Demographics

As the population ages, more older adults sustain both high- and low-energy trauma injuries. Increasing activity levels in the elderly also contribute to more serious injuries in this age group. Although there is a lack of consensus about the definition of elderly, most studies set the age criterion as ≥ 65 years old.1 According to the United States Census Bureau, 13.0% of the population was older than 65 in 2010, and that is expected to grow to 20.7% in 2050. In 2010, there were approximately 40 million persons older than 65 years of age. That number is expected to triple to 87 million, by 2050. The fastest growing segment of the population is those over age 85, which made up 2.0% of the population in 2010 but will increase to 5.0% in 2050.2

Older adults sustain a disproportionate number of fractures.3 In 2000, there were an estimated 9.0 million osteoporotic fractures worldwide in adults over age 50, of which 1.6 million were at the hip, 1.7 million at the forearm, and 1.4 million of the vertebrae.4 The lifetime prevalence of hip fractures is one in three in women and one in 12 in men.5 In a study of the Medicare database, it was determined that between 1986 and 2005, the annual mean number of hip fractures was 957 per 100,000 in women and 414 per 100,000 for men.6

In a survey of self-reported hip, wrist, and spine fractures in persons aged 45 and over, it was found that 12% of these fractures were hip fractures, 19% were spine fractures, and 69% were wrist fractures.7 Hip fractures, although not the most common fragility fractures, tend to be the most studied, as they cause significant morbidity and mortality. Wrist fractures are the most common fractures in geriatric patients. One study estimated the prevalence of low-energy distal radius fractures in those aged 65 to 69 years as 800 per 100,000 for women and 120 per 100,000 for men.8 For those over the age of 80, the prevalence increased to 1,120 per 100,000 for women and 210 per 100,000 for men. Spinal compression fractures have no widely accepted definition; studies differ on how much loss of height is required to define a compression fracture. This lack of agreement results in highly variable estimates of prevalence.7 One study estimated lifetime prevalence in women over age 50 to be 26% when compression fractures are defined as a reduction in vertebral height of greater than 15%.9

One problem encountered in treating elderly trauma patients is that most traditional treatment protocols are designed for younger patients. Older adults differ in many important ways from younger adults. Providers should consider these special characteristics and problems, such as increased risk of mortality, physiological changes, and preexisting medical conditions (comorbidities).10

Mortality

Mortality risk represents an important factor for the orthopaedic surgeon to consider when caring for an elderly patient. This section discusses both high- and low-energy trauma and resulting mortality.

Treatment Setting

Decisions on triage that are made prior to the patient′s arrival at the hospital have an impact on the outcome. Under-triage is common, and yet it is harmful to geriatric patients. It is thought to occur because older patients often do not exhibit hypotension or tachycardia in response to a significant trauma.

Abbreviation: NA, not available.

Source: Adapted from Schnell S, Friedman SM, Mendelson DA, Bingham KW, Kates SL. The 1-year mortality of patients treated in a hip fracture program for elders. Geriatr Orthop Surg Rehabil 2010;1:6–14.

A review of a trauma system found that under-triage of patients older than 55 years of age occurs 71% of the time.24 Patients classified with physiological, anatomic, and mechanistic criteria (see text box) were taken to a trauma center for immediate care by a dedicated trauma team.

Upon initial evaluation of geriatric trauma patients, the physician must keep in mind that normal presenting vital signs may not accurately reflect injury severity.15,25 There are two reasons for this: polypharmacy and comorbidities. For example, beta-blockers can mask hypotension and tachycardia in the setting of hypovolemia.26 Similarly, many older adults have preexisting hypertension; consequently a normal blood pressure for a younger adult may represent hypotension in the older geriatric patient.1 In low-energy trauma cases, physicians must be careful not to aggressively reduce the older adult′s blood pressure, because an ischemic insult to the brain, kidney, or other organ system may result.

Because of high under-triage rates, some centers have added old age as a criterion for trauma team activation. In an effort to avoid missing patients who might benefit from activation of the trauma system, Meldon et al27 suggested using patient age > 55 as a criterion for considering transportation to a trauma center, whereas Demetriades et al28 suggested trauma team activation for all patients over age 70 years. In a follow-up study, the same group modified their criteria for trauma team activation to include age 70 years or over, and also instituted a protocol of early aggressive monitoring and resuscitation of hemodynamics.29 They reported a significant decline in mortality after this new protocol was instituted, from 53.8% to 34.2%.

