Treatment of Fractures in the Elderly Author: Kenneth J. Koval, MD At the 21st Annual Orthopaedic Trauma Seminar held Feb 28-March 3, 2000, in Snowmass, Colorado, presenter Kenneth J. Koval, MD, discussed medical and surgical challenge of treating fractures in the elderly. Fracture management should be based on patient factors (preinjury medical and functional status) as well as injury factors (fracture level and degree of comminution, soft tissue status, and multiple organ system involvement). A "triumph of technology over reason" should be avoided, while simultaneous attempts to fully restore preinjury function are made. Patient Factors A detailed history of the patient's preinjury function must be obtained to establish a reasonable treatment plan. The management goals for femoral neck fracture in an active, ambulatory member of the community differ from those of an institutionalized, nonambulatory patient. The former requires surgical treatment with aggressive postoperative physical therapy, whereas the latter may best be treated without surgery by using bed-to-chair mobilization. Elderly fracture patients often have preexisting medical problems that affect fracture management. Cardiopulmonary disease, which is common in this population, can alter the patient's ability to tolerate prolonged recumbency, undergo surgery, and participate in rehabilitation. Neurologic problems, such as Parkinson's disease, Alzheimer's disease, and residual disorders from a previous cerebrovascular accident must be considered during fracture management. Clinical manifestations of Parkinson's disease can range from mild tremors without significant functional limitations to severe contractures resulting in incapacitation. Patients who have had a stroke are at increased risk for fracture, primarily because of residual balance and gait problems and osteoporosis of the paretic limb. A treatment plan that involves a high degree of patient cooperation is inappropriate for a patient with Alzheimer's disease. Endocrine problems, particularly diabetes, are common in the elderly. Diabetic patients generally have vascular compromise secondary to small vessel disease and are immunosuppressed.[1] Nonoperative treatment of select fractures may be preferred in these patients, particularly if there is a preexisting diabetic ulcer near the planned operative field. Elderly patients are frequently osteopenic, which may be caused by either osteoporosis or osteomalacia. Osteopenia greatly affects fracture management because it decreases the potential for the surgeon to achieve stable fixation and allow early range of joint motion. Soft tissue status guides patient care and implant choice. As a result of aging, the skin becomes more fragile and less tolerant of surgical insult. Age-related attrition can compromise soft tissue repair; aggressive surgical management requiring
prolonged rehabilitation may not be warranted in patients with preexisting severe tendinous compromise (ie, rotator cuff disease). The presence of decubiti near the fracture site is a relative contraindication to surgery and dictates the operative approach. Injury Factors Patients older than 65 years of age represent a disproportionate 28% of all fatal injuries in the United States, although they constitute only 12% of the population.[2,3] This statistic is related to the fact that for a given level of trauma, mortality and morbidity are greater in a geriatric person than in a younger person. Furthermore, traditional trauma rating systems, which are designed to help triage polytrauma patients and to predict mortality, are less reliable and predictive in the elderly. Identification of skeletal injuries in geriatric trauma patients requires vigilance. However, the presence of fractures should always be considered in geriatric patients with major trauma; visceral injuries rarely occur in the absence of orthopaedic injuries in this population. Open fractures require emergent treatment. Preexisting vascular insufficiency, diabetes mellitus, immunocompromise, and osteopenia increase the risk for treatment complications in the elderly. To optimize treatment results, the basic principles of open fracture management must be followed. Meticulous soft tissue and osseous debridement; fracture stabilization; and soft tissue coverage with early bone grafting, when appropriate, apply to all patients. Indications for Surgery Absolute indications for operative fracture treatment, regardless of the age of the patient, are open fracture, compartment syndrome, and neurovascular compromise. Relative surgical indications include displaced intraarticular fractures, diaphyseal fractures in which acceptable reduction cannot be obtained or maintained through nonoperative means, and fractures that require stabilization to mobilize the patient out of bed. Timing of Surgery For isolated fractures in the elderly, the timing of surgery is controversial. In general, surgery should be performed as soon as possible after injury and stabilization of all comorbid medical conditions, particularly cardiopulmonary disorders and fluid and electrolyte imbalances. In a prospective series of 367 elderly hip fracture patients, Zuckerman and colleagues[4] reported that a surgical delay of more than 2 calendar days from hospital admission approximately doubled the patient's risk for death before the end of the first postoperative year. Anaesthetic Considerations Although much has been written on the risks and benefits of the various anaesthetic techniques, no significant difference in survival rates has been found in elderly hip fracture patients having surgery under regional or general
