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Orthopedic Trauma in the Elderly

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Title: Orthopedic Trauma in the Elderly


1
Orthopedic Trauma in the Elderly
  • Age, Injury, and Outcome
  • Ellen Plummer,
  • RN,MSN, MBA, CCRN

2
CONFLICT OF INTEREST
  • I hereby certify that, to the best of my
    knowledge, no aspect of my current personal or
    professional situation might reasonably be
    expected to affect significantly my views on the
    subject on which I am presenting.
  • Ellen Plummer, RN, MSN, MBA, DL, MJ, CCRN

3
Theyre Here
4
Overview
  • Epidemiology
  • Mechanism of Injury
  • Age and Injury
  • The Big Three Orthopedic Injuries
  • Resuscitation and Treatment
  • Complications
  • Rehabilitation and Prevention
  • Outcomes Studies

5
Epidemiology - Elderly
  • Injuries are disproportionately severe
  • More likely to have co-morbidities
  • Suffer more complications
  • Die from trauma

6
Epidemiology Elderly
  • Increasing focus of healthcare providers
  • Limited literature available
  • Trauma is 7th leading cause of death in elderly
  • 25 of all trauma admissions

7
Epidemiology
  • Fastest growing segment of the population
  • By 2050 gt 20 gt age 65
  • One of the largest consumers of healthcare for
    resources and
  • Less frequently injured higher mortality
  • Treatment costs are higher
  • Outcomes less favorable

8
Factors Affecting Outcomes
  • Wide variability and lack of Evidence-based
    protocols
  • Less tolerate of minor derangements
  • Generic decisions are inappropriate

9
Factors Affecting Outcomes
  • Underlying Problems (P.E.D.)
  • System / Treatment Decisions
  • Can affect response to trauma
  • Insufficient cardiac reserves
  • ?? Peripheral Oxygen Delivery
  • Blood pressure unreliable
  • Chronic respiratory conditions

10
Mechanism of Injury
  • Motor vehicle crashes
  • 25 million drivers over the age of 65
  • Someone is more likely to die in a collision with
    an elderly driver than in a collision involving a
    younger driver
  • Belted and unbelted drivers and passengers
  • Impaired drivers (medications, illness)
  • High impact collisions fatal injuries

11
Motor Vehicle Crashes
  • More than 40 million older adults will be
    licensed drivers by 2020
  • 80 of fatalities occur during the daytime
  • 72 of fatalities occur on weekdays
  • 75 crashes involve another vehicle
  • Clear sky, no weather

12
Mechanism of Injury
  • FALLS
  • Nearly half of those 65 and over experience falls
  • Nearly 2 million seniors are treated in ER for
    fall related injuries gt1/3 hospitalized
  • Cost gt 20 billion 32 billion by 2020
  • Elderly have 1/3 of all hospital injury
    admissions gt80 are caused by falls

13
Mechanism of Injury
  • FALLS
  • 23 of injury death age 65 years and older
  • 34 of injury death age 85 and older
  • 2/3 of falls will fall again within 6 months
  • If hospitalized for a fall, risk of death in the
    year following fall is gt50
  • Women more likely to fall than men

14
Mechanism of Injury
  • FALLS
  • Elderly seek treatment for dizziness more
    frequently than for hearing loss
  • 4-6 of falls in elderly result in fractures
  • 1/4 are hip fractures
  • Identified risk factors..

15
Identified Risk Factors for Falls
  • Age
  • Cognitive impairment
  • Medications
  • Chronic disease / preexisting disease
  • Vertigo
  • Impairments in strength, balance, gait

16
Mechanism of Injury
  • Pedestrian Struck
  • Exposed to hazards
  • Traffic signals Crosswalks
  • Road design
  • Distractions
  • Weather
  • Vision impairments poor judgement

17
Mechanism of Injury
  • Elder Abuse
  • National health problem 1.5 million abused every
    year
  • Only 1 in 10 cases of abuse ever reported
  • Physical, sexual, psychological, financial,
    neglect
  • Vulnerable adults easy targets
  • Physical abuse can result in orthopedic injuries

18
Signs of Physical Abuse
  • Sprains, dislocations, fractures
  • Restrictive wounds
  • Bruises
  • Bilateral bruising to the arms
  • wrap around bruising to arms, legs
  • Multicolored bruises and injuries in various
    stages of healing

19
Patterns of Injury
  • Matching the story to the injuries
  • Old or new?
  • Obvious injuries
  • Which came first? Fall or injury?
  • How were they found?
  • Look for everything as clues

20
Age, Injury, and Preexisting Problems
  • Normal Physiological changes gettin old
  • Cardiac
  • Respiratory
  • Renal
  • Neurological
  • GI / GU

