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CSI 6 Flashcards

1
Q

what are the stats fro falls in people over 65?

A

1/3 of those over 65 who live at home will have at least one fall a year

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2
Q

What should you do if you fall?

A

Dont get up to quickly

if strong enough roll onto your hands and your knees and look for a stable piece of furniture, such as a chair or bed.
Hold on to the furniture with both hands to support yourself and, when you feel ready, slowly get up. Sit down and rest for a while before carrying on with your daily activities.

If you’re hurt or unable to get up, try to get someone’s attention by calling out for help, banging on the wall or floor, or using your aid call button (if you have one). If possible, crawl to a telephone and dial 999 to ask for an ambulance.
Try to reach something warm, such as a blanket or dressing gown, to put over you, particularly your legs and feet.
Stay as comfortable as possible and try to change your position at least once every half an hour or so.

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3
Q

Why are older people more likely to fall?

A
  • balance problems and muscle weakness
  • poor vision
  • a long-term health condition, such as heart disease, dementia or low blood pressure (hypotension), which can lead to dizziness and a brief loss of consciousness
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4
Q

What is the most common cause of death in people over 75 in the UK

A

Falling

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5
Q

What non-medical reasons can mean a fall is more likely to occur?

A
  • floors are wet, such as in the bathroom, or recently polished
  • the lighting in the room is dim
  • rugs or carpets are not properly secured
  • the person reaches for storage areas, such as a cupboard, or is going down stairs
  • the person is rushing to get to the toilet during the day or at night
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6
Q

What is a common cause of falls among older men?

A

falling from a ladder while carrying out maintenance work

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7
Q

Why can falls be more dangerous to older people?

A

because they are more likely to have OSTEOPOROSIS

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8
Q

What can cause osteoporosis?

A
  • smoking
  • drinking excessively
  • steroid medication
  • family history of hip fractures
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9
Q

Why are older women more at risk of developing osteoporosis?

A

its often associated with hormonal changes that occur during the menopause

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10
Q

How can you prevent a fall?

A
  • using non-slip mats in the bathroom
  • mopping up spills to prevent wet, slippery floors
  • ensuring all rooms, passages and staircases are well lit
  • removing clutter
  • getting help lifting or moving items that are heavy or difficult to lift
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11
Q

What might a GP do to make sure an older person isn’t at high risk of falling?

A
  • simple tests to check your balance
  • check to see if any medication their taking has side effects that might increase the risk of falling

GP may also recommend:

  • having a sight test if you’re having problems with your vision, even if you already wear glasses
  • having an ECG and checking your blood pressure while lying and standing
  • requesting a home hazard assessment, where a healthcare professional visits your home to identify potential hazards and give advice
  • doing exercises to improve your strength and balance (read about exercise for older adults)
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12
Q

What is the definition of a hip fracture?

A

A hip fracture is a bony injury of the proximal femur typically occurring in the elderly.

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13
Q

What are the risk factors of a hip fracture?

A
  • Increasing age
  • Osteoporosis
  • Low muscle mass
  • Steroids
  • Smoking
  • Excess alcohol intake
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14
Q

What is the average age of a hip fracture?

A

80

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15
Q

How much do hip fractures cost the NHS and social care per year?

A

1 billion

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16
Q

How much more common is a hip fracture in women than in men

A

4x

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17
Q

What is the mortality due to a hip fracture?

A

40%

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18
Q

What does the proximal femur consist of?

A
  • head
  • neck
  • trochanters(greater and lesser)
  • shaft

largest bone in the human body

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19
Q

What are the names of the lines on the neck of the proximal femur?

A

INTER-TROCHANTERIC

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20
Q

Where is the hip capsule attached?

A

proximally to the margins of the acetabulum (hip socket) and transverse acetabular ligament

Distally to the inter-trochanteric line, bases of greater and lesser trochanters and to the femoral neck posteriorly

It is around the neck of the proximal femur

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21
Q

What is in the Hip capsule?

A

retinacular vessels - a major component of the blood supply to the femoral head.

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22
Q

Describe the blood supply to the femoral head?

A

Receives blood from 3 sources:

1)RETINACULAR VESSELS - main blood supply, originates from the extracapslar arterial ring, supplied by the MEDIAL AND LATERAL CIRCUMFLEX VESSELS(profunda femoris A.)
Reinforced by the superior and inferior gluteal arteries (internal iliac A.).