The assertion that trauma centers have significantly better outcomes than community care hospitals in treating older injured patients has been supported by the literature. In a retrospective review of 455 very elderly (age ≥ 80) trauma patients treated in a single county′s trauma system (level I and level II trauma centers and community hospitals), Meldon et al27 found that patients taken to level II trauma centers experienced lower mortality rates (5.2%) than those taken to community hospitals (9.9%). Mortality rates at level I centers were higher (24%), but these hospitals also cared for patients who were injured more seriously than the other groups, with an average ISS of 13 for level I patients compared with an average ISS of 5 and 4 for level II and community hospitals, respectively. Trauma centers (levels I and II) were also shown to have significantly better survival rates than community hospitals in severely injured patients with an ISS of 21 to 45 (56% vs 8% survival). Based on these findings, the authors suggested that patients over age 80 benefit from transfer to a trauma center if they are severely injured or require admission.

Additionally, Friedman et al30 have shown improved outcomes of patients treated in a designated geriatric fracture program when compared with the usual care for treatment of hip fracture patients. Several other authors have published similar findings.31–33

Mechanisms of Injury

One of the largest and most comprehensive studies examining the mechanisms and outcomes of serious injury in geriatric trauma patients was performed by Richmond et al.34 They queried a trauma database for seriously injured patients and excluded those who sustained isolated hip fractures after falls from standing height. A total of 38,707 patients over the age of 65 years were included in the study over a 10-year period. The findings regarding mechanism of injury are listed in Table 8.2, and demonstrate that falls and motor vehicle accidents are the most common etiology of injury, a finding that is supported by a similar study performed by Champion et al35 (Table 8.3). Furthermore, the authors found that as patients get older, falls become the most common mechanism, responsible for 49.2% of traumas in the 65- to 74-year age group and 81.1% in the above 85-year age group.34 As these data show, falls are the leading cause of injury for persons over the age of 65 in the United States.7 When a fall from standing height or lower results in a broken bone, it is termed a fragility fracture.36 Fragility fractures are common: 50% of women and 25% of men over the age of 50 will have an osteoporosis-related fracture in their lifetime.7 Physicians should also be cognizant of elder abuse, which has an estimated prevalence of 32 cases per 1,000 persons.37 Unlike child abuse, there is no typical fracture pattern associated specifically with elder abuse. It should be suspected when there are ambiguous or inconsistent stories that do not match with the presenting injury.

Source: Adapted from Richmond TS, Kauder D, Strumpf N, Meredith T. Characteristics and outcomes of serious traumatic injury in older adults. J Am Geriatr Soc 2002;50:215–222.

Source: Adapted from Champion HR, Copes WS, Buyer D, Flanagan ME, Bain L, Sacco WJ. Major trauma in geriatric patients. Am J Public Health 1989;79:1278–1282.

Even though falls from a standing height often are relatively benign in other population groups, they can be very harmful in the elderly. Older adults can sustain multiple injuries from low-energy trauma.38 The reason for the frequency of falls in the elderly is multifactorial. Physiological changes take place with aging, including decreased visual, auditory, proprioceptive, and vestibular inputs, which combine with diminished reaction times, unsteady gait, and loss of strength and coordination to contribute to the increased likelihood of falls. This may be compounded by cardiac dysrhythmias and orthostatic hypotension of various etiologies, including polypharmacy.1 Dementia is commonly associated with falls.

Finally, it is important to consider not only the mechanism of injury but also the reason why the patient was injured. A motor vehicle accident involving an older driver may have occurred as a result of benign causes (presbyacusis, presbyopia, and dementia) or more ominous ones such as transient ischemic attack, stroke, arrhythmia, or hypoglycemia. Ascertaining the cause of the trauma not only can significantly alter the patient′s immediate course of care, but also can help to prevent future injuries.

Thus, there are a number of possible mechanisms for injury in a geriatric patient, with falls being the most common. However, because older adults are remaining active, an increasing number of injuries from all mechanisms are expected.15

Physiology and Comorbidities

There are several important physiological differences between old and young adults. Older adults have reduced physiological reserves and diminished compensatory mechanisms, and are therefore less able to deal with the added stress presented by trauma. This narrow physiological tolerance and the limited reserves should be expected when managing geriatric trauma patients.1 Patients’ chronological age might not equal their physiological age, which is modulated by their preexisting conditions (Table 8.4). Comorbidities often make management of these patients difficult, and they may be unknown at the time of initial presentation.

Abbreviations: CAD, coronary artery disease; CHF, congestive heart failure; HTN, hypertension; COPD, chronic obstructive pulmonary disease.

