4.8 Fragility fractures and orthogeriatric care
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1 Introduction
Life expectancy is dramatically increasing globally and the population is aging at an unprecedented rate. By 2050, people aged 60 years or older will exceed the number of younger people. This worldwide trend is believed to be irreversible and is coupled with lower birth rates and lower fertility.
The fastest growing demographic of the world population is those older than 80 years and in some countries more than 10% of patients with hip fracture are older than 90 years. In many orthopedic trauma departments, patients with fragility fractures now represent the largest group of patients (30%).
Fragility fracture was defined by the World Health Organization in 1998 as “a fracture caused by injury that would be insufficient to fracture normal bone; the result of reduced compressive and/or torsional strength of bone”.
From a clinical perspective, a fragility fracture is defined as a fracture that occurs as a result of a minimal trauma, such as a fall from a standing height or less [1].
Osteoporosis is defined as “a systemic skeletal disease characterized by low bone mass and microarchitectural changes with a consequent increase in bone fragility and susceptibility to fracture” [2].
The most common fractures associated with osteoporosis are those at the hip, spine, distal radius and proximal humerus. Many other fractures after the age of 50 years are associated with low bone mass and should therefore be regarded as osteoporotic [2]. Over the years, many patients sustain multiple fractures ( Fig 4.8-1 ), so osteoporosis can be considered a chronic disease with intermittent acute episodes (fracture).
The two major pillars in the treatment of fragility fractures are:
Orthogeriatric comanaged care in the acute phase (30–35 days) including the rehabilitation process
Lifelong secondary fracture prevention
1.1 Epidemiology
Osteoporosis is a major public health problem, affecting hundreds of millions of people worldwide.
It is estimated that an osteoporotic fracture occurs every 3 seconds worldwide. One in two women and one in five men aged 50 years and older will suffer a fracture in their remaining lifetime. The average lifetime risk for a 50-year-old adult of suffering an osteoporotic fracture has been estimated at 40–50% for women and 13–22% for men [3]. Approximately 50% of people with one osteoporotic fracture will have another, with the risk of new fractures rising exponentially with each fracture [4].
In general, the incidence of fragility fractures increases with age. However, the proportion of fractures at any site also varies with age. For example, the median age for distal radial fractures in women is 65 years and for hip fractures is 80 years [3].
1.1.1 Hip fracture
Hip fracture incidence has been shown to increase exponentially with age and the worldwide hip fracture incidence has been predicted to increase dramatically during the next three decades, mainly due to the increasing number of older people [5].
Estimates suggest that there are approximately 0.6 million hip fractures per annum in the European Union and about 0.3 million hip fractures in the US [6, 7].
In a recently published systematic review [8], it was shown that there is a greater than 10-fold variation in hip fracture risk and fracture probability among countries ( Fig 4.8-2 ). The low incidence of osteoporosis in developing countries may be partly due to the lower life expectancy. However, by the year 2050, more than half of all hip fractures in the world will occur in Asia ( Fig 4.8-2 ).
1.1.2 Vertebral fracture
Vertebral fractures are the most common osteoporotic fracture. However, the incidence of vertebral fractures is not well documented due to the fact that only approximately 30% of these fractures come to clinical attention, so-called clinical vertebral fractures [9]. Most vertebral fractures are asymptomatic and may be only detected on x-rays (radiographic or morphometric vertebral fractures).
1.1.3 Distal radial fractures
In contrast to hip or vertebral fractures, the incidence of distal radial fractures appears to increase rapidly during the early postmenopausal period and there is evidence of a plateau in the incidence of fracture during the mid-60s [10]. The average lifetime risk in a 50-year-old caucasian adult of suffering a distal radial fracture has been estimated at 20% for women and at 5% for men [3].
1.1.4 Proximal humeral fracture
The average lifetime risk for a 50-year-old white adult of suffering this type of fracture has been estimated at 13% for women and at 4% for men [11, 12]. In populations with sufficient epidemiological data on different fracture types, the overall age-adjusted incidence of humeral fractures is approximately 50–60% of hip fracture incidence rates.
