Orthopedic Concerns in the Elderly
Authors: Steven F. Fisher, MD, Department of Emergency Medicine, Brown University School of Medicine, Rhode Island Hospital, Providence, RI; Selim Suner, MD, MS, FACEP, Assistant Professor, Department of Emergency Medicine, Brown University School of Medicine, Rhode Island Hospital, Providence, RI.
Peer Reviewers: Melissa E. Clarke, MD, Assistant Professor, Howard University Hospital, Division of Emergency Medicine, Washington, DC; Deborah T. Gold, PhD, Associate Professor of Medical Sociology, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC.
The world’s aging population is a distinct segment of society with specific medical concerns. While the majority of the orthopedic injuries afflicting the elderly are not immediately life-threatening, these injuries precipitate untimely mortality. Furthermore, orthopedic injuries lead to long-term morbidity and a significant decline in function, which may greatly restrict the independence of some individuals.
This article is devoted to addressing the common orthopedic concerns encountered by the elderly. Common fractures, predisposing factors, therapeutic techniques, and preventive measures will be discussed. The value of a thorough evaluation and the prompt initiation of care by emergency physicians will be stressed. Moreover, to better advocates for their patients, emergency physicians should be well versed in the preventative strategies that may benefit patients at risk.
— The Editor
Epidemiology
Fractures in the elderly are of great medical and economic concern. The proportion of the world’s elderly population continues to grow rapidly, largely because of an increased life expectancy. Improved health care and heightened health consciousness account for this longevity. By the year 2020, the U.S. Census Bureau predicts that the average life expectancy will be 82.0 years for women and 74.2 years for men.1 In fact, this segment of the population is now the fastest growing group in the United States and other developed countries.2 As the elderly population continues to grow, so will their encumbrance upon an already overwhelmed health care system. For this reason, strategies for improved medical care and prevention must be devised. Similarly, the demand for emergency physicians well-versed in the management of fractures in the elderly will increase to counter the challenge of an increasing number of elderly patients presenting with common fractures. As the emergency department is the portal to medical care for many, the emergency physician must be cognizant of current therapies and preventative strategies in order to reduce morbidity, mortality, and the costs of hospitalization. Furthermore, the task of coordinating the multidisciplinary care of patients often befalls the emergency physician.
Predisposing Factors
The etiology of fractures in the elderly may be subdivided into intrinsic and extrinsic factors. Intrinsic factors are those predisposing conditions innate to bone, such as osteoporosis and other disease-related processes. Conversely, extrinsic factors, such as trauma and elder abuse, are those that are not related to the innate properties of bone. Most commonly, traumatic injuries affecting the elderly are the result of falls or motor vehicle accidents. Excepting non-traumatic osteoporotic or pathologic fractures, the elderly are susceptible to the same mechanical forces placed upon younger people in traumatic injury. The elderly, however, cannot tolerate these same mechanical forces and suffer heightened injury.
Osteoporosis. Osteoporosis is the most common metabolic bone disease in the United States and a significant cause of morbidity among the elderly. Affecting the physical and psychological prosperity of nearly 28 million Americans, it is one of the most predominant diseases associated with aging.3 In addition to aging, osteoporosis is the consequence of genetic, hormonal, and nutritional factors, as well as physical forces.4 It is characterized by a concomitant reduction in bone mass and deterioration in skeletal microarchitecture, which ultimately compromises bone integrity. Moreover, the link between osteoporosis and the preponderance of fractures in the elderly cannot be disputed.
For white women, the lifetime risk of suffering a hip fracture is 19%, a distal forearm fracture is 16%, and a vertebral fracture is 15.6%. In fact, a white woman has a 40% chance of suffering one of these fractures during her lifetime.5 Furthermore, in the United States, approximately 80% of osteoporotic fractures occur in women, and the age-specific incidence of these fractures is higher in women than men.6 Although the number of men afflicted with osteoporosis is unknown, estimates of lifetime fracture risk range from 13% to 25%.7
Osteoporosis alters the usual balance between formation and resorption of bone during remodeling. Bone is resorbed by osteoclasts at a greater rate than it is formed by osteoblasts, resulting in a loss of both bone mass and density. Due to this unbalanced resorption, the bone becomes so fragile that it cannot withstand the normal mechanical forces placed upon it. Ultimately, a fracture occurs and osteoporosis becomes a clinically evident problem. The most common orthopedic injuries associated with osteoporosis are vertebral compression fractures, distal radius fractures, and proximal femur (hip) fractures. Hip fractures result in considerable morbidity and mortality.8 Vertebral compression fractures and distal radius fractures also lead to significant morbidity, and in the case of vertebral fractures, also substantial mortality. No matter the specific outcome, few with an osteoporosis-related fracture elude a reduction in quality of life.