2) Foveal artery - not a major source. During skeletal development, supplies the epiphysis with a small amount of blood. Said to become obliterated in adult life (ligamentum teres).
3) Metaphyseal vessels - not a major source. After skeletal maturity, metaphysical arteries also contribute blood to the femoral head.

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23
Q

What are the classifications of hip fractures?

A

Above inter-trochanteric line= intra-capsular

Below inter-trochanteric line = extra-capsular

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24
Q

What are intra-capsular fractures associated with?

A

higher risk of disruption to the blood supply of the femoral head than extra-capsular fractures because they are closer to the RETINACULAR VESSELS

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25
Q

What are the further sub categories of intra-capsular fractures?

A

sub classified according to GARDENS CLASSIFICATIONS:

TYPE I- incomplete, impacted in valgus
Type II-complete, undisplaced
Type III-complete partially displaced
Type IV-complete, completely displaced

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26
Q

What is the difference between Gardens classifications type 1 and 2 VS Type 3 AND 4?

A

1 and 2 -minimal displacement and therefore a lessened risk of disruption to the femoral head blood supply

Type 3 an 4- greater displacement and therefor e higher risk

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27
Q

What are hip fractures usually caused by in the elderly?

A

falls

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28
Q

What are features of bones in the elderly?

A

OSTEOPAENIC

DEFICIENT IN ELASTIC

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29
Q

What are hip fractures usually caused for in younger people?

A
  • major trauma e.g. vehicle accidents
  • gait disturabance e.g multiple sclerosis in which they are at increased risk of falls
  • Certain medications, such a prolonged corticosteroid use, can also predispose to osteopaenia(tend to both reduce the body’s ability to absorb calcium and increase how fast bone is broken down)
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30
Q

How are hip fractures diagnosed?

A

radiologically

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31
Q

What are clinical features of a hip fracture?

A
  • recent fall/trauma
  • need to know the nature of the fall e.g mechanical-slipping on wet floor OR precipitated event-stroke etc
  • patients report inability to bear weight
  • patients report pain in affected side
  • reduced range in movement
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32
Q

What are the symptoms of a hip fracture?

A
  • Hip / knee pain
  • Inability to bear weight
  • Limited range of motion
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33
Q

What are the signs of a hip fracture?

A
  • Bony tenderness over affected hip

- Shortened / externally rotated leg (only present if significant displacement)

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34
Q

What investigations are used to aid the diagnosis of a hip fracture?

A

Bedside:

  • Observations
  • Urine dip
  • ECG
  • Required pre-operatively
  • ACS, undiagnosed arrhythmia (e.g. AF)

Bloods:

  • full blood count-abnormally high
  • C reactive protein(high levels due to inflammation)
  • Clotting

Imaging:

  • Chest XRay: required pre-operatively
  • Plain films: XRay pelvis, hip, femur + knee (affected side); need to image the entire length of femur
  • MRI/CT: if plain films are inconclusive, to rule out occult fracture
  • Cardiac echo: if new murmur is auscultated or abnormal ECG, often required pre-operatively
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35
Q

What should a normal x-ray show?

A

SHENTONS LINE- an imaginary curved line drawn along the inferior border of the superior ramus, along the inferomedial border of the proximal femur. It should be continuous and smooth.

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36
Q

How can you manage a hip fracture?

A

-treat surgically (unless there are significant co-morbidities restricting this)

Rare(poor outcome):

  • traction
  • bed rest
  • restricted mobilisation
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37
Q

When should hip surgery be performed?

A

NICE guideline suggest Day of or day after admission to hospital-

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38
Q

Describe the surgical management of hip fractures type Garden 1 and 2?

A

Minimally or non-displaced intracapsular fractures (e.g. Gardens I/II) - usually treated with cannulated hip screws (often 2 or 3).

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39
Q

Describe surgical hip management of fracture 3 and 4 ?

A

-Displaced intra-capsular fractures (e.g. Gardens III/IV) - NICE recommends total hip replacement (THR) for fit patients; or hemi-arthoplasty for patients with significant comorbidity.

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40
Q

Describe surgical management of extra-capsular fractures of the hip?

