austin hill md mph - seton · to fix, replace, or let go - ... proximal humerus fractures can do...
TRANSCRIPT
Austin Hill MD MPH
Assistant Professor – Dell Medical School Dept of Surgery and Perioperative Care
Orthopaedic Trauma
Disclosures
Orthopedic Implant Company – ownership, stock, or options
Increasing volume of trauma in patients > 65
Account for 30+% of mortality in trauma
High energy – low energy
Complex underlying medical illness
Wrist Fractures: 200,000+
Hip Fractures: 300,000+
Vertebral Fractures: 700,000+
Other Fractures: 300,000+
Source: National Osteoporosis Foundation, 2000
1.5 Million Fractures Annually
Associated Injuries Evaluate for:
Head injuries
Rib fractures
Spine fractures
Cardiac/Seizure/
Syncope?
Fractures beget Fractures Risk of future fractures
increases 1.5-9.5 fold following
initial fracture
History of fragility fracture is
more predictive of future
fracture than bone density
Viewed as a sentinel event
Fracture Prevention Osteoporosis treatment
Calcium/Vit D supplementation
Pharmacotherapy
Fall Prevention
Home safety evaluation
Update corrective lenses
Minimize sedating/mood altering meds
Maintenance of medical comorbidities
Patient/Family Education
Impact on Quality of Life and Independence
Not as dramatic as hip fractures, but still cause significant dependence up to 6 months after injury
Functional considerations Many geriatric patients use their arms to ambulate with
walkers
Ability to feed themselves
Ability to dress themselves
Splints and slings can be difficult to manage
Higher Functioning Many patients > 65 have active lives and hobbies
Golf
Tennis
Hunting/Fishing
Early post-op period – improved function with surgery
No difference at 6 or 12 months
Try closed reduction whenever possible
Some Patients tolerate significant malunions
Tale of 2 cases - 89 yo F – Fall from
standing
PMH – HLD
Home ambulator
Medical issues are controlled
Fracture was “reduced” and casted
Tale of 2 cases - 3 months s/p injury
Normal motion
No pain
Tale of 2 cases - 69 yo F with RA, HTN, Hypothyroid, DM
Realtor, high functioning
Tale of 2 cases - 1st post op visit
Normal motion, off pain meds, back to work
Operative vs Non-operative Tx Case by Case
Involve family when possible
Recognize what goals are important, which ones are obtainable?
Return to work or hobbies
Keep patients ambulating
To fix, replace, or let go - Non-operative –
Simple proximal humerus fractures
Clavicle fractures
Distal radius fractures
Radial Head/Neck fractures
Operative –
Humeral shaft fractures
Fracture dislocations
Open fractures
Radius/Ulna shaft fractures
Distal Humerus fxs
Olecranon fxs
Surgical Considerations Regional Anesthesia,
LMA, limit narcotics
Minimize time in the OR – know when it is time to get out
Family Support
Pre-Optimization
Fall prevention – consider OT home evaluation
Clavicle Fractures Non-operative treatment
is usually well tolerated
Can bear some weight within 3-4 weeks
Soft tissues are rarely a problem
Clavicle Fractures 79 yo F – MVC
C-Spine injury
ICH
4 weeks s/p injury
Flexion – 100 degrees
Abduction – 80 degrees
Minimal Pain, Out of the sling, Using a walker
Humerus Fractures Proximal Humerus fractures can do well without surgery
Displaced Humeral shaft fxs can be debilitating
Distal Humerus fractures have a high nonuni0n rate if treated non-operatively
Humeral Shaft Fractures 85 yo female
Ambulates with a walker
CAD, COPD, HTN
Attempted non-op tx x 3 weeks - Did not tolerate splinting
2 weeks post op Decreased pain,
improved motion, happy 2 weeks post-op
Allowed to WBAT
6 weeks later Minimal pain
ROM > 90/90
Combined Proximal Humerus & Shaft Fractures 82 yo F community
ambulator
HTN, DM
Lives alone independently
12 hours in a splint,
not amused
IM nailing – “minimally invasive”
Arthroplasty vs ORIF vs Sling? 72 yo F – Fall from
standing at Walmarts
Sedentary, Moderate obesity, community ambulator
PMH – CAD, DM, etc
Reverse Total Shoulder Poor bone quality, bad fracture pattern, reasonable
goals regarding function
But Wait, There’s More!
6 months later, fall #2
Distal Humerus Fractures 72 yo F biking in
Slovenia
Healthy, active
Higher Energy Trauma
Open Distal Humerus Fx
Trauma Principles Abx
Evaluate for associated injuries
Early motion, PT
12 months post op Patient healed without
infection, limited ROM from 45-85 degrees
Significant Heterotopic Ossification
Contracture release, HO excision ROM: 10-150
PT the next day
Nerve Catheter for pain management, allow for immediate motion
Guarded optimism
Fractures & Dislocations around the elbow 65 yo F
Hx of Breast CA on Tarceva, otherwise healthy
Younger patient, same principles Arthroplasty and soft
tissue repair to mitigate poor bone quality
Strive for significant early gains in function
6 weeks post op Lacks only 15 degrees
extension
Full flexion
Occasional Tylenol for pain
Olecranon Fractures Usually ORIF, but
sometimes patients make the decision for you…
Can have soft tissue compromise
Bone quality is poor
Olecranon Fractures 82 yo F, FFS
HTN
Community Ambulator
Impending Skin necrosis on Exam
Olecranon Fractures Patient and daughter
agreed with ORIF
4 weeks post-op – MVC
Elbow motion- normal!
Fixation is often gratifying, But the functional
difference differs for each patient
79 yo F at SNF, fell 4-6 weeks ago
PMH – Dementia, osteoporosis, frequent falls, multiple fxs
Normal elbow motion, limited pain
Treatment Tips Each patient is different
Focus on function and Safety
Fracture Prevention
One solution does not fit all
Thank You!