© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. Terms of Use The In...

© Copyright Annals of Internal Medicine, 2011Ann Int Med. 155 (11): ITC6-1.

Terms of Use The In the Clinic® slide sets are owned and copyrighted by the

American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets constitutes copyright infringement.


* For Best Viewing:

Open in Slide Show Mode Click on icon or

From the View menu, select the Slide Show option

* To help you as you prepare a talk, we have included the relevant text from ITC in the notes pages of each slide


in the clinic

Hip Fracture


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


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


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


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)

Factors most predictive of osteoporotic fracture:

History previous low-impact fracture

Low 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


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


What is the role of exercise in preventing hip fracture?

Can reduce risk factors* for falls and fractures

Particularly balance training, t'ai chi

Hip protectors may also reduce risk

Effectiveness unclear, compliance poor

*Risk factors

Physical inactivity

Inability to rise from chair w/o using the arms

Gait instability

Lower-extremity weakness


Screening and Prevention


What is the differential diagnosis of hip fracture?

Pathologic fracture

Pelvic fracture

Osteoarthritis

Osteonecrosis

Rheumatoid arthritis affecting hip

Lumbar spine disease(spinal stenosis, arthritis, disk disease)

Septic hip joint

Dislocation

Soft tissue injury

Trochanteric bursitis

Meralgia paresthetica (nerve entrapment)

Paget disease of bone

History & physical exam and X-rays usually distinguish fracture from other conditions


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


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


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


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


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


Diagnosis


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


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)


How is the appropriate surgical approach determined?

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)

Fracture location & severity of displacement

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)


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


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)


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


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


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


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


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


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


Treatment and Management


What should patients be told about immediate care after a fall and the detection of hip fracture?

≈50% regain ambulatory status

Function gains mostly in first 6 months

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


Patient Education

Date post:	25-Dec-2015
Category:	Documents
Upload:	isabella-park
View:	223 times
Download:	2 times

© Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. Terms of Use The In...

Documents