1 Introduction

Fragility fracture patients (FFPs) represent up to 40% of patients in many orthopedic trauma units worldwide. This trend is increasing. As a consequence, over the last decade, refined surgical care approaches have been developed from growing experience and close collaboration with geriatricians in order to improve patient outcomes and lower healthcare expenses.

Similar to fracture care in children, geriatric fracture care also differs in many aspects from the standard treatment of middle-aged adults. Due to the relative paucity of randomized trial data for many treatments, many of the following recommendations represent expert opinions with some based on biomechanical or clinical investigations.

The four AO Principles certainly apply to the care of fragility fractures and should be carefully adhered to:

1. 
   

   Fracture reduction and fixation to restore anatomical relationships

   
   
2. 
   

   Stability by fixation or splinting, as the personality of the fracture and the injury requires

   
   
3. 
   

   Preservation of blood supply to soft tissues and bone by careful handling and gentle reduction techniques

   
   
4. 
   

   Early and safe mobilization of the part and the patient

2 Goal setting

The entire patient must be considered including his/her medical problems, medications, living situation, and goals for care. Overall, the following issues assume prominence in care of FFPs:

• 
  

  Pain relief

  
  
• 
  

  Prevention of functional decline

  
  
• 
  

  Maintenance of independence

  
  
• 
  

  Prevention of complications, such as reoperations, pneumonia, pressure sores, urinary tract infection, and delirium

Making the right therapeutic decisions is much more complex than with younger patients. Fragility fracture patients are functionally and physiologically variable (from nonambulatory “No-goes” to ambulatory “Go-goes”) that the benefits and risks of treatment are not as clear as in younger patients. Therefore, it is essential to establish a consensus for the treatment goals among all of the team members.

Defining individual goals for each FFP is an important step which should be established and agreed upon as early as possible by the interdisciplinary team. The individual goals influence diagnostic and therapeutic surgical and medical measures and should be clearly communicated. Goal setting avoids unnecessary steps and streamlines the treatment. Goals may be adjusted during the treatment process.

First, treatment goals should be very specific, clear and easy. Second, if you cannot measure it, you cannot manage it. Third, a goal needs to be attractive and acceptable to the patient and the clinical team. Fourth, the goal should be realistic, meaning achievable or “doable”. Fifth, the timeline to achieve the goal should be considered by setting a time frame.

It is useful to find short-term as well as long-term goals. Usually, the long-term goal is the expected outcome in several weeks or months, like to live independently or to walk without using a walking aid. When approaching a long-term goal, you need different short-term goals for each problem, like walking with a rolling walker after the first week, or removing a urinary catheter within 2 or 3 days after surgery.

The goals may be modified due to medical or surgical complications or if patients become unwilling or unable to continue or if they progress more slowly or quickly than expected. Goal setting should be integrated in the regular team meetings.

3 Time matters

Most studies suggest that performing surgery within the first 24–48 hours of admission decreases the number of complications and mortality. Delays longer than 72 hours are associated with an increased risk of multiple complications and mortality.

Surgical fixation reduces pain and blood loss significantly. It is also unethical to unnecessarily delay surgery.

The earlier surgical stabilization is performed, the better. This guiding principle is often violated because of the patient condition, patient consent, or hospital system barriers. The system of care must be optimized to avoid delay and iatrogenic problems.

The operating time should be as short as possible to reduce the stresses of surgery and its burdens on the patient.

The decision-making process regarding the definitive treatment in complex situations or relative indications is often delayed for multiple reasons. Goal setting and standardized communication pathways help to avoid unnecessary delay and expedite treatment.

4 Soft-tissue conditions

The musculoskeletal system of older patients is more vulnerable to problems and less tolerant of stress:

• 
  

  Skin may be thin and less elastic due to atrophy or malnutrition and making pressure sores and degloving injuries more common. Wounds in older adults may also heal poorly for similar reasons. During positioning and draping, the surgeon must remember that the older patient′s skin is fragile and can tear or be avulsed with minimal shear stresses. Shear forces from manual traction, removal of surgical drapes or localized pressure by splints and traction devices must be avoided ( Fig 1.2-1 ). In surgery, meticulous positioning helps avoid skin breakdown.

  
  
• 
  

  Trophic changes: Arterial disease may result in ischemic changes and poor healing while venous hypertension produces edema, ulcers, and chronic skin changes. Using minimally invasive surgical (MIS) techniques may help to reduce problems.

  
  
• 
  

  Hematoma: Surgeons must take great care to lose as little blood as possible. Meticulous hemostasis helps avoid tipping the patient out of equilibrium. Subcutaneous hematoma should be evacuated even with active anticoagulation to avoid rapid skin breakdown.

  
  
• 
  

  Muscles are frequently atrophied and weaker than in younger patients (sarcopenia). Any manipulations during surgery should be carried out gently. Minimally invasive procedures are generally preferred.