Heightened bone resorption commences circa the beginning of menopause in many women (type I), and age-related bone loss (type II) becomes evident in the sixth decade of life in many men and women.9 In women, bone mass and density peak between menarche and the fourth decade.10 Thereafter, there is a small premenopausal decline in bone mass, but the onset of menopause propagates a more precipitous loss of bone mineral density. In fact, interruption of the endogenous supply of estrogen during menopause appears to increase the activation of new remodeling sites.11 An increased number of active remodeling units leads to the complete penetration of trabecular bone. The consequence of which appears to be a loss of the template upon which new bone may be formed and a subsequent permanent deficit in bone mass and structure.12 The average rate of decline in bone mineral density in untreated women is highest during the initial five years after the onset of menopause or after the discontinuation of estrogen replacement. In fact, an annual loss of approximately 2-4% of bone mineral density can be expected.13 Although bone loss persists indefinitely, the rate of such loss gradually declines to approximately 1-1.5% per year by 10 years postmenopause. In one study, however, a possible acceleration of bone loss was noted after the age of 70.14
In men, the three major causes of osteoporosis are alcohol abuse, glucocorticoid excess, and hypogonadism. These etiologies account for 40-50% of all men with osteoporosis.7 Nevertheless, it is important to consider occult gastrointestinal (GI) disease when treating a man whose osteoporosis is not readily explained. Interestingly, these men are typically not symptomatic of GI manifestations. The list of other potential causes of osteoporosis in men is extensive. Unfortunately, when all known or likely causes are ruled out, approximately 40-50% of men will not have a known etiology.15 Therefore, the diagnosis of idiopathic osteoporosis in men is common. An arbitrary upper age limit is imposed for this diagnosis, as eventually age alone can account for bone loss in both men and women.16
Measurement of bone mass is used in the diagnosis and monitoring of osteoporosis. The methods for measuring bone mass have improved greatly in recent years. Specifically, dual energy x-ray absorptiometry (DXA), quantitative computed tomography (QCT), and single-photon absorptiometry (SPA) currently are the most commonly used techniques. DXA allows for the rapid and precise determination of the body’s bone mineral mass, in addition to lean vs. fat soft-tissue composition. More importantly, the x-ray-based system evaluates bone mineral density at individual anatomic locations such as the spine, hip, and forearm. Conversely, QCT offers the advantage of less radiation while quantifying the absorption of ionizing radiation by calcified tissues. These measurements are then compared to standard reference material in order to calculate bone mineral equivalents. QCT, however, is limited by its high cost. Finally, SPA employs a beam of low-energy photons to assess bone mineral density at peripheral sites such as the radius or calcaneous, where the thickness of surrounding soft-tissue is low and may be controlled. It has the advantages of being radiation-free and having low cost.17
DXA, however, has been the most successful technique due to its ability to measure bone mass at virtually all skeletal sites. This is important, as bone mass at one site cannot be predicted from measurements performed at another site, even in the same individual.18 Therefore, assessment at particular sites is preferable. Nevertheless, all of the aforementioned modalities, as well as prospective techniques currently under development, may be excellent predictors of future fracture risk.
Falls. Falls are a common event in the lives of older persons, and may result in significant morbidity, mortality, and health care utilization. Nearly 20% of elderly adults require the assistance of another person or a device (such as a cane or walker) to ambulate. Furthermore, such assistance is necessary in almost 40% of patients age 85 older.19 Per annum, falls occur in 32% of individuals between the ages of 65 and 74, in 35% of those between ages 75 and 84, and in 51% of those 85 years or older.20 Approximately 4-6% of falls in elderly persons result in fractures, one-fourth of which occur at the hip.21 Additionally, falls account for 12% of all deaths (directly or indirectly) in the aged.20 More often, falls result in restriction of mobility or activity and can lead to a loss of independence and fear. This fear is validated by the fact that more than two-thirds of those elderly who fall will do so again within six months.22 Decreased confidence in the ability to safely ambulate can lead to further functional decline, depression, feelings of helplessness, and social isolation. Furthermore, the inability to rise after a fall is distressing and dangerous. Elder persons found on the ground for prolonged periods are at increased risk of subsequent complications, not limited to dehydration, hypothermia, decubitous ulcers, pneumonia, and rhabdomyolysis.
Falls are the result of different etiologies and circumstances. Unearthing the precipitant of a fall is as vital as the identification and treatment of the subsequent injuries. Identified risk factors for falling include age, cognitive impairment, medications, chronic disease, vertigo, and impairments in strength, balance, and gait.21 The combined number of risk factors is also quite pertinent. One community-based prospective study demonstrated that 8% of elderly persons with no risk factors, as opposed to 78% of those with four or more risk factors, fell within the year.23 Additionally, the chance of suffering multiple falls directly increased with the number of risk factors.24
As individuals age, they are inevitably besieged with multiple medical conditions, which may lead to an increased susceptibility to falls. It is estimated that known syncope accounts for 2-15% of falls in the elderly, but many syncopal episodes go unidentified. Thus, it should be considered a potential precipitant of all unwitnessed falls and, therefore, investigated.25 The most frequent causes of syncope in elder persons are vasovagal reactions, cardiac arrhythmias, and orthostatic hypotension. Likewise, delirium is another common antecedent for falls in the elderly. Approximately 10% of elderly patients older than age 65 meet the criteria for delirium. Unfortunately, fewer than 25% of delirious patients are identified.26 Gait disorders, another precipitant of falls, are present in 20-50% of the elderly population.27 These disorders may be attributed to multiple factors, including chronic diseases that impair sensory, cognitive, neurologic, or musculoskeletal function. Last, medications also can be a cause of falls. Drugs implicated included sedatives-hypnotics, diuretics, and cardiac medications.
