Mendelson Fragility Fractures, An Issue of Clinics in Geriatric Medicine

1. Auflage 2014
ISBN: 978-0-323-26657-4
Verlag: Elsevier HealthScience EN
Format: EPUB
Kopierschutz: Adobe DRM (»Systemvoraussetzungen)

E-Book, Englisch, Band Volume 30-1, 241 Seiten

Reihe: The Clinics: Internal Medicine

This issue of Clinics in Geriatric Medicine is centered on the management of the geriatric fragility fracture patient. This issue features expert clinical reviews on topics such as Principles of comanagement, Lean business model and implementation of a Geriatric Fracture Center, Preoperative optimization and risk assessment, Preoperative reversal and management of anticoagulation and antiplatelet agents, Classification and surgical approach to hip fractures for non-surgeons, Special anesthetic consideration for the fragility fracture patient, Non-surgical management and palliation of fragility fractures, and Management of post-operative complications including Delerium, Anemia, Venous thromboembolism, and Cardiovascular disease and volume management. Also included are articles on Transitions in care and rehabilitation, Osteoporosis related secondary fracture prevention, Post-operative assessment of falls risk and prevention, and Fragility fractures requiring special consideration.

Autoren/Hrsg.

Mendelson, Daniel A

Inhaltsverzeichnis

1;Front Cover;1
2;Fragility Fractures;2
3;copyright
;3
4;Contributors;4
5;Contents;8
6;Clinics In Geriatric Medicine
;13
7;Preface
;14
8;Epidemiology of Fragility Fractures;16
8.1;Key points;16
8.2;Introduction;16
8.3;Prevalence/Incidence;17
8.4;Outcomes;17
8.5;Clinical correlation;18
8.6;Predictors of fragility fracture;19
8.7;Summary;20
8.8;References;20
9;Principles of Comanagement and the Geriatric Fracture Center;24
9.1;Key points;24
9.2;Introduction;24
9.3;Principles of comanagement;25
9.3.1;Most Patients Benefit from Surgical Stabilization of Their Fracture;25
9.3.2;The Sooner Patients Have Surgery, the Less Time They Have to Develop Iatrogenic Illness;25
9.3.3;Comanagement with Frequent Communication Avoids Common Medical and Functional Complications;26
9.3.4;Standardized Protocols Decrease Unwarranted Variability;27
9.4;Discharge planning begins at admission;28
9.5;Discussion;29
9.6;Summary;29
9.7;References;29
10;Lean Business Model and Implementation of a Geriatric Fracture Center;32
10.1;Key points;32
10.2;Introduction;32
10.3;What is a lean business model and why is it relevant to hip fracture care?;33
10.4;The geriatric fracture center (Rochester model) for care of hip fractures;34
10.5;Planning to implement a GFC;36
10.6;Development of a basic business plan;36
10.6.1;The 10-Step Business Plan;36
10.7;Partnering for success;39
10.8;Development of care maps and protocols;40
10.9;Dealing with barriers to implementation;41
10.10;Do you need a consultant?;42
10.11;How much does it cost to implement a GFC?;43
10.12;How to measure success of your program;44
10.13;Summary;44
10.14;References;44
11;Preoperative Optimization and Risk Assessment;48
11.1;Key points;48
11.2;Introduction;48
11.3;Implications of normal aging;48
11.4;Preoperative principles in the geriatric fracture patient;49
11.5;Early surgery;49
11.6;Preoperative risk assessment in older patients;50
11.6.1;Cardiovascular Evaluation;50
11.6.2;Cognitive Impairment;51
11.6.3;Functional Status;52
11.6.4;Nutritional Status;52
11.6.5;Polypharmacy;52
11.7;Preoperative optimization;53
11.7.1;Preoperative Fluid Management;53
11.7.2;Medication Management;54
11.7.3;ß-Blockers;55
11.7.4;Pain Control;55
11.7.5;Laboratory Testing;55
11.8;Nonoperative management;56
11.9;Summary;56
11.10;References;56
12;Preoperative Management of Anticoagulation and Antiplatelet Agents;60
12.1;Key points;60
12.2;Introduction;60
12.3;Anticoagulant management;61
12.3.1;Medications and Reason for Use;61
12.3.2;Risk Assessment of Stopping Anticoagulant;62
12.3.3;How to Manage Anticoagulation in Preparation for Surgery/Timing of Surgery;62
12.3.3.1;Vitamin K antagonist: warfarin;62
12.3.4;Novel Oral Anticoagulants: Dabigatran, Rivaroxaban, and Apixaban;64
12.3.4.1;Dabigatran;64
12.3.4.2;Rivaroxaban and apixaban;65
12.4;Antithrombotic Management;65
12.4.1;Aspirin;65
12.4.2;Antiplatelet Agents;65
