Osteoporotic fractures are fragility fractures and are the most serious consequence of osteoporosis. It can occur with minor trauma or during daily activities due to decreased bone strength and is a complete fracture with a high prevalence. Common fracture sites are the spine, hip, and distal radius and ulna, and other sites are also susceptible to fracture. The risk of re-fracture after a fracture is significantly higher. The internal fixation is poorly secured and easily loosened. Slow fracture healing. Osteoporotic fractures are a serious threat to the physical and mental health of the elderly and affect their quality of life, with a high rate of disability and death. In addition to the treatment of fracture, osteoporosis should be actively treated.
I. Clinical manifestations
1. Fracture: Fracture is the most serious consequence of osteoporosis, and is often the first symptom and reason for consultation for some osteoporosis patients. After the fracture, pain, deformity, functional impairment and other fracture-specific manifestations appear.
2. Shortening of height and hunchback: The vertebral body is mainly composed of cancellous bone, and compression fractures occur earlier, resulting in shortening of height or hunchback deformity.
3. Pain: Osteoporotic fractures often lead to pain or aggravation of pain.
II. Diagnosis and differential diagnosis
Diagnosis is based on gender, age, traumatic violence, fracture history, clinical manifestations, and imaging examinations.
1. History and signs of fracture: usually minor trauma or no obvious history of trauma, but signs of fracture.
2. Imaging examination: imaging examination is an indispensable and important tool for the diagnosis of fracture, which can determine the fracture site, type, direction and degree of displacement, and is of great value for fracture diagnosis and treatment. Generally, frontal and lateral films are required, and special positions can be added if necessary. It should be noted that the adjacent joints of the injury site should be included when taking the film to avoid missing the diagnosis. The reasonable application of CT and MRI examination is of great value in the display of vertebral fractures and microfractures, especially in making differential diagnosis; CT three-dimensional imaging technology can clearly display intra-articular or periarticular fractures: MRI examination is of great significance in distinguishing fresh and old osteoporotic vertebral fractures.
3. Bone density examination: all patients with proposed osteoporotic fractures can undergo bone density examination. See primary osteoporosis treatment guidelines. 4. Differential diagnosis: attention should be paid to the differentiation of primary osteoporotic fractures from fractures caused by bone tumors and other bone diseases.
III. Treatment principles
Displacement, fixation, functional exercise and anti-osteoporosis treatment are the basic principles in the treatment of osteoporotic fractures. The ideal fracture treatment is the organic combination of the four, without aggravating the local injury and the fracture fixation should not hinder the limb activities as much as possible. Early functional exercise and the use of medication can achieve a more desirable result in fracture healing and functional recovery.
Fracture revision and fixation: There are two methods of fracture revision and fixation, namely surgical and non-surgical treatment, which should be decided according to the specific site of the fracture, the degree of injury and the patient’s general condition. The purpose of fracture revision and fixation is to provide favorable conditions for fracture healing. No matter which treatment method is chosen, it should not affect the healing of the fracture. The principle of easy, safe and effective fracture revision and fixation for the elderly should be the principle of treatment. It should be chosen for the purpose of less trauma, less impact on joint function and early restoration of pre-injury quality of life. In the specific method, the anatomical repositioning of the fracture should not be forced, but should focus on functional recovery and tissue repair, reducing mortality, complications and disability rate.
Due to the reduced ability of the elderly to repair their own fractures, more coexisting diseases and poor surgical tolerance, which increases the risk of surgical treatment, but long-term bed rest and joint braking in elderly fracture patients will inevitably affect the recovery of joint function and lead to other systemic complications, which can cause the death of the patient in severe cases. Therefore, the systemic and local conditions of elderly patients with osteoporotic fractures must be correctly and comprehensively evaluated, and the advantages and disadvantages of surgical and non-surgical treatments must be weighed to make a reasonable choice.
In addition to preventing and treating local complications of fractures, patients with osteoporotic fractures in advanced age also need to actively prevent and treat complications such as deep vein thrombosis (DVT) of the lower extremities, fat embolism syndrome, crushing pneumonia, urinary tract infection and decubitus ulcers.
Along with surgical treatment, it is essential to actively treat osteoporosis to improve bone quality and reduce the occurrence of re-fracture.
IV. Common fracture sites, characteristics and treatment
Osteoporotic fractures are commonly found in the spine, hip, and distal radius and ulna.
1. Spine fracture: The spine is the most common site of osteoporotic fracture, 85% of which have pain and other symptoms, while 15% can be asymptomatic. Spinal fractures are easily misdiagnosed as lumbar strain or missed because of very mild injury or no obvious history of trauma. Because of the high mobility of the thoracolumbar spine and the concentration of stress in the spine, fractures in this area account for about 90% of all spinal fractures.
Treatment of spinal fractures: There are two types of treatment for osteoporotic spinal fractures, surgical and non-surgical, which should be reasonably selected according to the condition. If there is spinal cord, nerve root compression and severe compression fracture, surgical decompression can be considered, and internal fixation can be selected according to the bone quality as appropriate. However, due to the osteoporosis, the internal fixation is easy to be loosened, and complications may easily arise. Treatment of fractures should be accompanied by active treatment of osteoporosis.
Minimally invasive spine techniques – percutaneous vertebral plasty (vertebral plasty) and kyphoplasty (kyphoplasty) are indicated for fresh, painful vertebral compression fractures not associated with spinal cord or nerve root symptoms. Pain relief, spinal stabilization and early mobility can be achieved. The indications should be strictly selected and the risks of surgery should be considered, and attention should be paid to the standardization of operation techniques to prevent complications.
2. Hip fracture: including femoral neck fracture and intertrochanteric fracture.
(1) Characteristics of hip fracture: ①High mortality rate: due to the high age of the patient, often accompanied by a variety of elderly diseases, post-injury complications such as pneumonia, urinary tract infection, decubitus ulcer, lower limb venous thrombosis and other complications are likely to occur, and the mortality rate is high. ②High rate of osteonecrosis and non-healing: due to the anatomical reasons, the intracapsular fracture of the femoral neck is subjected to high torsional and shear stress, which affects the stability of fracture repositioning; also due to the special characteristics of the blood supply to the femoral head, the rate of non-healing is high: the ischemia of the femoral head after fracture can also cause ischemic necrosis of the femoral head, the incidence of which is about 20% to 40%. ③High rate of deformity and disability: inter-rotor fracture of the hip often leaves deformities such as hip inversion, external rotation and shortening of the lower limb, thus affecting the function of the lower limb, with an incidence of up to 50%. ④ Slow rehabilitation: Elderly patients have high requirements for rehabilitation and care due to poor physical recovery. Because of the above characteristics, the treatment of hip fracture is not only the treatment of the fracture itself, but also the treatment of complications and concomitant diseases.
(2) Treatment: The fracture can be treated surgically or non-surgically according to the patient’s condition. Surgical treatment includes internal fixation, artificial joint replacement and external fixator. Along with the treatment of fracture, osteoporosis should be actively treated.
3. Distal radius-ulnar fracture: Osteoporotic distal radius-ulnar fractures in the elderly are mostly comminuted fractures and involve the articular surface, which are prone to residual deformity after fracture healing and often cause functional impairment of the wrist and fingers. The treatment method is usually by manual repositioning, splinting or plaster fixation, or external fixator fixation. For a few unstable fractures, surgical treatment can be considered.