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  • Best practice in Elderly

    Orthopedic patients

    ผศ.นพ.วราห์ ยนืยงววิัฒน์

    ภาควิชาศลัยศาสตร์ออร์โธปิดิกส์และกายภาพบ าบดั

    คณะแพทย์ศาสตร์ มหาวิทยาลยัสงขลานคริทร์ พว. ธัญลักษณ์ ณรงค์กูล

    หอผู้ ป่วยศลัยกรรมกระดกูและข้อหญิง

  • Introduction

     Common elderly problem

    ◦ Hip fracture

    ◦ OA hip and knee

     Scope

    ◦ Disease information

    ◦ Treatment

    ◦ Nursing care

  • Hip fracture

  • Hip fracture

     Fracture neck of femur

     Intertrochanteric fracture

  • Epidemiology

     250,000 Hip fractures annually in USA

    ◦ Expected to double by 2050

     At risk populations ◦ Elderly: poor balance&vision, osteoporosis, inactivity,

    medications, malnutrition

     incidence doubles with each decade beyond age 50

    ◦ higher in white population

    ◦ Other factors: smokers, small body size, excessive caffeine & ETOH

  • Hip fracture incidence

    Melton et al. Calcif Tissue Int 1987; 41:57

    500

    1000

    1400

    40 50 60 70 80

    500

    1000

    1400

    40 50 60 70 80

    Femoral Neck

    Men Women

    Femoral Neck

    Intertrochanteric Intertrochanteri

    c

    In ci

    d e n ce

    p e r

    1 0 0 ,0

    0 0 p

    e rs

    o n

    -y e a rs

    Age (years) Age (years)

  • Cause

     Most hip fractures occur in elderly result

    of minimal trauma

    - a fall from standing height

     Prevent by environment prepared

    http://images.google.co.th/imgres?imgurl=http://www.alaskalawblog.com/falling_man.jpg&imgrefurl=http://www.alaskalawblog.com/2008/07/the_shocking_loss_of_a_gritty.html&usg=__O4HvUcQMoRBPfpmMwQSUq4RIIqo=&h=1000&w=1152&sz=56&hl=th&start=16&um=1&tbnid=xk8O6ZfHxbSb1M:&tbnh=130&tbnw=150&prev=/images?q=banana+peel&hl=th&um=1

  • Neck femur & Intertrochanteric

  • Clinical presentation

    History

     thigh or groin pain.

     unable to ambulate.  some cases may be able to walk.

    (Nondisplaced or impacted fractures)

    http://images.google.co.th/imgres?imgurl=http://www.joint-pain-expert.net/images/hip_pain2.jpg&imgrefurl=http://www.joint-pain-expert.net/hip-pain.html&usg=__LOoUftQ7jWsL3rsCkLVXY8jNk-w=&h=448&w=317&sz=19&hl=th&start=30&um=1&tbnid=zPBcfX2NKT3FPM:&tbnh=127&tbnw=90&prev=/images?q=hip+pain&ndsp=20&hl=th&sa=N&start=20&um=1

  • Physical examination

    Observation

    Posture

     Shortening and rotation of the lower extremity

     Skin and soft tissue

     Swelling

     Ecchymosed(Intertroch fracture)

    Range of motion

     Limited range of motion due to pain

  • Investigation

     Plain -ray

  • Fracture neck of femur

  • Fracture neck of femur

    Normal x-ray Fracture

  • Intertrochanteric fracture

  • Intertrochanteric fracture

  • Loss of

    function

    50%

    Mortality

    20%

    Regained

    functional

    capacity

    30%

    Sernbo 1993

    Outcome after hip fracture

    The situation one year after fracture

    Sernbo et al. Osteoporos Int. 1993; 3:148-53

  • Outcome

     mortality rate of hip fractures is 15-20%,

     increase to 36% over the year of fracture

     Rate of mortality is greatest in the first

    few months following injury

    (remains high for 1 year)

  • Outcome

     Mobidity

    - Morbidity from immobilization

    - Morbidity from surgical procedures

  • Outcome

     Morbidity from immobilization

    - deep vein thrombosis

    - pulmonary embolism

    - pneumonia

    - muscular deconditioning

  • Outcome

    . Morbidity from surgical procedures

    - complications of anesthesia

    - postoperative infection

    - loss of fixation

    - malunion or nonunion

  • Treatment

    Goals of treatment of a hip fracture

     reducing mortality  early ambulation as

    soon as possible

     return the patient to walking

  • Treatment

    Pre-operative Considerations Surgical Timing

    - Surgical delay

    Increased mortality, complications,

    length of stay

    - If delayed > 2 days , have a 17% higher mortality rate at 1 month.

