Transcript Clinical Slide Set. - Annals of Internal Medicine

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© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
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© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
in the clinic
Hip Fracture
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
What medical comorbid conditions
increase the risk for falls and hip fracture?
 Advanced age (>75 years)
 Sensory impairments (i.e., hearing or vision loss)
 Conditions causing gait instability or abnormal proprioception
 Depression
 Muscular weakness
 Orthostatic hypotension
 Impaired cognition
 Using ≥4 medications long-term, alcohol, or benzodiazepines
 Osteoporosis
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
What are the mechanical risk factors for
hip fracture?
Mechanical risk factors
 Gait instability
 Foot deformities
 Environmental hazards at home
 Home safety evaluations recommended for older
people who have fallen or have risk factors for falls
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
What is the role of bone densitometry in
assessing risk for hip fracture?
 To diagnose osteoporosis and predict fracture risk
 1-SD decrease BMD at femoral neck = 2.6 RR hip fracture
Risk factors warranting bone densitometry:
 History of fracture
 Glucocorticoid use
 Family history of fracture
 Cigarette smoking
 Excessive alcohol intake
 Low bodyweight
 Note: Repeated screening is no more predictive of
subsequent fracture than original measurement
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
 Fracture risk assessment tool (FRAX):
Predicts 10-y risk for hip fracture in untreated men and
women 40-90 yrs (w/ or w/out BMD)
FRAX Tool: Estimate 10-yr risk for fracture:
Free calculation tool: www.shef.ac.uk/FRAX
• Age
• Sex
• Height
• Weight
• Ethnicity (US calculator only)
• Optional item: femoral neck BMD
Yes/no:
• Previous fracture
• Parent with hip fracture
• Current smoking
• Glucocorticoid use
• Rheumatoid arthritis
• 2° osteoporosis
• ≥3 units of alcohol/day
Factors most predictive of osteoporotic fracture:
 History previous low-impact fracture
 Low BMD
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
What pharmacologic interventions can
prevent hip fracture?
 Calcium and vitamin D
 Bisphosphonates (alendronate, risedronate,
ibandronate, zoledronic acid)
 HRT: estrogen (*several health risks)
 Selective estrogen-receptor modulators: raloxifene,
risedronate
 Anabolic: parathyroid hormone, strontium renelate
 Calcitonin (less potent than others)
 Monoclonal antibody: denosumab
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
What is the role of exercise in preventing
hip fracture?
 Can reduce risk factors* for falls and fractures
 Particularly balance training, t'ai chi
*Risk factors
 Physical inactivity
 Inability to rise from chair w/o using the arms
 Gait instability
 Lower-extremity weakness
 Hip protectors may also reduce risk
 Effectiveness unclear, compliance poor
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
Screening and Prevention
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
What is the differential diagnosis of hip
fracture? History & physical exam and X-rays usually
distinguish fracture from other conditions
 Pathologic fracture
 Septic hip joint
 Pelvic fracture
 Dislocation
 Osteoarthritis
 Soft tissue injury
 Osteonecrosis
 Trochanteric bursitis
 Rheumatoid arthritis
affecting hip
 Meralgia paresthetica
(nerve entrapment)
 Lumbar spine
disease(spinal stenosis,
arthritis, disk disease)
 Paget disease of bone
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
What are the important elements of the
history when hip fracture is suspected?
 Trauma (esp fall from standing with impact on hip)
 Hip pain (in groin, buttock; referred to knee or thigh)
 Inability to bear weight or pain with weight-bearing
 Circumstances surrounding fall
 Previous minimal trauma fracture or loss of height
 Risk factors for osteoporosis and fracture
 CVD and other comorbid conditions
 Premorbid function
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
What are the important elements of the
physical when hip fracture is suspected?
 Position and length of limb + gentle ROM determination
 ? leg shortened, externally rotated, abducted when supine
 Musculoskeletal and neurologic survey
 ? evidence concomitant injury; ? head trauma
 Distal motor, sensory, and vascular integrity of affected limb
 ? interruption of neurovascular blood supply
 Cardiac and general physical exam
 ? unstable comorbid illness: may need presurgical
management
 ? conditions associated with osteoporosis
 Mental status testing
 Delirium present in up to 60% with hip fracture
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
What are the different types of hip
fracture?
 Classified by area of upper femur affected
 Intracapsular
  at level of head and neck of femur
 Intertrochanteric
  between neck of femur and lesser trochanter
 Subtrochanteric
  below lesser trochanter
 Classified by whether displacement present
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
What other injuries commonly occur with
hip fracture?
 Soft tissue injuries
 Other sites of fracture
 Head trauma
 DVT, skin ulceration, pneumonia, rhabdomyolysis
 If patient remained on the ground for prolonged time
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
What radiographs and other imaging
studies are used?
