NE Nebraska Trauma Conference Tristan Hartzell, MD November 8, 2017

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1 NE Nebraska Trauma Conference 2017 Tristan Hartzell, MD November 8, 2017

2 Traumatic arm injuries in the elderly Fractures Hand Wrist Elbow Shoulder Soft tissue injuries

3 Definitions Elderly? old or aging showing signs of aging > x years old?

4 Fractures Fragility fractures versus other fracture types

5 What is a fragility fracture? A Fragility Fracture is any fall from a standing height or less, that results in a fracture. Our bodies should be able to sustain a fall from this height without a fracture unless there is an underlying cause that makes the bones fragile. The most common areas involved include the hip, spine, and the wrist.

6 Fragility fracture facts Osteoporosis has no signs or symptoms until a fracture occurs - this is why it is often called a "silent disease. One half of all women and up to one quarter of all men will suffer a fragility fracture in their lifetime. If you've had a previous fragility fracture, you are twice as likely to suffer a fracture in the future Fragility fractures have become nearly epidemic in the United States among older adults with over 2 million fractures occurring each year - more than heart attacks, stokes, and breast cancer combined.

7 Osteoporosis diagnosis DEXA scan Bone mineral density test Low dose x-ray to measure bone density in hip and spine The lower the score the worse Normal Osteopenia Osteoporotic

8 Treatment Alcohol in moderation Smoking cessation Calcium Vitamin D Exercise Bisphosphonates/Hormone therapy

9 Other fractures Pathologic Traumatic

10 Hand fractures - Anatomy Distal phalanx Middle phalanx Proximal phalanx Metacarpals

11 Generalizations Distal phalanx most common fracture Most metacarpals and most distal phalanx fractures non-operative Most proximal and middle phalanx operative

12 Distal phalanx Volar static splint If operative vast majority pining with a k-wire

13 Proximal and middle phalanx Splinting Closed reduction and pinning Open reduction and internal fixation

14 Metacarpal Many are nonoperative Fix if angulated significantly or rotated

15 Tailor to the patient Underlying arthritis Functional status Occupation Hobbies

16 Wrist fractures - anatomy 8 carpal bones (scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, hamate) Distal radius and distal ulna

17 Generalizations Most non-displaced are non-operative Most displaced are operative The ligaments! Scaphoid The patient!

18 Scaphoid fractures Poor blood supply

19 Ligament injuries Scapholunate ligament tear SLAC wrist Scapholunate advanced collapse

20 SLAC wrist

21 Treatment Steroid injections Proximal row carpectomy +/- capitate resurfacing arthroplasty Arthrodesis

22 Arthrodesis Limited Total

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24 Distal radius fractures Second most common fracture in the arm

25 Distal radius fractures Evolving paradigm Assess the patient s function Cast Reduction and fixation

26 Treatment Cast ORIF Ex-fix Antiquated

27 Comparison

28 Elbow fractures - anatomy Humerus Radius Ulna Ligaments

29 Elbow fractures Complex articulation of bones with unique patterns of ligaments Truly specialized care Many are very difficult

30 Complex Fracture/dislocations

31 Distal humerus Non-operative Non-displaced Closed Rare

32 Non-operative treatment Hinged elbow brace

33 Essentially anything that is displaced Operative

34 The standard of care most of the time Dual plating

35 All purpose

36 Elbow dislocations Simple vs Complex Simple Reduce and start moving Complex Fracture dislocations Terrible triad Transolecranon Monteggia variants

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39 When to consult? If fractured and dislocated consult If fractured and displaced consult

40 Olecranon osteotomy

41 Humerus fractures - anatomy Well-enveloped in muscle and soft tissue good prognosis for healing

42 Humerus fractures Proximal Shaft Distal (covered with elbow earlier)

43 Epidemiology 3-5% of all fractures The energy spectrum of injury Young males high energy (direct trauma) Elderly females low energy (indirect trauma)

44 Associated injuries Radial nerve injury Neuropraxia at time of injury generally resolves Decreased nerve function after manipulation or surgery nerve entrapped or injured and needs exploration

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46 Treatment Proximal humerus: Goal establish union with acceptable alignment in an acceptable timeframe Humeral shaft: Goal establish union with acceptable alignment in an acceptable timeframe Distal humerus: Goal establish union with congruent articular surface in a manner that can begin early motion

47 Proximal humerus fractures Tolerate a significant amount of deformity depending on goals Sling

48 Humeral Shaft Non-operative Non-displaced closed simple fractures Displaced closed fractures with less than 20 degrees anterior angulation, 30 varus/valgus angulation, less than 3 cm of shortening

49 Non-operative treatment Sarmiento brace or humeral fracture brace Transition to these Treating fractures while allowing function

50 Non-operative outcomes >90% heal 2 months Or until clinical/radiographic evidence of healing Those that don t Interposed tissue Medical co-morbidities

51 Humeral shaft - Operative Unable to maintain reduction Nerve injuries after reduction Open Segmental Multiple extremities Intra-articular extension

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53 Soft tissue injuries in the Elderly

54 Hematomas Anti-coagulation Fragile skin with loss of elasticity

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57 Degloving injuries Minor Skin tears Major

58 Skin tears - Minor Dressings Steri-strips Sutures Skin graft Die as a flap, live as a graft

59 Soft tissue injuries - Major ABCs

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65 Infections Cat bites Treat aggressively Dog bites Treat conservatively Cellulitis Can be slow to resolve Sick aggressive bacteria

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71 Thank you!