Orthopedic considerations in the older adult
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Orthopedic Considerations in the Older Adult. What to worry about in the old folks!!!. Topics to cover and relate…. Arthritis Osteoporosis disease and prevention Falls and prevention Types of Injuries. The elderly…a increasing concern.

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Orthopedic considerations in the older adult

Orthopedic Considerations in the Older Adult

What to worry about in the old folks!!!

Topics to cover and relate

Topics to cover and relate…..

  • Arthritis

  • Osteoporosis disease and prevention

  • Falls and prevention

  • Types of Injuries

The elderly a increasing concern

The elderly…a increasing concern

  • Although the big surge in the elderly population is not expected until the baby boomers turn 65 in the next century, significant demographic shifts are already underway. In 1940 only 7 percent of Americans had a chance of living to age 90; in 1980, it was 24 percent. In 1950 there were 4,475 persons age 100 years or older; by 1990, the number was 54,000.



Osteoporosis and the orthopedic surgeon

Osteoporosis and the Orthopedic Surgeon

  • First fracture may be warning sign

  • Osteoporosis, or "porous bone" is a medical condition that weakens bone by making it more porous and less dense. Bone density is one of the factors that determine bone strength, so individuals with low bone density have a higher risk for fracture and refracture.



  • Disease of adolescence!!

  • 35 and 50 years old:

  • You may have begun to gradually lose bone. At this stage in your life, getting enough calcium (1,000 mg each day) and exercise are crucial to keep bone loss to a minimum. Most women enter menopause between the ages of 42 and 55.



  • You should be getting 1,000 mg of calcium each day. If you rarely get out in the sun, vitamin D also may be recommended

  • (2 Na free TUMS!)

  • Try to walk, jog or perform a resistance workout for at least 20 minutes, three times a week.



  • Over 50 years old:

  • For women who have gone through menopause, they may be losing bone at a rate of 1 to 6 percent per year

  • Adequate calcium intake and exercise still are important

Men and osteoporosis

Men and Osteoporosis ? 

  • Men should also be concerned about osteoporosis. Approximately one in eight men will have an osteoporotic fracture. Men with a history of hypogonadism, thyroid dysfunction, long-term steroid therapy, high alcohol consumption or low physical activity are especially at risk. One-third of all hip fractures experienced by men are related to osteoporosis, and one-third of these men will die within the first year after the fracture.

Osteoporosis and fractures

Osteoporosis and Fractures

  • The risk of a serious fracture can double after a first fracture in certain high-risk groups. Additionally, many patients, particularly those who suffer hip fractures, are at high risk for premature death or loss of independence after the fracture.

Osteoporosis and fractures1

Osteoporosis and Fractures

  • One out of four people who have an osteoporotic hip fracture will need long-term nursing home care.

  • Half of those who experience osteoporotic hip fractures are unable to walk without assistance.

  • Those who experience the trauma of an osteoporotic hip fracture have a 24% increased risk ofdyingwithin one year following the fracture

Osteoporosis and fractures2

Osteoporosis and Fractures

  • Osteoporosis is a contributing factor in as many as 1.5 million fractures each year, including:

  • About 300,000 hip fractures

  • About 700,000 vertebral (spine) fractures

  • About 250,000 wrist fractures

  • About 300,000 fractures at other sites

Osteoporosis and fractures3

Osteoporosis and Fractures

  • Hispanic women may be among those at highest risk. Between 13 percent and 16 percent of Hispanic women have osteoporosis. As many as 49% of Mexican-American women 50 years of age or older have low bone density.

  • Although the rate of hip fractures is lower in Asian-American women, the rate of vertebral fractures is about equal between Asian-American and Caucasian women.

  • About 10 percent of African-American women over 50 have osteoporosis. An additional 30 percent have low bone density. Between 80 percent and 95 percent of all fractures experienced by African-American women over age 64 are related to osteoporosis.

Osteoporosis and fractures4

Osteoporosis and Fractures

  • . Make sure you get enough calcium and vitamin D in your diet. The National Academy of Sciences recommends 400 to 800 units of Vitamin D and 1,000 to 1,500 mg of Calcium per day.

