Everything you need to know about bone fracture in the elderly, its treatment and prevention
Panaji: Hip fractures in the elderly are quite common. Usually, they are called fragility fractures, which occur due to low-energy trauma. A minor fall or jerk results in a break in an already weak bone. Weak bones are associated with old age, especially in women who have been through menopause for several years. If they are not on treatment for osteoporosis, they are more susceptible to such fractures.
We now have a very high senior population compared to the past. This is due to an improved lifestyle, better medical facilities, and a better understanding of the issues of geriatrics. Proportionally, there is an increase in the number of hip fractures.
In the past, these fractures were considered the beginning of the end. A famous saying of yesteryear was: “We enter the world by the edge of the pelvis and leave the world by the neck of the femur. However, with advances in medical science, safer anesthesia and better implants, today almost all patients who have had these fractures are returning to their original lifestyle. We no longer think this is the beginning of the end.
The elderly usually have associated comorbidities, such as diabetes mellitus, hypertension, ischemic heart disease, kidney disease, bronchial asthma and stroke with paralysis, Alzheimer’s disease, etc., which complicate the disease. supported. Hip fractures can be of two types: Intracapsular, which are close to the head of the femur.
Extracapsular, which are located at the junction of the neck and the stem of the femur. The two fractures, however, are about an inch apart. They have different characteristics due to the anatomy of the femoral neck. Extracapsular fracture has good blood supply and heals faster, and intracapsular fractures do not heal well due to the nature of the blood vessel distribution.
The head of the femur is supplied with blood through the neck of the femur, and as a result, if there is a fracture, the blood supply is compromised. This leads to nonunion of the fracture, and the head of the femur becomes avascular and may die. Due to the hip fracture, the person is unable to support their weight on the leg. Any elderly person is healthier when they are standing up and once they are bedridden, various lying down complications are likely to occur.
The decubitus problems are:
1: Circulatory problems: Tthere thromboembolic phenomenon. Due to the stasis of blood flow, there is probably thrombus formation in the veins of the calf muscle. This thrombus can form emboli and lodge in the pulmonary veins causing sudden death. The same can get lodged in the cerebral vessels and cause paralysis. These dangerous problems can be solved by early mobilization of the patient.
2: Respiratory complications: Due to the constant lying position, there is a trade-off on the expansion of the chest. This can cause consolidation in the lungs. Older people rarely aspirate the fluids they drink, which can lead to complications such as aspiration pneumonia. It is also a dangerous complication.
3: bedsores or bedsores are common in bedridden people. They occur in areas of the body that are in contact with the bed, especially on a bony prominence. Due to constant pressure on the skin, the blood supply is compromised and the skin and underlying tissues die, resulting in the formation of an ulcer. The only treatment for pressure ulcers is to relieve pressure through early mobilization. Prevention is the best treatment for pressure ulcers.
4: Kidney complications: To avoid the problem of urinating in bed, most older people avoid drinking enough water. This causes an increase in blood urea and an electrolyte imbalance. The indwelling catheter, too, has its own problems like infection. In the elderly, due to the lack of immunity, there is a risk of sepsis, especially in patients with diabetes mellitus.
5: Psychological problems: Depression is common in older people due to lying down. It is more common in patients who do not have adequate family or financial support. Due to depression, their participation in the rehabilitation program becomes difficult.
All of the above issues are medical in nature. However, due to changing demographic patterns, there are many social issues associated with fractured seniors. In nuclear families, often the elderly person lives alone or has no responsible parent who could be responsible. Often times we meet older people with hip fractures who have their children settled or working abroad. There are no relatives who could offer support.
The goal of hip fracture treatment is to make the patient painless and outpatient. This goal can only be achieved by surgical methods. Non-operative treatment has no place in the management.
In the event of a fracture of the neck of the femur, there is a high chance of pseudarthrosis and avascular necrosis of the head of the femur; it is best treated by prosthetic replacement. This is a simple operation that allows very early mobilization and ambulation.
Likewise, fractures around the trochanters can also be effectively repaired using special devices. Fixing such a fracture allows early and painless ambulation.
Surgeries are associated with a fair amount of risk. The risk varies depending on the associated comorbidities. Before patients can undergo surgery, it is imperative that all medical issues be addressed. There should be good blood sugar control in diabetics, correction of low hemoglobin, correction of renal parameters and electrolytes. In cases under treatment with anticoagulants, surgery should be postponed for at least one week after stopping the drug.
Avoiding surgery is also an associated risk due to the various pressure problems, as mentioned earlier. The outcome of a conservatively treated trochanter fracture is always uncertain, and more often than not, the person succumbs to one or more of the complications of lying down.
By weighing the two options, the balance tilts strongly towards operative treatment. For a good result of hip fractures in the elderly, a combined effort of a team of doctors, orthopedic surgeons, anesthesiologists and a good physiotherapist is imperative. Everyone has a defined role in management, and everyone must support each other for a successful result.
Prevention of hip fracture in the elderly is the best treatment. If certain guidelines are followed, this incident can be avoided.
Avoid clutter in the house: Often times, falls are due to things like toys, loose rugs, dog chains, etc., which are left on the floor.
Good lighting in the house: Most older people have reduced vision and dim lighting is undesirable. A torch or switch should be near the bed.
Hearing aids: Often, falls or accidents are due to a lack of hearing. Whenever possible, the use of hearing aids can help prevent such incidents.
Dentures: Whenever there is a chewing problem, we tend to avoid foods high in protein. This causes osteoporosis, which could cause hip fractures.
Daily essentials: Appropriate clothing and footwear and a walking aid like a cane for strolling or walking outside also help prevent falls, especially in wet weather.
A hip fracture is a mishap in the life of the elderly person and their family. Fortunately, modern treatment has always given good results. The attending physician and the patient’s family must weigh the benefit / risk ratio and make a decision. One should not hesitate to make the decision in favor of surgical treatment if it is advised.
(The author is a consultant orthopedic surgeon)
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Posted on: Sunday October 24th, 2021 08:26 IST