Geriatric Conditions, Falls, osteoporosis, and fractures

1. Muscle weakness (often the case because of age but more because of becoming sedentary) 2. History of falls (best predictor) 3. Gait deficit (including use of an assistive device) 4. Balance deficit 5. Visual deficit (vision impairments double the risk for falls) 6. Neurological deficits (neuropathies; impaired proprioception; impaired reflexes; impaired brain function; impaired motor control) 7. Arthritis 8. Impaired ADLs 9. Depression 10. Cognitive impairment 11. Cardiovascular deficits

(Intrinsic) Risk Factors associated with falling

Osteoblasts

(cells that make the organic matrix of bone and then mineralize bone)

osteoclasts

(cells that resorb bone)

bone mineral

(inorganic substances occurring in nature usually with a crystal structure)

bone matrix

(intercellular substance of bone tissue consisting of collagen fibers, ground substance, and inorganic bone salts)

restricted activity levels, weakness, deconditioning, and stiffness leading to functional decline

. The fear of falling is associated with serious physical consequences

a. Osteoporosis is much more common in the US. b. The two disorders may coexist. c. Their clinical expression is similar.

1. Osteopenia is decreased bone mass caused by osteoporosis and/or osteomalacia

women to ~ 3 to 5% per year for ~ 5 to 7 years

Beginning with menopause, bone loss accelerates in

whites or Asians (Hispanics have intermediate bone mass).

Blacks reach higher bone mass than

a. At least 1000mg of elemental Ca daily (1200 to 15OOmg/day recommended for postmenopausal women and older men) (dairy products, salmon, broccoli, tofu) b. Ca supplements are needed (e.g., Ca carbonate or Ca citrate) since diet alone is rarely adequate. c. 400 U-1000 U of vitamin D once/day (spending 10 min/day in the sun) i. Vegans: fortified soymilk and almond milk, tofu, mushrooms ii. Nonvegans: fortified milk, eggs, cheese, butter, liver

Ca and vitamin D intake

orthostatic hypotension, carotid sinus syndrome/hypersensitivity

Cardiovascular deficits

exaggerated response to carotid sinus baroreceptor stimulation.

Carotid sinus hypersensitivity (CSH) is an

dizziness or syncope from transient diminished cerebral perfusion. Although baroreceptor function usually diminishes with age, some people experience hypersensitive carotid baroreflexes. For these individuals, even mild stimulation to the neck results in marked bradycardia and a drop in blood pressure.

Carotid sinus hypersensitivity (CSH) results in

a. Torus fractures involve buckling of the bone cortex. b. Greenstick fractures have cracks in only one side of the cortex.

Childhood fractures

a. Poorly-fitting foot wear (low-heeled shoes) or clothing that drags on the floor can lead to tripping. b. An anti-slip shoe device reduced rate of falls in icy conditions.

Clothing and footwear that help reduce falls

a. Segmental fractures b. Avulsion fractures are caused by a tendon or ligament dislodging a bone fragment.

Comminuted fractures

1. Transverse fractures are perpendicular to the long axis of the bone. 2. Oblique fractures are not perpendicular to the long axis of the bone. 3. Spiral fractures imply a rotatory mechanism. 4. Comminuted fractures have more than two bone fragments. 5. Impacted fractures shorten the bone (they may be visible as a focal abnormal density in trabeculae or irregularities in bone cortex). 6. Childhood fractures

Common types of fracture lines

1. Pain with particular exercises 2. Inflammation 3. Severe cardiopulmonary disease (severe CAD, carditis, cardiomyopathy) (clearance from physician needed post MI or post CABG)

Contraindications to resistance training for osteoporosis

1. Increase lighting 2. Periodic eye exams or checkups 3. Appropriate glasses

Corrective lenses and cataract surgery

A. Dual-energy x-ray absorptiometry (DEXA or DXA) B. Magnetic resonance imaging (MRI) of the spine is performed to evaluate vertebral fractures for evidence of underlying disease, such as cancer, and to assess the newness of the fracture. C. Computed tomography (CT) scanning of the spine is performed to assess for alignment and fractures. D. Plain x-rays

Diagnosis of osteoporosis

1. Means of measuring bone mineral density (BMD) 2. Two X-ray beams with differing energy levels are aimed at the patient's bones; when soft tissue absorption is subtracted out, the BMD can be determined from the absorption of each beam by bone. 3. DXA is the most widely used and most thoroughly studied bone density measurement technology. 4. Used in screening for and diagnosis of osteoporosis

