A Guide to Improving the Care of Patients with Fragility Fractures, Edition 2

Abstract

Over the past 4 decades, much has been learned about the pathophysiology and treatment of osteoporosis, the prevention of fragility fractures, and the perioperative management of patients who have these debilitating injuries. However, the volume of published literature on this topic is staggering and far too voluminous for any clinician to review and synthesize by him or herself. This manuscript thoroughly summarizes the latest research on fragility fractures and provides the reader with valuable strategies to optimize the prevention and management of these devastating injuries. The information contained in this article will prove invaluable to any health care provider or health system administrator who is involved in the prevention and management of fragility hip fractures. As providers begin to gain a better understanding of the principles espoused in this article, it is our hope that they will be able to use this information to optimize the care they provide for elderly patients who are at risk of or who have osteoporotic fractures.

Keywords: foot and ankle surgery; fragility fractures; geriatric medicine; geriatric trauma; metabolic bone disorders; nonoperative spine; osteoporosis; systems of care; trauma surgery; upper extremity surgery.

Figure 1.

Clinical photograph of the lower extremities of a patient with a left hip fracture. The left side is shortened and externally rotated.

Figure 2.

Standard radiographic views of the hip (A) anterior–posterior (AP) and (B) lateral views of the hip.

Figure 3.

This image shows the 3 typical locations of hip fractures, namely, femoral neck, intertrochanteric, and subtrochanteric regions.

Figure 4.

The AO/OTA classification of the extra-capsular proximal femur fractures (intertrochanteric-subtrochanteric region). According to this classification system, the femur is labeled bone 3, and the proximal femur segment is labeled 1. The “A” types are extracapsular fractures. Types A1.1 to A2.1 are generally considered to be stable patterns. Types A2.2 to 3.3 are usually considered unstable fractures.

Figure 5.

Wound infection after patella fracture surgery.

Figure 6.

A nonhealing intertochanteric hip fracture with cutout of a sliding hip screw.

Figure 7.

A long stemmed calcar replacing stem used to treat failed fixation in an intertrochanteric hip fracture.

Figure 8.

Abraded skin at the site of a hip fracture.

Figure 9.

The 4 parts of the proximal humerus as described by Codman: A, greater tuberosity. B, Lesser tuberosity. C, Anatomical head. D, Humeral shaft.

Figure 10.

The common zones of injury in the humerus, that is, the anatomic head, tuberosity region, and surgical neck area.

Figure 11.

Plain radiograph of a compression fracture suspicious for foraminal involvement.

Figure 12.

Sagittal magnetic resonance imaging (MRI) scan showing a fracture with retropulsion into the spinal canal.

Figure 13.

Computed tomography (CT) scan showing a vertebral compression fracture.

Figure 14.

Standard radiograph showing an L1 vertebral compression fracture.

Figure 15.

Magnetic resonance imaging (MRI) showing marrow edema with an acute vertebral compression fracture.

Figure 16.

Lateral radiographs showing treatment of compression fractures with kyphoplasty cement augmentation.

Figure 17.

Computed tomography (CT) scan showing a comminuted acetabular fracture. The pieces of the broken acetabular surface makeup the wings of the “sea gull sign.” This is an indicator that total hip, either acute or delayed is a better treatment option.

Figure 18.

Three-dimensional computed tomography (CT) scan of an acetabular fracture in an elderly patient showing comminution of the weight-bearing area of the joint and posterior wall involvement.

Figure 19.

Computed tomography (CT) scan showing femoral head impaction injury which is an indicator of poor outcome for open reduction and internal fixation (ORIF) of an acetabular fracture in an elderly patient.

Figure 20.

A model showing a posterior column plate with acetabular component in place.

Figure 21.

Radiographic view of simultaneous acetabular fracture fixation and total hip replacement.

Figure 22.

Breaking the fragility fracture cycle with a multidisciplinary program.

Figure 23.

How the Program Works: Bringing “Communities” Together.