Falls Flashcards
Who are te demographic that are most likely to fall?
Older people are more vulnerable especially if they have a long term health condition
What’s the statistics for falls for those over 65
1 in 3 over 65 who live at home will have at least 1 fall a year Half of them will have more frequent falls
What are the psychological effects of falls
Loss of confidence Become withdrawn Feeling of losing independence
What should a person do if they fall and they were NOT hurt
Keep calm, if you feel strong enough to get up don’t do it quickly Roll on hands and knees and look for stable chair or bed Hold furniture to support yourself to get up SLOWLY when you feel ready Sit and rest for a while before carrying out daily activities
What should a person do if they fall AND they were HURT or unable to get up
Call out for help by banging on wall or floor Use aid call button if you have one, crawl to telephone and dial 999 Try to reach something warm like blanket to cover yourself esp legs and feet Stay comfortable and try to change position every half an hour
What can increase chances of older people falling ?
Balance problems and muscle weakness Poor vision Long term condition: Heart disease, dementia ,hypotension. This can lead to dizziness and brief loss of consciousness
What are the external factors (not biological) that can increase frequency of falls
Wet or recently polished floors (e.g bathrooms) Dim lighting in room Rugs or carpets not properly secured Person rushing to go to toilet during day or night Person reaching for storage areas or going downstairs
What is a common cause of falls particularly older men
Falling from ladder when carrying out home maintenance work
Why can falls be problematic for men and women?
Osteoporosis
What are the ways in which osteoporosis can develop for both men and women
Smoking Excess alcohol Steroid medication Family history of hip fractures
Why are older women most at risk of osteoporosis?
Osteoporosis more associated with Hormonal changes that occurs during menopause
What are the simple measure to prevent falls at home?
Use non slip mats in bathroom Mopping up spills to prevent wet slippery floors Ensuring rooms, passages and staircases are well lit Removing clutter Getting help to lift or move heavy items
What can the GP recommended to support older people who falls
Sight test- chef problem with vision even if you wear glasses ECG- check BP while lying and standing up Doing exercise to improve strength and balance Home hazard assessment- health prof comes to risk asses your home
What else can your GP do to support older people with falls
Simple test to check balance Review medicines to see if any side effect increases chances of falls
Define a hip fracture?
Bony injury of proximal femur
What factors predispose older peoples to fracture
Gait unsteadiness Reduced bone mineral density
What are the other risk factors that increases chance of getting a fracture
Age Osteoporosis Low muscle mass Steroids Smoking Excess alcohol intake
Draw and label the proximal femur
Head, neck Greater and lesser trochanters
What is the purpose of the inter-trochanter is line?
It lies on anterior surface of femoral neck running between trochanters It demarcates the inferior attachments of the hip capsule
Where does the capsule of the hip attach proximally to?
Margins of acetabulum and transverse acetabular ligaments
Where does the capsule of the hip attach distally to?
Inter-trochanters line, bases of greater and lesser trochanters and femoral neck (approx 0.5 inch from the trochanter is crest)
What does the hip capsule contain
RETINACULAR vessels- major blood supply to femoral head
What are the 3 sources of blood supply to the femoral head?
1) Retinacular vessels - MAJOR source 2) Foveal artery 3)Metaphyseal vessels
What give rise to the retinacular vessels
Originates from extra-capsular arterial ring, Profundus femoris to lateral and medial circumflex which give rise to the retinacular vessels
What reinforces the Retinacular vessels?
Superior and inferior gluteal arteries (internal iliac A)
What is the significance of the foveal artery
Supplies epiphysis with small amount of blood during skeletal development Becomes destroyed in adult life (ligamentum teres)
What is the classification of hip fractures?
Intra-capsular; ABOVE inter-trochanteric line Extra-capsular- BELOW inter-trochanteric line.
What class of hip fracture have the greater risk of disrupting blood flow to femoral head
INTRA-CAPSULAR- disrupt retinacular vessels
What are the Garden classes of intra-capsular fractures?
