The population of the developed world is ageing rapidly. The problems of the elderly have come to dominate orthopaedic and trauma services. There are a number of special problems:

• Falls, both because of weakness and loss of balance.
  
• Fractures, because of falls and because bones are weakened by osteoporosis.
  
• Osteoarthritis.
  
• Malignant disease, producing pathological fractures.
  
• Foot problems, causing painful bunions and corns.
  
• The rotator cuff around the shoulder weakens and may tear.
  
• Arthritis in the spine may cause symptoms of nerve root compression.

• Their bones are weakened by osteoporosis.
  
• Their physiological and mental reserves are reduced.
  
• They may be on medication which drops their blood pressure or increases confusion.
  
• Their muscle bulk to weight is reduced.

Old people value their independence just like everyone else but rehabilitation after an accident becomes increasingly difficult with age. Accidents need to be prevented if possible, and treated quickly and efficiently when they do, otherwise even a trivial injury can become the ‘straw which breaks the camel’s back’ precipitating an independent patient into one who is in permanent care.

Bone density falls with age, especially in thin women after the menopause (see Chapter 30). Trivial falls can then lead to major fractures.

The commonest sites of these osteoporotic fractures are the wrist, spine and neck of the femur.

Wrist

At the wrist the fracture involves impaction (crushing) and bending backwards of the forearm bones just above the wrist joint, sometimes called the ‘dinner fork’ deformity or Colles’ fracture. The fracture tends to be stable because of the impaction and some surgeons feel that it is best not to reduce the fracture (and so make it unstable), but let it heal quickly in its new position. This offers the best chance of preserving the patient’s independence as they may only need a simple splint for comfort for a couple of weeks if the fracture is left alone, rather than a full plaster for over a month if it is reduced (see Chapter 9).

Spine

Crush fractures of the spine are stable and rarely compress nerves, although they can be very painful. Treatment is symptomatic (see Chapter 13).

Neck of the femur

Fractures of the neck of the femur are very different. There are two types (see Chapter 19):