A

-Extra-capsular fractures - either a dynamic hip screw (DHS) or intra-medullary (IM) nail are utilised. DHS are unique in the fact that they allow the fracture ends to ‘slide’; this is thought to promote bone healing.

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41
Q

What are risk factors for falls in the elderly?

A

Neurological:

  • Confusion
  • Cognitive impairment
  • Depression
  • Poor vision
  • Poor balance
  • Poor coordination

Unmodifiable:

  • Age
  • female
  • History of falls

Chemical(could make people drowsy, reduce BP etc):

  • Polypharmacy
  • Particular drug culprits
  • Alcohol

Cardiovascular:

  • Orthostatic hypotension
  • Arrhythmias
  • syncope

Neuromuscular:

  • Muscle weakness
  • Gait disorders
  • Peripheral neuropathy including sensory ataxia, foot drop
  • arthritis and joint disorders

Other:

  • Fear of falling
  • -Incontinenece
  • frailty syndrome

Environmental:

  • Home hazards
  • Inappropriate footwear
  • Insufficient home modifications
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42
Q

What are examples of gait disorders?

A

walking abnormality:

  • Parkinsons
  • hemiplegia
  • cerebellar disease
  • antalgic
  • normal pressure hydrocephalus
  • proximal myopathy including sensory ataxia
  • foot drop
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43
Q

What are fragility fractures

A

Fractures that result from mechanical forces that would not ordinarily result in fractures (low energy trauma) e.g falling form normal height or less

-some fragility fractures can even happen without a fall

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44
Q

Why might hypotension increase the risk of a fall?

A

causes lower blood pressure =when you stand up there is reduced blood flow to brain causing dizziness=could fall

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45
Q

How could diabetes increase the risk of a fall?

A

diabetes can lead to peripheral neuropathy which can increase the risk of a fall

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46
Q

What is a major risk factor of a fragility fall?

A

reduced mineral bone density e.g seen in osteoporosis

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47
Q

What is osteoporosis?

A
  • low bone mass
  • microarchitectural disruption
  • skeletal fragility
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48
Q

How is osteoporosis diagnosed?

A

By low BONE MASS DENSITY (BMD) -measured on a DEXA scan

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49
Q

How many fractures occur annually due to osteoporosis?

A

9 million

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50
Q

What is the trabecular network?

A

TRABECULAE- thin columns and plates of bone that create a spongy stucture in CANCELLOUS BONE(end of long bones)

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51
Q

Describe the sequential trabecular loss leading to osteoporosis?

A

1- perfect trabecular network
2- thinning and loss of the horizontal trabeculae
3-thinning of horizontal trabeculae and widening of vertical structures as vertical trabeculae are lost
4-breakdown of the entire network

(risk factors can decrease with better mobility)

52
Q

Why are elderly females more at risk of osteoporosis?

A

Have sudden drop in OESTROGEN during menopause:

  • Oestrogen stimulates osteoblasts and decreases osteoclast activity
  • in menopause oestrogen levels drop=reduced osteoblast activity and increased bone reabsorption
  • in younger women bone reabsorption and formation are regulated by interplat between osteoblast and osteoclast activity but with increasing age the balance shifts towards more bone reabsorption than bone formation and since older bone is more osteoporatic anyway this =high fracture risk

-stem cells for osteoblasts decrease and are replaced by ADIPOCYTES= strength of bone decrease

whereas men start of with higher bone density so they have to lose more to get into the fracture range

53
Q

What is the mechanostat theory?

A

Regulatory mechanism in bone

below a certain threshold of mechanical use(Stress on the muscle) bone is reabsorbed (osteocyte apoptosis as body thinks you don’t need them )=reduces bone mass =weaker bone

above a certain threshold of mechanical use bone formation occurs(osteocyte perturbation)=increases strength

more stress on muscle =more bone formation to an extent

This is a homeostatic mechanism

54
Q

What is sarcopenia?

A

A syndrome characterised by progressive and generalized loss of skeletal muscle mass and strength

basically the equivalent of osteoporosi but in muscle

55
Q

What are the risk factors for sarcopenia?

A
  • age
  • gender
  • level of physical activity
56
Q

What is increased sarcopenia correlated with?

A
  • Physical disability
  • falls
  • low BMD
  • poor quality of life
57
Q

What is there a bi-directional relationship between?