  • How many Sodium free TUMS is that??



  • Participate in activities that will strengthen bone and muscle. Regular exercise is one of the best things you can do to prevent osteoporosis. Weight-bearing exercises like walking, jogging and tennis and low-impact exercise classes are best for building and maintaining strong bones.



  • Because falls are the most common cause of fractures, do some balance activities to reduce your risk.

Fall prevention

Fall Prevention:

  • If you have osteoporosis and you fall, you are likely to break a bone. Ten million people currently have osteoporosis; another 34 million have low bone mass and therefore are at risk of developing the disease. More than 1.5 million Americans each year sustain a fracture related to osteoporosis.

Steps to take

Steps to take

Prevent falls

Prevent Falls

Orthopedic surgery

Orthopedic Surgery

  • Hip fractures remain a major source of morbidity and mortality in the elderly, and their incidence is increasing as the population ages. Surgical management followed by early mobilization is the treatment of choice for most patients with hip fractures. However, all co morbid medical conditions, particularly cardiopulmonary and fluid-electrolyte imbalances, must be evaluated and stabilized prior to operative intervention

Hip fractures

Hip Fractures

  • Non displaced femoral-neck fractures should be stabilized with multiple parallel lag screws or pins. The treatment of displaced femoral-neck fractures is based on the patient's age and activity level: young active patients should undergo open reduction and internal fixation; older, less active patients are usually treated with hemiarthroplasty, either uncemented or cemented. Regardless of treatment method, the goal is to return the patient to his or her prefracture level of function.

Hip fractures mortality and outcomes

Hip Fractures: Mortality and Outcomes

  • Mortality rates in the first year following a broken hip are around 25%, and the rates are highest in older populations. The cause of mortality following a hip fracture is often due to blood clots, pneumonia, or infection. Furthermore, only about 25% of patients who sustain a broken hip return to their pre-injury level of activity.

Hip fractures mortality and outcomes1

Hip Fractures: Mortality and Outcomes

  • Most important factor was the mental acuity of the patient prior to and after the fracture. (hip fractures VA Hospital Study)

Femoral neck fractures

Femoral Neck Fractures

  • Garden Classification

  • 1-2 Non Displaced

  • 3-4 Displaced

  • Disruption of blood flow with resulting avascular necrosis

  • Internal Fixation vs Arthroplasty

Femoral neck fractures garden classification

Femoral Neck Fractures:Garden Classification

Femoral neck fractures1

Femoral Neck Fractures:

  • Difficult to see non displaced fractures

  • May need bone scan or CT or MRI to diagnose

  • Low velocity falls

  • May be diagnosed late

  • May turn nondisplaced into a displaced fx

Femoral neck fractures2

Femoral Neck Fractures:

Bone scan

Femoral neck fractures3

Femoral Neck Fractures:

Femoral neck fx orif vs arthroplasty

Femoral Neck Fx: ORIF vs. Arthroplasty

Femoral neck fx protocol

Femoral Neck Fx: Protocol

  • High index of suspicion

  • Xray ap/lat and cross table lat of femoral neck

  • Exam is not always helpful

  • Need further studies MRI CT or bone scan

  • When in doubt, act like its broken!!!!

Femoral neck vs intertrochanteric fractures

Femoral Neck vs. Intertrochanteric Fractures

Percutaneous pinning of femoral neck fractures

Percutaneous pinning of femoral neck fractures

Pelvic fractures the great pretender

Pelvic Fractures: the great pretender!!!!

Colle s fracture colles fracture

Colle’s Fracture (Colles’ fracture?)

  • Colles Fracture

  • Most common upper extremity fx in the elderly

  • Wet leaves, snow, throw rug, tripped over a pet…….

  • Hyper extension deformation force to the wrist

Comminuted distal radius fracture

Comminuted Distal Radius Fracture

  • Silver fork deformity

Comminuted distal radius fracture1

Comminuted Distal Radius Fracture

Compression fractures thoracic and lumbar

CompressionFracturesThoracic and Lumbar

Can any of you tell me whether this is

Lumbar or Thoracic??

