CSI - Falls Flashcards
What are the clinical outcomes of a fall?
- 10% of patients die within 1 month
- 30% patients die within a year
- 10 - 20% of patients are discharged to a residential home
- 50% return to a previous level of mobility
- 75% of cases are females
- 20% suffer post-operative complications
What is delirium?
Delirium is an acute, fluctuating change in mental status, with inattention, disorganised thinking and altered
levels of consciousness.
• Manifested by delusions, disorientations, hallucinations, or extreme excitement,
• Symptoms are infrequent – episodes vary in length more immediate.
What are 3 types of delirium?
Hypoactive delirium: Abnormally withdrawn and sleepy
Hyperactive delirium: Abnormally alert, restless, agitated and aggressive
Mixed type
What are symptoms of delirium?
Symptoms
• Symptomatic patterns are sudden, worsening at specific times during the day (evening or at night).
• Changes: State of confusion, changes in alertness (agitated), lack of concentration and easily
distracted.
• Disorientation
• Rambling speech
• Sleep apnoea
• Prone to emotional swings
• Hallucinations
• Paranoid beliefs
What are the causes of delirium?
Causes
• Infection
• Constipation
• Pain
• Analgesia
• Polypharmacy
• Changed environment & unfamiliarity with medical staff
• Dehydration
• Postoperative state
• Visual and hearing impairments
• Recent bereavement
What are the treatment and support offered to people with delirium?
Clinicians review patient’s medication and prevent administration of drugs associated with causing delirium.
Ensure that the patient is: Free from pain, hydrated, nourished and oxygenated
- orientate patients with a calendar, 24 hour clock
- hearing aids and glasses
- avoid noise at night
- bring personal items, cooperate with family and friends
What is the role of geriatricians in the MDT?
Fragility fractures predominantly affect the elderly
demographic.
Refer to Care for the Elderly – advisable to
reduce morbidity and mortality associated with
injury and post-surgery.
Appropriate inpatient care
What is the role of physiotherapists in the MDT?
Physiotherapists focus on promoting adequate movement
for patients as part of strength regain.
Provide exercise and stretch programmes that
assist with healing.
Muscle-strengthening exercises, and balance
training
Occupational therapists also play a role in
rehabilitation during admission and following
discharge.
What is the role of GPs in the MDT?
General practitioners have a role in identifying fragility
fractures and managing secondary prevention.
Help identify patients who are at risk, and thus
implement primary preventative measures.
What is the role of the Liason psychiatry team?
- play a role in supporting and managing patients with dementia
- manage patients with visual and hearing impairments
What is Shenton’s line?
Shenton’s line is an imaginary curved line along the inferior border of the superior
ramus, along the inferomedial border of the proximal femur.
• It is continuous and smooth
How do you image osteoporosis?
Imaging
• Plain films: X-ray of pelvis, hip, femur and knee: The entire length of the femur needs to be
visualised in order to establish an entire radiographical picture to lead a suitable intervention.
• MRI/CT: If plain films are inconclusive, conduct alternative forms of imaging to exclude occult
fractures.
• Chest X-ray: Required pre-operatively.
• Echocardiogram: Conducted if a new murmur is auscultated in in patients with ECG abnormalities.
What are the clinical features of osteoporosis?
Clinical diagnostic features of osteoporosis:
Parameter - Normal range
Vitamin D - 30-100ng/ml (Optimum)
• <20ng/ml – Deficiency
• 20-20ng/ml – Insufficiency
cCa2+ - 2.2-2.7 mmol/L
Oxygen Saturation - >95%
Respiratory Rate - 12-20 Breaths per Minute
Heart rate - 60-100 Beats per Minute
Full blood count - detection of haematological features or pathological disorders in blood.
Other investigations involve Urine & Electrolytes test, CRP and clotting
What are the pharmacological treatments for osteoporosis?
- zoledronic acid
- raloxifene
- teriparatide
- biphosphonate treatment
- denosumab
- strontium ranelate
What is the affect of zoledronic acid?
Inhibition of bone resorption through inhibiting osteoclastic activity and induces osteoclast apoptosis.