12.4.2.1;Determine reason for antiplatelet use;65
12.4.2.2;Risk assessment of stopping antiplatelet agents;66
12.4.2.3;Management for surgery;66
12.5;Summary;67
12.6;References;67
13;Classification and Surgical Approaches to Hip Fractures for Nonsurgeons;70
13.1;Key points;70
13.2;Introduction;70
13.3;Anatomy and fracture risk;71
13.4;Fracture types;71
13.4.1;Femoral Neck Fractures;72
13.4.2;Intertrochanteric Fractures;75
13.4.3;Subtrochanteric Fractures;78
13.5;Summary;79
13.6;References;79
14;Special Anesthetic Consideration for the Patient with a Fragility Fracture;84
14.1;Key points;84
14.2;Introduction;84
14.2.1;Initial Workup Considerations;85
14.2.2;Risk Stratification;85
14.2.2.1;Preoperative pulmonary risk stratification;85
14.2.2.2;Preoperative cardiac risk stratification;85
14.2.2.3;Preoperative central nervous system evaluation;86
14.2.2.4;Overall risk stratification;86
14.2.3;Effects of General Anesthetics by System;87
14.2.3.1;Cardiovascular effects;87
14.2.3.2;Respiratory effects;88
14.2.3.3;Cerebral effects;91
14.2.4;Effects of Regional Anesthetics;91
14.2.4.1;Neuraxial: spinal and epidural;92
14.2.5;Complications of Neuraxial Anesthesia;93
14.2.5.1;Peripheral nerve blocks;93
14.2.5.2;Upper extremity;93
14.2.5.3;Side effects and complications;93
14.2.5.4;Brachial plexus blocks below the clavicle;96
14.2.5.5;Lower extremity;96
14.2.6;Choice of Anesthetic by Fracture;96
14.2.6.1;Extremity fracture;96
14.2.6.2;Hip fracture;96
14.2.6.3;Strategies for postoperative pain management;97
14.2.6.3.1;Multimodal analgesia;97
14.3;Summary;97
14.4;References;97
15;Management of Postoperative Complications;102
15.1;Key points;102
15.2;Introduction;102
15.3;Overview of the postoperative period;103
15.4;Implications of physiologic changes of aging on postoperative complications;103
15.4.1;Respiratory System;103
15.4.2;Cardiovascular System;104
15.4.3;Renal System;104
15.4.4;Skin;105
15.5;General approach;105
15.5.1;Early Mobility;106
15.5.2;Freedom from Tethers;106
15.5.3;Pain Management;106
15.5.4;Malnutrition and Pressure Ulcers;107
15.5.5;Prevention of Infections;108
15.5.6;Management of Cognition;108
15.5.7;Other Considerations;109
15.6;Summary;109
15.7;References;109
16;Management of Common Postoperative Complications;112
16.1;Key points;112
16.2;Introduction;112
16.3;Diagnosis;112
16.4;Management goals;114
16.5;Nonpharmacologic strategies;114
16.5.1;Controversies;116
16.6;Pharmacologic strategies;116
16.6.1;Maximal Effective Dose;117
16.6.2;Timing;117
16.6.3;Cholinesterase Inhibitors;117
16.6.4;Controversies;117
16.7;Summary/discussion;117
16.8;References;118
17;Management of Postoperative Complications;120
17.1;Key points;120
17.2;Introduction;120
17.3;Patient evaluation;121
17.4;Management goals;121
17.5;Risks of transfusion;123
17.6;Evaluation and adjustment;124
17.7;Summary;124
17.8;References;124
18;Venous Thromboembolism and Postoperative Management of Anticoagulation;126
18.1;Key points;126
18.2;Introduction/Epidemiology;126
18.3;Patient evaluation overview;127
18.4;Pharmacologic treatment options;128
18.5;Nonpharmacologic treatment options;129
18.6;To bridge or not to bridge;130
18.7;Summary;130
18.8;References;130
19;Management of Postoperative Complications;134
19.1;Key points;134
19.2;Introduction;134
19.3;Implications of normal cardiovascular aging;135
19.4;Core principles for postoperative management in older patients;135
19.5;Common cardiovascular responses to uncomplicated orthopedic surgery;136
19.6;Common cardiovascular complications and strategies;136
19.6.1;Hypotension;136
19.6.2;Atrial Fibrillation;137
19.6.3;Heart Failure and Volume Assessment;137
19.6.4;Myocardial Ischemia;138
19.7;Perioperative considerations with common chronic cardiovascular medications;139
19.7.1;ß-Blockers;139
19.7.2;ACE Inhibitors;139
19.7.3;Calcium Channel Blockers;139
19.7.4;Digoxin;140
19.7.5;Loop Diuretics (Furosemide, Torsemide, Bumetanide);140
19.7.6;Aldosterone Antagonists (Spironolactone, Eplerenone);140
19.7.7;Antiplatelet Agents and Anticoagulants;140
19.8;Summary;140
19.9;References;141
20;Transitions of Care and Rehabilitation After Fragility Fractures;144
20.1;Key points;144
20.2;Transitions in care;144
20.3;Types of rehabilitation settings;146