Dual-energy x-ray absorptiometry (DEXA or DXA)

1. Medications/Polypharmacy 2. Environmental deficiencies

Environmental (Extrinsic) Risk Factors

1. Bed, couch, and armchair height (e.g., bed low enough so feet touch floor when sitting; firm chairs with armrests instead of couches and chairs that are too low; elevated toilet seat) 2. Lighting (e.g., night lights; adequate light in garage and stairs; night lights in bathroom; flashlight or phone near bed) 3. Floor surfaces (e.g., eliminate, reposition or anchor scatter rugs with double stick tape; keep walks, driveways, floors and floor coverings in good repair; clean up liquids, lotions, oils, food scraps in kitchen and bathrooms) 4. Stairways (repair if broken; add handrail; add bright strips of tape to the edge of each stair; keep free from clutter) 5. Grab bars in toileting and bathing areas (shower chair or tub bench also) 6. Absence of clutter (e.g., avoid tripping hazards; put shoes away; put clothes away; keep sleeping or slow-moving pets out of traffic areas; put bells on pets; remove boxes, papers, magazines; generally do not move furniture that they're accustomed to) 7. Important objects within reach (e.g., use a cell phone) 8. Clothing and footwear 9. Signage 10. Individualized toileting plan (ALF or NH)

Environmental assessment and modification (checking for hazards and making modifications and suggesting special equipment)

a. In the community b. In the nursing home setting

Environmental deficiencies

a) Using over-bed tables and wheelchairs as walkers b) Wheelchair brakes that do not lock (or the residents fail to lock them)

Equipment misuse and malfunction

1. There are no standardized exercise guidelines 2. Exercise programs designed to prevent falls in older adults also seem to prevent injuries caused by falls, including the most severe ones. Such programs also reduce the rate of falls leading to medical care 3. Exercise can also reduce the fear of falling.

Exercise for falls

a. Exercises as part of an overall plan can help prevent falls among people at risk of falling who live in nursing or residential homes. But exercises on their own are not enough to prevent falls in these people. b. This pattern of commitment to exercise interventions suggests that exercise programs may need to be specially tailored for individual seniors' changing needs, interests, physical, and cognitive capabilities.

Exercise programs that improve balance, strength, walking ability, and physical functioning among nursing home residents.

(-30%), assisted living facilities nursing homes (50% to 75%)

Fall are common among older adults in the community

1. Assessing patients after a fall to identify and address risk factors and treat the underlying medical conditions. 2. Educating staff about fall risk factors and prevention strategies 3. Reviewing prescribed medicines to assess their potential risks and benefits and to minimize use 4. Making changes in the nursing home environment to make it easier for residents to move around safely. 5. Providing patients with hip pads that may prevent a hip fracture if a fall occurs (the ultimate goal of any fall prevention program is to prevent fall-related morbidity) 6. Using devices such as alarms that go off when patients try to get out of bed or WC or move without help. 7. Exercise programs can improve balance, strength, walking ability, and physical functioning among nursing home residents. 8. Physical restraints?

Fall prevention in nursing homes (from the CDC)

healthcare issue for older adults

Falling is a significant

morbidity and mortality in the elderly and are one of the most common problems that threaten older people's independence

Falls are associated with significant

injury-related death among older adults

Falls are the leading cause of

1. Osteoarthritis 2. Rheumatoid Arthritis

Geriatric Arthritis

A. Falls B. Osteoporosis C. Fractures D. Arthritis E. Hand Deformities F. Foot and Toe Deformities G. Total Joint Replacement Arthroplasty

Geriatric Conditions

1. Hallux Valgus 2. Mallet Toe 3. Hammer Toe 4. Claw Toe

Geriatric Foot and Toe Deformities

1. Humerus Fracture 2. Radial Head Fracture 3. Colles Fracture 4. Pelvic Fracture 5. Hip Fracture 6. Ankle Fracture 7. Vertebral Fracture

Geriatric Fractures

1. Mallet Finger 2. Swan-Neck Deformity 3. Boutonniere Deformity

Geriatric Hand Deformities

1. Total Hip Arthroplasty 2. Total Knee Arthroplasty 3. Total Shoulder Arthroplasty

Geriatric Total Joint Replacement Arthroplasty

health care for the elderly. Technically, it is a medical specialty focused on care and treatment of older persons.

