When frail or elderly people suffer bone fractures due to mild trauma to their bodies, we might tend to think of these injuries simply as a common risk of old age. However, these “fragility fractures” – which usually occur in those with weak bone tissue – can be serious and may even lead to death.
Fragility fractures are bone injuries that occur after a minor fall or other mild physical event, which normally would not affect someone with healthy bone tissue. One way to think of them is to imagine a patient entering an emergency room with a broken ankle or hip. If the patient had an auto accident or fell off a ladder, the injury would not seem unusual. But if that patient had only fallen from a seated position onto a carpeted floor or simply stepped down too hard at the last step of a staircase, then that may be a fragility fracture.
Fragility fractures affect an estimated 3 million people annually in the United States, making them a significant and growing health concern. At-risk patients include the elderly and those with thyroid disease, diabetes, high blood pressure, and heart disease.
The cause of fragility fractures is the bone disease osteoporosis (brittle, porous bones). Healthy bone tissue has microscopic holes and spaces that look like a honeycomb. In people with osteoporosis, these holes and spaces are much larger, indicating a loss of bone mass and density. As bones become less dense, they weaken and are more likely to break. The disease usually is painless in the beginning, but as it progresses, fragility fractures can occur with a minor trip or fall, a sneeze, or even a hug from a loved one.
Treatment and Prevention
Because fragility fractures can lead to death in some cases, preventing and quickly treating them are priorities for orthopaedic doctors, especially at UAB Medicine. Orthopaedic trauma surgeon Clay Spitler, MD, says the UAB Fragility Fracture Program can help.
“We have a care pathway set out primarily for hip fractures in our senior population of patients 65 and older,” Dr. Spitler says. “Those patients need surgery to be performed with some level of urgency, which means they need medical clearance for any other medical conditions they might have. So UAB has a system in place to get those patients into an operating room as quickly as possible, depending on their condition and what type of surgery they need. There’s solid evidence that if such a patient does not receive treatment within 48 hours, the risk of complications and death increases within the first 30 days. In spite of our best efforts, even with appropriate medical and surgical care, almost 30% of patients with hip fractures live less than one year after injury.”
The key risk factor for older patients who undergo surgery for major fragility fractures of the hip or spine is loss of mobility, which can lead to bedsores, pneumonia, and other problems. Immediate care and rehabilitation are essential for preventing such conditions.
“Patients in their 20s or 30s might get away with being bed-ridden for two or three days after surgery and then start rehab without too much difficulty,” Dr. Spitler says. “But immobility for elderly patients is a serious issue, because they get deconditioned so quickly. We have our therapists mobilize them as soon as possible. We know that pain associated with these injuries and surgery can make physical therapy difficult. In the emergency room, our colleagues provide nerve blocks to decrease both pain and the amount of narcotics needed. It’s a delicate balance to provide medication for older patients, who are vulnerable to side effects such as delirium and over-sedation. But the pain blocks can help make the quick transition to early rehab much easier.”
The next step in the UAB Fragility Fracture Program, once a patient is recovering, is a follow-up evaluation in UAB Medicine’s Osteoporosis Clinic. It provides a nutrition plan; helps patients work on strength, balance, and posture; and prescribes medication, if needed. Patients also are encouraged to follow up with their primary care physician for future screenings. Careful evaluation helps orthopaedic surgeons better identify the cause of fractures and create a treatment plan to help prevent them.
“Our follow-up care is designed to prevent future injuries,” Dr. Spitler says. “A fragility fracture patient with a broken wrist is at risk for a more serious injury, like a hip fracture or vertebral compression fracture. We assess that risk and consider medications and other preventive measures, because the next fracture could be a life-changing event. Patients with hip fractures, for example, typically lose one level of mobility. If they were using a cane before injury, then they are probably on a walker afterward. If they already needed a walker, then the injury will likely put them in a wheelchair. That’s how serious a fragility fracture can be.”