5 Bone quality

Bony quality varies substantially from the typical wide osteoporotic tube with thin cortices to a thickened but brittle cortex in atypical fractures. Thus, cortex perforation or other iatrogenic damage generated by clamps or lag screws is more likely to occur than in normal bone ( Fig 1.2-2 ). Forceful reduction maneuvers and aggressive handling of bone may result in extension of the injury beyond the original pattern. The use of clamps must be performed cautiously to avoid additional damage ( Fig 1.2-3 ). Avoid the use of crushing reduction forceps helps avert worsening the comminution. Fracture patterns are often complex, with impaction occurring in the setting of a low-energy trauma.

Interestingly, the impact of osteoporosis as a standalone factor on “mechanical failures” of implants could not be shown in several clinical studies. Quality of reduction and implant placement are obviously even more important [1, 2]. In a retrospective study of proximal humeral fractures, it was shown that the risk for mechanical failure increases significantly with the combination of several negative factors [3].

6 Bone deformation

Anterior and lateral bowing of the femur have a clinical impact in geriatric fractures and may make it very challenging to use standard intra and extramedullary implants [4]. A recent report also found that a significant increase in the lateral and anterior bow of the femur was associated with low-energy femoral shaft fractures. Therefore, the increased bowing of femoral shaft should be recognized as an important risk factor of this injury [5].

Specifically, lateral bowing of the femoral shaft may be increased in older adults as well as in younger patients with decreased bone mineralization.

Osteoporosis or osteomalacia induce a varus or bowing of the femur. The lateral femoral shaft is subjected to tensile strains during a variety of physical activities; walking has the strongest impact. This effect will be pronounced with bowing in osteoporotic patients [6]. Preexisting advanced varus knee osteoarthritis, with shifting the mechanical axis medially, has been considered as a minor reason for bowing of the femoral shaft.

Although atypical femoral fractures have been associated with long-term use of bisphosphonates (BPs), it was also noted that these fractures may develop without BPs use, especially in patients of Asian descent. In 2013, the Task Force of the American Society for Bone and Mineral Research revised the definition of atypical femoral fracture, removing specific diseases and drug exposures as one of the association from the minor features [7]. According to this definition, stress fractures caused by femoral bowing deformity may also be classified as atypical femoral fractures.

Despite being the most commonly recommended implant choice, intramedullary (IM) nails can be difficult to insert, as the curvature of IM nail is different from that of the radius of bowed femur. In cephalomedullary nailing, the distal end of nail may break or penetrate the anterior cortex of femur in the distal segment.

Reaming is often difficult as well and must be performed gently due to the narrow medullary canal and the brittle nature of the bone.

Also, the nailing may cause an inadvertent fracture or malreduction with a bony gap on the medial aspect of the bone, especially in the atypical femoral shaft fractures with bowing [8]. This effect may result in impaired fracture healing or even nonunion.

Plate fixation can be a solution in bowed femoral fractures. In such cases, the plate may need to be contoured before fixation, considering the contralateral, noninjured leg. Otherwise, the proximal or distal end of plate will step off the bone, and it may be a source of malreduction when screws are tightened [4].

7 Classification

Classification of fragility fractures is often challenging because of different fracture patterns. Osteoporotic fractures often occur in patterns not described in the currently used classification schemes. This frustrates attempts to classify the fractures and may result in incorrect procedure or implant selection. The AO/OTA Fracture and Dislocation Classification is useful for many, but not all, fragility fractures.

8 Indications for fixation

Most fractures of the lower extremity should be surgically managed. In a small group of bedridden, terminal patients, nonoperative palliative management of hip and other lower leg fractures may be adequate. Those decisions should be team decisions made with the geriatrician, patient, family, and medical team.

For the upper extremity, the need to preserve function should be considered to allow the patient to accomplish activities of daily living like eating, self-care, grooming, and ambulation. Attaining these goals may involve taking more surgical and overall risk. Therefore, surgical treatment may only be indicated if it will result in a significant improvement in function. In the proximal humerus, olecranon, and distal radius, nonsurgical management often leads to an acceptable functional result [9–11].

Some nonsurgical approaches are not tolerated as well as in younger individuals. Casts interfere with functionality and increase the risk of falls. Immobilization may render old patients immediately dependent for basic activities like eating and grooming, and promote accelerated functional decline. In a sense casts are also tethers that patients have difficulties to deal with. The cast will prevent a patient from accomplishing daily activities like walking, and the patient may therefore require placement in a nursing home. Casts and braces tend to exacerbate delirium in older adults ( Fig 1.2-4 ).

Complete recovery after trauma is typically the goal of treatment below the age of 60 years. This does not apply to FFPs. In this age group, we focus on the restoration of individual functional needs. Decision making can be difficult due to the variable physiological and functional nature of older patients. It is often necessary to individualize treatment approaches with the consensus of the orthogeriatric team and patients’ family.