Geriatrics refers to

1. Scientific studies of processes associated with the bodily changes from middle age through later life; 2. Multidisciplinary investigation of societal changes resulting from an aging population and ranging from the humanities (e.g., history, philosophy, literature) to economics; and 3. Applications of this knowledge to policies and programs.

Gerontology includes

a. Uncommon b. Occurs in children and young adults of both sexes

Idiopathic osteoporosis

a. A special focus on the modification of environmental circumstances appears to be critical, as they are often more easily and efficiently addressed by nursing staff and an interdisciplinary fall prevention team. b. Gait training and appropriate use of ambulation devices assistive device assessment and optimization

Making changes in the nursing home environment to make it easier for residents to move around safely include

putting in grab bars, adding raised toilet seats, lowering bed heights, and installing handrails in the hallways.

Making changes in the nursing home environment to make it easier for residents to move around safely. Such changes include

a. Maintain adequate body weight b. Increase weight-bearing exercise c. Minimize caffeine and alcohol intake d. Stop smoking

Modification of risk factors when possible

a. Abnormal ratio of bone mineral to bone matrix b. Due to demineralization and depletion of Ca from bone (usually because of severe vitamin D deficiency or abnormal vitamin D metabolism) c. Osteomalacia results from a defect in the bone-building process, while osteoporosis develops due to a weakening of previously constructed bone. d. In children, this condition is called rickets.

Osteomalacia (softening of bones)

1. Osteopenia is decreased bone mass caused by osteoporosis and/or osteomalacia 2. Osteoporosis (porous bones) 3. Osteomalacia (softening of bones)

Osteopenia resulting from Osteoporosis vs. Osteomalacia

a. Normal ratio of bone mineral to bone matrix . b. Due to low peak bone mass, increased bone resorption and impaired bone formation.

Osteoporosis (porous bones)

1. Cortical thickness and the number and size of traceculae decrease, resulting in porosity. 2. Trabeculae may be disrupted or entirely absent.

Osteoporotic bone loss

cortical and trabecular or cancellous bone (thin rods and plates of bone tissue; porous bone; spaces are filled with bone marrow).

Osteoporotic bone loss affects

mid 20s, peaks for ~ 10 years, then bone loss occurs at a rate of ~ .3 to .5% per year.

Peak bone mass in men and women occurs by

i. Safe, effective and cost-effective for elderly people with osteoporotic vertebral compression fractures ii. Causes some correction of the kyphosis in most patients

Percutaneous vertebroplasty

1. A big part of our job is to encourage people to participate in activity in order to build their self-efficacy (confidence in one's ability to perform an activity). 2. However, participation also causes a greater exposure to environmental threats, possibly leading to a fall.

Physical activity (participating in leisure and social activities) helping with reducing falls

a. Thirty minutes a day is recommended. b. A physical therapist or physical therapist assistant can help. c. Resistance exercise, especially weight-bearing resistance exercise. b. Aerobic exercise11 c. Combinations of exercise types (e.g., Pilates)

Physical activity for osteoporosis

a. Routinely using restraints does not lower the risk of falls or fall injuries. They should not be used as a fall prevention strategy. b. Restraints can actually increase the risk of fall-related injuries and deaths (limiting a patient's freedom to move around leads to muscle weakness and reduces physical function). c. Since federal regulations took effect in 1990, nursing homes have reduced the use of physical restraints. d. Some nursing homes have reported an increase in falls since the regulations took effect, but most have seen a drop in fall-related injuries.

Physical restraints

1. Idiopathic osteoporosis 2. Type I osteoporosis (postmenopausal osteoporosis) 3. Type II osteoporosis (involutional or senile osteoporosis)

Primary osteoporosis (more than 95% of osteoporosis)

a) Perform only one set of several reps of low-intensity resistance exercises for 6 to 8 weeks (want to increase bone density, but not cause a pathological fracture). b) Progress intensity and volume gradually: eventually up to 3-4 sets of each exercise at moderate intensity (if appropriate). c) Recent research has concluded that high-intensity strength training (70% to 90% of 1 RM for 8 to 12 reps of 2 to 3 sets) is effective in maintaining and/or increasing BMD in postmenopausal women. d) Perform resistance exercises in weight-bearing postures that involve high-impact, low-impact to no-impact (e.g., lunges or step-ups).10 e) Avoid trunk flexion with rotation and end-range flexion of the spine (could result in anterior compression fracture).