The realization that a fall may be a sentinel event in the life of an aged person should prompt emergency physicians to initiate appropriate interventions for these people. The diagnostic assessment of an elderly person who has suffered a fall should focus on identifying risk factors that can be ameliorated to reduce the likelihood of future falls. (The basic components of the clinical assessment are outlined in Table 1.) The coordination of multi-specialty care through appropriate referrals is paramount. Interventions that improve functional status or curb functional decline may increase a patient’s well-being as well as longevity.
| Table 1. Imperatives in Assessment of the Elderly Patient Who Has Sustained a Fall | |
| Pertinent History | |
| Precipitants of Fall | |
| Loss of balance | |
| Environmental hazards | |
| Postural change | |
| Medication alterations | |
| Alcohol use | |
| Elder abuse | |
| Associated Symptoms | |
| Chest pain | |
| Dyspnea | |
| Palpitations | |
| Lightheadedness | |
| Vertigo | |
| Weakness | |
| Confusion | |
| Comorbid Conditions | |
| Previous CVA | |
| Parkinsonism | |
| Osteoporosis | |
| Seizure disorder | |
| Cardiac disease | |
| Joint dysfunction | |
| Sensory deficit | |
| Prior fall | |
| Alcohol abuse | |
| Pertinent Medications | |
| Antihypertensives | |
| Diuretics | |
| Antidepressants | |
| Narcotics | |
| Neuroleptics | |
| Sedatives | |
| Physical Examination | |
| General appearance | |
| Vital signs, including orthostatics | |
| Hydration status | |
| Nutritional status | |
| Mental status | |
| Focal neurologic deficit | |
| Signs of neurologic disease | |
| Evidence of traumatic injury | |
| Decreased visual acuity | |
| Carotid bruits | |
| Cardiac bruits | |
| Cardiac murmurs or arrhythmias | |
| Abdominal masses or bruits | |
| Arthritic changes | |
| Motion limitation | |
| Functional Assessment | |
| Gait and balance | |
| Rising from chair | |
| Walking | |
| Turning | |
| Sitting down | |
| Mobility | |
| Command of assistive devices | |
| Endurance | |
| Activities of Daily Living | |
| Bathing | |
| Dressing | |
| Continence | |
| Transferring | |
Pathological Fractures. Pathological fractures are those that result from a focal disease process, which compromises the integrity of bone. Typically, the fracture occurs during normal activity or with minor trauma. The two most common etiologies of pathological fractures are malignancies and Paget’s disease. Metastatic carcinoma remains the most common malignancy of bone.28 In fact, the most likely primary cancers to invade bone are breast, lung, thyroid, kidney, and prostate. Multiple myeloma is the most common primary malignancy of bone, but other cancers of the hematopoietic system, such as lymphoma and leukemia, may precipitate pathologic fractures.28 Less commonly, osteosarcoma and chondrosarcoma, cancers of the bone itself, may lead to fractures as well.
Paget’s disease (osteitis deformans), a pathological increase in bone turnover, is a common bone disorder in the geriatric population. Second only to osteoporosis, it is characterized by the resorption of normal bone and the excessive deposition of abnormal bone.29 Although the newly formed bone is dense, it is structurally abnormal and a precursor to pathological fractures. While Paget’s disease may involve only one bone, typically multiple sites are implicated in an asymmetrical distribution. In 75% of cases, the affected sites include the pelvis, the lumbar spine, and the femur.30
Ninety-five percent of patients with Paget’s disease are asymptomatic, making it difficult to diagnose. For those patients who do experience symptoms such as bone pain, skeletal deformity, and fracture; diagnosis is difficult nevertheless because such symptoms may be attributed to concomitant or pre-existing arthritic changes. In fact, up to 30% of patients who experience symptoms do so for at least 10 years prior to diagnosis.30 While its presentation is insidious, Paget’s disease leads to significant morbidity in elder persons.31 In fact, it may affect up to 3% of adults older than age 40.32
Elder Abuse. Elder abuse is a real and significant problem that plagues the elderly population and is an occasional cause of fractures. The House Select Committee on Aging estimates that 1-2 million elder Americans are abused each year.33 The true prevalence of elder abuse may be much higher, however, as many cases are not reported.34 In fact, a Boston survey demonstrated that only one in 14 cases of elder abuse is reported, and reporting is rarely done by physicians. One Michigan study demonstrated that only 2% of reported cases in the state were made by physicians.35
Emergency physicians may be the only persons to encounter a victim of elder abuse and are, therefore, uniquely positioned to identify and assist them. A random survey in 1992, however, revealed that only 27% of emergency physicians had protocols available for the appropriate management of suspected elder abuse. Interestingly, 75% of these physicians reported having algorithms in place for suspected child abuse.36 In contrast to cases of suspected child abuse, mandatory reporting of elder abuse may infringe upon the autonomy and privacy of the competent adult. Furthermore, mandatory reporting may discourage abused elderly from seeking medical care because of the fear of embarrassment and institutionalization. For these reasons, elder abuse may necessitate specific laws and management that differ from classic abuse models. Nevertheless, mandatory reporting laws exist in all 50 sates and the District of Columbia.37
Elder abuse is typically divided into four categories: physical, emotional, financial, and neglect.38 Sexual abuse is often included within the category of physical abuse. Similarly, neglect may be divided into "passive neglect" and "active neglect." The active form of neglect implies that the caregiver willfully fails to provide essential care, while passive neglect may result from a caregiver’s ignorance or lack of skills.39
An elderly patient’s chief complaint may be indicative of abuse. Falls, dehydration, and failure to thrive may reflect abusive situations. A thorough physical exam may uncover signs of abuse. These signs may include bruises and fractures of various ages, rope and restraint marks, habitual and neurotic disorders, and signs of general neglect. Avoiding confrontation and asking non-judgmental questions regarding a caregiver’s difficulties in caring for an elderly patient may uncover signs of an abusive relationship. Victims are likely to withhold information regarding abuse, as they often feel embarrassed or guilty. Additionally, they may fear retaliation by the caregiver or subsequent institutionalization.
Treatment
Although the elderly are subject to the same mechanisms of injury as younger people, their response to injury is unique. Traditional trauma-care protocols, which have been devised for younger patients, should be adapted or augmented for the elderly. The declining health and reduced physiologic reserves of the elderly lead to worsened outcomes after traumatic injury. Additionally, the cause of the patient’s traumatic injury must be investigated. Often, acute illness, myocardial events, and syncopal episodes may have precipitated the mechanism that resulted in the patient’s injury. The emergency physician should attempt to recreate the injury scene in order to predict potential injuries the patient may have suffered.