Type 1- incomplete, impacted in vagus Type 2- complete, undisplaced Type 3- complete, partially displaced Type 4- complete, completely displaced
Which garden fracture has a higher risk of disrupting femoral head blood supply and why
Type 3&4- greater displacement
Unlike type 1&2 where there’s minimal displacement
In the elderly what is likely the cause of hip fractures?
Falls; directly or twisting when foot is planted and body rotates Bones are osteopaenic and deficient in elastic reserve
In younger patients what are the most likely causes of hip fractures?
High energy trauma Gait disturbances (multiple sclerosis) Corticosteroid use
Why can falls occur
Mechanical; sliding and slipping Precipitated by stroke, MI, UTI, chest infection etc
How can hip fractures be diagnosed?
Radiologically However may be suspected clinically
What are the symptoms of hip Fracture
Hip/knee pain on affected side Inability to bear weight Limited range of motion
What are the signs of hip fracture
Bonny tenderness over affected hip Shortened or externally rotated leg (present if significant displacement occurs)
What are the bedside investigations needed to aid diagnosis and look for complicating pathology?
Observations Urine dip ECG- required pre-op. ACS, undiagnosed arrhythmia
What are bloods investigations
FBC U&E CRP Clotting Group and save
What are imaging investigations?
Chest XR: required pre-op Plain films: need to image entire length of femur , hip, pelvis, knee MRI/CT: only if plain films are inconclusive also to rule out OCCULT fracture Cardiac echo: if new murmur is auscultation or abnormal ECG, required pre-op
How can you interpret the X-ray to rule out or confirm fracture of the hip
Shenton’s line- continuous and smooth in absence of fracture
Where is the Shenton line drawn across?
Drawn along inferior border of superior ramus and along inferomedial border to proximal femur
How are hip fractures treated? ANY EXCEPTIONS?
SURGICALLY Except wen there are co-morbidities
How does surgical management differ?
Depends on whether it is intra or extra capsular fractures
What is involved in conservative treatment and what are the outcomes for the patient ?
Involves traction, bed rest or restricted mobilisation Outcomes are often very poor
What is the NICE guidelines for hip surgery? Why
Surgery performed on day or 1 day after admission To allow patient to fully weight bear immediately after post-op period. This is not often possible
What does NICE recommend for Gardens 3/4 displaced fracture treatment?
Total hip replacement for FIT patients Hemi-arthoplasty for patients with significant comorbidity
What is the treatment procedure for Garden 1/2?
Cannulated hip screws (2 or 3 of them)
What is the treatment procedure for Extra-capsular fractures?
Dynamic hip screw or Intra-medullary nail
What is unique about dynamic hip screw treatment?
Allow fracture ends to slide; promotes bone healing
what are the risk factors for falls in the elderly?
- Postural hypotension
- neurological- poor vision, confusion
- environmental- poor lighting steep stairs. furntiture not at right height for patient
- fear of falling
what are the causesof postural hypotension?
- ageing
- low blood circulation
- grugs- for high BP
what are fragiltiy fractures?
occurs from mechanical forces that wouldnt normally result in fracture (low energy trauma). it can even happen without falling but its normally from a fall
what is the major risk for fragiltiy fracture-
reduced bone mineral density such as seen in osteoporosis
however it can occur in patients without osteoporosis
what are the causes of fragiltiy fractures?
- fall
- lifting
- coughing
- banging into something
what is a characterisitc of osteoporosis?
low bone mass, microarchitectural disruption and skeltal fragiltiy
loss of horizontal trabeculae in spongy bone (more porous)
when do people who have osteoporosis realise that they have it?
when they have fallen and have a fracture
why are females more at risk of osteoporosis than men, explain the pathophysiology
menopause; less oestrogen secretion
theres more bone resorption than formation- more osteoclast activity than osteoblast
oestrogen reduces osteoclast activity and increases osteoblast activity
what happens to the bone with age; that increases risk of osteoporosis
Bone marrow become syellow- adipocytes formed
no osteoblasts made
what are the risk factors for osteoporosis
age, gender (female), Hypocalcaemia
how does hypocalcaemia increase risk of osteoporotic fracture?
less calcium in blood, increased PTH secretion and hence more osteoclast activity
what scan is used to diagnosed osteoporosis?