A

muscle and bone, as seen in the relationship between sarcopenia and osteoporosis due to the mechanostat theory-as muscle use decreases so does bone density

58
Q

What percentage of people with hip fractures die within a month?

A

10%

59
Q

What percentage of people with hip fractures die within a year?

A

30%

60
Q

What percentage of people with hip fractures are discharged to a residential home?

A

10-20%

61
Q

What percentage of people with hip fractures return to their previous level of mobilitiy?

A

50%

62
Q

What percentage of those with hip fractures are female?

A

75%

63
Q

What percentage of those with hip fractures suffer post operative complications?

A

20%

64
Q

What are the clinical steps protocol for a hip fracture?

A

1-history taking
2-physical examination
3-Blood/lab tests
4-X-ray

65
Q

How can you treat a intertrochanteric fracture?

A

intramedullary nail -type of extra-capsular fracture

66
Q

What is the normal range for vitamin D?

A

20-50ng/mL

67
Q

What is the management plan for someone who keeps falling, has osteoporosis and low vitamin D?

A

1:give Alendronic acis
2+3: Calcium+calciferol(vit D)
4: send them to a falls clinic

68
Q

What does alendronic acid do ?

A

Type of BIPHOSPHATE
helps bones stay strong

lines the bone and acts to decrease the number of osteoclasts available so bone reabsorption decreases

-It is the go to drug to give to people with osteoporosis

69
Q

What form is alendronic acid given in?

A

tablets, can be soluble tablets

taken weekly

70
Q

What is the risk of alendronic acid?

A

can sometimes damage your jaw

-can cause reflux/heartburn

-can cause OESOPHAGITIS =inflammation of the lining of the oesophagus(this is caused by reflux
)

-dont give to people at risk of these things

71
Q

What is alendronic acid called when mixed with calciferol?

A

Fosavance

72
Q

What is calciferol?

A

Vitamin D3

73
Q

What other medication can you give instead of alendroninc acid?

A

Zoledronic acid IF you dont think the patient will comply with taking alendronic acid-this is given by IV once a year

74
Q

What are the problems of giving calcium and calciferol to elderly people?

A

could cause kidney function to decline

75
Q

What is a falls clinic?

A

educates the patient on how to reduce risk of falls in the future

76
Q

What is delerium

A

an acute confusional state

77
Q

What are the causes of delerium?

A
  • strong painkillers
  • infection
  • multiple medicines(this is especially relevant for elderly people as they are on tons)
  • changed environment
  • dehydration
  • surgery
  • constipation
  • pain
  • analgesia(inability to fell pain)
  • injuries
  • lonliness
  • shock
  • poor nutrition
  • delerium is often MULTIFACTORAL meaning many causes contribute to it
78
Q

How can delerium be combated in a hospital setting?

A
  • calm, well lit environment
  • improving vision and hearing impairment
  • avoid moving beds/wards
  • involve family and carers
  • clear communication
  • treat underlying cause
  • avoid unnecessary noise at night
  • making sure hearing aids and glasses are working properly before worn
  • a 24 hour clock and easily visible calender
79
Q

How many people in nursing homes and hospitals have delerium?

A

nursing home-10%

Hospital-20%

80
Q

What tests can you run on patients with delerium to find causes that can be treated?

A

-run tests to find infections, elctrolyte imbalances, metabolic imbalances and intracerebral pathology

81
Q

How is delerium different from dementia?

A
  • delerium symptoms come over a matter of a few hours or days
  • dementia symptoms develop over a period of months or years

-symptoms of delerium will vary a lot over the course of a day but his is not the case for dementia patients

82
Q

What are the symptoms of delerium?

A

The symptoms of delirium will start suddenly and may come and go over the course of the day. They can be worse in the evening or at night. A person with delirium will show some of the following changes.
•Being more confused than normal
•Changes in alertness – such as being either unusually sleepy or agitated
•Having a lack of concentration or becoming easily distracted.
•Becoming disorientated – not knowing where they are or what day it is.
•Rambling speech.
•Showing changes in behaviour.
•Having disturbed patterns of sleeping and waking.
•Being prone to rapid swings in emotion.
•Experiencing hallucinations.
•Having abnormal or paranoid beliefs.

83
Q

What is hypoactive delerium?

