December 13, 2022

Fractures are some of the most common bone injuries affecting people of all ages. Before we get down to understanding them, we need to understand an important term, Bone Density or Bone Mineral Density (BMD). It is the amount of bone mineral in the bone tissue. In layman’s term it tells you how dense your bone is. The image below shows the difference in bone density between the spine of a healthy person and that of a person suffering from Osteoporosis. There is a clear relationship between BMD and risk of fractures. The lesser the density the chances of fractures are more.

Now that we understand what Bones Mineral Density is, we can get to understanding fractures. Like with every structural support, which our skeletal system is, there is a breaking point at which different bones of the body can either display a hairline fracture or a complete open fracture. These most often happen when bones are subjected to forces beyond their tolerance levels. This can occur by falls, trauma, or because of a direct blow or kick to the body.

Now taking a deeper dive into our central theme, i.e., Geriatric (Elderly people) Fractures, it occurs under similar circumstances as mentioned above but to people older in age. The primary difference being it takes place at levels of forces below the tolerance level of bones of younger people.

The surgical techniques of treating the same type of fractures do not differ with age. However, general medical condition and/or mental makeup of the patient and their family members are to be considered additionally before offering the best possible care.

The frequently asked questions to an orthopedic surgeon in his/her practice with regards to geriatric fractures:

1. Which are the common sites of geriatric fractures?

While there is no bone in the body that cant suffer from a fracture, statistically the back, wrist, shoulder and the hip bone are the common sites of geriatric fractures for various reasons.

2. What are the reasons for fractures in the elderly people?

While a significant trauma can break a bone in anyone, a trivial trauma can result in a fracture in the elderly due to osteoporosis (Low BMD).

Associated medical conditions of poor eyesight, imbalance from weakened nervous system, vertigo/giddiness occurring from age related BP fluctuations or diabetes make older people vulnerable to situations that will exert additional force to their bones resulting in fractures.

3. What are the precautions that one can take to minimize the chances of geriatric fractures from occurring?

Two things need to be considered:

• Strengthening the bones
• Minimizing the chance of injuries

Strengthening the bones can be achieved by a multimodal approach which includes

• Good diet, which includes but not limited to sea food, greens, ragi, milk, egg white. This improves BMD
• Exercising by walk daily on a level surface for 30 mins to an hour as tolerated. Improves BMD and balance.
• Paying equal importance to mental wellbeing, resulting in fewer scenarios leading to fractures.
• Following up on prescribed age related and appropriate medications.

Minimizing the chance of injuries

• As poor vision is one of the primary causes for injuries a well let surrounding is important.
• Keep the surfaces dry, though obvious is again one of the most common reasons for fall among the elderly.
• Supports like railings in the bathrooms, gives additional traction while changing positions.
• Avoid sharp edge furniture in the room. Incase of a fall, sharper or harder the edge more is the force of impact.
• Protective clothing like padded underwear, this helps with the hip related injuries as it gives a certain degree of cushioning when the fall occurs.
• Keeping a watch on their whereabouts. Though a sensitive subject, one that needs more understanding, mental imbalance among the elderly causes them to face scenarios that can lead to injuries and falls.

4. What are the mediations that are available to strengthen the bones?

Calcium with vit D: The daily requirement of calcium in an adult is 1.2 -1.5 g. In most cases with a balance diet, the daily requirement can be reached. In cases of postmenopausal women, men with co morbidities like diabetes, those who smoke and do heavy drinking and those individuals on long term epilepsy medications and steroids, calcium supplements are crucial and are prescribed.

Multiple formulations of Calcium are available such as Citrate, Carbonate etc. A more recent formulation called Aquamin, has lesser effects from gastritis and constipation, usually associated with traditional Calcium supplements.

Additionally, medications such as Calcitonin nasal spray: One puff per day in alternate nostrils for a period of 2 months, strengthens the back bone and reduces the pain. Bisphosphonates : A weekly or monthly oral formulation or an annual injection like inj Zolendronic acid. Denusomab: An annual injection for strengthening of bones is a rather expensive but effective option.

Ancillary medications include anabolic steroids like nandrolone, isoflavones etc.

5. Is calcium supplement absolutely necessary and will it cause kidney failure ?

Consumption of Calcium supplements is not mandatory but advisable. Contrary to common misconception, consumption of calcium supplements does not increase the chances of Kidney failure. Patients who have an increased tendency of kidney stones formation can have more occurrences.

6. What needs to be done in the case of an unfortunate incident resulting in a fracture?

The site of the fracture and the general condition and activity demand of the patient would govern the necessary decisions.

Spine Fractures: These are usually managed non surgically through rest, braces, analgesics, and anti-osteoporotic treatment.

If the pain persists after conventional measures beyond the 3-6 week window, a procedure called vertebroplasty is advised , wherein a specialized bone cement is injected to the spine to reduce the pain.

Hip fractures: There are two principle fractures that can occur

• Fracture neck of femur
• Inter trochanter fractures

Fracture neck of femur: As this fracture doesn’t selfheal naturally, surgery is a must without which a person would be bed bound. The surgeries advised are a total hip replacement ( currently advocated) or hemiarthroplasty ( patients whose medical condition doesn't allow a total hip replacement to be done )

X RAY OF A TOTAL HIP REPLACEMENT

Inter trochanteric fractures: Surgery is an advisable option as it would help in the earlier healing of the fracture resulting in faster pain relief and early mobility /

PFN SURGERY FOR INTER TROCHANTERIC FRACTURES

Wrist fractures: These fractures heal with or without surgery. However, the decision is taken depending on the following factors

• Displacement of the fracture
• Activity demand of the patient
• Other co morbidities.

If the fracture is displaced, surgery is a better option to avoid mal alignment of the wrist joint and restriction of stiffness resulting in decreased functionality of the hand.

XRAY OF A WRIST FRACTURE FIXATION

7. What are the problems faced if hip fractures aren't operated on?

This might result in the patient being bed bound, which in turn results in multiple issues including bed sores, chest infections, urinary infections, bowel disturbances, aspiration of food and liquids into the lungs, vein blockages of the lower limbs which might even
result in Death.

8. Will the surgery be hundred percent successful?

This is another common question faced by the health care providers. There is no 100% assurance about any surgery that's performed even in the most skilled hands, however the recent medical and surgical advances have significantly mitigated risks of the procedure. There is definitely an age-related risk in operating on an elderly person when compared to a youngster but if things pan out as planned which is usually the result these days we can alleviate the suffering of our loved ones.