20.4;Reimbursement for rehabilitation;148
20.5;Goals of rehabilitation;150
20.6;Common medical issues in rehabilitation;151
20.6.1;Pain Management;151
20.6.2;Pressure Sore Prevention;152
20.6.3;Thromboprophylaxis;152
20.6.4;Nutrition;152
20.6.5;Delirium;153
20.6.6;Other Medical Issues;153
20.7;Outcomes in rehabilitation;153
20.8;Secondary prevention in rehabilitation;154
20.9;References;155
21;Secondary Prevention After an Osteoporosis-Related Fracture;158
21.1;Key points;158
21.2;Burden of fragility fractures;158
21.3;The evidence for pharmacologic and nonpharmacologic agents on fracture risk reduction;159
21.3.1;Pharmacologic Agents;159
21.3.2;Nonpharmacologic Agents, Including Supplements;160
21.4;The concept of fracture risk is replacing a diagnosis of OP and osteopenia;160
21.5;Clinical practice guidelines acknowledge the need to intervene in patients who are at risk for future fracture;161
21.6;The Introduction of Postfracture Secondary Prevention Programs;161
21.7;The Scope of Postfracture Secondary Prevention Programs;161
21.8;The effect of postfracture secondary prevention programs;163
21.8.1;Reduction in Health Care Costs;163
21.8.2;Improved Investigation and Treatment Rates;163
21.8.3;Participation in Exercise;163
21.8.4;Reduction in Refracture Rates;163
21.8.5;What Makes a Program Effective?;163
21.9;Potential reasons for these gaps in bone health still exist despite postfracture secondary prevention programs;164
21.9.1;Patients Do Not Connect Their Fragility Fracture to Underlying Bone Health;164
21.9.2;Patients Are Unclear About Several Aspects of Their Care;164
21.9.3;Patients Are Concerned About Side Effects;164
21.9.4;OP Pharmacotherapy Use Fluctuates;165
21.9.5;Programs that Target Primary Care Providers Alone Are Not Enough;165
21.9.6;BMD Test Reports Underestimate Fracture Risk;165
21.10;Future research directions in postfracture secondary prevention;165
21.11;Summary;166
21.12;References;166
22;Postoperative Prevention of Falls in Older Adults with Fragility Fractures;174
22.1;Key points;174
22.2;Introduction;174
22.3;Risk factors for falls;176
22.4;Risk assessment;179
22.5;Strategies for secondary prevention of falls;181
22.5.1;Postoperative Inpatients;181
22.5.2;Postoperative Outpatients;183
22.6;Summary;184
22.7;References;185
23;Atypical Femur Fractures;190
23.1;Key points;190
23.2;Introduction;190
23.3;Clinical presentation;191
23.4;Epidemiology and pathophysiology;192
23.5;Evaluation and work-up of patients;194
23.6;Management of patients with atypical femur fracture;196
23.7;Management of patients without atypical fractures on long-term bisphosphonates;198
23.8;Summary;199
23.9;References;200
24;Fragility Fractures Requiring Special Consideration;202
24.1;Key points;202
24.2;Introduction;202
24.2.1;Epidemiology;202
24.2.2;Challenge: Geriatric Patient;203
24.2.2.1;Comorbidities;203
24.2.2.2;Osteoporosis;203
24.2.2.3;Disability;204
24.2.2.4;Treatment goals;204
24.3;Special considerations;204
24.3.1;Cervical Spine Fractures;204
24.3.1.1;Upper cervical spine fractures C1-C2;204
24.3.1.2;Lower cervical spine C3-C7;205
24.3.2;Thoracic and Lumbar Spine;205
24.4;Summary;207
24.5;References;207
25;Fragility Fractures Requiring Special Consideration;214
25.1;Key points;214
25.2;Introduction;214
25.2.1;Epidemiology;215
25.2.1.1;Pelvis fracture epidemiology;215
25.2.1.2;Acetabulum fracture epidemiology;215
25.2.1.3;Morbidity and mortality statistics;215
25.2.2;Anatomic and Biomechanical Considerations;216
25.2.2.1;Pelvis anatomy;216
25.2.2.2;Acetabulum anatomy;217
25.3;Evaluation;217
25.3.1;History and Physical Examination;217
25.3.2;Imaging;218
25.3.2.1;Plain radiographs;218
25.3.2.2;Advanced imaging;219
25.3.3;Laboratory Analysis;219
25.3.4;Author’s Preferred Management;220
25.4;Management goals;220
25.5;Nonpharmacologic strategies;221
25.5.1;Nonoperative Considerations;222
25.5.1.1;Pelvis;222
25.5.1.2;Acetabulum;222
25.5.2;Operative Considerations;223
25.5.2.1;Pelvis;223
25.5.2.2;Acetabulum;223
25.5.2.3;Post-operative care;224
25.6;Pharmacologic strategies;224
25.6.1;Vitamin D/Calcium;224
25.6.2;Bisphosphonates;224
25.6.3;Human Recombinant Parathyroid Hormone;225
25.7;Summary;225
25.8;References;226
26;Index;228