    ◦ If patient unstable --> Can delay surgery up to 72 hours

  • Treatment

    Phase of treatment

     Initial treatment

     Definite treatment

    http://images.google.co.th/imgres?imgurl=http://www.worldsikhnews.com/14 Janaury 2009/Image/Red Cross.jpg&imgrefurl=http://www.worldsikhnews.com/14 Janaury 2009/Officials looted it Red now High Court is very Cross.htm&usg=__FErBQccC24iWgqAD2_mmqE98irg=&h=332&w=340&sz=37&hl=th&start=19&um=1&tbnid=pFbEepIgDbv-tM:&tbnh=116&tbnw=119&prev=/images?q=red+cross&hl=th&um=1

  • Initial treatment

    Goal

    -Supportive pain

    -Prevent complication before definite treatment

    http://images.google.co.th/imgres?imgurl=http://www.ruh.nhs.uk/zz_images/pain_clinic/Drug.jpeg&imgrefurl=http://www.ruh.nhs.uk/patients/services/clinics/pain_clinic/drug_treatments.asp&usg=__-Z-Xz1c8siPYSSk4r6rty7OZTW4=&h=187&w=280&sz=13&hl=th&start=7&um=1&tbnid=VV5ZcaY2gfYq7M:&tbnh=76&tbnw=114&prev=/images?q=analgesic&hl=th&um=1

  • Initial treatment

    Supportive pain

     Immobilization

     Analgesic

    Prevent complication  Pressure sore

     Pneumonia

     Urinary tract infection

     Deep vein thrombosis/Pulmonary embolism

    http://images.google.co.th/imgres?imgurl=http://i195.photobucket.com/albums/z63/achariyakood/medicine-user.gif&imgrefurl=http://larndham.net/index.php?showtopic=29928&st=172&usg=__W9mA67K6iUaY7wU5dh3z8D6iN_o=&h=245&w=245&sz=19&hl=th&start=38&um=1&tbnid=iZkm_Rs_j5U6zM:&tbnh=110&tbnw=110&prev=/images?q=medicine&ndsp=20&hl=th&sa=N&start=20&um=1

  • Immobilization

     Skin traction

     Pillow

  • Definite treatment

     Surgery

    -Main treatment

     Non operative treatment

    -Patient who excessively high risk for

    operation(extremely medical condition)

    -Non ambulate patient who have minimal comfort from fracture

  • Non operative treatment

     Traction  non displace fracture

     Early mobilization

  • Fracture neck of femur

    Surgery

     Internal fixation

    - Non displace fracture

     Prosthetic replacement - Displacement fracture in elderly (Avoid chance for further surgery)

  • 61 years : Neck impact fracture

  • 80 years : Neck total displace

  • Intertrochanteric fracture

     Easy to union  internal fixation

  • Complication

     Pressure sore

     Pneumonia

     Deep vein thrombosis/Pulmonary embolism

  • Pressure sore

    Prevention

    -Adequate analgesia

    -Frequence change position

  • Pneumonia

    Prevention

     Upright as tolerate

     Breathing exercise

     Triflow

  • Deep vein thrombosis/Pulmonary embolism

    Prevention

     Calve exercise

     Pneumatic pump

     Medical prevention

  • Post op complication

     Wound care

     Early ambulation

     Avoid hip dislocation

  • Nursing care

  • Nursing care : Hip fracture

     1.Pre operative  2.Post operative  3.Pre-discharge

  • Pre operative

    History ประวัตกิารใช้ยา การพลัดตกหกล้ม ภาวะเส่ียงด้านต่างๆ

     โรคประจ าตัว

  • Pre operative

     ประเมินความรู้ความเข้าใจและความพร้อมด้าน ร่าง