Initially, the principles regarding the care of the multiply injured elderly patient remain the same as those of the younger patient. Priority must be placed upon a proper primary survey. The patient’s airway must be secured utilizing a manual airway maneuver, oropharyngeal or nasopharyngeal adjuncts, or endotracheal/nasotracheal intubation. Should these techniques fail, a surgical airway via cricothyrotomy should be obtained. Concurrent with airway maintenance, the patient’s cervical spine should be immobilized. Cervical immobilization is necessary to prevent spinal cord injury in the presence of an occult vertebral fracture or ligamentous neck injury that may compromise the integrity of the spinal column. Immobilization may be accomplished by manually holding the head in neutral anatomic position. This position must be maintained during all movements, transports, and procedures, including intubation. While this is best accomplished utilizing a hard cervical collar secured to a hard board with rigid lateral support material, the elderly patient may require some modifications. Arthritis or severe thoracic kyphosis may alter the normal anatomic positioning of the neck, which may be held in severe flexion. This altered anatomy poses a significant challenge, and proper immobilization may require additional support under the patient’s head.
After the airway is secured and the cervical spine satisfactorily stabilized, proper ventilation must be assured. Should the patient’s respiratory status be uncertain or in jeopardy, assistance should be provided with bag-valve-mask ventilation and high flow oxygen. Furthermore, any precipitants of ventilatory compromise must be sought. The presence of pneumothorax and hemothorax should be ruled out and, if present, treated immediately with tube thoracostomy. Subsequently, adequate circulation should be assessed and maintained. Visible hemorrhage should be controlled with appropriate, direct pressure. Concurrently, fluid resuscitation via large-bore peripheral intravenous catheters should be initiated with crystalloid fluid and/or blood products as necessary. The use of pneumatic anti-shock garments (PASG) is controversial, but may stabilize the pelvis and have a role in maintaining circulatory pressure in trauma patients with pelvic fractures. Most importantly, immediately life-threatening causes of circulatory compromise, such as pericardial tamponade, tension pneumothorax, and massive pulmonary embolism, must be detected and alleviated.
Only after the primary survey is complete should the assessment of musculoskeletal trauma begin. Nevertheless, the role of musculoskeletal trauma in precipitating immediate mortality or severe morbidity should not be underestimated. Elderly patients who possess poor physiological reserve may develop shock subsequent to blood loss. In fact, an isolated femur fracture, which may lead to a liter or more of blood loss, can precipitate hemorrhagic shock. Nevertheless, the hypotensive trauma patient with an obvious lower extremity injury necessitates a full traumatic work up to ensure that concomitant cardiac, pulmonary, abdominal, renal, pelvic, or spinal injuries do not exist.
Hip Fractures
Introduction. Sustaining a hip fracture is a devastating event, which leads to hospitalization, surgical correction, increased morbidity and mortality, reduced mobility, and often, the inability to live independently. The long-term morbidity associated with hip fractures is significant. In fact, one study found that only half of the patients who could walk independently prior to a hip fracture regained this capability.40 Further, one-third of patients with hip fractures became totally dependent upon others to perform the most basic activities of daily living.41 Elderly patients who suffer a hip fracture experience a 12-20% reduction in survival, with 5-20% excess mortality within the first year, after a hip fracture as compared to patients of the same age, race, and gender who have not suffered the same.8,42,43
Epidemiology. Projections estimate that the annual number of hip fractures worldwide will rise to 6.26 million by the year 2050.44 This projected increase can be attributed to the growth of the world’s elderly population, most prominently in Asia, Africa, Latin America, and the Middle East. In fact, these areas of the world are projected to account for more than 70% of the estimated 6.26 million hip fractures in the year 2050.45 Similarly, in North America the number of hip fractures is increasing with the projected incidence of 650,000 per annum by the year 2050. Currently, more than 350,000 Americans fracture their hips each year and more than 90% are attributed to falls.46 It is important to note, however, the age-specific incidence rates of hip fractures concurrently are increasing with the expanding elderly population.47 For this reason, the projected increase in hip fractures cannot be based solely upon an aging population.
The frequency of hip fractures varies markedly between populations and races. Whites of Northern European and North American descent account for the highest incidence of hip fractures worldwide. Minority populations also suffer significant morbidity and mortality from hip fractures. Rates of fractures in both Asian and Hispanic populations are significant, and the incidence of hip fractures increases exponentially with age in every cluster. The lifetime risk of a hip fracture is 5-6% in white men and 16-18% in white women.48 Ninety percent of all hip fracture patients are older than age 65.49 In fact, by the age of 80, one-fifth of all women have suffered a hip fracture. By the age of 90, almost half of all women will have broken a hip.50 In 1990, worldwide, the incidence of hip fractures in women was approximately double that of men. The preponderance of fractures in women is explained by a lower bone mass and density, as well as a higher frequency of falling.45 Thus, while hip fractures may be more prevalent in some populations, they are a significant cause of morbidity and mortality in all groups.
Evaluation. After the initial evaluation and stabilization of the elderly trauma patient, the secondary survey may commence. The clinical presentation of a hip fracture may vary greatly with the type of fracture involved. Non-displaced fractures may be relatively symptom free, while displaced fractures are likely to be accompanied by severe pain and loss of function. Often, patients with displaced fractures will be unable to ambulate and the extremity may be shortened and externally rotated. If a traction device has been placed in the field, it should be removed to facilitate an adequate examination. The extremity should be immediately assessed for sites of external bleeding and obvious deformities. Importantly, any wound near a likely fracture should be considered an open fracture until proven otherwise and wrapped in a sterile dressing. The extremity should be palpated for areas of tenderness, swelling, deformity, or crepitus. Furthermore, an examination of the distal extremity for vascular or neurologic compromise is imperative. Pulse discrepancies, coolness, pallor, paresthesia, and motor abnormalities are suggestive of an arterial injury. Similarly, paresis, paralysis, and paresthesia are indicative of neurologic compromise.