21
Injury and Outcome
  • Predictive Parameters pre injury activity level
    , previous health status
  • Some of the aged do not return to their prior
    functional state (esp. with lower extremity
    fractures)
  • Active aged have the best chance of returning to
    an independent functional state

22
Disease Processes
  • Osteoporosis most common metabolic bone
    disease significant cause of morbidity
  • Epilepsy
  • Cardiac arrhythmias
  • Stroke
  • Diabetes
  • Syncope (2-15 of falls in elderly)

23
Musculoskeletal Considerations
  • Within limits of patients baseline
  • Limited mobility, joint flexibility
  • Muscle atrophy
  • One fracture? ? look for other injuries
  • Vertebral compression fractures gt50 are
    asymptomatic

24
Medications
  • Can affect response to trauma
  • Beta blockers
  • Anti-hypertensives
  • Diuretics
  • Antidepressants
  • Alcohol
  • Coumadin/Other anticoagulants

25
Types of Injuries
  • The Big Three
  • Cervical Spine Fractures
  • Hip Fractures
  • Pelvic Fractures
  • Pathological Fractures

26
Cervical Spine Injuries
  • 1-3 of traumatic injury survivors have a
    C-spine injury
  • Most common MOI high speed MVC
  • Associated with head injury
  • 80 of fatalities Atlanto-occipital dislocation
    (C1-C2 fracture)

27
Cervical Spine Injuries
  • Severe neurological injury less common with C1-C2
    fractures (cord only occupies 1/3 of vertebral
    canal at that level)
  • C2 C3 Hangmans Fractures- severe
    hyperextension 70 associated CHI
  • C5-C7 fx 30-70 have neuro deficit
  • Below C5 vertebral column narrow 50
    subluxations with severe SCI

28
Cervical Spine Injuries
  • 10-20 of fractures are delayed diagnosis or
    missed injury
  • Death from injury 2-15 times that of other
    injuries
  • ICU stay 1 week 2-4 weeks in hospital
  • Economic burden Billions

29
Cervical Spine Injuries
  • Diagnosis difficult in elderly / clearance
  • Osteoporosis
  • Arthritis
  • Difficult to obtain / read x-rays
  • Differentiating between old and new injury
  • Degenerative disease
  • Pain / no pain deficit / no deficit

30
Hip Fractures
  • Falls, Motor Vehicle Crashes, Pedestrians
  • Hospitalization, surgical correction
  • Increased morbidity and mortality
  • Reduced mobility
  • 12 20 reduction in survival
  • 5-20 mortality in first year

31
Hip Fractures
  • 350,000 per year in elderly
  • 90 attributed to falls
  • 90 of all hip fracture patients are older than
    65 years of age
  • By age 80, 1/5 of all women will have sustained a
    hip fracture

32
Hip Fractures
  • Evaluation
  • Initial evaluation
  • Non displaced hip fractures may be asymptomatic
  • Displaced severe pain, loss of function
  • Unable to ambulate, extremity may be shortened
    and rotated

33
Hip Fractures
  • Immobilization and support of extremity
  • Position of comfort
  • Hare Traction Splint
  • Contraindications
  • Sufficient traction to reduce a fracture should
    not be used
  • When sciatic nerve injury is suspected

34
Hip Fractures
  • Posterior Hip Fractures
  • Anterior Hip Fractures
  • Femoral Neck Fractures
  • Intertrochanteric Fractures

35
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36
Pelvic Fractures
  • Motor Vehicle Crashes / Pedestrian cause 60 of
    pelvic fractures
  • 35 40 are from falls
  • Small, compact cars T-bone crashes
  • Associated with increased mortality (from
    hypotension)
  • Survival is worse for open pelvic fractures and
    for pedestrians

37
Pelvic Fractures
  • Blood supply comes from iliac and hypo gastric
    arteries fed by superior gluteal artery (can be
    injured in posterior fx)
  • Accurately diagnosed by PE
  • High index of suspicion based on MOI
  • Look for isolated rotation of LE
  • Discrepancy in limb length

38
Pelvic Fractures
  • Tenderness over trochanter acetabular fx
  • GU complications
  • ΒΌ of pelvic fractures
  • 6 of women and 11 of men have urethral injury
  • Blood at meatus or high riding prostate
  • 90/10 Rule

39
Pelvic Fractures
  • Classification Systems
  • Tile Classification
  • Young Burgess Classification
  • Based on direction of injury, pelvic stability,
    and forces involved
  • Burgess Lateral Compression, Anterior Posterior
    Compression, Vertical Shearing, Combined Mechanism

40
Ramus and Acetabulum
  • Low force injuries
  • Stable
  • 1/3 of all pelvic fractures are individual bone
    fractures and do not involve the pelvic ring
  • Elderly Fall non displaced pubic rami fx
  • Superior/Inferior Pubic Rami fx stable

