by Michele F. Bellantoni, M.D
Fractures can occur even with the most aggressive osteoporosis management. Fractures of distal extremities such as forearm and ankle are often managed in the outpatient setting. The orthopedic surgeon performs either open or closed reduction of the fracture and casting for bone healing. The primary health care provider manages pain and immobility that result from the fracture. Pain management is challenging in the elderly as the adverse effects of narcotics including over sedation, delirium, and constipation must be balanced with effective pain relieve and preservation of physical function. Outpatient physical and occupational therapy, often in the home setting for homebound elderly are helpful in maintaining muscle strength and in providing adaptive responses to the injury.
The management of vertebral compression fracture is evolving. Vertebroplasty is FDA approved for the management of pain and physical deformity that result from chronic vertebral compression fracture. Studies are being conducted to assess the benefits vs. risks of vertebroplasty in the management of acute vertebral compression fractures. Calcitonin has been shown in short-term studies to reduce the pain and physical dysfunction of acute vertebral compression fractures. There are data to suggest that bisphosphonates can impact bone pain, but insufficient to recommend their use for pain management. Often in the setting of new fracture the gastrointestinal side effects of daily bisphosphonates outweigh their potential benefits. Data do not show that any of the anti-resorptive treatments impair bone healing after acute fracture. What are strategies for reducing risk of poor prognosis following fracture?
Acute Hospital Management
The acute hospital course requires a team approach for effective management of hip fractures and other fractures that require operative procedures and inpatient care. Ideally, the orthopedic surgeon provides management of fracture stabilization, whether that be operative or nonoperative. Early mobilization may prevent postoperative complication resulting from deconditioning and bed rest, and is promoted if surgery takes place within 24 to 48 hours of hospital admission followed by high frequency physical and occupational therapy.(ref 39) The orthopedic surgeon makes recommendations regarding wound care, weight-bearing status, and limitations of fractured bones. The internist provides management of cardiopulmonary function, particularly peri-operative fluid and electrolyte management and patient focused assessment of ischemia; pain control, and prevention of common complications such as delirium, deep venous thrombosis, pulmonary emboli, infections, incontinence, constipation, depression, anemia, and pressure sores. Physical and Occupational Therapists assess the functional state of the patient and make recommendations for the rehabilitation setting; inpatient vs outpatient ambulatory, vs in home program. Social workers coordinate rehabilitation based on team recommendations, and arrange for the rental or purchase of equipment such as assistive devices, portable commodes, and wheelchairs.
A multi-disciplinary team provides optimal patient care.(ref 40) A randomized controlled trial has shown that accelerated rehabilitation reduces the cost of care by approximately 17%.(ref 41)
- Medical care– most medical issues require adjustments in care based on patients increased frailty as a result of fracture. An example is adjustment of diabetes regimen in the setting of decreased oral intake due to limited access to food, depression, and/or nausea secondary to pain medications, constipation, or other causes. Rehabilitation is the time when cardiac ischemia and symptomatic orthostasis first present as the patients oxygen consumption increases during ambulation with an assistive device, often in the setting of post-fracture blood loss and new medications that contribute to orthostasis.
- Physiatrists provide recommendations improve rehabilitation outcomes. They focus on pain management, functional impairments and methods to improve function using physical and pharmacologic modalities. For example, a physiatrist may recommend an individualized exercise program to strengthen isolated muscle groups, or to reduce weight-bearing to areas to improve pain.
- Nursing care– nursing provides frequent assessments for changes in vital signs or clinical symptoms that suggest the early signs of the above mentioned complications (ischemia, pulmonary emboli, infection). Nursing extends the rehabilitation plan established by physical and occupational therapies. Nursing also prevents pressure sores through positioning, establishes bladder retraining programs for incontinence, and educates patients and families on the rehabilitation plan.
- Physical Therapy– This discipline addresses mobility and lower body function. Physical therapy provides gait retraining, safe and proper use of assistive devices, fall prevention, and pain management through local modalities of heat, cold, massage, ultrasound, and electrical stimulation.
- Occupational Therapy– This discipline addresses activities of daily living and upper body function. Occupational therapy provides retraining in bathing, grooming, dressing, toileting, meal preparation, and housekeeping.
- Nutrition Assessments– Assessments of the patients nutritional status and caloric needs are made. This should include assessment of dietary calcium and vitamin D for osteoporosis management.
- Psychology– Depression is common after loss of independence. Counseling and pharmacotherapy may improve patients motivation and performance during rehabilitation.
Most inpatient rehabilitation programs are of one to several weeks duration. Many older people will need longer term management of pain or functional impairments. In home physical therapy and occupational therapy should be considered in those who have not regained their prefracture level of physical function at the time of discharge due to plateau in function. Osteoporosis management should begin post-fracture and should be continued long-term.