Austin Hill MD MPH

Assistant Professor – Dell Medical School Dept of Surgery and Perioperative Care

Orthopaedic Trauma

Disclosures

Orthopedic Implant Company – ownership, stock, or options

Increasing volume of trauma in patients > 65

Account for 30+% of mortality in trauma

High energy – low energy

Complex underlying medical illness

Wrist Fractures: 200,000+

Hip Fractures: 300,000+

Vertebral Fractures: 700,000+

Other Fractures: 300,000+

Source: National Osteoporosis Foundation, 2000

1.5 Million Fractures Annually

Associated Injuries Evaluate for:

Head injuries

Rib fractures

Spine fractures

Cardiac/Seizure/

Syncope?

Fractures beget Fractures Risk of future fractures

increases 1.5-9.5 fold following

initial fracture

History of fragility fracture is

more predictive of future

fracture than bone density

Viewed as a sentinel event

Fracture Prevention Osteoporosis treatment

Calcium/Vit D supplementation

Pharmacotherapy

Fall Prevention

Home safety evaluation

Update corrective lenses

Minimize sedating/mood altering meds

Maintenance of medical comorbidities

Patient/Family Education

Impact on Quality of Life and Independence

Not as dramatic as hip fractures, but still cause significant dependence up to 6 months after injury

Functional considerations Many geriatric patients use their arms to ambulate with

walkers

Ability to feed themselves

Ability to dress themselves

Splints and slings can be difficult to manage

Higher Functioning Many patients > 65 have active lives and hobbies

Golf

Tennis

Hunting/Fishing

Early post-op period – improved function with surgery

No difference at 6 or 12 months

Try closed reduction whenever possible

Some Patients tolerate significant malunions

Tale of 2 cases - 89 yo F – Fall from

standing

PMH – HLD

Home ambulator

Medical issues are controlled

Fracture was “reduced” and casted

Tale of 2 cases - 3 months s/p injury

Normal motion

No pain

Tale of 2 cases - 69 yo F with RA, HTN, Hypothyroid, DM

Realtor, high functioning

Tale of 2 cases - 1st post op visit

Normal motion, off pain meds, back to work

Operative vs Non-operative Tx Case by Case

Involve family when possible

Recognize what goals are important, which ones are obtainable?

Return to work or hobbies

Keep patients ambulating

To fix, replace, or let go - Non-operative –

Simple proximal humerus fractures

Clavicle fractures

Distal radius fractures

Radial Head/Neck fractures

Operative –

Humeral shaft fractures

Fracture dislocations

Open fractures

Radius/Ulna shaft fractures

Distal Humerus fxs

Olecranon fxs

Surgical Considerations Regional Anesthesia,

LMA, limit narcotics

Minimize time in the OR – know when it is time to get out

Family Support

Pre-Optimization

Fall prevention – consider OT home evaluation

Clavicle Fractures Non-operative treatment

is usually well tolerated

Can bear some weight within 3-4 weeks

Soft tissues are rarely a problem

Clavicle Fractures 79 yo F – MVC

C-Spine injury

ICH

4 weeks s/p injury

Flexion – 100 degrees

Abduction – 80 degrees

Minimal Pain, Out of the sling, Using a walker

Humerus Fractures Proximal Humerus fractures can do well without surgery

Displaced Humeral shaft fxs can be debilitating

Distal Humerus fractures have a high nonuni0n rate if treated non-operatively

Humeral Shaft Fractures 85 yo female

Ambulates with a walker

CAD, COPD, HTN

Attempted non-op tx x 3 weeks - Did not tolerate splinting

2 weeks post op Decreased pain,

improved motion, happy 2 weeks post-op

Allowed to WBAT

6 weeks later Minimal pain

ROM > 90/90

Combined Proximal Humerus & Shaft Fractures 82 yo F community

ambulator

HTN, DM

Lives alone independently

12 hours in a splint,

not amused

IM nailing – “minimally invasive”

Arthroplasty vs ORIF vs Sling? 72 yo F – Fall from

standing at Walmarts

Sedentary, Moderate obesity, community ambulator

PMH – CAD, DM, etc

Reverse Total Shoulder Poor bone quality, bad fracture pattern, reasonable

goals regarding function

But Wait, There’s More!

6 months later, fall #2

Distal Humerus Fractures 72 yo F biking in

Slovenia

Healthy, active

Higher Energy Trauma

Open Distal Humerus Fx

Trauma Principles Abx

Evaluate for associated injuries

Early motion, PT

12 months post op Patient healed without

infection, limited ROM from 45-85 degrees

Significant Heterotopic Ossification

Contracture release, HO excision ROM: 10-150

PT the next day

Nerve Catheter for pain management, allow for immediate motion

Guarded optimism

Fractures & Dislocations around the elbow 65 yo F

Hx of Breast CA on Tarceva, otherwise healthy

Younger patient, same principles Arthroplasty and soft

tissue repair to mitigate poor bone quality

Strive for significant early gains in function

6 weeks post op Lacks only 15 degrees

extension

Full flexion

Occasional Tylenol for pain

Olecranon Fractures Usually ORIF, but

sometimes patients make the decision for you…

Can have soft tissue compromise

Bone quality is poor

Olecranon Fractures 82 yo F, FFS

HTN

Community Ambulator

Impending Skin necrosis on Exam

Olecranon Fractures Patient and daughter

agreed with ORIF

4 weeks post-op – MVC

Elbow motion- normal!

Fixation is often gratifying, But the functional

difference differs for each patient

79 yo F at SNF, fell 4-6 weeks ago

PMH – Dementia, osteoporosis, frequent falls, multiple fxs

Normal elbow motion, limited pain

Treatment Tips Each patient is different

Focus on function and Safety

Fracture Prevention

One solution does not fit all

Thank You!