DEXA scan- T score of less than -2.5 (compared with healthy 25 yr old individuals)
Z score; compared with healthy people with same age bracket
what are the potential causes of hypocalcaemia?
- low calcium in diet
- low sunlight
- liver diease
- kidney disease
- inactive vit D receptors
what is the mechanostat theory?
Regulatory mechanisms in bone adjusts to strain placed on it to meet demands. low starin = low bone density (homeostasis and energy conservation). High strain = high bone density
Above strain therhold theres only bone formation (osteob last activity)
Describe this fracture, its severity and treatment options
Garden 2; high chance of damaging vessels.
treatment- dynamic hip screw or cannulated hip screw
what is sarcopenia and what are it’s risk factors
loss of skeletal muscle mass and strength
risk facitrs: age, gender, physcial activity
lead to death, falls, low BMD (mechanostat theory as increased muscle mass put more strain on bone)
why do people die due to falls?
- HEART FAILURE
- infection, HAI
- Co-morbidities
what are the different types of drugs used to treat osteoporosis?
- Teriparatide- PTH competitive inhibitor
- Raxofeine
- Zoledronic acid- given IV, Bisphosphonate; ihibit osteoclast, help in mineralisation using calcium hydroxyapatite
- Alendronic acid- given to Mrs Wilkins; taken orally daily or weekly contraindications are acid reflux and upset tummy. Oestrogen receptor modulator -reduce vertebrae fracture
- Strontium renalte- cause myocardial infarction, used as last basis
- Denosumab- monoclonal antibody, given subcutaneously 6 monthly
- HRT- young premature menopause
- ibandronate- bisphosphonate- given orally monthly or IV 3 monthly
what is the technique needed to look for fractures?
Look at cortex of bone and see if its smooth line- fracture is where there’s break in the line.
what are the contraindications of giving Alendronic acid?
acid reflux or upset tummy
why other supplements are given to those with osteporosis?
Vit D and calcium
why is it important to refer to falls clinic after?
help in rehabilitation- MDT team of physiotherapist, OT, geriatric team et.c can help
what are the factors of delirium?
- Dehydration
- opoids- cause bowel problemwhich exarcebate it
- change in medication
- MCI
- sleep deprivation
- triedness
- infection
- electrolyte dysfunction
- Age
how can delirium be combated in hospital setting?
- Bring familiar objects
- continuity of care
- relatives- remind them and talk in short sentences
- rehydration
- meal time buddies- red tray to encourage eating
- 24hr clock
- don’t move between wards unnecessary
- don’t give medication unless they seriously pose harm to themselves or others, give low doses
- dont give unnecessary noise at night or in wards
Describe this fracture and its severity. Give treatment options
Intratrochanteric fracture- doesnt affect retinacular vessels as much
treamtnet Intramedullary nail or DHS
Describe this fracture, its severity and treatment options
Garden 4; no shenton line seen. Very high chance of disrupting retinacular vessels
treatment- total hip replacement or hemiarthroplasty where the acetabulum (in blue) is still in place
What are the symptoms of compression fractures?
- Pain and morbidity associated with high doses of analgesia.
- Loss of height.
- Difficulty breathing.
- Loss of mobility.
- Gastrointestinal symptoms.
- Difficulty sleeping.
- Symptoms of depression.
What are the component of post-op care?
- Pain control.
- Antibiotic prophylaxis where appropriate.
- Monitoring of FBC and correction of postoperative anaemia where required.
- Routine systems examinations to detect complications early or exacerbation of existing comorbid conditions.
- Regular assessment of cognitive function.
- Prevention and management of pressure sores.
- Monitoring of nutritional status and renal function.
- Monitoring of bowel and bladder function, and management of problems as required.
- Wound care.
- Early mobilisation.
What are the symptoms of delirium
- 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.
