Fragility Fractures Flashcards
What are fragility fractures?
Fracture resulting from a simple fall, at standing height or less
(a normal human skeleton should withstand such a force and therefore such an injury is a diagnostic indicator of possible osteoporosis (or other pathological condition of bone))
What are the 5 common osteoporotic fractures?
Vertebral body Distal radius Neck of femur Neck of humerus Pubic ramus
(any possible - low energy trauma)
Name 5 high energy fractures of young adults that are also seen now as fragility fractures
Femoral shaft
Elbow (distal humerus, prox forearm)
Knee (distal femur, proximal tibia)
Ankle (bimalleolar and trimalleolar)
Cervical spine
What would be in a differential diagnosis for fragility fractures?
(someone presents with a fragility fracture what would you consider being a cause?)
Osteomalacia
Tumour
Other conditions
-e.g. Paget’s disease, osteogenesis imperfecta etc
Back pain
-Always rule out infection and tumour
What is the difference in bone weakness between osteomalacia and osteoporosis?
Osteomalacia
-Qualitative bone weakness
Osteoporosis
-Quantitative bone weakness
Are bone tumours more commonly primary or secondary?
Metastatic 25x commoner than primary malignant, but rare distal to elbow or knee
What is the commonest osteoporotic fracture?
Vertebral Compression Fracture (VCF)
-half of all osteoporotic fractures
What is the most common location for a vertebral compression fracture in osteoporosis?
Thoracic vertebra
wedge fracture
What deformity does vertebral fracture in osteoporosis cause?
kyphotic deformity of thoracic spine
“Dowager’s spine”
After the first vertebral compression fracture what is the risk of a subsequent VCF?
After first VCF, risk of subsequent VCF increases by more than 5-fold
What are the clinical features of Vertebral compression fracture acutely?
Sudden onset of back pain with little or no trauma
e.g. bending, turning, coughing
What are the clinical features of vertebral compression fracture chronically?
Spinal deformity - kyphosis
“Dowager’s hump”
Loss of height
Protuberant abdomen
-loss of appetite
Chronic pain, possible nerve root entrapment
What aspect of vertebral compression fracture effects mortality?
VCF reduces pulmonary function
- One thoracic VCF causes 9% loss of FVC
- One thoracic VCF makes another 5x more likely so downward spiral
-Lung function (FVC, FEV1) is significantly reduced in patients with thoracic and lumbar fracture
How do you treat VCFs?
Treat the osteoporosis
-Commenced on drug therapy regardless of T-score
Symptomatic (analgesia)
-Avoid bed rest and braces/supports (only weaken bone and muscle further)
(future? -> surgery: correct deformity by vertebroplasty or kyphoplasty, strengthen with artificial bone substitute or bone cement)
What is the second most common osteoporotic fracture?
Wrist
-Colles’ fracture
What is broken in a Colle’s fracture and what is the deformity?
Distal radius
-1” proximal to radiocarpal joint, classically with fracture of ulnar styloid process
Deformity:
- Dorsal displacement
- Dorsal angulation
- Shortened
- Radial deviation
- Supination
- (dinner-fork)
What is the treatment for wrist break in osteoporosis?
Classically Manipulation Under Anaesthesia and PoP; also + K-wires
Or
External Fixator
OR
Open reduction and internal fixation
What are the complications of a wrist fracture?
classically Colles’
(20% of patients)
Malunion
- Dorsal angulation
- Radial deviation and shortening
Stiffness
-Many fractures are I/A
Median nerve entrapment
-Carpal tunnel syndrome
Complex regional pain syndrome type I
-Reflex sympathetic dystrophy
Rupture of tendon of EPL (late)
What is the mortality for hip fractures at 1 month, 4 months, 1 year and 2 years?
1 month = 10%
4 months = 20%
1 year = 30%
2 years = 50%
What is the epidaemiology of hip fracture?
mean age, M:F, incidence
Mean age 80 years
M:F = 1:3.5-4
Incidence increasing by 1-3% per year due to the aging population
What is the aetiology of hip fracture?
Weak bone (usually osteoporosis) + Fall
also other factors - shape of prox. femur, other bone pathology etc
What are the types of hip fractures?
2 broad types but expand
Intracapsular (50%)
- Undisplaced
- Displaced
Extracapsular (50%)
- Basal cervical
- Intertrochantic
- Subtrochanteric
How do you treat the different types of intracapsular hip fracture?
Undisplaced - ORIF (screws)
Displaced
- “young” = ORIF (screws or SHS)
- “elderly” = hemiarthroplasty (or total hip replacement)
How do you treat the different types of extracapsular hip fracture?
Basal cervical = ORIF (sliding hip screw)
Intertrochantic = ORIF (sliding hip screw)
Subtrochanteric = ORIF (intramedullary nail)
What “fast track” protocols are in place in all emergency departments for hip fracture patients
50% of patients to be transferred to ward within 2 hours, 100% within 4 hours
Fast track protocol/hip fracture admission form in use
Appropriate patient placement
Inform recieving speciality with 2 hours of arrival in ED
Patients from peripheral hospitals should be transferred within 24 hours of first presentation for definitive care
What are the “Big Six” things that should be done/started in ED with someone presenting with a hip fracture?
- Analgesia
- SEWS chart started
- Blood samples taken
- Fluid assessment: oral/IV fluids
- Cognition screening (4AT- Delirium Screening)
- Pressure areas assessed
Name 4 things to be completed within 24 hours on the ward in hip patients
Cogition assessment (AMTS10 or AMT4 or MMSE)
Nutritional assessment
Falls risk assessment
Pressure areas assessment
Name 3 complications of a neck of humerous break?
Axillary nerve palsy
Malunion
Stiffness
How do you treat neck of humerus fracture?
Vast majority conservative, with collar and cuff (weight of arm reduces fracture by soft tissue traction - ligamentotaxis)
2 part - conservative or ORIF
3-4 part dislocation - (conservative) or (ORIF) or hemiarthropathy
What is the usual presentation of pubic ramus fracture?
type of patient and symptoms
Eldery (very) female patient
History of fall
Unable to walk
Pain and tenderness in groin and on leg movement
What is the treatment of pubic ramus fracture?
Short period of bed rest (48hr) Then mobilise (with physio)