What is raloxifene?
Selective oestrogen receptor modulator and exhibits agonist characteristics to the oestrogen
location
When is teriparatide prescribed and why?
Treatment is prescribed in advanced circumstance of osteoporosis, a portion a parathyroid
hormone, amino acid sequence 1-34 PTH mediates the osteoblast during intermittent injections.
Why is strontium ranelate prescribed?
Strontium Ranelate
In postmenopausal women and men at a high risk of osteoporosis, SR is suggested.
• There is an associated risk of myocardial infarction – therefore is not administered to patients with a
past medical history of coronary heart disease.
What is denosumab and why is it given?
Denosumab
Monoclonal antibodies that reduce osteoclast activity, and thus bone resorption.
• Administered to postmenopausal women as secondary prevention of osteoporosis in individuals with
bisphosphonate intolerance
What is bisphosphonate treatment and how does it work?
Bisphosphonate treatment
Bisphosphonates: Alendronate inhibits osteoclast-mediated bone resorption. Attach to hydroxyapatite
binding sites on superficial bone surfaces undergoing active resorption.
• Bisphosphonate impairs the ability of the osteoclasts forming ruffled border, to adhere to the bony
surface and produce proteins necessary for continued bone resorption.
• Reduced osteoclast activity by decreasing osteoclast progenitor development, and recruitment,
promotes osteoclast apoptosis.
Bisphosphonate should be prescribed alongside
Calcium/Vitamin D.
What are the main anatomical features of the femur?
Femur
- The proximal femur is anatomically characterised with a head and neck, and two large projections referred
to as the greater and lesser trochanters residing on the
superior shaft.
Why is the head of the femur important?
- the spherical nature of the head allows it to aritculate with the acetabulum of the pelvic bone, forming a ball and socket synovial joint
What forms the hip joint?
the articulation of the femur and pelvis
this allows the axial skeleton to connect with the lower extremity
What is the neck of the femur and why is it important?
Neck: The neck is a cylindrical strut projecting
superomedially from the shaft, forming a connection
with the head of the femur. Despite being a site of
structural weakness due to the narrow nature of the neck,
the orientation of the neck increases the range of motion
of the hip joint
Why is the shaft important?
The superior aspect of the femoral shaft bears the greater and lesser trochanter, providing attachment
sites for muscles that articulate the hip.
What is the greater trochanter?
Greater trochanter: Extends superiorly from the femoral shaft, continuing posteriorly to the medial
surface (Surface as a deep groove forming the trochanteric fossa).
N.B: The muscles that attach to the greater trochanter of the femoral shaft are: Gluteus medius, gluteus
minimus, piriformis, obturator externus and obturator internus.
What is the lesser trochanter?
Lesser trochanter: A smaller, blunt conical shape that projects posteromedially from the femoral shaft
inferior to the junction with the neck.
N.B: The muscles that attach to the lesser trochanter of the femoral shaft are: Insertion of the tendon of the
psoas major and iliacus muscle.
What is the Inter-trochanteric line?
Resides on the anterior surface along the junction of the femoral neck and
shaft traversing between the two trochanters.
N.B: Demarcates the inferior attachments of the hip capsule.
What is the hip capsule?
Hip capsule: The acetabular notch is spanned by the transverse acetabular ligament, the fossa contains
fibro-fatty tissue, thus the articular surface is a horshoe shape to minimise contact stress with the acetabulum.
• Deepened by the rim of cartilage known as the acetabular labrum.
• Head of the femur and acetabular notch are connected by the ligamentum teres from the transverse
acetabular ligament and the fovea of the femoral head
Why is the hip capsule important?
The hip capsule contains retinacular vessels that perfuse the femoral head
What are retinacular vessels? Why are intracapsular fractures so dangerous?
Retinacular vessels are branches of the medial and lateral circumflex femoral arteries that extend to the
head of the femur within the retinacular folds of the synovial membrane, penetrating the capsule of the hip
joint at the intertrochanteric line (Intracapsular).
Intracapsular fractures lead to a significant disruption to the vasculature of the femoral head and neck leading
to avascular necrosis.