Aging of the cardiovascular and respiratory systems reduces the patient′s ability to respond to hypoxia and shock.1 The aging heart often is affected by coronary artery disease or congestive heart failure, and it accommodates poorly to hypovolemia. A low cardiac rate, combined with reduced preload from hypovolemia, results in a decreased cardiac output. This in turn results in myocardial ischemia and an additional reduction in cardiac output. Older patients are more likely to have a baseline ventilation/perfusion mismatch (pulmonary shunting), which makes them more susceptible to developing hypoxia. Many also have chronic pulmonary obstructive disease, which can complicate their perioperative management.

Aging is accompanied by diminished renal function and reduced creatinine clearance, which is masked by a serum creatinine that is falsely normal because muscle mass is lost. Many older patients have chronic malnutrition, which can impair healing and recovery. Their dura mater becomes adherent to the cranium, eliminating the epidural space.1 With concomitant age-related brain atrophy, the bridging veins are more susceptible to injury. Consequently, epidural bleeds are less frequent but subdural bleeds are more common in the older population. Preexisting cervical arthritis increases the risk of developing central cord syndrome. Their integument has impaired thermoregulation and loss of subcutaneous cushion, the latter of which can lead to more degloving injuries. Both diabetes and peripheral vascular disease complicate wound healing and predispose to infection and nonunion.3

The musculoskeletal system, affected by muscle atrophy (sarcopenia) and osteoporosis, is often subject to more severe injuries even when less kinetic energy is imparted on the limb. Weakness, when compounded by decreased proprioception and equilibrium, places the geriatric patient at increased risk of ground-level falls. The presence of an orthopaedic implant, such as a joint replacement or other implant, almost always alters the fracture pattern and the necessary treatment of the injury.

Osteoporosis

The effect of osteoporosis on the care of the geriatric patient cannot be overemphasized. Osteoporosis is a condition characterized by decreased bone mineral density, and it results from an imbalance of bone formation and resorption. Osteoporosis is categorized as primary or secondary. Primary osteoporosis is the loss of bone mass and bone quality associated with aging. Peak bone density is attained in young adulthood (ages 25 to 30) and decreases steadily thereafter. Secondary osteoporosis can develop from a variety of causes, including insufficient intake of calcium, vitamin D, gastrointestinal malabsorption, metabolic derangements (hyperparathyroidism, hypo- or hyperthyroidism, Cushing′s syndrome, renal pathology), medications (anticonvulsant drugs, prednisone), and deficiencies of gonadal hormone (estrogen deficiency, low testosterone levels).39

Many of these causes can be detected with laboratory tests or by taking a history.39 A metabolic bone workup includes a basic metabolic panel with serum calcium levels, a 24-hour urine calcium measurement, a 25-hydroxy-vitamin D level, as well as thyroid stimulating hormone and parathyroid hormone levels. Additional tests can be ordered based on the history and physical examination. Patients with fragility fractures should be considered for a dual-energy X-ray absorptiometry (DXA) scan if one has not been recently obtained. Indications for ordering a DXA scan, which can vary by health care system, are the following:

• 
  

  Long-term steroid use

  
  
• 
  

  Early surgical menopause

  
  
• 
  

  Postmenopausal woman with a family history of fractures

  
  
• 
  

  Alcoholism

  
  
• 
  

  Heavy tobacco use

  
  
• 
  

  Body mass index (BMI) < 18.5

All patients with a fragility fracture should receive calcium and vitamin D supplements.39 Secondary causes of impaired bone quality should be sought in all fragility fracture patients.39 An estimated 33% of fragility fracture patients have an identifiable cause of secondary osteoporosis.

Osteoporosis is common, affecting 45% of women and 15% of men over the age of 50.40,41 The lifetime prevalence of osteoporosis is 13 to 18% in women and 3 to 6% in men.42 The prevalence of osteoporosis increases with age (Table 8.5), with 48% of women and 12% of men over age 85, respectively, living with the disease. In women with fragility fractures, the prevalence is 30%.43 This number is higher for lower-risk patients such as men and premenopausal women.44 Known risk factors for osteoporosis include female sex, multiparity, BMI < 18.5 kg/m², smoking, excessive alcohol consumption, certain medications (see text box), and northern European or Asian ancestry.

Source: Adapted from: Osteoporosis and bone health. In: Jacobs J, ed. The Burden of Musculoskeletal Diseases in the United States: Prevalence, Societal, and Economic Cost, 2nd ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2011:103–127.