Resistance exercise, especially weight-bearing resistance exercise guidelines

Improves muscle mass and strength and functional abilities

Resistance exercise, especially weight-bearing resistance exercise.

(minimization of inappropriate prescribing of psychotropic and psychoactive medications in elderly nursing facility residents, as mandated by current federal guidelines, may affect the risk of falls in nursing facility patients

Reviewing prescribed medicines to assess their potential risks and benefits and to minimize use

A. Person (Intrinsic) Risk Factors (physiological changes and pathological conditions) B. Environmental (Extrinsic) Risk Factors

Risk factors associated with falling

1. Accounts for < 5% of osteoporosis cases 2. Many possible causes (other than just from aging)

Secondary osteoporosis

i. Severe forearm pain ii. Painful and limited finger movement iii. Prominent veins and purple discoloration of the hand iv. Initial parethesias soon followed by anesthesia in the hand v. Loss of radial pulse followed by loss of capillary refill vi. Pallor and paralysis in the hand

Signs of arterial vascular compromise:

1. Distraction refers to the amount of separation in the longitudinal axis. 2. Displacement refers to the degree to which the fractured ends are out of alignment with each other (described in millimeters or bone width percentage). 3. Angulation refers to the angle of the distal fragment measured from the proximal fragment

Spatial relationship between fracture fragments

1. Proximal humerus (surgical neck most common) 2. Radial head (one third of all elbow fractures involve the radial head) 3. Distal radius (posteriorly displaced or angulated fractures are called Colles' fractures) 4. Pelvis 5. Hip (most common among the elderly, especially those with osteoporosis) 6. Ankle 7. Vertebral compression fractures are usually in weight-bearing vertebrae (T6 and below).

Specific fractures

Alzheimer's disease and other forms of dementia

Sundowning symptoms commonly occur in people with

confusion that takes place near the end of the day, usually lasting into the night. Other symptoms include anxiety, wandering, paranoia, disorientation, aggression, and agitation.

Sundowning syndrome involves a period of

C. Ecchymosis D. Deformity E. Abnormal motion F. Crepitus G. Decreased ROM, joint play, strength, and endurance H. Scar tissue adhesions I. Functional limitations

Swelling of fractures can cause

a common fear reported by older adults

The fear of falling is

people 65 years of age and older.

The terms "elderly" or "older people" refer to an age group that is not easy to define precisely, but typically refers to

a) The largest proportion of falls (13.4%) occurred between 6:00pm and 8:00 p.m. b) The second largest proportion of falls (11.9%) occurred from 2:00 p.m. to 4:00 p.m.

Time of day (busy times when things are chaotic)

a. Orthopedic support b. Analgesics c. Heat and massage with muscle spasms

Treating pain and maintaining function: Acute back pain from vertebral compression fractures

a. An orthopedic garment b. Exercises to strengthen paravertebral muscles c. Avoid heavy lifting. d. Bed rest should be minimized. e. Consistent, carefully designed weight-bearing exercise should be encouraged.

Treating pain and maintaining function: Chronic backache

a. Results from increased osteoclast activity and affects primarily trabecular bone b. Occurs between ages 51 and 75 c. Six times more common in women than in men d. In women, estrogen loss is thought to increase activity of osteoclasts in trabecular bone (increased risk with late menarche, early menopause and nulliparity). e. In men, prematurely low levels of serum testosterone can increase osteoclast activity. f. Largely responsible for fractures affecting predominantly trabecular bone (e.g., vertebral compression fractures and Colles' [distal radius] fractures)

Type I osteoporosis (postmenopausal osteoporosis)

a. Results from normal gradual decline in the number and activity of osteoblasts that occurs with aging and affects both trabecular and cortical bone. b. Typically affects patients > 60 c. Twice as common in women as in men d. Estrogen deficiency is probably an important factor in both men and women. e. Reduction in Ca or vitamin D intake or vitamin D synthesis or resistance to vitamin D activity may contribute. f. Can result in vertebral compression, femoral neck, proximal humerus, proximal tibia and pelvis fractures

