NE Nebraska Trauma Conference 2017 Tristan Hartzell, MD November 8, 2017
Traumatic arm injuries in the elderly Fractures Hand Wrist Elbow Shoulder Soft tissue injuries
Definitions Elderly? old or aging showing signs of aging > x years old?
Fractures Fragility fractures versus other fracture types
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.
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.
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
Treatment Alcohol in moderation Smoking cessation Calcium Vitamin D Exercise Bisphosphonates/Hormone therapy
Other fractures Pathologic Traumatic
Hand fractures - Anatomy Distal phalanx Middle phalanx Proximal phalanx Metacarpals
Generalizations Distal phalanx most common fracture Most metacarpals and most distal phalanx fractures non-operative Most proximal and middle phalanx operative
Distal phalanx Volar static splint If operative vast majority pining with a k-wire
Proximal and middle phalanx Splinting Closed reduction and pinning Open reduction and internal fixation
Metacarpal Many are nonoperative Fix if angulated significantly or rotated
Tailor to the patient Underlying arthritis Functional status Occupation Hobbies
Wrist fractures - anatomy 8 carpal bones (scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, hamate) Distal radius and distal ulna
Generalizations Most non-displaced are non-operative Most displaced are operative The ligaments! Scaphoid The patient!
Scaphoid fractures Poor blood supply
Ligament injuries Scapholunate ligament tear SLAC wrist Scapholunate advanced collapse
SLAC wrist
Treatment Steroid injections Proximal row carpectomy +/- capitate resurfacing arthroplasty Arthrodesis
Arthrodesis Limited Total
Distal radius fractures Second most common fracture in the arm
Distal radius fractures Evolving paradigm Assess the patient s function Cast Reduction and fixation
Treatment Cast ORIF Ex-fix Antiquated
Comparison
Elbow fractures - anatomy Humerus Radius Ulna Ligaments
Elbow fractures Complex articulation of bones with unique patterns of ligaments Truly specialized care Many are very difficult
Complex Fracture/dislocations
Distal humerus Non-operative Non-displaced Closed Rare
Non-operative treatment Hinged elbow brace
Essentially anything that is displaced Operative
The standard of care most of the time Dual plating
All purpose
Elbow dislocations Simple vs Complex Simple Reduce and start moving Complex Fracture dislocations Terrible triad Transolecranon Monteggia variants
When to consult? If fractured and dislocated consult If fractured and displaced consult
Olecranon osteotomy
Humerus fractures - anatomy Well-enveloped in muscle and soft tissue good prognosis for healing
Humerus fractures Proximal Shaft Distal (covered with elbow earlier)
Epidemiology 3-5% of all fractures The energy spectrum of injury Young males high energy (direct trauma) Elderly females low energy (indirect trauma)
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
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
Proximal humerus fractures Tolerate a significant amount of deformity depending on goals Sling
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
Non-operative treatment Sarmiento brace or humeral fracture brace Transition to these Treating fractures while allowing function
Non-operative outcomes >90% heal 2 months Or until clinical/radiographic evidence of healing Those that don t Interposed tissue Medical co-morbidities
Humeral shaft - Operative Unable to maintain reduction Nerve injuries after reduction Open Segmental Multiple extremities Intra-articular extension
Soft tissue injuries in the Elderly
Hematomas Anti-coagulation Fragile skin with loss of elasticity
Degloving injuries Minor Skin tears Major
Skin tears - Minor Dressings Steri-strips Sutures Skin graft Die as a flap, live as a graft
Soft tissue injuries - Major ABCs
Infections Cat bites Treat aggressively Dog bites Treat conservatively Cellulitis Can be slow to resolve Sick aggressive bacteria
Thank you!