2 Etiology
Bone strength reflects the integration of two main features: bone density and bone quality:
Bone density is expressed as grams of mineral per area of volume and in any given individual is determined by peak bone mass and amount of bone loss.
Bone quality refers to architecture, turnover, mineralization and damage accumulation, eg, microfractures. A fracture occurs when force exceeds the strain tolerance of bone and osteoporotic bone has a much lower strain tolerance than normal bone. In severe osteoporosis, even normal physiological strain may exceed this tolerance and result in fracture, eg, many vertebral fractures.
Osteoporosis influences both strength and stiffness of bone. Both decrease with age and degree of demineralization. This is true for cortical and cancellous bone. Osteoporosis involves a loss of bone mass, reduction in bone quality by deterioration of microarchitecture and reduced ability of bone to withstand loading. It is important to understand the difference between bone mineral density (which reflects the calcium content) and the deterioration of bone quality measurable in reduced resistance to loading. Usually, the quality of bone reduces much more with age in cancellous bone than in cortical bone.
2.1 Cortical bone
Cortical bone in a 25-year-old adult is dense, thick, and strong. The pattern of age-related cortical bone loss involves loss of cortical thickness that is more marked at the endosteum with an increase in medullary diameter; particularly in women ( Fig 4.8-3 ).
The changes in outer and inner cortical diameter affect the bending and torsional characteristics of the whole bone. If we assume a diaphyseal bone is a tube, the formula Π/4(R4-r4) describes the calculation of the bending stiffness of a tube (R, r = outer and inner radii of a tube). Bending stiffness depends on the inner and outer radius of the tube.
2.2 Cancellous bone
In cancellous bone, the change in bone structure is due to decreasing trabecular thickness, interruption of the trabecular network, reduction in the number of trabeculae, and reduction of trabecular connectivity. As well as age and hormonal changes, reduced physical activity also leads to deterioration of bone. There is vast evidence that mechanical usage influences bone mass (Wolff′s law) but, unfortunately, exercise only leads to a minimal increase in bone mass.
With aging, the bone trabeculae change in shape from flatter structures to more rod-like structures. These changes weaken the internal architecture of the cancellous bone making it more likely to fracture with minor trauma ( Fig 4.8-4 ).
2.3 Significance for fracture fixation
Biomechanical studies have demonstrated that osteoporotic changes reduce implant anchorage. Decreased cortical thickness significantly affects the holding capacity of screws.
2.4 Measurement of osteoporosis
Dual-energy x-ray absorptiometry (DEXA) has become the standard method for measuring bone mineral density as a proxy measure and accounts for approximately 70% of bone strength. The World Health Organization operationally defines osteoporosis as bone density 2.5 standard deviations below the mean for young caucasian adult women. It is not clear how to apply this diagnostic criterion to men, children, and across ethnic groups.
Indications for obtaining a DEXA scan include:
Long-term steroid use
Early surgical menopause
Postmenopausal women with alcoholism, heavy tobacco use, a body mass index < 18.5, or a family history of fragility fractures
Baseline measurement for monitoring bone-protection therapy
Follow-up measurement after bone-protection therapy
Clinically, in the acute fracture situation, the degree of osteoporosis should be estimated by consideration of preoperative x-ray imaging, intraoperative haptics while drilling or fixing bone and additional parameters such as gender, age, and comorbidities.
2.4.1 Falls
Most fractures are caused by falls. Therefore, falls, osteoporosis, and fractures must be addressed together. Several measures have been suggested for the prevention of falls in older patients including strength and balance training, home hazard assessment and modification, vision assessment, medication review, cardiac pacing when necessary, and cognitive behavioral interventions.
Risk factors for falls are similar to those for fracture: previous falls, weakness, poor balance, gait disorders, and taking certain medications, such as psychoactive drugs, anticonvulsants, and antihypertensive drugs.
2.4.2 Other mechanisms of injury
High-impact trauma has increased as people have become more active during their retirement, continuing to drive and enjoy outdoor activities more than was seen in the past. Falls down stairs are a particular hazard and can result in frail patients suffering high-energy and complex trauma.