Type II osteoporosis (involutional or senile osteoporosis)

a. "Dinner fork" deformity b. Morbidity and loss of function c. Chronic pain d. Traumatic arthritis (90%) e. Neuropathies (e.g., carpal tunnel syndrome and CRPS)

Warnings, Concerns, Potential Complications of Distal radius (Colles' fracture)

a. Intestinal injuries and genitourinary injuries (e.g., urethral or bladder tears) are common. b. Male and female sexual function may be significantly decreased after traumatic pelvic fracture. c. Vascular injuries may cause hemorrhagic shock. d. Mortality rate is about 8.3% (increased risk with unstable fractures due to exacerbated injury severity). e. Painful (patients are reluctant to move and must be convinced of the importance of getting OOB despite the pain)

Warnings, Concerns, Potential Complications of Pelvis fractures

a. Contractures may develop after only a few days of immobilization (especially in the elderly) b. A tendency for displaced fragments due to pull of muscles c. Adhesive capsulitis d. Complex regional pain syndrome (CRPS)

Warnings, Concerns, Potential Complications of Proximal humerus fractures

a. Volkmann contracture (muscular atrophy from an arterial circulatory compromise)

Warnings, Concerns, Potential Complications of Radial head

a. Multiple thoracic compression fractures eventually cause thoracic kyphosis with exaggerated cervical lordosis (Dowager's hump). b. Inability to remain active leads to other complications.

Warnings, Concerns, Potential Complications of Vertebral compression fractures

a. Bimalleolar fracture: fracture of medial malleolus of the distal tibia and the lateral malleolus of the distal fibula. b. Trimalleoar fracture: fracture through the lateral malleolus of the fibula and the medial malleolus and posterior process (malleolus) of the tibia.

Warnings, Concerns, Potential Complications of ankle fractures

A. Fat embolism B. Arterial injury C. Compartment syndrome D. Nerve injuries E. Infection F. No stretch or resistive forces distal to the fracture site until the bone is radiologically healed. G. No excessive joint compression or shear for several weeks after the period of immobilization. H. Use protected weight-bearing until the site is radiologically healed. I. In the elderly, cognitive impairments after fracture often result from the hospitalization process (stress, anxiety, sleep disturbance, and medications). J. Specific fractures

Warnings, Concerns, Potential Complications of fractures

a. Hip fractures have a 23% mortality rate within the first year. b. Patients with hip fracture are at two fold risk for further hip fracture and the subsequent mortality rate is highly increased. c. Inability to stand up, sit down or walk two weeks after operation are predictors for mortality among operated hip fracture patients. d. Prolonged bed rest should usually be avoided in elderly patients. e. Avascular necrosis (death of tissue due to insufficient blood supply) leading to a THR (especially with femoral neck fractures)

Warnings, Concerns, Potential Complications of hip fractures

A. Pathological fractures most commonly occurring in the vertebrae, hips, wrists, and ribs. B. There is an increased risk for falls with an increased thoracic kyphosis when muscle weakness is present? C. Contraindications to resistance training D. Osteoporosis could be an early risk factor for dementia.

Warnings, Concerns, Potential Complications of osteoporosis

quantitative CT (QCT).

a technique that can be used to subjectively measure bone density and determine whether vertebral fractures are likely to occur.

a. Stable fractures b. Unstable fractures disrupt any combination of two or more of the structures stabilizing the ankle ring (medial malleolus, lateral malleolus, deltoid ligament, lateral ligament).

ankle fractures

"psychotropic"

any chemical substance that changes brain function and results in alterations in perception, mood, or consciousnes

1. Typically result from osteoporosis (may develop after minimal, unapparent, or no trauma). 2. Vertebral fractures often cause hyperkyphotic postures, but hyperkyphotic postures may also be an important risk factor for future vertebral fractures.4

causes of Vertebral compression fractures

A. Fractures are usually caused by a single application of significant force (e.g., distal humerus fractures typically result from a direct force or a fall on an outstretched upper extremity). B. Pathological fractures typically result from mild forces to bone weakened by cancer or another disorder. C. Stress fractures typically result from repetitive forces. D. Specific fractures

causes of fractures

1. Subcapital fractures may result from minimal forces (e.g., walking); further fracture may occur secondary to a fall after the initial fracture. 2. Intertrochanteric fractures usually result from falls or direct blows.