A

in older people especially those with dementia-causes them to be abnormally withdrawn and sleepy (can be easily missed or mistaken for depression)

84
Q

What is hyperactive delerium?

A
  • makes a person abnormally alert, restless, or agitated and possibly even aggressive
  • person may have delusions(believing things that arn’t true), hallucinations
85
Q

What is mixed delerium?

A

alternating between hyperactive and hypoactive delerium throughout the day

86
Q

What should you do if you start to develop the symptoms of delerium?

A

see a doctor

take someone with the to tell the doctor that the behaviour exhibited by the person is not normal

87
Q

Which type of dementia has very similar symptoms to delerium?

A

dementia with LEWY BODIES

88
Q

Who gets delerium?

A
  • 20% of older people in hospital
  • people with dementia in hospital
  • people in care homes
89
Q

What factors put people at higher risk of getting delerium?

A
  • having dementia(strongest risk factor and risk increase as dementia progresses)
  • being over 65
  • being frail or having multiple medical conditions
  • having poor hearing or vision
  • being on multiple medications (for example. antipsychotics, benzodiazepines, antidepressants
90
Q

How can delerium be prevented?

A
  • prevented in about 30% of people at risk
  • soon after a person comes into hospital or long term care, staff should check whether they are a trisk of delerium. If so non-drug approaches can be taken
91
Q

How can you diagnose delerium?

A
  • doctor looks at a person clinical history
  • looks at underlying health and mental state
  • ask someone who knows the person how they have changed
  • various clinical tools but no blood tests so it is often missed
92
Q

How can you treat and support someone with delerium?

A
  • find iunderlying cause for the delerium e.g. infection and treat this
  • -review meds and stop them taking any drugs related to delerium
  • make sure the person is free from pain, properly hydrated, well nourished and that their blood has enough oxygen in it
93
Q

How can a persons family help them with their delerium?

A
  • talking calmly to the person in short and clear sentences
  • reminding them of where they are and providing them with reassurance
  • bring personal objects such as photographs from home
94
Q

When would you consider giving drugs to someone with delerium?

A
  • should not be given generally as medication can make it worse
  • only given when their behaviour possess a risk to themselves or other people
  • OR if the hallucinations or delusions are causing the person severe stress
  • In either case the doctor may try a low dose of ANTIOPSCHOTIC
95
Q

How long can it take for delerium to be treated?

A

few days to weeks

96
Q

What can a person who has recovered form delerium experience after?

A
  • A person may have distressing memories of delirium, sometimes linked to feelings of fear or anxiety, for months afterwards. Those close to the person should support them to talk openly about their experience and feelings.
  • permanent changes- for example someone may not be able to something that they used to be able to do after experiencing delerium
  • increases the chances that someone might need to go into a care home
  • In some case a person will not have dementia going into hospital but after having delerium there symptoms worsen and will later be diagnosed with dementia
  • higher risk of death in the following year
97
Q

What is an osteoporotic fracture?

A

A fragility fracture that has occurred due to osteoporosis

98
Q

What are the risk factors of fragility fractures?

A
  • Advancing age.
  • Other conditions affecting bone strength, such as acromegaly or osteogenesis imperfecta.
  • Predisposition to falls due to loss of balance or poor muscle strength.
  • Osteoporosis
99
Q

How many fractures are due to osteoporosis per year in the UK and how much does this cost the NHS?

A
  • 200,000

- 1.7 billion

100
Q

Why are women more affected by fragility fractures than men?

A

They have a higher incidence of osteoporsis

101
Q

What are the causes of vertebral fractures?

A

often occur without a causative fall and may follow normal activity such as bending or lifting or sneezing

102
Q

What are the risk factors for fragility fractures?