anaesthesia.[5,6] Many anesthesiologists, internists, and surgeons believe that patients "look better" after regional anaesthesia. However, studies have documented no difference in postoperative mental status in patients after regional or general anaesthesia. Studies have demonstrated the efficacy of regional anaesthesia (spinal and epidural) in prophylaxis for deep vein thrombosis and pulmonary embolus. Implant Choice The implant of choice for patients with osteopenic bone is an intramedullary device. Intramedullary nails are positioned closer to the mechanical axis and are thus less likely to fail by fatigue than are plates; in addition, they can function as loadsharing devices that align the ends of the bone while allowing force transmission across the fracture. Plates are dependent on the holding power of the screw in bone to obtain and maintain compression across a fracture surface and to provide stable plate-osseous attachment. If there is gap of any size between the fracture ends, the plate will keep the fragments separated and become a load-bearing device. Fixation Enhancement Methylmethacrylate can be used to enhance screw fixation in osteoporotic patients who have minimal cortical holding power. Liquid methylmethacrylate is injected with a syringe into the loose screw hole, and the screw is then inserted. Extravasation of the methylmethacrylate into the fracture site and surrounding soft tissue must be avoided. Placement of a nut on the opposite cortex of a bolted bone screw increases the screw pull-out strength, thereby lessening the risk for screw back-out from the plate. Screws can be locked to the plate either with a nut placed under the plate or through use of a tapped hole plate. Locking the screws to the plate causes the plate-screw construct to act as a fixed-angle device. Intramedullary devices can be used in conjunction with plates and screws to increase fixation stability. A recent study reported that intramedullary Kirschner wires in conjunction with a plate and screws provided better fixation of comminuted and osteopenic ankle fractures than plate and screws alone.[7] Postoperative Management To avoid the complications of recumbency, postoperative management should be directed at early patient mobilization. Thromboembolic prophylaxis should be considered, particularly in patients with lower extremity fractures. The patient's weight-bearing status is based on the fracture pattern, implant choice, and fracture stability. Geriatric patients have great difficulty ambulating if weight bearing is restricted; this significantly limits their ability to regain ambulatory ability.
Conclusion Fracture treatment in the elderly must be based on a careful assessment of both the patient and the fracture. Many patient characteristics have important effects on fracture management. In addition, the fracture must be managed in the context of the patient's preinjury medical and functional status. Medical stabilization, surgical timing, implant selection, and postoperative management all affect outcome and must be considered as essential elements of patient care. References 1. Loder RT. The influence of diabetes mellitus on the healing of closed fractures. Clin Orthop. 1988;232:210-6. 2. Martin RE, Teberian G. Multiple trauma and the elderly patient. Emerg Med Clin North Am.1990;8:411-20. 3. DeMaria EJ, Kenney P, Merriam MA, et al. Survival after trauma in geriatric patients. Ann Surg. 1987;28:738-743. 4. Zuckerman JD, Skovron ML, Koval KJ, Aharonoff GB, Frankel VH. Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip. J Bone Joint Surg. 1995;77A:1551-1556. 5. Davis FM, Woolner DF, Frampton C, et al. Prospective, multi-centre trial of mortality following general or spinal anaesthesia for hip fracture surgery in the elderly. Br J Anaesth. 1987;59:1080-1088. 6. Valentin N, Lomholt B, Jensen JS, Hejgaard N, Kreiner S. Spinal or general anaesthesia for surgery of the fractured hip? Br J Anaesth. 1986;58:284291. 7. Koval KJ, Petraco D, Kummer F, Zuckerman JD. The treatment of complex ankle fractures in the elderly. Program and abstracts of the Annual Meeting of the American Academy of Orthopaedic Surgeons; February 22-26,1996; Atlanta, Georgia. Abstract 84.