causes of hip fractures

1. Stable fractures typically result from minor injuries (e.g., household falls) especially in patients with osteoporosis. 2. Unstable fractures typically result from severe forces (e.g., high speed MVAs).

causes of pelvis fractures

a. Prolonged immobilization b. Prolonged disuse and inability to bear weight c. Long-term use of medications

causes of secondary osteoporosis

A. Immobilization or extended sedentary periods B. Being thin C. Insufficient dietary intake of Ca, P, and vitamin D D. Cigarette smoking E. Excessive caffeine F. Excessive alcohol G. Whites and Asians H. Family history I. Other factors (e.g., decreasing amounts of sex hormones)

causes/ risk factors of osteoporosis

a. Alzheimer's disease and related dementias. b. sundowning, agitation, wandering, lack of awareness of one's abilities, impatience, impulsiveness (e.g., not wanting to wait for someone to assist with ambulation). c. NH dilemma: Staff wants to encourage activity and honor and respect residents' right to do as much as they can, but this presents more opportunities for falling.

cognitive impairment include

poor lighting, slippery floors, uneven floors, throw rugs, lack of handrails especially in toilet and shower/tub areas; clutter on floor and in pathways: extension cords, magazines, boxes

community environmental deficiencies

fractures

cracks or breaks in bones

A. X-rays B. MRI if necessary C. CT (especially for pelvic fractures) if necessary

diagnosis of fractures

a. Biophosphonates are the first-line drug therapy (inhibit bone resorption). b. Salmon calcitonin (less effective than biophosphonates) c. Estrogen (increases the risk of thromboembolism and endometrial cancer and may increase the risk of breast cancer) d. Raloxifene (for women who cannot take biophosphonates) e. Parathyroid hormone (for patients who fail to respond to antiresorptive drugs as well as Ca, vitamin D and exercise)

drugs used for osteoporosis

A. Calcium and Vitamin D are necessary for effective healing. B. Healing typically occurs within weeks or months via remodeling; new tissue (callus) is produced and is reshaped. C. Normal remodeling requires gradual increase in normal motion and weight bearing (danger of re fracture if done prematurely). D. Fall prevention!

education of fractures

Pathological fractures

fracture of a bone already weakened by disease that occurs as a result of very minor stresses)

billions

health care system costs associated with falling is in the

a. - Subcapital fractures involve the femoral neck. b. Intertrochanteric fractures extend from the greater to the lesser trochanter.

hip fractures

A. A multifactorial approach, or interventions that address more than one risk factor or identified cause of fall, have the greatest benefit. B. Exercise appears to be the most effective factor in reducing the risk of falls and injuries from falls. C. Physical activity (participating in leisure and social activities) D. Environmental assessment and modification E. Medications are reviewed and modified F. Pacemakers G. Corrective lenses and cataract surgery H. Fall prevention in nursing homes

interventions used for falls

crowded with a small walking path because of bed cranks sticking out, bedside tables, TV, other furniture, visitors

limited space in room includes

1. Intensive physical therapy in the acute hospital setting can improve functional independence and can reduce hospital length of stay. 2. Delayed ambulation after hip fracture surgery is related to the development of new onset delirium and pneumonia postoperatively as well as to increased length of hospital stay. Early ambulation after hip fracture surgery should be encouraged. 3. Hip muscle strength after operative treatment directly influences patient outcome. 4. Moderate and high-intensity resistance exercise is appropriate for elderly people who have had a hip fracture. 5. People with mild to moderate dementia show similar benefits with rehab after a hip fracture.

management of Hip fracture with ORIF and early mobility

a. With stable fractures, immobilization in a cast for 6 weeks. b. With unstable fractures, ORIF.

management of ankle fracture

a. Closed reduction and immobilization in a cast or splint in 15° to 30° of wrist extension (advice and exercise provided by a physical therapist after removal of the cast). b. Surgical options include ORIF, external fixation, percutaneous pinning, and bone substitutes.

management of distal radius (colles' fracture) fracture

A. Analgesics B. Home care: PRICE (protection, rest, ice, compression and elevation) C. Angulation must be corrected D. Immobilization in cast or splint/brace E. Open reduction internal fixation (ORIF) F. Closed reduction percutaneous fixation (CRPF) G. External fixation

management of fractures

1. Drugs 2. Modification of risk factors when possible: 3. Ca and vitamin D intake 4. Physical activity

management of osteoporosis

a. Treatment is directed at associated injuries b. A pelvic stabilizer (e.g., Traumatic Pelvic Orthotic Device or T-POD®) may be used to provide circumferential compression in order to prevent hypovolemic shock in unstable fractures. c. Surgical repair (ORIF or external fixation) in cases of large displacement of fracture and chronic ailments caused by pressure on the sciatic nerve.