Once identified, an injured extremity may be immobilized and supported. A position of comfort (flexion, abduction, and external rotation at the hip) may be achieved with a pillow beneath the thigh.51 A Hare traction splint may be applied to reduce the fracture as well as discomfort. Importantly, there are two contraindications to the application of the Hare splint or any other traction device. First, sufficient traction to reduce an open fracture should not be applied. Realigning the contaminated ends before debridement of the wound in the operating room may precipitate or propagate infection. Second, traction should be avoided when injury to the sciatic nerve is suspected. Further force upon an already stretched or partially torn nerve could be devastating.52
Initial radiographic assessment of the hip includes an anteroposterior view of the hip and pelvis. If a high index of suspicion for hip fracture exists, a cross-table lateral view may be obtained initially as well. The cross-table lateral view is preferred to the frogleg lateral view, which requires positioning that is difficult for patients with hip fractures and a subsequently reduced range of motion. Furthermore, frogleg positioning may result in increased displacement of the fracture fragments. An internal rotation view of the hip may allow identification of otherwise occult nondisplaced or impacted fractures. Typically, the view is obtained with the lower extremity in 15 degrees of internal rotation, which allows visualization of the entire femoral neck. When a suspected fracture remains unidentified, a technetium bone scan or magnetic resonance imaging (MRI) may be utilized. The sensitivity and specificity of bone scanning, 93% and 95% respectively, are not altered by the patient’s age or time after injury.53 Similarly, MRI has been shown to be equally efficacious in locating occult fractures.54 Following radiographic studies, the extremity should be re-immobilized for comfort.
The majority of patients with hip fractures are in severe pain and, in addition to immobilization, parenteral analgesia should be provided when not contraindicated by an associated injury. Alternatively, femoral nerve blockade may be attempted. Also, prophylactic antibiotics, when not contraindicated, should be initiated in patients who are likely to undergo immediate internal fixation. Typically, a parenteral bolus of a first-generation cephalosporin should be sufficient.55 Antibiotics are also recommended for open fractures. Importantly, the size and perceived cleanliness of the wound dictates the antibiotic regimen that should be utilized. In reasonably clean wounds of less than one centimeter, a first-generation cephalosporin should be ample. Conversely, dirty wounds and/or those greater than one centimeter may require increased gram-negative coverage, such as an aminoglycoside.56 Penicillin may be added to the antibiotic regimen if the wound is grossly contaminated and potentially inoculated with clostridia.57 Furthermore, the patient’s tetanus status must be determined. For those elderly persons whose vaccination history indicates unknown or partial immunization, tetanus immune globulin (TIG) and tetanus vaccine (Td) should be administered concomitantly.
Finally, all fractures of the proximal femur necessitate orthopedic consultation. Unless a specific contraindication to surgical repair exists, surgical intervention is required. In fact, surgical management with early mobilization, to avoid the sequelae of prolonged immobilization, is the generally accepted therapy in the elderly. Surgical correction of the fracture should take place as soon after the injury as possible, but only after stabilization of the patient is ensured. Interestingly, when the factors of age, sex, and number of comorbidities were controlled in one prospective study, delaying the operative management of the fracture by 48 hours doubled the patient’s risk of mortality during the first postoperative year.58 Therefore, it is imperative that an orthopedic surgeon be contacted promptly and encouraged to expeditiously perform operative repair. Also, the emergency physician should obtain appropriate preoperative laboratories such as a complete blood count, type and screen, coagulation studies, and urinalysis, in addition to an ECG and chest x-ray, to facilitate the process.
Femoral Neck Fractures
The femoral neck, which connects the femoral head to the shaft of the femur in the region of the trochanters, is extremely susceptible to fracture in the elderly. (See Figure 1.) Age-related bone loss or osteoporosis is believed to be the major determinant of the incidence of femoral neck fracture; hence, as previously noted, an increased preponderance of these fractures can be expected as the population ages.59 The mean age of patients suffering this fracture is 74 to 78 years.60 Often, because femoral neck fractures are associated with osteoporosis, the inciting traumatic event may be seemingly trivial. In fact, many femoral neck fractures may occur before the patient hits the ground.61 In older adults, hip fractures cause falls almost as frequently as they result from falls.
Classification. The Garden classification system is most commonly used to describe femoral neck fractures. The system is based upon the degree of displacement of the fracture fragments. This potentially complex classification system may be simplified by grouping types I and II (non-displaced) and types III and IV (displaced). This simplification allows femoral neck fractures to be appropriately classified as to treatment and prognosis and, therefore, obviates the need for further differentiation.62
Treatment. Surgical management of femoral neck fractures is the therapy of choice, barring relative contraindication because of severe medical or mental problems. Impacted or non-displaced femoral neck fractures should undergo in situ internal fixation with multiple screws or pins. Some authors prefer three cannulated 6.5 mm cancellous lag screws inserted in parallel under fluoroscopy.63 Interestingly, internal fixation is not advocated for displaced femoral neck fractures in the elderly. A high rate of nonunion and osteonecrosis has led to the implementation of primary prosthetic replacement as the therapy of choice.63 Nevertheless the treatment decision should be based upon the individual patient. Emphasis should be placed upon the patient’s age, associated medical problems, extent or comminution of the fracture, and the quality of bone.