For care of the older patient with polytrauma, trauma centers have shown significantly better outcomes than acute care hospitals [12]. Injury patterns differ from younger patients with higher Injury Severity Scores and mortality, as well as more pelvic and upper extremity injuries [13]. Trauma registries have demonstrated that increased age is an independent variable for death in polytrauma with significant risk increases in patients older than 64 and 89 years ( Fig 4.8-5 ).
3 The fragility fracture patient
A clinical definition of a fragility fracture patient is:
Acute injury caused by a low-energy trauma
Older than 70 or 80 years with reduced general health status
Factors that contribute to a reduced general health status include the number of comorbidities (two or more), cognitive state and functional disabilities that result in reduced mobility and increased need for social support. One of the common factors for many of these patients is that they are frail and have sarcopenia due to complex medical and rehabilitation problems. They have a higher need for specialist medical care.
3.1 Relevant comorbidities
Fragility fractures are much more common in patients with preexisting medical conditions—comorbidities. Preexisting comorbidities also have a significant impact on outcomes of older trauma patients. While some of these comorbidities are apparent, others might remain unrecognized yet cause complications and result in an unfavorable outcome. Therefore, comorbidities should be assessed systematically and treatment goals should be set.
Established and helpful tools to assess the morbidity burden of an older patient are the Charlson Comorbidity Index with 19 items and the Cumulative Illness Rating Scale. Comorbidities should be documented at admission when the relevant information may be easiest to collect.
Common comorbidities in patients with fragility fractures include cardiac disease, dementia, renal dysfunction, pulmonary disease, hypertension, diabetes, and malignant disease.
Often, multiple comorbidities lead to the problem of polypharmacy. Each of these conditions is likely to be treated with at least one medication. The number of medications increases the risk of adverse drug reactions and unexpected drug-drug and drug-disease interactions. A special problem is the high prevalence of anticoagulation drugs in older adults.
These problems are best managed with an orthogeriatric team approach.
3.1.1 Preexisting conditions
Preexisting conditions cannot be changed fundamentally; they are common in fragility fracture patients and have to be recognized. The preoperative evaluation of geriatric patients should aim to identify all preexisting conditions but recognize that delay to treat most of these conditions is unlikely to reduce the risks of surgery. The key is to identify those that require immediate medical measures to lower the risks of surgery (see section 3.1.2 in this chapter). However, if the risk of surgery cannot be altered, surgery should be performed without further delay. Delaying surgery usually adds unnecessary risk [14]:
Cardiac diseases: Hypertension, coronary heart disease, heart failure, atrial fibrillation, and valve disease are frequent among fragility fracture patients. In a stable patient, they present a higher risk for surgery but are not a contraindication. The challenge for the orthogeriatric team is the management of the medication, especially anticoagulation.
Pulmonary diseases: Patients with severe pulmonary disease need strong collaboration with the anesthesiologist. Blood gases may help to estimate the pulmonary status. In cases where neuroaxial anesthesia is not feasible, severe pulmonary disease may be a contraindication for surgery.
Renal dysfunction: 40% of patients with a hip fracture have chronic kidney disease (defined as an eGFR < 60), but all patients are at risk of acute kidney disease in the perioperative period. Inappropriate fluid management, nephrotoxic medication or computed tomographic scans with contrast agent increase the risk for acute kidney injury, which is also more common with increasing age, two or more comorbidities, and in those with chronic kidney disease.
Diabetes: Hypoglycemia is more dangerous than hyperglycemia; nevertheless, blood glucose level should be lower than 200 mg.
Dementia is an important risk factor for delirium and an independent risk factor for mortality. Patients should have a formal assessment of cognitive function on admission and there are a number of validated scoring systems, such as the abbreviated mental test score, that can be used.
3.1.2 Active conditions
Conditions that need medical stabilization before surgery are active geriatric medical conditions:
Decompensated heart failure, acute cardiac ischemia
Acute stroke
Acute infection, such as pneumonia or septicemia
Unstable angina
Severe hypotension
Acute bleeding, eg, gastrointestinal
Rhabdomyolysis
Acute kidney injury
Comorbidities, especially cardiopulmonary and renal conditions and medication, such as anticoagulants, may influence the type of anesthesia and timing of surgery. An anesthetist should be involved as early as possible to avoid any unnecessary delay.