41
Ramus and Acetabulum
  • 20 of pelvic fractures Acetabulum
  • May involve injury of femoral head
  • Posterior hip dislocations common with
    posterior acetabular fx
  • Injury to sciatic nerve complicate gt 10 of
    acetabula fix

42
Pelvic Ring Fractures
  • High energy
  • Higher transfusion requirements
  • Associated injuries
  • Displacement requires a break in 2 places
  • A/P or L/C injuries
  • Open book fractures (Head on crashes)
  • Vertically stable but rotationally unstable

43
Pathological Fractures
  • Result from focal disease process
  • Compromised bone integrity
  • Fracture occurs during normal activity
  • Etiology
  • Malignancies
  • Pagets Disease

44
Pathological Fractures
  • Metastatic Carcinoma most common malignancy of
    bone
  • Multiple myeloma most common primary malignancy
    of bone
  • Others Lymphoma, Leukemia

45
Pathological Fractures
  • Pagets Disease (Osteo Deformans)
  • Pathological increase in bone turnover
  • Common in geriatric population
  • Reabsorption of normal bone and excessive
    deposition of abnormal bone
  • Usually involves only one bone
  • Pelvis, lumbar spine, femur

46
Pathological Fractures
  • Pagets Disease
  • 95 of patients are asymptomatic
  • Bone pain, skeletal deformity, fracture
  • Diagnosis is difficult (resembles arthritis)
  • Leads to significant morbidity in elderly
  • Affects 3 of adults over age 40

47
Resuscitation and Treatment
  • Airway, Breathing ,Circulation
  • Volume Crystalloid, Blood
  • Immobilization
  • X-rays, CT Scan
  • Decision Making Process
  • Damage Control

48
Hypothermia
  • Hypotension or Resuscitation????
  • Hypothermia is present in 2/3 of severely injured
    patients
  • Associated with severe complications
  • Arrhythmias
  • Coagulopathies
  • Cardiac performance and death
  • lt 32 degrees nearly 100 mortality

49
Hypothermia
  • Causes
  • Large amounts of cold blood and IVF
  • Unable to separate shock, exposure, and fluid
    resuscitation all occur simultaneously
  • Hemorrhage -gt hypotension-gt hypothermia

50
Pain Management
  • Not That Simple
  • Elderly have diminished pain receptor activity
  • May have disease process (DM, renal)
  • Age is most important variable to influence
    analgesic response
  • Morphine generally preferred but has prolonged
    clearance rate

51
Pain Management The Friends and Family Plan
  • History of patient must be accurate
  • Iowa study
  • 72.3 meds obtained without prescription
  • 14.4 women and 10.5 men take 2 or more
  • 6.4 women and 11.3 men - take both Rx and non
    Rx meds
  • Use of friends or relatives meds

52
Pain Management
  • What to use?
  • Morphine, Percocet, Dilaudid, Fentanyl
    recommended
  • Demerol, Methadone, Propoxyphene can be
    considered
  • Patient Controlled Analgesia

53
End Points of Resuscitation
  • Lactate
  • Correct quickly - lt2.0 within 2-4 hours
  • Longer poor prognosis
  • Base deficit
  • Urinary Output
  • May need hyper-dynamic state

54
Treatment Options
  • Depends on injury/severity
  • Depends on type of orthopedic injury
  • Depends on resources
  • Depends on potential outcome ability
  • Surgical
  • Conservative or Aggressive?

55
Operative / Non Operative Treatment
  • Cervical Spine Fractures
  • Ranges from immobilization in collar to surgical
    intervention
  • Stable with deficit
  • Maintain stability physical and physiologically
  • MRI
  • Cervical Traction
  • Operative intervention

56
Operative / Non Operative Treatment
  • Cervical Spine Unstable with deficit
  • Volume (1-2L)
  • Pressors
  • Intubation
  • Cervical traction
  • Operative intervention

57
Operative / Non Operative Treatment
  • Hip Fractures
  • Pulse discrepancies, coolness, pallor, motor
    deficit suggestive of arterial injury
  • Paresis, paralysis, parasthesia neurological
    compromise

58
Operative / Non Operative Treatment
  • Hip Fractures
  • Proximal Femur surgical intervention
  • Delays of over 48 hours higher mortality
  • Femoral Neck Fractures surgical intervention is
    treatment of choice
  • Non displaced ORIF screws and pin
  • Displaced ORIF not advocated in elderly
  • Decision based on age, extent of fracture

59
Operative / Non Operative Treatment
  • Intertrochanteric Fractures
  • Operative management is advocated for virtually
    all
  • Instability may necessitate fracture alignment in
    addition to fixation (hip screw, IM nail)
  • Early weight bearing

60
Operative / Non Operative Treatment
  • Pelvic Fractures
  • Goal Prevent death
  • Acute bleeding management
  • Damage control
  • Several Options