A

•Increasing age (risk increase partly independent of reducing BMD).
-reduced Bone mineral density
•Female gender.
•Low body mass (<20 kg/m2) and anorexia nervosa.
•Parental history of hip fracture.
•Past history of fragility fracture (especially hip, wrist and spinal fracture).
•Corticosteroid therapy (current treatment at any dose orally for three months or more).
•Cushing’s syndrome.
•Alcohol intake of three or more units per day.
•Smoking.
•Ethnicity. Caucasian men and women are at higher risk than other ethnic groups.
•Other causes of abnormal bone - eg, osteogenesis imperfecta and acromegaly[4, 5].
•Falls and conditions increasing the risk of falls, such as:
•Visual impairment.
•Lack of neuromuscular co-ordination or strength.
•Cognitive impairment.
•Sedative medication and alcohol.
•Secondary causes of osteoporosis, such as:
•Rheumatoid arthritis and other inflammatory arthropathies. (Rheumatoid arthritis also increases risk of fracture independently of BMD and use of steroids.)
•Prolonged immobilisation or a very sedentary lifestyle.
•Primary hypogonadism (men and women).
•Primary hyperparathyroidism.
•Hyperthyroidism.
•Post-transplantation.
•Chronic kidney disease.
•Gastrointestinal disease such as Crohn’s disease, ulcerative colitis and coeliac disease.
•Untreated premature menopause (<45 years) or prolonged secondary amenorrhoea.
•Type 1 and type 2 diabetes mellitus[6].
•Chronic liver disease.
•Chronic obstructive pulmonary disease.

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103
Q

Where are the most common sites for a fragility fracture and other known sites?

A

Common

  • vertebrae
  • hip(proximal femur)
  • wrist(distal radius

other:
-pelvis, rib, arm, shoulder

104
Q

What can happen following a fracture?

A

-loss of confidence
-anxitey
-reduced quality of life
-•Pain and morbidity associated with high doses of analgesia.
•Loss of height.
•Difficulty breathing.
•Loss of mobility.
•Gastrointestinal symptoms.
•Difficulty sleeping.
•Symptoms of depression

105
Q

How do you manage a fragility fracture?

A

-management of associated chronic disease
-fluid management
-fracture stabilisation
-surgery potentially(these decisions should take into account comorbidity and pre-fracture condition
-if surgey is involved pre operative investigations to prevent complications tp
-or exacerbation of existing conditions and would ususlly include:
-ChEST x-ray
-ECG
-FBC, blood count, clotting studies
-Renal Function
-Glucose
Assessment of cognitive impairment

106
Q

Describe the rehabilitation of fragility fractures?

A

-Early physiotherapist
-muscle stenghtening exercise
-fall prevention measures
-balance training
-

107
Q

What pharmological factors predispose you to a fall?

A
  • smoking
  • weight
  • diet
  • exercise
108
Q

What is the treatment of low bone density?

A

ensure adequate calcium intake and vitamin D status

109
Q

What is the adequate daily intake for calcium?

A

1000mg/day

110
Q

How much vitamin D should you consider prescribing to someone who is getting an adequate amount of calcium?

A

10micrograms(400 units)

111
Q

What should you to prescribe to someone who is getting less than the adequate amount of calcium?

A
  • 1000mg of calcium daily

- 10 microgram sof vitamin D

112
Q

What should be done if someone has a risk of fragility fracture and has a risk factor of low bone mineral density with clinical risk factors?

A

Bisphosphonates-Alendronate and risedronate can be given orally daily or weekly. Ibandronate is given orally each month or by IV injection three-monthly. Zoledronic acid is given by IV infusion annually.

Denosumab -is a monoclonal antibody that reduces osteoclast activity (and hence bone breakdown) which is given by six-monthly subcutaneous injections. NICE has approved it for secondary prevention for postmenopausal women with increased risk of fractures who cannot comply with the special instructions for administering alendronate or risedronate, or have an intolerance or a contra-indication to those treatments[15].

-Strontium ranelate should only be used to treat severe osteoporosis in postmenopausal women and men at high risk of fracture, for whom treatment with other approved options are not possible, due to an increase in the risk of myocardial infarction. It cannot be used in patients with current or past history of coronary heart disease, uncontrolled hypertension, peripheral arterial disease and/or cerebrovascular disease.

Raloxifene -is a selective oestrogen receptor modulator and inhibits bone resorption. It is approved for the treatment and prevention of osteoporosis in postmenopausal women, in a daily oral dose. It has been shown to reduce vertebral fracture risk but not other types of fractures.

Teriparatide -is a recombinant fragment of parathyroid hormone prescribed in secondary care. It may be considered for those with very severe osteoporosis or very high fracture risk who are unable to use bisphosphonates, or in whom bisphosphonates have not been effective.

Hormone replacement therapy - may be an option in younger perimenopausal women who also need treatment for symptoms of menopause.