Leseproben

Epidemiology of Fragility Fractures
Susan M. Friedman, MD, MPHa*[e-mail] and Daniel Ari Mendelson, MD, MSab,     aDivision of Geriatrics, Geriatric Fracture Center, Highland Hospital, University of Rochester School of Medicine and Dentistry, 1000 South Avenue, Box 58, Rochester, NY 14620, USA; bMonroe Community Hospital, 435 East Henrietta Road, Rochester, NY 14620, USA *Corresponding author. As the world population of older adults—in particular those over age 85—increases, the incidence of fragility fractures will also increase. It is predicted that the worldwide incidence of hip fractures will grow to 6.3 million yearly by 2050. Fractures result in significant financial and personal costs. Older adults who sustain fractures are at risk for functional decline and mortality, both as a function of fractures and their complications and of the frailty of the patients who sustain fractures. Identifying individuals at high risk provides an opportunity for both primary and secondary prevention. Keywords Frailty Incidence Outcomes Predictors Osteoporosis Key points
• The incidence of fragility fractures is increasing rapidly, although age-adjusted rates seem to be declining. • Poor outcomes are related both to fractures and their comorbidities and to the frailty of the patients who sustain fractures. • Identifying individuals who are at highest risk, using a prediction tool such as the FRAX, can allow for targeted primary prevention. • A person who sustains one fracture is at 50% to 100% higher risk of having another one; fractures, therefore, provide important opportunities for secondary prevention. • Hip fractures cost Medicare more than $12 billion per year. Introduction
The United States and the rest of the world are experiencing a silver tsunami. Since 2011, 10,000 American baby boomers are turning 65 daily. The older adult population in the United States is predicted to more than double, from 35 million individuals in 2000 to 72 million in 2030, and will account for approximately 20% of the population.2 The oldest old, those over age 85, are the fastest growing segment of the population. The baby boomers will start turning 85 in 2031, and it is predicted that the population over age 85 will increase 3-fold, from 5.5 million in 2010 to 19 million in 2050.2 Although there is evidence that people are living healthier lives for longer,3 and that age-adjusted fracture risk is decreasing, 4,5 these individuals remain at highest risk of sustaining fragility fractures.6 Fragility fracture is defined as a fracture that results from a low trauma event, such as falling from a standing height or less.1 As the incidence of fragility fractures rises, it becomes more important to optimize their prevention and treatment. Prevalence/Incidence
For each decade after age 50, the risk of hip fracture doubles.7 At age 50, an American white woman has a 17% lifetime risk of sustaining a hip fracture, 8,9 and a woman who lives to age 90 has a 1 in 3 chance of sustaining a hip fracture.10 The increased risk with age combined with a rapidly expanding older adult population translates to a projected increase in worldwide hip fracture incidence, from 1.7 million in 1990 to 6.3 million in 2050.11 The incidence of hip fractures has been demonstrated to be increasing in many countries around the world, including Asia, North America, and Europe.12 The risk of a hip fracture varies significantly based on gender, race, and ethnicity. The graph in Fig. 1 shows how the expected number of hip fractures is changing over time in 8 regions around the world.11
Fig. 1 The expected number of hip fractures over time in 8 regions around the world. (Modified from Cooper C, Campion G, Melton LJ 3rd. Hip fractures in the elderly: a world-wide projection. Osteoporos Int 1992;2(6):285–9; with permission.) When reflecting on the full burden of osteoporotic or fragility fractures, it is essential to also consider the morbidity associated with fractures other than hip fractures. The lifetime incidence of any osteoporotic fracture is estimated to be 40% to 50% in women and 13% to 22% in men.9 At age 50, an American white woman has a 15% chance of sustaining a Colles fracture and a 32% chance of sustaining a vertebral fracture.10 Outcomes
