Front Cover 1
Fragility Fractures 2
copyright 
3 
Contributors 4
Contents 8
Clinics In Geriatric Medicine 
13 
Preface 
14 
Epidemiology of Fragility Fractures 16
Key points 16
Introduction 16
Prevalence/Incidence 17
Outcomes 17
Clinical correlation 18
Predictors of fragility fracture 19
Summary 20
References 20
Principles of Comanagement and the Geriatric Fracture Center 24
Key points 24
Introduction 24
Principles of comanagement 25
Most Patients Benefit from Surgical Stabilization of Their Fracture 25
The Sooner Patients Have Surgery, the Less Time They Have to Develop Iatrogenic Illness 25
Comanagement with Frequent Communication Avoids Common Medical and Functional Complications 26
Standardized Protocols Decrease Unwarranted Variability 27
Discharge planning begins at admission 28
Discussion 29
Summary 29
References 29
Lean Business Model and Implementation of a Geriatric Fracture Center 32
Key points 32
Introduction 32
What is a lean business model and why is it relevant to hip fracture care? 33
The geriatric fracture center (Rochester model) for care of hip fractures 34
Planning to implement a GFC 36
Development of a basic business plan 36
The 10-Step Business Plan 36
Partnering for success 39
Development of care maps and protocols 40
Dealing with barriers to implementation 41
Do you need a consultant? 42
How much does it cost to implement a GFC? 43
How to measure success of your program 44
Summary 44
References 44
Preoperative Optimization and Risk Assessment 48
Key points 48
Introduction 48
Implications of normal aging 48
Preoperative principles in the geriatric fracture patient 49
Early surgery 49
Preoperative risk assessment in older patients 50
Cardiovascular Evaluation 50
Cognitive Impairment 51
Functional Status 52
Nutritional Status 52
Polypharmacy 52
Preoperative optimization 53
Preoperative Fluid Management 53
Medication Management 54
ß-Blockers 55
Pain Control 55
Laboratory Testing 55
Nonoperative management 56
Summary 56
References 56
Preoperative Management of Anticoagulation and Antiplatelet Agents 60
Key points 60
Introduction 60
Anticoagulant management 61
Medications and Reason for Use 61
Risk Assessment of Stopping Anticoagulant 62
How to Manage Anticoagulation in Preparation for Surgery/Timing of Surgery 62
Vitamin K antagonist: warfarin 62
Novel Oral Anticoagulants: Dabigatran, Rivaroxaban, and Apixaban 64
Dabigatran 64
Rivaroxaban and apixaban 65
Antithrombotic Management 65
Aspirin 65
Antiplatelet Agents 65
Determine reason for antiplatelet use 65
Risk assessment of stopping antiplatelet agents 66
Management for surgery 66
Summary 67
References 67
Classification and Surgical Approaches to Hip Fractures for Nonsurgeons 70
Key points 70
Introduction 70
Anatomy and fracture risk 71
Fracture types 71
Femoral Neck Fractures 72
Intertrochanteric Fractures 75
Subtrochanteric Fractures 78
Summary 79
References 79
Special Anesthetic Consideration for the Patient with a Fragility Fracture 84
Key points 84
Introduction 84
Initial Workup Considerations 85
Risk Stratification 85
Preoperative pulmonary risk stratification 85
Preoperative cardiac risk stratification 85
Preoperative central nervous system evaluation 86
Overall risk stratification 86
Effects of General Anesthetics by System 87
Cardiovascular effects 87
Respiratory effects 88
Cerebral effects 91
Effects of Regional Anesthetics 91
Neuraxial: spinal and epidural 92
Complications of Neuraxial Anesthesia 93
Peripheral nerve blocks 93
Upper extremity 93
Side effects and complications 93
Brachial plexus blocks below the clavicle 96
Lower extremity 96
Choice of Anesthetic by Fracture 96
Extremity fracture 96
Hip fracture 96
Strategies for postoperative pain management 97
Multimodal analgesia 97
Summary 97
References 97
Management of Postoperative Complications 102
Key points 102
Introduction 102
Overview of the postoperative period 103
Implications of physiologic changes of aging on postoperative complications 103
Respiratory System 103
Cardiovascular System 104
Renal System 104
Skin 105
General approach 105
Early Mobility 106
Freedom from Tethers 106
Pain Management 106
Malnutrition and Pressure Ulcers 107
Prevention of Infections 108
Management of Cognition 108
Other Considerations 109
Summary 109
References 109
Management of Common Postoperative Complications 112
Key points 112
Introduction 112
Diagnosis 112
Management goals 114
Nonpharmacologic strategies 114
Controversies 116
Pharmacologic strategies 116
Maximal Effective Dose 117
Timing 117
Cholinesterase Inhibitors 117
Controversies 117
Summary/discussion 117
References 118
Management of Postoperative Complications 120
Key points 120
Introduction 120
Patient evaluation 121
Management goals 121
Risks of transfusion 123
Evaluation and adjustment 124
