Updated: 1/19/2020

Geriatric Patient Trauma

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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
  • 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 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 q
    • 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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Questions (4)
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(OBQ17.199) An 85-year-old woman is found to have an isolated left hip fracture after a fall from standing. All of the following have been demonstrated to be a benefit of an orthopaedic geriatric comanagement service EXCEPT? Tested Concept

QID: 210286
1

Decreased time to surgery

20%

(377/1916)

2

Decreased post-operative mortality

6%

(111/1916)

3

Decreased post-operative complication rate

3%

(57/1916)

4

Decreased need for post-discharge rehab facility

47%

(902/1916)

5

Increased post-operative mobility

23%

(444/1916)

L 4 A

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