Back and spine

Back and Spine

  • Back or spine injuries are the most prevalent musculoskeletal impairments

  • Difficult to diagnose masquerade as cardiac or gastric or pulmonary discomfort in the elderly

Dowager s hump

Dowager’s Hump

Compression fractures

Compression Fractures

  • Burst type

  • Cord impingement

  • Usually from activity or a fall

  • Usually higher velocity injury

Compression fracture

Compression Fracture

  • Wedge pattern

  • Much more common

  • Function of osteoporosis an lack of structural support

  • Look for other causes!!!!! METASTASIS INFECTION

Orthopedic considerations in the older adult

MRI of Compression Fracture

Orthopedic considerations in the older adult

May need bone scan for diagnosis





  • Early results show kyphoplasty is a safe and effective method of vertebral reconstruction and stabilization in the treatment of osteoporotic VCFs. Like all surgeries, kyphoplasty does have risks.

  • Complications may require additional treatments. These may be medications or surgery. Kyphoplasty is associated with excellent pain relief due to the vertebral body collapse. Well over 95 percent of patients rate their treatment a success. They are able to return to all of their pre-VCF function.

More kyphoplasty

More Kyphoplasty…….

  • Occasionally, patients complain of persistent pain after kyphoplasty. This may be due to irritation of tissues involved in the procedure itself. It is more likely due to the underlying arthritis and degeneration of the spine.

  • Restoring vertebral body height and size is best accomplished when kyphoplasty is performed soon after the VCFs happen.



  • After kyphoplasty, severe osteoporosis may cause other fractures at other levels in some patients.

  • There is a small risk of the bone cement leaking from within the boundaries of the vertebral body. In most cases, this rare event (occurrence less than 10 percent) does not cause any problems.



  • In very rare circumstances the cement may irritate or damage the spinal cord or nerves. This can cause pain, altered sensation, or even, very rarely, paralysis (estimated risk is less than 1 in 10,000). Should the cement leak further, more significant surgery may be needed to stop the irritation of the nerves or spinal cord.

  • There is also a very small chance of the cement traveling to lungs.

Humeral neck fractures

Humeral Neck Fractures

  • Very common fracture in the osteoporotic bone of the humeral neck

  • Can come in different types and requires different treatments

  • Non displaced early AROM/PROM

Humeral neck fractures1

Humeral Neck Fractures

  • Lack of healing secondary to loss of blood supply

  • “Bag o Bones” TX vs.

  • Humeral arthroplasy

Treatment of humeral neck fractures

Treatment of Humeral Neck Fractures

Hip and knee arthritis

Hip and Knee Arthritis

  • Arthritis or chronic joint symptoms affect nearly 70 million Americans (about 1 in 3 adults), making it one of the most prevalent diseases in the United States.

  • By 2020, an estimated 12 million Americans will be limited in daily activities because of arthritis.

Arthritis and the elderly

Arthritis and the elderly

  • Arthritis is the leading chronic condition reported by the elderly.

Knee and hip arthritis

Knee and Hip Arthritis

  • In 2002, more than 557,000 hip or knee replacement surgeries were performed

Knee arthritis

Knee Arthritis

  • Conservative treatment options


  • Surgery

  • Realignment

  • Arthroscopic

  • Replacement

Knee arthroplasty

Knee Arthroplasty

Other orthopedic considerations

Other Orthopedic Considerations

  • Medical history is terrible/Compliance is difficult

  • Skin problems, IV Access

  • DVT, Pressure sores

  • Lack of “stamina” or will (therapeutic inertia…to return to health)

  • Lack of ability or willingness to cooperate

  • Depressed Immune system

  • Lack of Cardiac and other systems reserve

  • Wound healing and Nitrogen balance

To close


  • Don’t fall down or trip over preventable causes without taking your calcium and exercising with weak bones and no therapeutic inertia and break your hip or knee or shoulder or wrist while having arthritis……….


Orthopedic considerations in the older adult

Have a milkshake!!!!

Thank you

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