A hip fracture can be a life-changing, or life-ending, event (Box 1). The surgery itself carries a 4% mortality overall,13 and within a year, approximately 20% die. 14–17 Patients with hip fracture experience a 5- to 8-fold increase in all-cause mortality in the first 3 months after the fracture, with men experiencing particularly high risk.18 This excess risk declines over time but never resolves completely, likely reflective of the frail population who sustain the fractures in the first place. The lifetime risk of death in women from hip fractures has been noted to be comparable to that associated with breast cancer.19 Box 1   Outcomes of hip fractures • Increased mortality • Loss of function • Reduced mobility • Need for increased health care services • Risk of nursing home admission • Depression • Cognitive impairment • Increased risk of future fracture • High cost In addition to the risk of mortality, hip fractures can lead to loss of function and mobility, which in turn can result in a loss of independence. A year after surgery, more than half of those who were previously independent are still unable to climb 5 stairs, get in and out of a shower, get on or off a toilet, walk a block, or rise from an armless chair without either equipment or human assistance.20 Only 60% have recovered to their previous level of walking.21 One-third of previously community-dwelling individuals require long-term nursing home care.22 Morbidity after a hip fracture is not just physical; there is a high incidence of depression that can occur early after a hip fracture,23 and both temporary and permanent cognitive impairment are also common.24 Hip fractures are costly events in the United States. The incremental direct cost to Medicare of a hip fracture has been estimated to be more than $25,000 during the period 1999–2006.25 Although hip fractures account for only 14% of fractures, they account for 72% of costs, amounting to more than $12 billion in 2005.26 These costs are driven by acute inpatient and postacute institutional care needs.27 Although fractures of the hip may be the most feared, other fragility fractures have important prognostic and functional significance. In addition to the acute and chronic pain associated with vertebral fractures, these fractures can lead to multiple outcomes that limit function. Kyphosis that occurs from vertebral collapse can lead to neck pain, reduced pulmonary function,28 costo-iliac impingement syndrome,29 and fear of falling.30 The mortality after a vertebral fracture has been noted to be similar to that after a hip fracture.31 An individual who sustains one fracture is 50% to 100% more likely to sustain a fracture of another type.8 Vertebral deformities from a fracture are associated with a 2.8-fold increased risk of hip fracture and 5 times the risk of another vertebral fracture in 3 years.30 The epidemiology of fractures at different sites varies, however; the median age for sustaining a Colles fracture is 66 versus 79 for the median age of first hip fracture.10 Identification of the fracture and understanding of future risk thereby provide an important opportunity for secondary prevention. Clinical correlation
As primary prevention efforts improve, the onset of first fracture is delayed. The age of hip fracture patients has increased over time,4 and, as a concomitant phenomenon, patients have more comorbidities.4 Fragility fractures are, therefore, not only an outcome of frailty but also a marker of frailty. Perioperative risk is increased in the face of comorbidities, with a higher burden of chronic conditions leading to an elevated risk of postoperative complications 32,33 and mortality. 32,34 The need to optimize comorbidities in the acute setting at the time of fracture, as well as the need to manage increasingly...