As a rule, the time needed for medical stabilization should not exceed 72 hours. Any delay of surgery for more than 72 hours causes significant increase in complications. The team should define clear goals for the optimization, determine the responsibility, and set a time frame.
3.2 Functional disabilities
Beside medical comorbidities, older patients suffer from functional disabilities. They can be assessed systematically by using a standardized geriatric assessment. Functional needs and resources are helpful in terms of goal setting. Older adult patients often require the use of their upper extremities to assist with ambulation by using a cane or walker. It is impossible for older adult patients to limit their weight bearing on an injured extremity.
3.3 Frailty and sarcopenia
Frailty is a common clinical syndrome in older adults that results in an increased risk for poor outcomes including falls, disability, hospitalization, and mortality. In frail patients, the physiological reserve is limited and so the ability to compensate for poor medical or surgical management is drastically reduced.
Frailty is defined as a clinically recognizable state of increased vulnerability resulting from an aging-associated decline in reserve and function across multiple physiological systems, such that the ability to cope with every day or acute stressors is comprised [15].
At admission, frailty cannot be influenced. Nevertheless, it is important to assess it. Frail patients have a higher risk of complications and in-hospital death. Their functional outcome is drastically limited. All goals and treatment decisions should be considered carefully. The overall goal should be “not to harm these patients”.
Sarcopenia is a syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength that result in a risk of adverse outcomes, such as physical disability, poor quality of life, and death.
Depending on the definition used for sarcopenia, the prevalence in people 60–70 years of age is reported as 5–13% and ranges from 11–50% in people older than 80 years [16]. Usually, sarcopenia is a part of frailty. Nutrition, vitamin D3, and mobilization may help to avoid further progression of sarcopenia during a hospital stay.
3.4 Immobilization
Older adult patients do not tolerate prolonged bed rest either before or after surgery. This predisposes to problems, such as thromboembolism, decubitus ulcers, urinary tract, and chest infections.
Immobilization leads to a loss of 0.5% of muscle mass and up to 4% of muscle strength per day [17]. Nutrition and mobilization are the cornerstones in preventing sarcopenia due to immobilization.
3.5 Facilities
Older adult patients have specific needs and requirements that need to be met by specialized facilities to protect them from harm:
Patient rooms, therapy rooms, bathroom facilities, and the floor must be accessible without obstacles and offer enough space and safety, eg, handrails to help patients with their personal hygiene.
A therapy room located on the ward helps to avoid patient transportation.
Facilities should be designed to avoid the development of delirium.
Good lighting, contrasting colors, and other visual characteristics.
Low beds, large clocks, and large windows for sufficient day light.
Common areas where patients can meet, eat, and talk with each other.
4 Orthogeriatric comanagement
4.1 The Comorbidity Construct
The Comorbidity Construct [18] is a helpful tool to provide a better overview of older patients ( Fig 4.8-6 ):
The index disease leads to hospital admission.
Comorbidities always have a strong relationship to the index disease.
Gender is an issue, especially in terms of social and psychological conditions.
The impact of age is not significant.
The biological age of patients and estimated life expectancy are more relevant for the outcome.
In older adult patients, intrinsic factors are a major contributor to falls.
In older adult patients, morbidity burden is not only described by the comorbidities but also by the functional disabilities and geriatric syndromes.
The complexity of these older adult patients result from a combination of their health problems and their nonhealth-related individual attributes.
4.2 Goal setting
Therapeutic decision making is much more complex in older adult patients. Fragility fracture patients are not homogeneous and the benefits and risks of treatment are not as clear as in younger patients. It is essential to find agreement for the treatment goals from all team members.
It is useful to set short-term as well as long-term goals. The long-term goal is the expected outcome in several weeks, eg, to live independently or to walk without using a walking aid. The goals may be changed due to medical complications or if a patient were to become unwilling or unable to continue or if they progress more slowly or quickly than expected.
4.3 Team approach and co-ownership
Comanagement requires that all core team members, ie, surgeons, anesthesiologists and geriatricians, are equal. Decisions are taken jointly. Leadership is not regulated by hierarchical structure but by medical qualification. Based on the knowledge and the expertise in the involved disciplines, leadership changes and depends on the clinical situation. However, each member has a specific role and expertise within the team.