Intertrochanteric Fractures
The intertrochanteric region, which encompasses both the greater and lesser trochanters, is the transitional area between the femoral neck and shaft. Trabecular bone, which effictively transmits and disburses mechanical stress, is prominent in this region. As opposed to the femoral neck, the intertrochanteric region is well vascularized and not at great risk of osteonecrosis or nonunion. (See intertrochanteric fracture in Figure 2.)
Classification. The Evans classification system is utilized to describe intertrochanteric fractures. The system is based upon fracture stability and the ability to convert an unstable fracture to a stable reduction.64 This classification system, however, may be difficult to reproduce, and intertrochanteric fractures may be better classified simply as stable or unstable. In general, stability is based upon whether the posteromedial cortex is intact.
Treatment. Operative management is advocated for virtually all intertrochanteric fractures. Instability or comminution of the fracture site, however, may necessitate anatomic fracture alignment, in addition to fixation. Fixation of the fracture may be accomplished with a sliding hip screw or an intramedullary nail and hip screw. In studies comparing these methods, both have been found to have a similar operative management, hospital course, complication rate, and implant failure. The intramedullary nail and hip screw, however, may lead to femoral shaft fractures at the nail tip or distal locking bolts.65 Therefore, the sliding hip screw is advocated by some authors.66 Regardless of the management selected, early weight-bearing ambulation should be encouraged following fixation.
Vertebral Fractures
Introduction. Elderly patients sustain a substantial number of spinal fractures because of osteoporotic changes associated with aging. The most clinically relevant of these changes is the demineralization of the vertebral body. Patterns of injury vary considerably, however, suggesting that other factors may contribute to spinal injury as well.67 Compression fractures of the vertebrae may occur spontaneously or with minimal trauma, such as occurs with coughing or simple household tasks like removing laundry from the washer. Multiple vertebral fractures may precipitate severe impairment, including kyphosis and the loss of the lumbar lordosis. Moreover, the eventual impairment of chest wall function in severe and debilitating kyphosis may reduce vital capacity.68 Therefore, diminished thoracic space may result in decreased exercise tolerance and the ability to perform the activities of daily life. Similarly, the compression of abdominal contents may be disfiguring and extremely painful. Reduced abdominal space may lead to premature satiety and accelerated weight loss.69
Epidemiology. Secondary to osteoporosis, more than 500,000 vertebral fractures occur annually in elderly patients in the United States.4 Vertebral fractures occur more frequently than fractures of the proximal femur or distal radius in women older than age 65. In fact, one-third of women in this age group sustain a vertebral fracture. By age 75, 90% of the population will have had plain radiographs demonstrating vertebral body compression.70 (See Figure 3.)
Evaluation. Patients with vertebral fractures usually develop back pain that leads to radiological assessment. Of note, however, pain in the lumbar or sacral regions is less predictive of vertebral compression fractures than is pain in the thoracic area. While height loss of more than 1 inch is a sensitive indicator of compression, it can occur without fractures due to narrowing of vertebral disks and postural changes. Conversely, many patients may be asymptomatic and their vertebral fractures found incidentally. Importantly, the most frequent fractures are in the thoracic vertebrae below T6 and in the lumbar vertebrae.71
When evaluating the aged spine, primary or metastatic disease must be considered as a potential etiology in vertebral body collapse. This diagnosis, however, is often difficult to make based solely on radiographic studies. While MRI may facilitate a diagnosis, a definitive diagnosis can only be made through examination of vertebral body fragments recovered during surgery.67
Treatment. Multiple vertebral fractures have a considerable impact upon the elderly by reducing their ability to engage in the activities of daily life. Recent findings contradict prior research on patients with vertebral fractures and suggest that the functional impact of these fractures can, in fact, be substantial. In one study, patients with vertebral fractures scored substantially lower on physical performance measures, such as functional reach and mobility skills, and their walking was slower, with reduced endurance.72 Moreover, patients who have suffered a vertebral fracture are at increased risk of future peripheral and vertebral fractures. Consequently, these patients lose self-esteem and may become depressed.69,73 The goals of acute management, therefore, are to maximize pain control, to expeditiously mobilize the patient, and to initiate appropriate social services.
Distal Radius Fractures
Introduction. The forearm is a complex structure that provides mechanical stability and enables coordinated movement of the wrist and elbow. Integrity of forearm is essential for intricate movements of the hand; therefore, fractures of the forearm may have a devastating effect upon a patient’s ability to perform even simple activities.
Epidemiology. Distal forearm fractures are the most common fractures encountered in orthopedics and account for approximately 15% of all fractures requiring emergency care.74 Women older than age 50 have been shown to have a significant increase in the incidence of distal radius fractures, while men older than age 70 had only a minimal increase.74 In fact, one study found that more than 85% of all distal radius fractures occur in women older than age 50.75 Also of note, prior to age 70, distal forearm fractures occur more frequently than hip fractures.76
Evaluation. A detailed understanding of anatomic relationships in the forearm provides the basis for evaluation in the emergency department. Muscles anchored to the dorsum of the forearm enable extension of the wrist and digits. Similarly, muscles attached volarly enable flexion of the same. Importantly, these muscular attachments may precipitate significant displacement of bones upon fracturing the wrist. For this reason, clinical and radiographic evaluations must be systematic and thorough. (See Figures 4a and b.) Radiographs should include the joints above and below the suspected fracture site.
