1
Q
What is the definition of a hip fracture?
A
a bony injury of the proximal femur typically occurring in the elderly
2
Q
What are the neurological risk factors for falls?
A
- Confusion
- Cognitive impairment
- Depression
- Poor vision
- Poor balance
- Poor coordination
3
Q
What are the unmodifiable risk factors for falls?
A
- Age
- Female gender
- History of falls
4
Q
What are the chemical risk factors for falls?
A
- Polypharmacy
- Particular drug culprits
- Alcohol
5
Q
What are the cardiovascular risk factors for falls?
A
- Orthostatic hypotension
- Arrhythmias
- Syncope
6
Q
What are the neuromuscular risk factors for falls?
A
- Muscle weakness
- Gait disorders: aprikinsons, hemiplegia, cerebellular disease, antalgic, normal pressure hydrocephalus, proximal myopathy etc,
- perisperhal neuropathy including sensor ataxia, foot drop
- arthritis and joint disorder
7
Q
What are the other risk factors for falls?
A
- Fear of falling
- Incontienence
- Frailty syndrome
8
Q
What are the environmental risk factors for falls?
A
- Home hazards
- Inappropriate footwear
- Insufficient home modifications
9
Q
What is a fragility fracture?
A
Fractures that result from mechanical forces that would not ordinarily result in fracture, known as low level (or low energy) trauma. These are forces equivalent to a fall from a standing height or less. Some fragility fractures (e.g. vertebral) can even have without a fall
- A major risk factor for fragility factors is reduced bone mineral density (BMD) (e.g. in osteroperosis)
- Can also occur with people no osteroperosis
10
Q
Why did she fracture her hip?
A
- Low oestrogen post menopause
- Bone strength reduced so more likely to fracture
11
Q
What happens if suspect osteoporosis?
A
- Dexus scan looking at bone mineralogy density is hip, wrist shoulder (look at sd away from normal) - lumbar spine and upper end of femur
- Characterised by low bone mass, micro architectural
12
Q
Why are elderly females are particular risk for osteoperosis>
A
- OSTEROGEN PROMOTE OSTEROBLAST ACTIVTIY DECRESASE OSTEOLAST ACTIVITY
- So menopause, big drop in oestrogen so reduce protective effect
- As older proportion of stem cells turning into osteoblasts decreases and adipocytes increased
13
Q
What is mechanostat activity?
A
describing the way in which mechanical loading influences bone structure by changing the mass (amount of bone) and architecture (its arrangement) to provide a structure that resists habitual loads with an economical amount of material
14
Q
What is sarcopenia?
A
- Syndrome characterised by progressive and generalised loss of skeletal muscle mass and strength
- Risk factors for sarcopenia include game gender and level of physical activity
- Sarcopenia is correlated with phsycal disability falls, low BMD, poor quality of life and death
15
Q
What are the statistics for hip fractures?
A
10%: dead within 1 month
30%: die within year
10-20%: are discharged to a residential or placement
50%: return to previous level of mobility
75%: affected are female;
20%: suffer post-operative complications e.g. chest infection, hearth failure, dvt
16
Q
What is zoledronic acid?
A
used to treat osteoporosis (given IV) given once a year and one serious complication is osteolysis of jaw (necrosis)
17
Q
What is raloxifene?
A
- used to treat osteoporosis (bone selective) steroid based so strong side effect
- a selective oestrogen receptor modulator and inhibits bone resorption. It is approved for the treatment and prevention of osteoporosis in postmenopausal women, in a daily oral dose. It has been shown to reduce vertebral fracture risk but not other types of fractures.
18
Q
What is alendornic acid?
A
used to treat osteoporosis (BISPHOSPHONATE) - prescribe immediately (except risk of reflux / oseophogitis - CHEAPER
19
Q
What is teriparatide?
A
PTH
- is a recombinant fragment of parathyroid hormone prescribed in secondary care. It may be considered for those with very severe osteoporosis or very high fracture risk who are unable to use bisphosphonates, or in whom bisphosphonates have not been effective.
20
Q
What would you use?
A
Calcium and colecalciferol: USE THIS - calcium reabsorb in key is v important and function
21
Q
What are contributions to delirium?
A
change in environment, change in medication, infection
22
Q
What is delirium?
A
confused, frightened, fluctuations, agitated, change mood, hallucinations, drowsiness, change in alertness
23
Q
What may have caused derlium?
A
Trauma causing hip fracture Medication MCI Loneliness Shock from fall Hypotension Certain drugs Stress
24
Q
What are some triggers for delirium?
A
Acute infection Certain proscribed drugs e.g. opiods Recent surgery Any kind of head injury Cardiac problems (arythmia) Metabolic abnormalities Vitamin Deficiency Hypothyroidism Drug use
25
How could derlium be combatted in hospital setting?
