– Isolated lesser tuberosity fractures require

operative fixation only if the fragment contains a large articular portion or limits internal rotation

– Isolated greater tuberosity associated with longitudinal cuff tears and require ORIF

Proximal Humerus

• Treatment– Displaced surgical neck fractures can be treated

closed by reduction under anesthesia with X-ray guidance

• Anatomic neck fractures are rare but have a high rate of osteonecrosis

– If acceptable reduction is not attained open reduction should be undertaken

Proximal Humerus• Treatment

– Closed treatment of 3 and 4 part fractures have yielded poor results

– Failure of fixation is a problem in osteopenic bone

• Locked plating versus prosthetic replacement

Proximal Humerus

• Treatment– Regardless of treatment all require prolonged,

supervised rehabilitation program– poor results are associated with rotator cuff tears,

malunion, nonunion– Prosthetic replacement can be expected to result in

relatively pain free shoulders– Functional recovery and ROM variable

Distal Radius• Background

– Very common fracture in the elderly

– Result from low energy injuries

– Incidence increases with age, particularly in women

– Associated with dementia, poor eyesight and a decrease in coordination

Distal Radius

• Epidemiology– Increasing in incidence

• Especially in women

– Peak incidence in females 60-70– Lifetime risk is 15%– Most frequent cause: fall on outstretched arm– Decreased bone mineral density is a factor

Distal Radius

• Radiographic evaluation– PA– Lateral– Oblique– Contralateral wrist

• Important to evaluate deformity, ulnar variance

Distal Radius

• Treatment– Non-displaced fractures may be immobilized

for 6-8 weeks– Metacarpal-phalangeal and interphalangeal

joint motion must be started early

Distal Radius• Treatment

– Displaced fractures should be reduced with restoration of radial length, inclination and tilt

• Usually accomplished with longitudinal traction under hematoma block

– If satisfactory reduction is obtained treatment in a long arm or short arm cast is undertaken

• No statistical difference in method

– Weekly radiographs are required

Distal Radius

• Treatment: Operative– if acceptable reduction not obtained– regional or general anesthesia– Methods

• ORIF

• Closed reduction and percutaneous pinning with external fixation

– Bone grafting for dorsal comminution

Distal Radius• Treatment

– Results are variable and depend on fracture type and reduction achieved

– Minimally displaced and fractures in which a stable reduction has been achieved result in good functional outcomes

Distal Radius

• Treatment– Displaced fractures treated surgically produce

good to excellent results 70-90%– Functional limits include pain, stiffness and

decreased grip

Vertebral Compression Fractures

• Background– Nearly all post-menopausal women over age 70

have sustained a vertebral compression fracture– Usually occur between T8 and L2– Kyphosis and scoliosis may develop

• markers for osteoporosis

Vertebral Compression Fractures

• Epidemiology– More common than hip fractures– 117/100,000– Twice as common in females– Lifetime risk in a 50 year old white female is

32%

Vertebral Compression Fractures

• Background– Present with acute back pain– Tender to palpation– Neurologic deficit is rare

• Patterns– Biconcave (upper lumbar)– Anterior wedge (thoracic)– Symmetric compression (T-L

junction)

Vertebral Compression Fractures

• Radiographic evaluation– AP and lateral

radiographs of the spine

– Symptomatic vertebrae 1/3 height of adjacent

– Bone scan can differentiate old from new fractures

Vertebral Compression Fractures

• Treatment– Simple osteoporotic vertebral compression

fractures are treated non-operatively and symptomatically

– Prolonged bedrest should be avoided– Progressive ambulation should be started early– Back exercises should be started after a few

weeks

Vertebral Compression Fractures

• Treatment– A corset may be helpful– Most fractures heal uneventfully– Kyphoplasty an option

Prevention

• Strategies focus on controlling factors that predispose to fracture

• Fall prevention

Prevention

• Multidisciplinary programs– Medical adjustment– Behavior modification– Exercise classes– Controversial

Prevention and Treatment of Bone Fragility

• Well established link between decreasing bone mass and risk of fracture

• Treatment of osteoporosis– Estrogen– Calcium/Vitamin D Supplements– Calcitononin– Bisphosphonates– Teriparatide (Forteo)

Prevention and Treatment of Bone Fragility

• Estrogen– 2-3% bone loss with menopause– Unopposed or combined therapy has been

shown to reduce hip fracture incidence in women aged 65-74 by 40-60% (Henderson et al. 1988)

– Risk of breast and endometrial cancer increased in unopposed therapy

Prevention and Treatment of Bone Fragility

• Fosmax– Shown to increase the bone density in femoral

neck in post menopausal women with osteoporosis (Lieberman et al. NEJM 1995)

– Reduced hip fracture rate by 50% in women who had sustained a previous vertebral fracture. (Black et al. Lancet 1996)

Prevention and Treatment of Bone Fragility

• Calcium/Vitamin D Supplementation– Recommended for most men and women >50 years

• Calcium

– Age <50 -- 1,000 mg/day

– Age >50 -- 1,200 mg/day

• Vitamin D

– Age 51-70 -- 400 IU/day

– Age >70 -- 600 IU/day

• Combining Vitamin D and calcium supplementation has been shown to increase bone mineral density and reduce the risk of fracture

Prevention and Treatment of Bone Fragility

• Calcitonin– Inhibits bone resorption by inhibiting osteoclast activity– Approved for treatment of osteoporosis in women who have

been post-menopausal for > 5 years• Daily intranasal spray of 200 IU

– Trial demonstrated 33% reduction of vertebral compression fractures with daily therapy (Chesnut Am J Med 2000)

• No effect on hip fractures demonstrated

Prevention and Treatment of Bone Fragility

• Bisphosphonates– Inhibits bone resorption by reducing osteoclast recruitment

and activity

– Bone formed while on bisphosphonate therapy is histologically normal

– Available formulations

• Alendronate

• Risendronate

• Ibandronate

• Strongest evidence for rapid fracture risk reduction– Decreasing the incidence of both vertebral and nonvertebral

fractures

Prevention and Treatment of Bone Fragility

• Teriparatide (Forteo)– Recombinant formulation of

parathyroid hormone– Stimulates the formation of new

bone by increasing the number and activity of osteoblasts

– Once daily subcutaneous injection of 20 g

• Study of 1637 post-menopausal women – 65% reduction in the incidence of

new vertebral fractures– 53% reduction in the incidence of

new nonvertebral fractures

Conclusions

• Prevention is multifaceted• Cost containment also a joint effort between

orthopaedists, primary care physicians, PT and social work

• Functional outcome is maximized by early fixation and mobilization in operative cases

• Number of elderly is increasing all will have to work together in difficult economic times

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