Depending on the fracture configuration and patient’s needs, timely surgery after consideration of options including minimally invasive approaches is of paramount importance.
With specialised geriatric care available in Tan Tock Seng Hospital, our elderly patients are all set to enjoy better recovery and improved mobility. Mobility among the elderly can be significantly affected when fractures are sustained.
Mobility and the Ageing Population
The ageing population in Singapore has been on the rise and today, most elderly folks in our society lead healthy and active lifestyles.
Trivial injuries are more likely to result in fractures among the elderly due to the presence of osteoporosis compared to the younger population.
Common fractures that occur in the upper limb are fractures around the shoulder, elbow and wrist joints. In the lower limb, the most common fractures involve the hip joint. The incidence of hip fractures in particular has been on the rise in recent years. One of the major challenges for these patients is to regain their pre-fracture mobility or function.
In today’s society, cultural norms demand every individual to be independent and self-sufficient, particularly in carrying out activities of daily living. Although caregivers may be present to care for the aged in a family unit, the elderly would usually hope to remain active and be able to care for themselves.
After sustaining a fracture, mobility is acutely lost, due to pain and loss of bodily function. Some fractures, particularly in the upper limb that are not displaced, may be treated conservatively with a cast or arm sling. Nevertheless, displaced fractures in the upper limb can benefit from a surgical procedure.
Loss in mobility proves more of a concern in the lower limb, as the patient will not be able to sit up or even walk after sustaining a fracture. Being bed bound poses other complications of immobility, such as deep vein thrombosis, bed sores, urinary tract infection, chest infection and depression.
Therefore, upon a decision for surgery with informed consent, surgery should be done as early as possible. Delays in surgery will significantly increase complications and impede commencement of rehabilitation.
Surgical Treatment Options
The surgical options for a fragility fracture are either a surgical fixation or surgical replacement.
- Surgical Fixation
Treatment of fragility fractures with surgical fixation aims to stabilise osteoporotic bones with the use of special plates designed for brittle bones. These plates have locking screws that make the fixation more stable. Furthermore, these newer plates are anatomical, as they are designed to conform to the bone with maximal options for screw purchase (Refer to Figure 1).
Newer designs also provide an option for augmentation with bone cement to further enhance the anchorage of the screw in severe osteoporotic bone. This is crucial in ensuring optimal stability so that the patient can start immediate mobilisation and weight bearing.
The surgical technique of applying the plate through a minimally invasive approach minimises skin incisions on fragile and thin skin. Furthermore, there will be less post-operative pain from smaller surgical wounds.
- Joint Replacement Surgery
Many types of fractures can benefit from joint replacement surgery. This is particularly so, when there is significant destruction of the joint surface that affects articulation (e.g. the shoulder joint, elbow joint, hip joint and knee joint).
In some instances, the fracture may involve the region that supplies blood to the articulating surface (e.g. the neck of the femur or neck of the humerus). This will eventually result in necrosis and collapse of the articulating head, even if the bones are stabilised with screws. Hence, a replacement surgery is advisable in such fracture patterns.
A joint replacement involves excising the damaged articulating surface and replacing it with a metal implant (prosthesis) that will allow for immediate articulation and weight bearing. This is considered a partial replacement. The replacement surgery may also involve the corresponding articulating surface, if required, and in this case, will be a total joint replacement.
Newer designs of joint replacement implants provide a wide range of modularity and options to allow for maximum stability and mobility. The newer designs also accommodate instrumentation of the implant in a minimally invasive approach.
Examples of Fragility Fractures
- Typical Fracture in Lower Limb
A typical fracture in the lower limb after a fall in the elderly is a hip fracture. Depending on the location of the fracture, the patient is either stabilised (intertrochanteric fractures) with a Dynamic Hip Screw (DHS) (Refer to Figure 2), a Proximal Femoral Nail (PFN) (Refer to Figure 3) or a replacement surgery (Refer to Figure 4).
With regard to replacement surgery, an active elderly patient will benefit from a total replacement (as compared to a partial replacement) as it allows for better functional recovery, mobility and long-term outcomes.
- Typical Fracture in Upper Limb
A typical fracture involving the upper limb after a fall, is a fracture of the humeral neck or head. While most neck fractures can be stabilised with an anatomical plate, humeral head fractures with significant osteoporosis will benefit from a replacement surgery.
Replacement surgery in such cases has the advantage of early mobilisation. In most situations, a partial replacement would suffice (Refer to Figure 5). Nevertheless, in cases where the shoulder cuff muscles are weak or torn, a total replacement (Reverse Shoulder) will be advantageous. For complex fractures involving the elbow joint that is not amenable to surgical fixation, a total elbow joint replacement is recommended (Refer to Figure 6).
A Multidisciplinary Team Approach
The involvement of multiple disciplines is often required to provide optimal patient care, especially for complex cases with pre-existing medical conditions (including osteoporosis and dementia).
A multidisciplinary approach, which includes an Orthopaedic Surgeon, a Geriatric Physician, an Anaesthetist and a Physiotherapist, is required to ensure that all aspects of patient care and treatment are managed optimally pre-and-post surgery.
In recent years, specialised care pathways have been established in many centres abroad to ensure optimal management of geriatric fractures.
At Tan Tock Seng Hospital, we have a well established integrated care pathway for geriatric hip fractures. With a dedicated Ortho-Geriatric care model, patients have shown promising recovery with minimal complications.
Under this care model, rehabilitation efforts and progress are followed through for one year to ensure optimal functional recovery. Furthermore, secondary fracture prevention is also practised by actively screening and treating osteoporosis. Patients are also assessed for ‘fall risk’, and both patients and caregivers are educated on ‘fall prevention’. This preventive effort is essential to minimise future falls and fractures.