OTA Comprehensive Fracture Course for Residents MODULE FACULTY, PRINCIPLES, AND SCHEDULES GERIATRIC MODULE Principles: Femoral Neck Fractures 1. Femoral neck fractures are classified as either stable (nondisplaced) or unstable (displaced). 2. Non-displaced fractures are usually treated with internal fixation with low rates of healing complications. 3. Displaced fractures are associated with higher rates of nonunion and osteonecrosis and are treated with either internal fixation or prosthetic replacement, dependent on patient characteristics such as age, activity level and mental status. 4. In young adults, a displaced femoral neck fracture should be treated emergently with anatomic reduction and internal fixation. 5. Hemiarthroplasty is a good treatment option for displaced femoral neck fractures in older individuals who have multiple medical problems and are relatively inactive. 6. In active healthy older individuals, the treatment of displaced femoral neck fractures is controversial with multiple studies reporting the best functional results with total hip arthroplasty. Intertrochanteric Fractures 7. Intertrochanteric fractures are classified as either stable or unstable based on the ability of an internally stabilized reduced fracture to withstand physiologic loads. 8. In general, fractures with a large posteromedial fragment or disruption of the lateral wall of the proximal femur are considered unstable. 9. Sliding hip screws and IM hip screws are both acceptable implants for stabilization of intertrochanteric hip fractures. 10. With use of either a SHS or IM device, the lag screw should be centered within the femoral head such that the tip apex distance is <25mm 11. There is no Level 1 evidence which favors one type of implant for routine IT hip fracture although there is evidence which supports use of an IM device for stabilization of subtrochanteric fractures. Periprosthetic Fractures 12. Most classifications of periprosthetic fracture are based on both fracture location and implant stability. 13. Treatment is dependent on fracture location, implant stability, bone stock and patient age and medical condition. 14. In general, if the implant is loose, a revision arthroplasty is performed. 15. Stable fixation can involve use of plates and screws, IM nail, cerclage wire/cable and/or allograft struts. Locked Plates 16. Conventional plate fixation relies on the screw purchase in the bone creating compression of the plate to the bone. 17. Non-locking implants are thought to fail sequentially, one at a time, as if the plate were pried off the bone from one end. 18. In locked plate fixation, the screw and plate create a fixed angle construct. It does not rely on screw purchase, plate to bone compression, or frictional forces for stability. As long as the patient load does not exceed the compressive strength of the bone surrounding all the screws (acting in unison), the construct is stable. 19. Failure of locking plates requires the entire construct to fail in unison, as the load is more evenly shared among the screws. 20. The most common indications for the use of locking plates is metaphyseal comminution and poor bone quality (osteoporosis). 21. Pure locking constructs require the surgeon to obtain fracture reduction before insertion of the locking screws. Osteoporosis 22. An insufficiency fracture is one that occurs during normal weight-bearing; a fragility fracture is one that results from a fall from a standing height. 23. Osteoporosis is defined as a Bone Mineral Density (BMD) 2.5 SD below the young adult average value (T). 24. Osteoporosis is an imbalance in the removal and replacement of calcium. It is not an organic matrix or mineralization defect. It results in loss of trabecular plates, cortical thinning and structural weakening. 25. Fracture management for patients with osteoporosis involves use of IM devices, long length locked plates, augmentation (biologic cements, strut grafts), or prosthetic replacement. 26. Osteoporosis treatment should: 1) address potential risk factors (alcohol and tobacco), 2) promote weightbearing exercises and supplementation with calcium and vitamin D, and 3) prescribe pharmacologic intervention when indicated (T-scores < -2.5 without other risk factors or T-scores < -1.5 with other risk factors). 27. Pharmacological therapy can involve either anti-resorptive medication (hormonal replacement therapy, Biphosphonates, Selective Estrogen Receptor Modulators) or bone forming drugs (Teriparatide). 28. Long-term use of Bisphosphonates has been associated with atypical long bone stress fractures. Peri-operative Considerations After Hip Fracture 29. Surgery after hip fracture should be performed in a timely fashion, once the patient has been medically optimized. 30. A multidisciplinary approach to care has been shown to improve the outcomes of older individuals sustaining a hip fracture. 31. Older individuals who sustain a hip fracture should be assumed to have osteoporosis directed toward treatment to prevent additional fragility fractures. Distal Radius 32. Treatment after distal radius fracture in the elderly should be individualized and based on both patient and fracture factors. 33. Common indications for surgery include: 1) post-reduction radial shortening >3mm;, 2) post- reduction dorsal tilt >10 degrees; 3) post-reduction intra-articular displacement or step-off >2mm and 4) fracture instability. 34. Both internal and external fixation are appropriate methods to stabilize a distal radius fracture. Proximal Humerus 35. Treatment after proximal humerus fracture in the elderly should be individualized and based on both patient and fracture factors. 36. One can augment plate and screw fixation by using suture placed deep to the rotator cuff insertion 37. Hemiarthroplasty gives satisfactory pain results with somewhat unpredictable functional results. Schedule: Lectures 10 min each 1. Osteoporosis evaluation and management 2. Locked plating basics 3. Femoral neck fractures 4. Intertrochanteric hip fractures 5. Periprosthetic fracture management Cases 25-30 min (should cover evaluation, treatment options, complications, and results) 1. Distal radius 2. Hip fracture 3. Periprosthetic femur fracture Labs 20-30 min 1. Distal radius 2. SHS 3. IM hip nail Module time allocation (a 10 minute break will occur between each section) 1. Lectures on osteoporosis and locked plating basics (10 min each) Distal radius case discussion (25 min) Lab (distal radius locked volar plating) (20 min) 2. Lectures on femoral neck and intertrochanteric fractures (10 min each) Hip fracture case discussion (FN/IT fxs) (30 min) Lab (sliding hip screw) (30 min) 3. Lecture on periprosthetic fractures (10 min) Periprosthetic case discussion (30 min) Lab (IM hip screw) (30 min).