All team members play their role at different phases of the treatment and even in different facilities. But they all must agree on the basic principles of treatment according to the guidelines and they all must feel responsible, in a sense of co-ownership, for the patient. They should know each other well and meet and communicate on a regular basis.
4.3.1 Orthopedic trauma surgeon
Decides if an older patient requires treatment in a geriatric fracture facility or not according to the type of trauma, age, and relevant comorbidities.
Starts the multidisciplinary process by contacting the geriatrician and anesthesiologist.
Initiates the diagnostic workup regarding injuries.
Takes part in the process of goal setting in cooperation with the geriatrician and anesthesiologist.
Plans and performs surgery, and should choose the appropriate technique and implant to allow immediate full weight bearing following surgery.
Cares for anticoagulation management, in cooperation with the geriatrician and the anesthesiologist.
Cares for pain management, starting immediately after admission and including local anesthesia, enteral and parenteral drug treatment and nonpharmacological measures.
Plans antibiotic management in the perioperative period.
Responsible for rehabilitation plans together with a physiotherapist and geriatrician. Range of motion, assisted or active motion, and weight-bearing status need to be determined.
Active management of wound infection.
Takes part in the multidisciplinary ward round and team meetings.
Together with other team members must audit the treatment process and adjust goals as necessary.
4.3.2 Geriatrician or medical leader
Should be involved as soon as possible, ideally in the emergency department.
Perform a physical examination, particularly focused on the cardiopulmonary, neurological and renal status. Collects medical history, especially comorbidities and medication. Cognitive function must be assessed using a tool such as the abbreviated mental test score. Basic assessment tools, like the Parker Mobility Score or CAM-Score, should be part of the clinical examination. Indicates further examinations, like laboratory tests, electrocardiography, chest x-ray or consulting other specialists based on this information.
If surgery is required, the most important task is to identify and treat conditions that require preoperative optimization.
Arranges preoperative fluid management.
Must consider the patient′s needs and living will. Both are essential aspects in terms of goal setting.
Postoperatively, the geriatrician is in charge of medical treatment, particularly of the comorbidities.
The geriatrician has an important role in the prevention and management of delirium.
Management of medication.
The geriatrician initiates calcium and vitamin D3 supplementation and considers specific osteoporosis drug treatment for every patient, eg, bisphosphonates.
Assess risk factors for falls and develop a specific treatment plan to reduce the risk of subsequent falls and fractures.
4.3.3 Anesthesiologist
Should be involved as soon as possible.
Involved in acute pain relief in the emergency department, eg, local anesthesic nerve blocks.
Clears (with the multidisciplinary team) the patient for surgery.
Determines the type of anesthesia.
Responsible for the immediate postoperative care of the patient.
Benefits from cooperation between surgeons and geriatricians.
4.3.4 Orthopedic nurses
Spend the most time with the patient. Therefore, the nursing staff have a major role in the multiprofessional team and stimulate patients in activities of daily living.
Assess risk factors for falls, pressure sores and wounds, malnutrition, delirium and infections, manage incontinence and catheters. A specialized orthopedic nurse may be involved in secondary fracture prevention. They choose the appropriate walking aid, counsel their patients and relatives about fall risk factors and osteoporosis.
Are involved in discharge planning together with families, carers, and social workers.
4.3.5 Physiotherapist
Should mobilize the patient from bed on the first postoperative day.
Helps to encourage recovery through mobilization.
Trains older adult patients to use walking aids in the correct way.
Helps with breathing therapy to decrease the risk of pulmonary infections.
4.3.6 Occupational therapist
Trains patient in activities of daily living, the use of walking aids and special devices.
Evaluates the home circumstances; this may involve a home visit.
Prescribes tools and aids that help with activities of daily living.
Should also be involved in the treatment of delirium. They have different options to work with confused patients and to help them to recover earlier from delirium.
4.3.7 Speech therapist
Provides treatment, support and care for older adult patients who have difficulties with eating, drinking, and swallowing. Swallowing disturbances are more frequent in older adults. An assessment of swallowing should be integrated in the treatment process.
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