Geriatric fracture case—

multiple osteoporotic fractures

case-based interactive lecture/moderated interactive session

AOTrauma Principles Course

86-year-old female

• Stumbled on a carpet at home

• Arrived at emergency department at 04:57 am

• Lives alone

• Pain in right shoulder, wrist, and hip

• Fully mobile without help prior to the accident

Medical history

• Bronchial asthma, severe COPD

• CHD and peripheral arteriosclerosis

• Cardiac insufficiency NYHA II–III

• Diabetes mellitus II (dietary)

• Arterial hypertension

• Osteoporosis without prior fractures

• Amaurosis left eye

• Hospitalized because of exacerbated COPD with pneumonia 2 weeks

before
DEXA: T-score
Examination

• 153 cm, 50 kg

• Blood pressure 140/90, heart rate ~100, rhythmic

• Dehydration

• Dyspnea due to severe COPD,

oxygen needed (4 l/min)

• Awake, fully oriented, good mental condition

• Malalignment of right wrist, swelling at right shoulder,

pain in right hip

• No palpable pulses on both feet,

sufficient capillary perfusion
Medication

• Fenoterol hydrobromide and ipratropium bromide as aerosol

• Fluticasone propionate and salmeterol xinafoate as aerosol

• Theophylline
3 drugs for COPD

• Acetylsalicylic acid

• Furosemide

• Pantoprazole

• Strontium ranelate, calcium, and vitamin D

Medication

• Fenoterol hydrobromide and ipratropium bromide as aerosol

• Fluticasone propionate and salmeterol xinafoate as aerosol

• Theophylline

• Acetylsalicylic acid coronary heart disease

• Furosemide

• Pantoprazole

• Strontium ranelate, calcium, and vitamin D

Medication

• Fenoterol hydrobromide and ipratropium bromide as aerosol

• Fluticasone propionate and salmeterol xinafoate as aerosol

• Theophylline

• Acetylsalicylic acid

• Furosemide heart insufficiency

contributes to dehydration
• Pantoprazole

• Strontium ranelate, calcium, and vitamin D

Medication

• Fenoterol hydrobromide and ipratropium bromide as aerosol

• Fluticasone propionate and salmeterol xinafoate as aerosol

• Theophylline

• Acetylsalicylic acid

• Furosemide

• Pantoprazole stomach protection

• Strontium ranelate, calcium, and vitamin D
Medication

• Fenoterol hydrobromide and ipratropium bromide as aerosol

• Fluticasone propionate and salmeterol xinafoate as aerosol

• Theophylline

• Acetylsalicylic acid

• Furosemide

• Pantoprazole

• Strontium ranelate, calcium, and vitamin D osteoporosis

medication
Preoperative examinations

• X-rays, CT scan of shoulder

• Thoracic x-ray

• ECG (normal rhythm)

• Laboratory tests (normal parameters of kidney and liver

function, hematocrit 42%)

• Seen by internal specialist

(high risk for surgery because of COPD, but no absolute
contraindication)

• Seen by anesthesiologist
Chest x-ray and ECG
Situation

• Three osteoporotic fractures on the right side

• Medically complex geriatric patient

• High risk for anesthesia

• Cleared for surgery within 6 hours

• Patient gives written consent for surgical treatment

What would you do?

Humeral head fracture

• Conservative treatment?
• Closed reduction and K-wires?
• ORIF?
• Intramedullary nailing?

Distal radial fracture

• Conservative treatment?
• Closed reduction and K-wires?
• ORIF?
• External fixator?
What would you do?

Pertrochanteric femoral fracture

• Cannulated screws?
• Dynamic hip screw (DHS)?
• Intramedullary nailing?
Treatment

• Distal radial fracture

conservative treatment: closed reduction, cast

• Immediate surgical treatment of

– Humerus: closed reduction and pin fixation,
humerus block
– Proximal femur: PFNa

• Spinal anesthesia combined with plexus anesthesia and ketamine

Postoperative course

• Sitting mobilization poor due to severe COPD with need for oxygen,
CPAP therapy
• Pain medication: conserves the kidney (diabetes,
– paracetamole iv
dehydration)
– morphine sc
morphine helps against dyspnea
• Enoxaparine sc
• Hematocrit 25% on 2nd day: 4 blood units
• Sacral decubitus ulcer
• Urinary tract infection
 ciprofloxacine
Postoperative course

• Pneumonia on 3rd day  switch to

piperacillin/tazobactame

• Discharge to rehabilitation
center on day 15,
improved general condition

• Still severe pain in the right

shoulder
Further course

• Start with full weight-bearing mobilization at the rehabilitation

center

• Shortening of K-wires (plexus anesthesia) and removing cast after

6 weeks

• After 8 weeks in rehabilitation center discharge to a nursing home

• Suffers from depression due to loss of independence

Outcome after another 3 months

• No pain, independently mobile with a walking stick, lives in residential

home

• Daily walks outside

• Still suffering from depression