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4.4

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(43)

Images
https://upload.orthobullets.com/topic/322053/images/changing_rate_of_fracture_with_age_court-brown_and_mcqueen.jpg
https://upload.orthobullets.com/topic/322053/images/aging_population_us_census_data.jpg
  • Definition
    • 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
    • Incidence
      • elderly population is growing in the US
      • >85 year old group had fastest growth (30%) between 2000-2010
  • Etiology
    • 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 common
        • 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
    • Cardiac work-up
      • risk of major adverse cardiac events assessed with revised cardiac risk index or NSQIP risk calculator
      • guides pre-opertive work-up and timing of operative procedures
  • 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 associated with
        • 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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