- Treat infection
- Continuity of care
- Normalise their life
- routine
- MDT approach
- Normalise sleep patterns
- Treat the triggers
- AVOID sedative medication (worsen delirium)
- regular reorientation
- Psychiatry team if needed
- Glasses and hearing aids available
26
When is a floor more likely to happen?
-floors are wet, such as in the bathroom, or recently polished
-the lighting in the room is dim
-rugs or carpets are not properly secured
-he person reaches for storage areas, such as a cupboard, or is going down stairs
the person is rushing to get to the toilet during the day or at night
-Another common cause of falls, particularly among older men, is falling from a ladder while carrying out home maintenance work.
27
What are some ways to prevent falls at home?
1. immediately mopping up spillages
2. removing clutter, trailing wires and frayed carpet
3. using non-slip mats and rugs
4. making sure all rooms, passages and staircases are well lit
5. organising your home so that climbing, stretching and bending are kept to a minimum, and to 6. avoid bumping into things
7. getting help to do things you're unable to do safely on your own
8. not walking on slippery floors in socks or tights
9. not wearing loose-fitting, trailing clothes that might trip you up
10. wearing well-fitting shoes that are in good condition and support the ankle
11. taking care of your feet by trimming your toenails regularly and seeing a GP or chiropodist about any foot problems
12. Strength and balance training
13. medication review + sight test
14. Home hazard assessment
15. personal alarm
16. Don't Drinking alcohol
28
Describe the femur
- The proximal femur consists of a head, neck, trochanters (greater and lesser) & shaft. It is the largest bone in the human body.
- The inter-trochanteric line lies on the anterior surface of the femoral neck, running between the trochanters. It demarcates the inferior attachments of the hip capsule.
29
What is the capsule?
The capsule of the hip is attached proximally to margins of acetabulum and transverse acetabular ligament. Distally, to the inter-trochanteric line, bases of greater & lesser trochanters and to the femoral neck posteriorly (approx. 1/2 inch from the trochanteric crest). It contains the retinacular vessels - a major component of the blood supply to the femoral head.
30
What are the reticular vessels?
- Where femoral head receives blood from
- main blood supply. Originates from an extra-capsular arterial ring, supplied by medial and lateral circumflex vessels (profunda femoris A.). Reinforced by the superior and inferior gluteal arteries (internal iliac A.).
31
What is the foveal artery?
- Where femoral head receives blood from
- not a major source. During skeletal development, supplies the epiphysis with a small amount of blood. Said to become obliterated in adult life (ligamentum teres).
32
What are metaphysal vessels?
- Where femoral head receives blood from
| - not a major source. After skeletal maturity, metaphysical arteries also contribute blood to the femoral head
33
When are hip fractures classified as intracapsular?
- above inter-trochanteric line.
- The type of fracture determines the likelihood of disruption to the blood supply of the femoral head.
- Broadly speaking, intra-capsular fractures are associated with a higher-risk of disruption, owing to the close proximity of the retinacular vessels
34
When are hip fractures classified as extra capsular
below inter-trochanteric line.
35
What are the four types of grades classification for intracapsular fractures?
Type I - Incomplete, impacted in valgus
Type II - Complete, undisplaced
Type III - Complete, partially displaced
Type IV - Complete, completely displaced
36
What is a type 1 fracture?
Incomplete, impacted in valgus
37
What is a type 2 fracture?
Complete, undisplaced
38
What is a type 3 fracture?
Complete, partially displaced
39
What is a type 4 fracture?
Complete, completely displaced
40
How does the type of fracture affect blood supply?
1. With type 1 & 2 there is minimal displacement, and therefore a lessened risk of disruption to the femoral head blood supply.
2. Conversely, with type 3 & 4, where there is much greater displacement, there is substantially higher risk.
3. Classification is based on the integrity of the trabecular lines in an AP projection. It is used to guide management.
41
What are symptoms of hip fracture?
Hip / knee pain
Inability to bear weight
Limited range of motion
42
What are the signs of hip fracture?
Bony tenderness over affected hip
| Shortened / externally rotated leg (only present if significant displacement)
43
How are hip fractures managed?
- Most hip fractures are treated surgically, unless there are significant co-morbidities restricting surgical intervention.
- Displaced intra-capsular fractures (e.g. Gardens III/IV) - NICE recommends total hip replacement (THR) for fit patients; or hemi-arthoplasty for patients with significant comorbidity.
- Minimally or non-displaced intracapsular fractures (e.g. Gardens I/II) - usually treated with cannulated hip screws (often 2 or 3).
- Extra-capsular fractures - either a dynamic hip screw (DHS) or intra-medullary (IM) nail are utilised.
- DHS are unique in the fact that they allow the fracture ends to ‘slide’; this is thought to promote bone healing.
44
Is delirium dementia?
- Delirium is different from dementia.
- For someone with delirium, symptoms come on over a matter of hours or a few days. The symptoms of dementia come on slowly, over a period of months or even years.
- Delirium is much more common in older people, especially those with dementia.
45
What are symptoms of delirium?
