Introduction Definition management of the orthopedic problems of aging and diseases of the elderly commonly defined as age >65 defining elderly based on physiologic age or frailty may be more clinically relevant Epidemiology elderly population is growing in the US >85 year old group had fastest growth (30%) between 2000-2010 Pathophysiology musculoskeletal related conditions of the elderly are common osteoarthritis osteoporosis 2.1 million fragility fractures annually falls 30% of persons >65 years old sustain at least 1 fall per year Presentation History mechanism of injury mechanical syncope elder abuse medication must obtain accurate medication list polypharmacy commong anticoagulation medications important for surgical planning baseline ambulatory status mental status Imaging Radiographs radiographs of joint above and below fracture may have other injuries or adjacent arthroplasty/implants Studies Preoperative evaluation admission improved outcomes and decreased cost with comanagement by geriatric or hospitalist service emergency room EKG CXR U/A labs optimization on floor optimization coagulopathy heart failure sepsis prevention avoid overly sedating medications avoid anticholinergics ulcer prophylaxis Treatment Nonoperative indications medical comorbidities low functioning patients family desires goals pain control ease of transfer Operative indications similar to fractures in other age groups with some exceptions acute arthroplasty may be indicated for certain fractures in the elderly comminuted distal humerus fracture proximal humerus femoral neck fracture acetabulum intra-articular distal femur adjunct or alternative fixation may be necessary allograft (fibular strut for proximal humerus) multiple implants locking technology goals early mobilization return to preoperative functional status pain control Complications Mortality hip fracture mortality rate in hospital and at one year: 6% and 30% respectively decreased postoperative complications, pain, length of stay, and mortality if treated within 48 hours spinal cord injury higher mortality rate compared to younger patients increased mortality seen need for mechanical ventilation at admission higher injury severity scores head injury Delirium incidence 13%-50% postoperatively in elderly orthopedic patients risk factors dementia polypharmacy narcotics Pre-operative fascia iliaca block and decrease overall narcotic use dehydration restraints foley catheters frequent awakenings treatment comanagement with geriatric or hospitalist team reorientation minimize narcotics early mobilization timely removal of catheters Medical complications pneumonia pulmonary embolism deep venous thrombosis pressure ulcers myocardial infarction stroke Reducing complications with co-management service orthopedic geriatric co-management of trauma patients has been demonstrated to yield decreased mortality, postoperative complications, time to surgery, and length of stay (though conflicting results on the length of stay) improved post-operative mobility at 4 months
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