Changes in the bony architecture explain why osteoporotic bone is prone to fracture. With advancing age, there is a loss of cortical bone, which leads to thinning cortices with a concomitant increase in the medullary diameter of long bones. Because these two processes occur simultaneously, there is an overall increase in the diameter of bones in osteoporotic patients. Biomechanically, this helps to maintain the bending and torsional strength of the bone, although not nearly enough to offset the decrease in the quality of bone from the disease process.36 In the medullary bone, there is decreased osteoblastic activity that leads to thinning trabeculae, which make the bone more prone to fracture with minor trauma.36 Additionally, these changes in the architecture of the bone can lead to fractures that may display a high-energy pattern and be challenging to treat in spite of being a low-energy mechanism.39

The reduced quality of osteoporotic bone makes fracture fixation difficult. Failure of fixation of hardware in osteoporotic bone typically occurs at the bone–implant interface, resulting in cutout, fracture subsidence, or pull-off of the plate. Failure happens when the load transmitted at the bone–implant interface exceeds the diminished strain tolerance of osteoporotic bone.41 Based on a cadaveric study on pullout strength in human tibiae whose bone density was assessed with computed tomography (CT) scanning, Seebeck et al45 demonstrated that decreased cortical thickness and loss of trabecular bone make it difficult to obtain good purchase with standard hardware in osteoporotic patients. Consequently, constructs that maximize surface contact area between the hardware and the bone are preferred.39 Examples include hardware with locking screws, screws with larger diameter, and bicortical screw purchase. Indeed, locking plate constructs have revolutionized operative care of fragility fractures, enabling bridge plating of many fractures that could not be treated with more conventional implants.36 Load-bearing devices, as opposed to load-sharing devices, are preferred in these patients.36,39 Examples of these devices include intramedullary nails and plate and screw constructs in which the fracture fragments are in contact. In addition to proper implant selection, the treating surgeon should perform thorough preoperative planning and accurate fracture reduction when treating these patients.

Many publications have shown that orthopaedic surgeons have not been proactive in referring patients for treatment of their osteoporosis. In a study of 1,162 older women who sustained distal radius fractures, only 24% underwent either diagnostic evaluation or treatment for osteoporosis.40 Paradoxically, those who were older were significantly less likely to be treated with appropriate bone active medications.40 Although patients between the ages of 55 and 59 received medical treatment for osteoporosis 36.0% of the time, that percentage fell to 25.7% among those aged 80 to 84 and 4.7% for those aged 85 years and over. A similar study was performed to assess management of osteoporosis in 300 patients over 55 years of age who sustained low-energy femoral neck fractures; it found that calcium supplements and anti-resorptive medications were under-prescribed at the time of discharge from the hospital.42 Although 19.3% of all patients received a prescription for some sort of anti-osteoporotic agent (estrogen, calcitonin, bisphosphonates, raloxifene), 13.3% of all patients received calcitonin and only 6.0% received an anti-resorptive medication.

Orthopaedists are usually the first to see the patient with fragility fractures. They should initiate the evaluation, commence treatment, or refer the patient to a provider who can do so.3 One center reported a > 95% rate in successful diagnosis, treatment, or referral after implementation of such a program, which involved a team consisting of a dedicated coordinator supported by surgeons, residents, allied health care professionals, and administrative staff.46 Administration of bisphosphonates, which are first-line agents in the treatment of osteoporosis, is important because they have been shown to decrease fracture rates.3,47 One study found that 3 to 4 years of treatment with alendronate in 3,658 osteoporotic women resulted in a relative risk reduction of 53%, 30%, and 45% in hip, wrist, and clinical vertebral fractures, respectfully.48

Secondary Prevention of Fractures

In addition to selecting the appropriate procedure to perform, the orthopaedic surgeon should also start patients on calcium and vitamin D supplementation to correct any preexisting vitamin D deficiency and optimize fracture healing in osteoporotic patients. In a study of 954 patients at metabolic bone clinics, 73 to 89% were found to have levels of vitamin D below the normal range (32 ng/mL, or 80 nmol/L). In those with hip fractures, this figure was 84 to 96%.49 When vitamin D levels fall below 10 ng/mL (25 nmol/L), the patient is at risk for secondary hyperparathyroidism, which can further complicate bone metabolism by altering calcium and phosphate homeostasis.50

There is mounting evidence that all patients with fragility fractures should have their vitamin D levels normalized.39 One study recommended that orthopaedists should correct 25-hydroxy-vitamin D levels to more than 32 ng/mL, as this is the level at which parathyroid hormone (PTH) secretion normalizes.51