61
OPTIONS
  • Pelvic Stabilization
  • Invasive management (gt6 Units blood /24 hrs.)
  • Early external fixator (15 minutes)
  • Wrapping pelvic girdle with bed sheet
  • Pelvic binder
  • Angiogram embolization

62
OPTIONS
  • Damage Control for bleeding
  • Attempts at surgical control of expanding pelvic
    hematomas are rarely successful
  • If other associated injuries more severe follow
    trauma guidelines specific management

63
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64
Operative / Non Operative Treatment
  • Coagulopathies CORRECT
  • Hypothermia CORRECT
  • Acid Base Disorders CORRECT

65
Orthopedic Repair
  • Non displaced stable fractures
  • Analgesia
  • Early mobilization
  • No surgery

66
Orthopedic Repair
  • External fixators
  • In place 6 12 weeks
  • Meticulous skin / pin care
  • Internal Fixators
  • Complex operation
  • Pfannenstiel incision

67
Complications
  • Systems failures (pulmonary, renal, etc.)
  • Immobility
  • Thromboembolic disease
  • DVT 80 of patients with multi-trauma
  • Infection
  • Skin breakdown

68
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69
Complications
  • Spinal Cord injuries
  • Immobilization
  • Respiratory complications pneumonia
  • Paralysis prolonged rehab
  • Long term care home or LTC facility
  • Death ethical decisions

70
Rehabilitation / Prevention
  • Essential part of care
  • Starts first day of injury
  • PT, OT, Rehabilitation services
  • Lifestyle changes
  • Assistance from spouse or family may be
    impossible if spouse is elderly or debilitated

71
Outcomes
  • May not always be favorable
  • Lifestyle changes loss of independence
  • Permanent disability
  • Ethical decision making as last resort
  • Abuse must report

72
Outcomes
  • Set realistic goals
  • At admission
  • At 3 months 24 return for some problem
  • Concerns about providing unwanted care can lead
    to suboptimal care

73
Outcomes AGE
  • Age is no determinate for care
  • Ageism must not masquerade as ethics or cost
    effectiveness

74
Treatment Decisions
  • The patient may look just fine
  • Remember blood can hide
  • TBI can be subtle often missed
  • Fixing the problem takes time
  • Orthopedic injuries may be subtle at first

75
Treatment Considerations
  • Same principals and concepts as young
  • Increased index of suspicion
  • Procedures may have to be adjusted
  • Intubation should be instituted rapidly
  • Time is of the essence
  • Treat hypothermia and shock
  • Pain management

76
Resuscitation
  • Assessment must be rapid and efficient
  • Increased ISS parallel increased mortality
  • Lower ISS must assess and intervene
  • Prevent low flow states
  • Keep em warm
  • Load em up if appropriate

77
Undertriage / Overtreatment
  • No clear data for care/decision making
  • Under triage is common
  • Under triage hurts the patient
  • Over triage 7-8
  • Undertriage 75-77

78
Undertriage / Overtreatment
  • Mental confusion is chronic
  • Old people have aches and pains
  • Chest pain is cardiac in nature
  • probably ok if they look ok at the scene
  • Time is critical often too late to recognize

79
Other considerations
  • Communication
  • Mobility
  • Nutrition
  • Skin breakdown
  • Modification of goals and outcomes
  • Survivability / Rehabilitation Potential
  • End of life care

80
Outcomes Studies Over the Years
  • Henry, et al (2001)
  • Pelvic Fractures in Elderly
  • More likely to get blood and lots of it
  • LC fractures about 5X more frequent
  • LC fractures minor, but require blood
  • Mortality higher than young

81
Outcomes Studies Over the Years
  • Mosenthal, et al. (2002)
  • Age as predictor of mortality in TBI
  • 694 patients over 5 years
  • Mortality for elder twice that of young
  • Poor functional outcome
  • Predominately age and GCS predicted

82
Outcomes Studies Over the Years
  • Grossman, et al (2003)
  • Functional Outcome in Octogenarians
  • Mortality rates higher than for Geriatric
  • Lower functional independence

83
Outcomes Studies Over the Years
  • Nirula, Gentilello (2004)
  • Futile resuscitation
  • Head, thoracic, abdominal injuries, comorbidities
  • Severe chest / abd, TBI, SBPlt90
  • Near 100 mortality

84
Research and Prevention
  • Tremendous need for research for optimal care of
    elderly trauma patients
  • Evidence based guidelines needed
  • Prevention efforts for falls, MVCs, burns
  • Costs are enormous, outcomes not always positive
  • Evolving challenges

85
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87
Thank You
  • Contact Information
  • Ellen Plummer, DL, MJ, RN, CCRN
  • eplummer_at_umm.edu
  • Trauma Resuscitation Unit
  • R Adams Cowley Shock Trauma Center
  • Baltimore, Maryland

88
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