 Radiographs
 For diagnosis and determining if surgical repair warranted
 Obtain plain anteroposterior pelvis and lateral radiographs
 MRI
 Evaluate for occult fracture if clinical suspicion high
despite negative plain radiographs
 Bone scan
 To diagnose fracture in patients who cannot undergo MRI
 May take up to 72 hours to register as positive
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
Diagnosis
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
When should conservative therapy be
considered?
 Consider for
 Patients too ill for surgery or anesthesia
 Patients bed- or wheelchair-bound before injury
 If modern surgical facilities unavailable
 Do not use skeletal or skin traction
 No evidence beneficial and associated with risks
 Conservative vs. surgical therapy
 Similar mortality, medical complications, long-term pain
 But surgery offers better chance for functional recovery
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
During what time frame should surgery be
performed?
 As soon as patient is medically stable
 Postpone if ≥ 1 unstable medical condition
 Active heart failure
 Ongoing angina
 Serious infection
 Hemodynamic instability (correct before surgery)
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
How is the appropriate surgical approach
determined?
Fracture location & severity of displacement
 Femoral neck fracture
 Internal fixation with screws (if nondisplaced or minimally
displaced in younger patient)
 Prosthetic replacement (if displaced or poor bone quality,
joint disease, or excessive propensity to fall)
 Intertrochanteric fracture
 Sliding screws or similar devices (minimally invasive
surgery lowers blood transfusion rate but not mortality)
 Subtrochanteric fracture
 Intramedullary nail or screw-plate fixation (intramedullary
nail may provide better outcomes)
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
Should preoperative cardiac risk be
assessed in all patients having surgery?
 Only in patients with comorbid cardiac conditions
 Unstable coronary syndromes
 Decompensated heart failure
 Significant atrial arrhythmias or ventricular arrhythmia
 Severe valvular disease
 Revascularization before surgery
 Beneficial if cardiac conditions severe or unstable
 β-blockers
 for patients with CAD or high cardiac risk
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
What is the expected mortality of hip
surgery?
 Surgical-specific mortality: 2%-3% most U.S. hospitals
 However…hip fracture confers
 5-fold increase in all-cause mortality for women
 8-fold increase in all-cause mortality for men
 (in first 3 months after fracture, compared with
age- and sex-matched controls)
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
What are the major postoperative
complications of hip fracture?
 Infection
 Dislocation and failure of prosthesis
 Delirium
 DVT
 Skin breakdown
 Bladder problems
 Complications may occur years after repair
 Osteonecrosis of femoral head after internal fixation
 Loosening of the prosthesis after arthroplasty
 Persistent pain
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
When should rehabilitation begin following
surgery and what are the goals?
 Patients should get out of bed on 1st postoperative day
 Progress to ambulation as soon as tolerated
 Prevents pressure ulcer formation, atelectasis, pneumonia,
muscle weakness
 Goal: Regain ambulation and independence
 ? best strategies
 Studies mostly small, methodologically limited
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
What is the role of prophylactic antibiotics
for patients having surgery for hip
fracture?
 Decrease deep wounds, superficial wounds, UTI
 Give 1st dose before surgery
 Continue for 24 hours after surgery
 Cephalosporins commonly used
 44% lower risk infectious complications with antibiotic
use vs. placebo
 40% reduction of infection with multiple vs. single doses
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
What are the major components of pain
management for hip fracture?
 Use adequate analgesia
 Improves patient comfort
 Facilitates rehabilitation
 Decreases the risk for delirium
 Avoid meperidine  strong risk factor for delirium
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
How common is thromboembolism
following a hip fracture, and should it be
prevented and treated?
 DVT: up to 50% if not treated prophylactically
 Fatal PE: 1.4%-7.5% within 3 months after surgery
 Use prophylaxis unless contraindicated
 Fondaparinux, low-dose unfractionated heparin,
adjusted-dose vitamin K antagonist, or LMWH
 Begin before surgery if procedure likely to be delayed
 Restart once postop hemostasis demonstrated
 Use up to 28-35 days after surgery
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
What is the correct approach to secondary
prevention in patients with hip fracture?
 Evaluation return of function
 Monitor for late postop complications
 Institute secondary prevention measures
 Osteoporosis education and treatment
 Fall prevention
 Modify risk factors: Poor vision, muscular weakness,
certain medications, environmental factors
 2.5% have 2nd hip fracture in the first year
 8.2% have 2nd hip fracture within 5 years
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
Treatment and Management
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
What should patients be told about
immediate care after a fall and the
detection of hip fracture?
 Fracture repair: usually on day 1 or 2 of hospitalization
 Rehabilitation: usually begun 1st day after surgery
 Rehab facility: for 2 weeks before return home
 Assistance at home: required for several months
 Further therapy: required for several months
 ≈50% regain ambulatory status
 Function gains mostly in first 6 months
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.
Patient Education
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (11): ITC6-1.