There are two forms of vitamin D supplementation: ergocalciferol (vitamin D₂), which is derived from plant and yeast sources, and cholecalciferol (vitamin D₃), which is derived from animal sources and produced in the skin.39 Numerous protocols exist for vitamin D supplementation. Bukata et al39 suggest supplementation based on baseline vitamin D levels. For patients with levels less than 10 ng/mL, aggressive ergocalciferol (vitamin D₂) supplementation with 50,000 IU three times weekly over 8 weeks is suggested; for those with levels between 10 and 20 ng/mL, 50,000 IU twice weekly over 8 weeks is suggested; and for those with levels more than 20 to 30 ng/mL, 50,000 IU once weekly over 8 weeks is suggested. After repletion, patients are advised to take 2,000 IU cholecalciferol (vitamin D₃) per day. This is followed by daily cholecalciferol (2,000 IU) in addition to the vitamin D contained in their multivitamin or calcium supplements as long-term therapy. With normalized vitamin D levels and bone metabolism optimized, the patient is at a reduced risk for fragility fractures. In a recent meta-analysis of 11 double-blind, randomized controlled trials, Bischoff-Ferrari et al52 found that high-dose vitamin D supplementation ≥ 800 IU daily resulted in a significant 30% decrease in hip fractures and 14% decrease in nonvertebral fractures in patients over age 65.

Prevention of falls represents the other factor in the secondary prevention of fractures. Falls cause 90% of fractures of the forearm, hip, and pelvis in geriatric patients.3 Risk factors for falling include a history of prior falls, psychotropic medication use, cognitive or visual impairment, lower extremity arthritis or deformity, foot problems, balance or gait abnormalities, neurologic conditions, and the use of an assistive device for ambulation.53,54 Strategies to reduce the risk of falls include vision correction, proper shoe wear, discontinuation of excessively sedating medications, and modification of the home environment.55 Examples of the latter include providing good lighting throughout the home, lowering the bed height, installing carpet over hard floors, eliminating throw rugs and thick carpets, and providing grab bars in the bathroom.56 Some geriatric fracture centers have begun providing fall prevention educational packets to patients in the surrounding community (Video 8.1). In addition to the aforementioned passive methods to prevent falls, patients can have an active role in preventing fragility fractures. Participating in exercise programs, particularly those that focus on dynamic balance such as Tai Chi, have been shown to reduce the risk of falls in elderly patients.57 Unfortunately, even with the best efforts at prevention, fragility fractures still occur. When patients present to the hospital emergency department, there are several steps that can be taken to provide care that is both appropriate and expedient, as discussed in the following sections.

Preoperative Management

Advances in medical and anesthetic management have permitted less healthy geriatric patients to undergo orthopaedic surgical procedures successfully that may not have been possible in the past because of their preexisting conditions.3 When performing a preoperative assessment, it is important to determine the past medical history, medication history, and history of allergies. Beta-blockers should be continued to avoid tachycardia in the perioperative period. The management of anticoagulants should be discussed with the consulting medicine provider. Reversal of warfarin (Coumadin) should be actively done with oral vitamin K or fresh-frozen plasma, or while waiting for hepatic synthesis of clotting factors; the international normalized ratio (INR) should be ≤ 1.5 before the patient is taken to the operating room.39 Patients on clopidogrel (Plavix) or other platelet inhibitors should not receive spinal or epidural anesthesia, but may undergo early surgery under general anesthesia.39 Many patients who are on clopidogrel after placement of drug-eluting stents are at increased risk for stent thrombosis if they discontinue the drug. Therefore, the risks and benefits of operating on a patient taking clopidogrel should be discussed with the patient′s cardiologist. Similar considerations pertain to newer anticoagulants such as dabigatran (Pradaxa) and rivaroxaban (Xarelto), as these medications have no direct reversal agents and take 1 to 2 days to be eliminated from the body. Medications to avoid in elderly patients include the following30,39:

• 
  

  Nonsteroidal anti-inflammatory drugs (NSAIDs), as they impair bone healing and kidney function

  
  
• 
  

  Centrally acting antihistamines

  
  
• 
  

  Meperidine

  
  
• 
  

  Most antiemetics

  
  
• 
  

  Benzodiazepines

  
  
• 
  

  H₂ (histamine) receptor antagonists

  
  
• 
  

  Anticholinergics

The American Geriatric Society has supported the use of STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions) criteria (see text box) to avoid adverse drug events, which may cause or contribute to urgent hospitalization in older patients.58 Some common adverse drug events that can be attributed to inappropriate prescription of medications in elderly individuals include falls (benzodiazepines, opiates, and neuroleptics), symptomatic orthostasis (antihypertensives, diuretics), constipation (opiates), acute kidney injury (diuretics), and gastritis/peptic ulcer disease (NSAIDs).59

Related posts:

The Polytrauma Patient Musculoskeletal Infection Associated with Skeletal Trauma Thoracic Spine Injuries Distal Humeral Fractures Femoral Neck Fractures Pelvic Ring Injuries

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