113
Q

What is the prognosis of having a fragility fracture?

A
  • varies widely with age
  • 20% die within a year of the event
  • 50% of those that sustain a hip fracture can not live independently afterwards
  • reduced quality of life
  • pain
  • disability
  • having one fragility fracture is a significant risk factor for having another
114
Q

How can you prevent fragility fractures?

A

-broadly consider a risk assessment in:

  • Those with a history of fragility fracture. Some guidelines suggest this should trigger BMD measurement; others suggest these should be considered for treatment without the need for further assessment.
  • Postmenopausal women with risk factors.
  • Women or men with significant risk factors.
  • Women or men on oral corticosteroid treatment. (Any dose taken continuously over three months or frequent courses. 7.5 mg prednisolone or equivalent per day over three months continuously is considered high dose by NICE and confers higher risk.)
  • All women aged over 65 and all men aged over 75 (NICE only).
115
Q

Why is it difficult for clinicians to decide whom too carry put risk assessment on or BMD measurements on?

A

Because there is no national screening protocol for osteoporosis. Guidelines from NOGG, NICE, SIGN and the International Osteoporosis Foundation (IOF) differ

116
Q

Why is there a debate about whether or not we should be assessing the risk of getting a fragility fracture and subsequently treating people?

A
  • some people think it may cause and overdiagnosis
  • evidence that treatment reduces fractures in the population over the age of 80 is not available but the risk adverse reaction is significant
  • some people believe that there is not strong enough evidence
117
Q

What is important when dealing with a patient with a neck of femur fracture?

A
  • To diagnose early
  • ensure their comfort throughout the journey
  • manage patient in an appropriate way
  • early surgery within 36 hours
  • post operative optimisation to minimise the complications
  • discharge off care package that allows them to function in the community as best as possible
118
Q

What is the best way to divide the management course for a patient with neck of femur fracture?

A
  • pre-operative
  • operation itself
  • post operative course(both on the ward and when they go home)
119
Q

What is important to know about your patient who has the neck of femur fracture?

A
  • know their comorbities
  • how mobile they were before the fall
  • whether they were walking miles and miles or walking with a stick or a frame or in a wheel chair
  • also their social history loike where they live, do they have stairs in their house, is the toilet upstairs or downstairs, who do they live with, how do they get out and about to do their shopping,
  • What might have triggered the patients fall
120
Q

Why is it important to know whether the patient with the neck of femur fracture is on certain drugs or not?

A

some drugs e.g. warfarin could cause bleeding both due to the fracture and secondarily to surgery

121
Q

What are common causes of falls?

A
  • infections
  • pneumnoina
  • drugs that patients are on that lead to syncope
  • postural hypertension
122
Q

What decides whether a patient will have surgery or not?

A
  • after thorough examination
  • fracture
  • surgeon preference to some extent
  • age
  • mobility status of the patient
123
Q

What decides what type of hip surgery occurs, and what are these options?

A

-if the fracture is extracapsular or intracapsular

options include:

  • replacing the head of the femur(either with a full hip replacement where the acetabulum and the head of the femur is replaced or with a half hip replacement where only the head of the femur is replaced)
  • if you dont replace the head of the femur, you can fix the fracture with a DYNAMIC HIP SCREW or INTRAMEDULLARY NAIL
124
Q

What is it called when only the head of the femur is replaced in hip surgery?

A

hemiarthroplasty

125
Q

What are the risks of not having hip surgery?

A

Prolonged bed rest in pain that can lead to:

  • Thromboembolism (obstruction of a blood vessel by a blood clot that had become dislodged from another site in the circulation)
  • urinary tract infection
  • Pneumonia
  • pressure sores
  • loss of muscle

These can be life threatening in a long period of time
-even if you have the operation you are low key at risk of these anyway

126
Q

How can we minimise the complications of hip surgery post operation?

A

-mobilise the patient early
-ideally get them up and walking either non-weight bearing or with a frame to reduce the risk of prolonged bed rest
-

127
Q

What are the common members of the multidisciplinary team involved in hip surgery and management?

A
  • Orthopaedic surgeon
  • a care of the elderly physician
  • nurses
  • occupational therapists
  • social workers
  • physiotherapists

CSI (5 decks)

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