Summary 124
References 124
Venous Thromboembolism and Postoperative Management of Anticoagulation 126
Key points 126
Introduction/Epidemiology 126
Patient evaluation overview 127
Pharmacologic treatment options 128
Nonpharmacologic treatment options 129
To bridge or not to bridge 130
Summary 130
References 130
Management of Postoperative Complications 134
Key points 134
Introduction 134
Implications of normal cardiovascular aging 135
Core principles for postoperative management in older patients 135
Common cardiovascular responses to uncomplicated orthopedic surgery 136
Common cardiovascular complications and strategies 136
Hypotension 136
Atrial Fibrillation 137
Heart Failure and Volume Assessment 137
Myocardial Ischemia 138
Perioperative considerations with common chronic cardiovascular medications 139
ß-Blockers 139
ACE Inhibitors 139
Calcium Channel Blockers 139
Digoxin 140
Loop Diuretics (Furosemide, Torsemide, Bumetanide) 140
Aldosterone Antagonists (Spironolactone, Eplerenone) 140
Antiplatelet Agents and Anticoagulants 140
Summary 140
References 141
Transitions of Care and Rehabilitation After Fragility Fractures 144
Key points 144
Transitions in care 144
Types of rehabilitation settings 146
Reimbursement for rehabilitation 148
Goals of rehabilitation 150
Common medical issues in rehabilitation 151
Pain Management 151
Pressure Sore Prevention 152
Thromboprophylaxis 152
Nutrition 152
Delirium 153
Other Medical Issues 153
Outcomes in rehabilitation 153
Secondary prevention in rehabilitation 154
References 155
Secondary Prevention After an Osteoporosis-Related Fracture 158
Key points 158
Burden of fragility fractures 158
The evidence for pharmacologic and nonpharmacologic agents on fracture risk reduction 159
Pharmacologic Agents 159
Nonpharmacologic Agents, Including Supplements 160
The concept of fracture risk is replacing a diagnosis of OP and osteopenia 160
Clinical practice guidelines acknowledge the need to intervene in patients who are at risk for future fracture 161
The Introduction of Postfracture Secondary Prevention Programs 161
The Scope of Postfracture Secondary Prevention Programs 161
The effect of postfracture secondary prevention programs 163
Reduction in Health Care Costs 163
Improved Investigation and Treatment Rates 163
Participation in Exercise 163
Reduction in Refracture Rates 163
What Makes a Program Effective? 163
Potential reasons for these gaps in bone health still exist despite postfracture secondary prevention programs 164
Patients Do Not Connect Their Fragility Fracture to Underlying Bone Health 164
Patients Are Unclear About Several Aspects of Their Care 164
Patients Are Concerned About Side Effects 164
OP Pharmacotherapy Use Fluctuates 165
Programs that Target Primary Care Providers Alone Are Not Enough 165
BMD Test Reports Underestimate Fracture Risk 165
Future research directions in postfracture secondary prevention 165
Summary 166
References 166
Postoperative Prevention of Falls in Older Adults with Fragility Fractures 174
Key points 174
Introduction 174
Risk factors for falls 176
Risk assessment 179
Strategies for secondary prevention of falls 181
Postoperative Inpatients 181
Postoperative Outpatients 183
Summary 184
References 185
Atypical Femur Fractures 190
Key points 190
Introduction 190
Clinical presentation 191
Epidemiology and pathophysiology 192
Evaluation and work-up of patients 194
Management of patients with atypical femur fracture 196
Management of patients without atypical fractures on long-term bisphosphonates 198
Summary 199
References 200
Fragility Fractures Requiring Special Consideration 202
Key points 202
Introduction 202
Epidemiology 202
Challenge: Geriatric Patient 203
Comorbidities 203
Osteoporosis 203
Disability 204
Treatment goals 204
Special considerations 204
Cervical Spine Fractures 204
Upper cervical spine fractures C1-C2 204
Lower cervical spine C3-C7 205
Thoracic and Lumbar Spine 205
Summary 207
References 207
Fragility Fractures Requiring Special Consideration 214
Key points 214
Introduction 214
Epidemiology 215
Pelvis fracture epidemiology 215
Acetabulum fracture epidemiology 215
Morbidity and mortality statistics 215
Anatomic and Biomechanical Considerations 216
Pelvis anatomy 216
Acetabulum anatomy 217
Evaluation 217
History and Physical Examination 217
Imaging 218
Plain radiographs 218
Advanced imaging 219
Laboratory Analysis 219
Author’s Preferred Management 220
Management goals 220
Nonpharmacologic strategies 221
Nonoperative Considerations 222
Pelvis 222
Acetabulum 222
Operative Considerations 223
Pelvis 223
Acetabulum 223
Post-operative care 224
Pharmacologic strategies 224
Vitamin D/Calcium 224
Bisphosphonates 224
Human Recombinant Parathyroid Hormone 225
Summary 225
References 226
Index 228