Classification. Numerous eponyms exist for fractures in this region, resulting in considerable confusion in the literature, as well as in clinical practice. Furthermore, no universally accepted classification system exists. While the literature regarding classification has evolved significantly, eponyms are still frequently used by clinicians to describe fractures. Examples of common eponyms include Colles’ fracture and Smith’s fracture which, respectively, describe dorsal and volar angulation of the displaced metaphyseal fracture. While eponyms allow for a rapid and simplified description of a fracture, a classification system should provide information as to the type and complexity of a fracture, in addition to a basis for treatment. For example, the Frykman classification system describes a distal radius fracture involving the radiocarpal or radioulnar joints with or without involvement of the ulnar styloid. (See Table 2.) This classification system categorizes fractures into types I-VIII. The complexity and difficulty of management increases respective to the type.77 More recent schemes have sought to describe fracture stability and direct reduction techniques and operative indications. Nevertheless, no perfect scheme exists at this time.
| Table 2. The Frykman Classification | |||||||
| Type I | Type II | Type III | Type IV | Type V | Type VI | Type VII | Type VIII |
| Extra-articular | Extra-articular | Involvement of the radio-carpal joint | Involvement of the radio-carpal joint | Involvement of the radio-ulnar joint | Involvement of the radio-ulnar joint | Involvement of both joints | Involvement of both joints |
| Intact ulnar styloid | Fractured ulnar styloid | Intact ulnar styloid | Fractured ulnar styloid | Intact ulnar styloid | Fractured ulnar styloid | Intact ulnar styloid | Fractured ulnar styloid |
Treatment. Nondisplaced fractures of the distal radius are amenable to non-operative treatment. After appropriate radiographic evaluation, the fracture may be immobilized in a short arm cast. Alternatively, the extremity may be immobilized initially with only a volar splint to allow for severe swelling. It should be noted that fiberglass is preferable to plaster in the elderly, as it is much lighter and permits greater mobility.
Displaced fractures, however, necessitate either closed or open reduction. Fracture reduction should be attempted in all closed displaced distal radius fractures. Importantly, due to atrophic skin, the elderly are susceptible to soft-tissue injury during attempted closed reduction. For this reason, the forearm should be pre-wrapped in web roll and the fingers placed carefully in the finger traps. Additionally, excessive traction upon and exaggeration of the fracture should be avoided.78 After fracture reduction, the forearm should be immobilized in a sugar-tong splint. The fracture, as well as the splint, should then be assessed radiographically.
The criteria for appropriate reduction of distal radius fractures remains controversial. Younger patients will tolerate only minimal post-reduction displacement or deformity at the fracture site. In these patients, a poor reduction may lead to debilitating pain and poor functional outcome. Conversely, elderly patients, particularly those who lead sedentary lifestyles, may tolerate more post-reduction displacement or angulation. Importantly, the patient must be re-assessed in one week. At that time, the sugar-tong splint may be changed to a short-arm cast. Additionally, if the fracture reduction has been compromised, it may be re-attempted. Repeated manipulation of the fracture, however, has been reported to lead to a satisfactory outcome less than half of the time.79 If signs of fracture instability exist after reduction, surgical intervention may be indicated. Importantly, in the elderly, functional requirements must be reviewed prior to subjecting a patient to surgical repair. Those with multiple medical problems, cognitive deficits, and sedentary lifestyles may be better managed non-operatively.
Fractures with a high degree of displacement, comminution, and soft-tissue injury may necessitate operative management. External fixation is typically the preferred approach in the elderly, because of the high frequency of comminution and osteopenia.75 Alternatively, open reduction and internal fixation is indicated for complex fractures involving articular surfaces, which are inherently unstable. Open fractures require aggressive management. Antibiotic therapy, tetanus toxoid, and surgical debridement are imperative. Following debridement, external fixation is typically advocated for fracture stabilization. While specific indications exist for either operative technique, they are well beyond the scope of this article.
Although in the majority of patients, the long-term functional consequences of sustaining a distal forearm fracture are minimal, some patients do experience restricted activity, chronic pain, and limited function.80 For these patients, the chronic pain associated with distal forearm fractures can alter their daily routine. These effects, however, can be ameliorated by the immediate initiation of treatment and physical therapy. In fact, the elderly may benefit greatly from a formal physical therapy regimen to maximize rehabilitation. Informal rehabilitation, however, may begin while the patient is still in the emergency room with finger range-of-motion exercises.81
Prevention
The prevention of diseases associated with old age should commence in youth. The value of primary prevention (hindering the development of disease processes) or secondary prevention (arresting the progression of disease) dissipate with increasing age; hence, a greater burden is placed upon tertiary prevention (minimizing disability due to disease). Importantly, an accurate assessment of the geriatric patient in the emergency department may identify those at risk for osteoporosis and other age-related conditions.
Osteoporosis. Alterations in lifestyle, such as regular weight-bearing exercise, smoking cessation, and reduced alcohol consumption may significantly reduce an individual’s susceptibility to osteoporosis. A sedentary lifestyle may reduce the mechanical forces exerted upon the skeleton and precipitate bone loss through increased resorption. Thus, physical activity is perhaps the most important means to improve bone mass and inhibit bone loss.48 Regular weight-bearing exercise may reduce the risk of hip fracture by at least 50%.82 Physical activity is also associated with improved muscle strength, stability, reaction time, balance, and coordination. Additionally, a woman who undergoes smoking cessation prior to menopause will reduce her fracture risk by approximately 25%.82 Furthermore, alcohol decreases bone density, while simultaneously increasing one’s risk of falling.83 Therefore, avoidance of excessive alcohol consumption is also of great importance.
