This article appeared in the July 2012 issue of Physician News.
Orthopedic Trauma Service and Geriatrics Partner to Improve Outcomes after Falls
The Orthopedic Trauma Service at Brigham and Women’s Hospital recently added a full-time geriatrician to its service to optimize the care and management of elderly patients who have incurred injuries related to a fall.
“Nearly 40 percent of our patients are over the age of 70, and many of these patients present with multiple associated medical conditions,” said Mitchel B. Harris, MD, Chief of the Orthopedic Trauma Service.
Houman Javedan, MD, a Brigham and Women’s Hospital geriatrician from the Division of Aging, works as an integral part of the Orthopedic Trauma Service team, evaluating every patient over the age of 70.
“A fall among an elderly patient is often a symptom of other medical conditions, and the mortality and morbidity among these patients is extremely high,” said Dr. Javedan. “It is critical to look at the big picture in order to improve both short- and longer-term outcomes.”
Dr. Javedan conducts a thorough evaluation of patients’ medical, cognitive, and emotional status, in addition to speaking with their family members. Then, he works with the trauma team to implement personalized geriatric-based patient care.
“As the general population continues to age, the incidence of fractures among the elderly is climbing,” said Michael Weaver, MD, an orthopedic surgeon in the Orthopedic Trauma Service. “We are taking the steps needed to best care for this population.”
Case Study: Hip Fracture in Patient with Multiple Conditions
A 90-year-old male patient with moderate dementia, gait instability, atrial fibrillation, gastro-esophageal reflux, hypertension, and hypercholesterolemia presents after fall and injury incurred by tripping on his walker because of poor safety insight, a common problem resulting from executive dysfunction of dementia.
The patient was admitted directly to the Orthopedic Trauma Service to be evaluated by a multidisciplinary team, including orthopedic surgeons, a dedicated geriatrician, anesthesiologists, nurses, occupational therapists, physical therapists, and a case manager. He received a comprehensive geriatric assessment prior to surgery. His pain medication regimen was set, his anticholinergic medications were held, and appropriate recommendations for possible post-operative delirium were implemented. His time to surgery was minimized in order to best achieve pre-trauma level activity after surgery, and specialized orthopedic trauma surgeons performed the surgery.
His fracture was typical of someone with osteoporosis, in this case a comminuted and displaced inter-trochanteric hip fracture (Figure 1). Given the fracture pattern and his overall medical condition, a minimally invasive technique was selected for the treatment of this injury. The fracture was reduced indirectly and fixed through two small incisions on the thigh. A titanium intramedullary hip screw stabilized the fracture and allowed for healing.
All members of the team continued to see the patient daily after surgery. He was encouraged to ambulate with the assistance of physical therapy and was able to stand at the bedside on the first day following surgery. The patient experienced mild delirium, which cleared by the second post-operative day. Geriatrics identified the delirium early, closely titrating the pain regimen, reviewing post-operative medications and holding unessential medications, removing his foley early, removing unessential continuous monitoring, minimizing overnight disruptions, encouraging family to be bedside, and working with nursing staff to adjust care and diet consistency to prevent aspiration. His medical co-morbidities were managed without decompensation, and he was discharged to an appropriate rehabilitation facility on the third post-operative day.
The patient was seen in clinic periodically following his discharge from the hospital. At three months post-procedure, he had returned to independent ambulation with the aid of a cane. Radiographs at his most recent clinic visit demonstrate the presence of the intramedullary hip screw and show the fracture to be fully healed in a good position (Figure 2).
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