1. The symptoms of delirium will start suddenly and may come and go over the course of the day.
2. They can be worse in the evening or at night. A person with delirium will show some of the following changes.
3. Being more confused than normal
4. Changes in alertness – such as being either unusually sleepy or agitated
5. Having a lack of concentration or becoming easily distracted.
6. Becoming disorientated – not knowing where they are or what day it is.
7. Rambling speech.
8. Showing changes in behaviour.
9. Having disturbed patterns of sleeping and waking.
10. Being prone to rapid swings in emotion.
11. Experiencing hallucinations.
12. Having abnormal or paranoid beliefs.
46
What is hypoactive delirium?
Withdrawn and sleepy
47
What is hyperactive delirium?
Abnormally alert / restless or agitated or aggressive
48
What is mixed delirium?
Alternasting between hyper and hypo active delirium throughout the day
49
What is a fragility fracture?
Fragility fractures are fractures that result from mechanical forces that would not ordinarily result in fracture, known as low-level (or 'low-energy') trauma, quantified by The World Health Organization (WHO) as forces equivalent to a fall from a standing height or less[1]. Vertebral fractures may occur without a fall.
50
What are risk factors of fragility fractures?
1. Increasing age (risk increase partly independent of reducing BMD).
2. Female gender.
3. Low body mass (<20 kg/m2) and anorexia nervosa.
4. Parental history of hip fracture.
5 Past history of fragility fracture (especially hip, wrist and spinal fracture).
6 Corticosteroid therapy (current treatment at any dose orally for three months or more).
7 Cushing's syndrome.
8 Alcohol intake of three or more units per day.
9 Smoking.
10. Ethnicity. Caucasian men and women are at higher risk than other ethnic groups.
11. Other causes of abnormal bone - eg, osteogenesis imperfecta and acromegaly
51
What increases risk of falls?
- Visual impairment.
- Lack of neuromuscular co-ordination or strength.
- Cognitive impairment.
- Sedative medication and alcohol.
52
What are some secondary causes of osteoporosis?
1. Rheumatoid arthritis and other inflammatory arthropathies. (Rheumatoid arthritis also increases risk of fracture independently of BMD and use of steroids.)
2. Prolonged immobilisation or a very sedentary lifestyle.
3. Primary hypogonadism (men and women).
4. Primary hyperparathyroidism.
5. Hyperthyroidism.
6. Post-transplantation.
7. Chronic kidney disease.
8. Gastrointestinal disease such as Crohn's disease, ulcerative colitis and coeliac disease.
9. Untreated premature menopause (<45 years) or prolonged secondary amenorrhoea.
10. Type 1 and type 2 diabetes mellitus[6].
11. Chronic liver disease.
12. Chronic obstructive pulmonary disease.
53
What are common places for fragility fracture?
- The most common sites for fragility fracture are the vertebrae, hip (proximal femur) and wrist (distal radius).
- Other sites affected include the pelvis, ribs, arm and shoulder. Presentation is commonly to an emergency department with acute pain after an injury; however, vertebral compression fractures may go unrecognised as a cause of worsening back pain.
54
What can compression fractures cause?
```
Pain and morbidity associated with high doses of analgesia.
Loss of height.
Difficulty breathing.
Loss of mobility.
Gastrointestinal symptoms.
Difficulty sleeping.
```
55
What is denosumab?
- Denosumab is a monoclonal antibody that reduces osteoclast activity (and hence bone breakdown) which is given by six-monthly subcutaneous injections.
- NICE has approved it for secondary prevention for postmenopausal women with increased risk of fractures who cannot comply with the special instructions for administering alendronate or risedronate, or have an intolerance or a contra-indication to those treatment
56
What is strontium ranelate?
-should only be used to treat severe osteoporosis in postmenopausal women and men at high risk of fracture, for whom treatment with other approved options are not possible, due to an increase in the risk of myocardial infarction. -It cannot be used in patients with current or past history of coronary heart disease, uncontrolled hypertension, peripheral arterial disease and/or cerebrovascular disease.
57
When would you consider a risk factor?
- Those with a history of fragility fracture. Some guidelines suggest this should trigger BMD measurement; others suggest these should be considered for treatment without the need for further assessment.
- Postmenopausal women with risk factors.
- Women or men with significant risk factors.
- Women or men on oral corticosteroid treatment. (Any dose taken continuously over three months or frequent courses. 7.5 mg prednisolone or equivalent per day over three months continuously is considered high dose by NICE and confers higher risk.)
- All women aged over 65 and all men aged over 75 (NICE only).
58
Describe osteoporosis
- Characterised by low bone mass, microarchitecural disruption and skeletal fragility
- Diagnosed by a low BMD (measured on DEXA scan)
- Results in decreased bone strength and an increased risk of fracture (particularly fragility fracture)
- Leads to 9 million fractures annually
- Sequential trabecular loss
Z YEAR 1 CSI Cases
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