In postmenopausal women, estrogen replacement therapy reduces the risk of hip fracture by at least 50%.84 In fact, hormone replacement therapy has been shown to be efficacious in reducing bone loss by approximately 40%.85 Estrogen appears to be most beneficial during the period of accelerated bone loss that occurs immediately after the onset of menopause. However, the high cost and fleeting benefits of estrogen therapy compromise its utility. Moreover, the merit of initiating estrogen therapy in women well into menopause remains uncertain. Conversely, one group demonstrated in a controlled trial that transdermal estrogen therapy reduced bone loss and fractures in women ages 47-75 who were all newly treated.86
Women should take calcium 1500 mg and vitamin D 750 units daily to deter the progressive loss of bone associated with osteoporosis. By doing so, they may reduce the risk of hip fractures by as much as 40%.22 In fact, the NIH Consensus Conference in 1994 recommended a daily intake of 1500 mg calcium for all persons older than age 65.87 Furthermore, one report regarding calcium and vitamin D3 found that an intake of 1500 mg/d of calcium and 800 units of vitamin D resulted in 43% fewer hip fractures and a 32% reduction in all non-vertebral fractures in those older than age 68.88
Antiresorptive therapy via bisphosphonates, such as alendronate, results in high bone mineral density and reduces fracture incidence by approximately 50% within two years of treatment.89 Bisphosphonates bind to bone surfaces and interfere with the resorptive actions of mature osteoclasts.90 They may also inhibit osteoclast activity by causing osteoblasts to release osteoclast-inhibiting substances.91 Moreover, bisphosphonates may indirectly decrease circulating IL-6 levels which stimulates osteoclasts.92 According to one study on women with postmenopausal osteoporosis, 10 mg of alendronate, daily, maximized spinal bone mass.93 (See Figure 6.)
Unfortunately, the identification and treatment of osteoporosis is not atop the priority list of many primary care health providers; hence, as patient advocates, emergency physicians must be cognitive of the disease and its disastrous effects. Proper recognition and appropriate referral will help those who suffer from osteoporosis and osteoporosis-related fractures tremendously.
Falls. In addition to therapies aimed at preventing or limiting osteoporosis, attention must be focused on other factors that precipitate fractures in the elderly. These include neuromuscular and sensory impairment, medicinal side effects, and environmental hazards. Investigations regarding the treatment of older persons to reduce the number or impact of identifiable risk factors are underway. Treatment of these risk factors could potentially decrease the incidence of falls. Older people who fall often reduce their level of activity secondary to fear of further falls and subsequent injury. However, a reduction in activity level leads to further deterioration and greater risk of falling in the future. A regular exercise regimen should include stretching exercises and activities to strengthen muscles in the arms and legs. For example, walking 3-5 times per week is a simple and effective means to increase life expectancy and functional independence and to reduce the risks of heart disease, osteoporosis, and depression.22
Many members of the elderly population are concurrently taking several medications. By doing so, they may be compromising their levels of alertness. Specific medications, dosing alterations, and polypharmacy are closely associated with an increased risk of falling.94 Multiple studies have implicated sedatives, antidepressants, neuroleptics, and antihypertensives as particularly likely medications to precipitate a fall.21 As many as 25% of elderly persons 65 years or older ingest at least one of 20 medications considered unsafe in the aged. Approximately 5% of this population are taking two or more of these drugs.22
Environmental factors that jeopardize the elderly should be altered. Importantly, 44% of falls occur in the presence of environmental hazards.23 Precipitants such as stairs, inadequate lighting, slippery or uneven flooring, electrical cords, and perilous transfers from bed to wheelchair or commode could likely be remedied with appropriate environmental evaluations by out-of-hospital providers. For example, the use of nightlights, handrails, stable footware, even flooring, and secured rugs should be encouraged in order to alleviate common household risks. Moreover, many falls are associated with poor vision; hence, ophthalmologic evaluation should be sought regularly.22
Alternatively, in one randomized clinical trial conducted among elderly nursing home residents with a high risk of falling, the use of energy absorbing hip pads reduced the risk of fracture by more than 50%.95 In addition, new assistive technology has introduced seats that give high-risk patients a biomechanical advantage to decrease bone stress. For example, a spring-loaded seat elevator that assists the elderly individual in standing reduces stress upon the hip.96 These methods of prevention may be beneficial in those who have already progressed beyond earlier preventative strategies.
Elder Abuse. The identification and avoidance of elder abuse are essential to the prevention of fractures in the elderly. According to adult protective services, public and professional awareness is the most significant factor in identifying and preventing elder abuse.97 Additionally, social and home health care services may be extremely beneficial in assessing patients at risk of being abused. While these services may be helpful, they must be activated by physician reporting. Emergency physicians must be cognizant of patient autonomy, while complying with mandatory reporting laws. Victims should be made aware that reporting is intended to make community services available—not to compromise their independence. Also, it must be stressed that emergency care is accessible at any time. Currently, physicians fail to report elder abuse because they are unfamiliar with the law, wary of offending patients, preoccupied with time limitations, and incognizant of available resources.39
Conclusion
While the majority of the orthopedic injuries afflicting the elderly are not immediately life-threatening, these injuries may precipitate untimely mortality, significant morbidity, and reduced independence. As the elderly population continues to grow, so will their encumbrance upon an already overwhelmed health care system. The emergency physician must, therefore, be cognizant of current therapies and preventative strategies in order to reduce morbidity, mortality, and the costs of hospitalization. Furthermore, the task of coordinating the multidisciplinary care of elderly patients often befalls the emergency physician. Most importantly, the elderly are a distinct segment of society and must be treated as such. To this end, it is absolutely imperative for emergency physicians to recognize the unique characteristics of the elderly and tailor their management accordingly.
The authors would like to thank Rachael Fisher, JD, Associate Attorney, Choate, Hall & Stewart, Boston, MA, for help with the preparation of this paper.
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