Austin Hill MD MPH. Assistant Professor Dell Medical School Dept of Surgery and Perioperative Care Orthopaedic Trauma

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Caroline Green
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1 Austin Hill MD MPH Assistant Professor Dell Medical School Dept of Surgery and Perioperative Care Orthopaedic Trauma

2 Disclosures Orthopedic Implant Company ownership, stock, or options

3 Increasing volume of trauma in patients > 65 Account for 30+% of mortality in trauma High energy low energy Complex underlying medical illness

4 1.5 Million Fractures Annually Vertebral Fractures: 700,000+ Wrist Fractures: 200,000+ Hip Fractures: 300,000+ Source: National Osteoporosis Foundation, 2000 Other Fractures: 300,000+

$fractures Spine fractures Cardiac/Seizure/ Syncope?$

5 Associated Injuries Evaluate for: Head injuries Rib fractures Spine fractures Cardiac/Seizure/ Syncope?

6 Fractures beget Fractures Risk of future fractures increases fold following initial fracture History of fragility fracture is more predictive of future fracture than bone density Viewed as a sentinel event

7 Fracture Prevention Osteoporosis treatment Calcium/Vit D supplementation Pharmacotherapy Fall Prevention Home safety evaluation Update corrective lenses Minimize sedating/mood altering meds Maintenance of medical comorbidities Patient/Family Education

8 Impact on Quality of Life and Independence Not as dramatic as hip fractures, but still cause significant dependence up to 6 months after injury

9 Functional considerations Many geriatric patients use their arms to ambulate with walkers Ability to feed themselves Ability to dress themselves Splints and slings can be difficult to manage

10 Higher Functioning Many patients > 65 have active lives and hobbies Golf Tennis Hunting/Fishing

11 Early post-op period improved function with surgery No difference at 6 or 12 months Try closed reduction whenever possible Some Patients tolerate significant malunions

12 Tale of 2 cases - 89 yo F Fall from standing PMH HLD Home ambulator Medical issues are controlled Fracture was reduced and casted

13 Tale of 2 cases - 3 months s/p injury Normal motion No pain

14 Tale of 2 cases - 69 yo F with RA, HTN, Hypothyroid, DM Realtor, high functioning

15 Tale of 2 cases - 1 st post op visit Normal motion, off pain meds, back to work

16 Operative vs Non-operative Tx Case by Case Involve family when possible Recognize what goals are important, which ones are obtainable? Return to work or hobbies Keep patients ambulating

17 To fix, replace, or let go - Non-operative Simple proximal humerus fractures Clavicle fractures Distal radius fractures Radial Head/Neck fractures Operative Humeral shaft fractures Fracture dislocations Open fractures Radius/Ulna shaft fractures Distal Humerus fxs Olecranon fxs

18 Surgical Considerations Regional Anesthesia, LMA, limit narcotics Minimize time in the OR know when it is time to get out Family Support Pre-Optimization Fall prevention consider OT home evaluation

19 Clavicle Fractures Non-operative treatment is usually well tolerated Can bear some weight within 3-4 weeks Soft tissues are rarely a problem

20 Clavicle Fractures 79 yo F MVC C-Spine injury ICH 4 weeks s/p injury Flexion 100 degrees Abduction 80 degrees Minimal Pain, Out of the sling, Using a walker

$Humerus Fractures Proximal Humerus fractures can do well without surgery Displaced Humeral shaft$

21 Humerus Fractures Proximal Humerus fractures can do well without surgery Displaced Humeral shaft fxs can be debilitating Distal Humerus fractures have a high nonuni0n rate if treated non-operatively

22 Humeral Shaft Fractures 85 yo female Ambulates with a walker CAD, COPD, HTN Attempted non-op tx x 3 weeks - Did not tolerate splinting

23 2 weeks post op Decreased pain, improved motion, happy 2 weeks post-op Allowed to WBAT

24 6 weeks later Minimal pain ROM > 90/90

25 Combined Proximal Humerus & Shaft Fractures 82 yo F community ambulator HTN, DM Lives alone independently 12 hours in a splint, not amused

26 IM nailing minimally invasive

27 Arthroplasty vs ORIF vs Sling? 72 yo F Fall from standing at Walmarts Sedentary, Moderate obesity, community ambulator PMH CAD, DM, etc

$fracture pattern, reasonable goals regarding$

28 Reverse Total Shoulder Poor bone quality, bad fracture pattern, reasonable goals regarding function

29 But Wait, There s More!

30 6 months later, fall #2

31 Distal Humerus Fractures 72 yo F biking in Slovenia Healthy, active Higher Energy Trauma Open Distal Humerus Fx

32 Trauma Principles Abx Evaluate for associated injuries Early motion, PT

33 12 months post op Patient healed without infection, limited ROM from degrees Significant Heterotopic Ossification

Contracture release, HO excision ROM: 10-150 PT the next day Nerve

34 Contracture release, HO excision ROM: PT the next day Nerve Catheter for pain management, allow for immediate motion Guarded optimism

35 Fractures & Dislocations around the elbow 65 yo F Hx of Breast CA on Tarceva, otherwise healthy

36 Younger patient, same principles Arthroplasty and soft tissue repair to mitigate poor bone quality Strive for significant early gains in function

37 6 weeks post op Lacks only 15 degrees extension Full flexion Occasional Tylenol for pain

38 Olecranon Fractures Usually ORIF, but sometimes patients make the decision for you Can have soft tissue compromise Bone quality is poor

39 Olecranon Fractures 82 yo F, FFS HTN Community Ambulator Impending Skin necrosis on Exam

40 Olecranon Fractures Patient and daughter agreed with ORIF 4 weeks post-op MVC Elbow motion- normal!

41 Fixation is often gratifying, But the functional difference differs for each patient 79 yo F at SNF, fell 4-6 weeks ago PMH Dementia, osteoporosis, frequent falls, multiple fxs Normal elbow motion, limited pain

42 Treatment Tips Each patient is different Focus on function and Safety Fracture Prevention One solution does not fit all

43 Thank You!

Case Presentation: Comminuted Fractures of the Proximal Ulna 11/28/2017. Disclosures. Surgical Strategy. Implant Choice. Melvin P.

Current Solutions in Orthopaedic Trauma Case Presentation: Comminuted Fracture of the Proximal Ulna Melvin P. Rosenwasser, MD Robert E. Carroll Professor of Surgery of the Hand Chief, Orthopaedic Hand