management of pelvis fractures

a. Immediate physical therapy after a minimally displaced ("stable") proximal humeral fracture results in faster recovery. Delayed rehabilitation by 3 weeks of shoulder immobilization produces a slower recovery. b. ORIF (although the trend is to treat even displaced fractures nonsurgically) c. CRPF seems to lower the risk of avascular necrosis in young patients. d. A complex fracture (e.g., 4-part fracture) may result in a hemiarthroplasty.

management of proximal humerus fracture

a. If minimally displaced and angulated, immobilized in splint with the elbow flexed to 90° (ROM exercises begin immediately or 5 to 10 days after the injury). b. If significantly displaced, possibilities include ORIF, surgical excision of the radial head, or radial head prosthesis with an osteochondral autograft from the second metatarsal base

management of radial head fracture

a. Orthopedic support, analgesics, heat, and massage when acute b. Exercises to strengthen paravertebral muscles c. Avoiding heavy lifting d. Weight-bearing exercise e. Bed rest should be minimized f. Percutaneous vertebroplasty

management of vertebral compression fractures

bone mass than women

men have higher

Gerontology

multidisciplinary and is concerned with physical, mental, and social aspects and implications of aging.

i. Call bells that cannot be reached ii. Poor lighting iii. Uneven and slippery surfaces iv. Limited space in room v. Obstacles in hallways and other areas vi. Equipment misuse and malfunction vii. Time of day

nursing home setting enviornmental deficiencies

wheelchairs, linen carts, medicine carts, tripping over shoes, tripping over other residents, uneven floor; poor lighting,

obstacles in hallways and other areas

parathyroid hormone, calcitonin, estrogen, vitamin D, cytokines and other local factors such as prostaglandins.

osteoblasts and osteoclasts are regulated by

a. Stable fractures do not disrupt the pelvic ring. b. Unstable fractures disrupt the pelvic ring in two places; disruptions can be fractures within bones or separations between the fibrous unions joining different bones (syndesmoses); cannot bear weight without jeopardizing the stability of the fracture site

pelvis fractures

four or more prescription drugs; especially in NH and NH patients with dementia; psychotropics, anticonvulsants, class 1A antiarrhythmic medications, diuretics

polypharmacy

florescent lighting not bright enough during the day

poor lighting

1. Individualized programs to increase physical stability and attenuate the risk for falls 2. Strengthening exercises 3. Hip pads

preventing osteoporosis fractures

1. Proximal humerus fractures typically result from a direct force or a fall on an outstretched upper extremity (particularly in females who are older than 60)3 2. Radial head typically results from a fall on an outstretched upper extremity. 3. Distal radius (Colles' fracture) typically results from wrist hyperextension. 4. Pelvis 5. Hip 6. Ankle fractures have multiple injury mechanisms. 7. Vertebral compression fractures

specific fractures

A. Pain B. Swelling

symptoms of fractures

A. Patients may be asymptomatic for years until fractures begin to occur (may develop after minimal, unapparent, or no trauma). B. Pain (particularly back pain) begins acutely, usually does not radiate, is aggravated by weight bearing, may produce local tenderness, and generally begins to subside in one week (residual pain may last for months or be constant). C. Vertebral compression fractures are common, usually in weight-bearing vertebrae (T6 and below). D. Excessive thoracic kyphosis and cervical lordosis (Dowager's hump) due to multiple thoracic compression fractures. E. Abnormal stress on the spinal muscles and ligaments cause chronic, dull, aching, pain (particularly in the lower back). F. Fractures can develop at the hip or wrist due to falls.

symptoms of osteoporosis

tendency to self-limit activities and social engagements (e.g., depression, feelings of helplessness, social isolation)

the fear of falling is associated with serious psychosocial consequences resulting from

a. strength b. balance and pertubation-based training c. indiviualized

types of exercises for falls

i. A young fit patient who needs to return to work may benefit from early motion after surgery ii. A patient with poor skin or at risk of infection may benefit from a cast after surgery.

unstable fractures, ORIF.