Fractures of a proksimalny hip at persons of advanced and senile age. Part 1
Performance on the 1st Congress of traumatologists-orthopedists of the capital. Moscow, on February 16-17 2012г.
The material is provided by the Medical center KLINIKA+31.
Change of proksimalny department of a hip at persons of advanced and senile age call complete violation of integrity of a bone in or out of the joint capsule, arisen owing to action of the injuring agent of small energy and bringing, as a rule, to loss of possibility of maintaining a former way of life. More often the mechanism of a trauma is falling from height of own growth. Much more rare – a direct stroke in area of proksimalny department of a hip.
Diagnostics of a change of proksimalny department of a femur, as a rule, does not cause special difficulties, and is based both on anamnesis data, and in a characteristic clinical picture and results of radiological research. The clinical picture of these damages is rather typical: the patient after falling from height of own growth complains of pain in vertelny area or in a groin and notes lack of an oporosposobnost of the bottom extremity. The extremity can be truncated, ротирована, active movements in a coxofemoral joint are impossible.
All patients with suspicion should be immediately delivered to a change of proksimalny department of a hip in profile medical institution. The final diagnosis is put after implementation of standard roentgenograms in perednezadny and axial (not always) projections (sometimes there is a need for implementation of roentgenograms for additional projections or a computer tomography).
In clinic after installation of the diagnosis anesthesia, inspection is carried out and tactics of further treatment is defined. The standard scheme of treatment of such patients in the conditions of standard medical institution in our country so looks now. However, this "scheme" very often is not carried out.
A significant amount of patients goes home from a reception with words: «You the elderly person, at you a fracture of a neck of a hip … Operation is impossible». Even more patients simply are not delivered in a hospital. After all still many experts consider that treatment of fractures of a proksimalny hip at elderly patients should pass houses and surgical intervention here is contraindicated. However universal practice of treatment of such patients proves that it not so.
For anybody not a secret that changes of the proksimalny end of a femur meet often. In 1990 of WHO counted up that that year in the world there was 1 million 700 thousand changes of proksimalny department of a hip at persons of advanced and senile age . During the present time it is observed and enormous growth of number of such traumas [1, 2, 11] is predicted. By 2050 the quantity of these changes can make 6 260 million thousands annually . Besides, according to authors from the USA, the fracture of a proksimalny hip is the most frequent damage among patients 65 years are more senior. It makes 38 % of cases from all changes at patients of this age group . It is interesting that using the PubMed database, authors from India and Great Britain analysed frequency of fractures of a proksimalny hip worldwide: big frequency met in the developed countries, smaller – in developing; big in the north, smaller – is closer to the equator. The biggest figures met in Northern Europe and the USA, smaller – in Latin America and Africa.
Researchers connect this regularity with demographic, ethnic and ecological factors . Authors from Norway also speak about bigger frequency of similar changes in the northern countries, than in the South and note sharp increase in number of such damages in winter months . Unfortunately, in Russia the adequate statistics which could show a real situation is not conducted. There is a lot of reasons for that, but, likely, the main – a far-fetched brand of incurability of a change at the elderly person allegedly conducting to fast death regardless of "biological" age of the patient.
All authors point to the huge social importance of adequate treatment of patients with fractures of a proksimalny hip [1, 2, 4, 5] practically. For example, according to researchers from Portugal, at conservative treatment within one year after a trauma die from 30 to 50 % of patients, 40 % become disabled people and only 10 % can be restored and return completely to a former standard of living. The same authors consider that only surgical treatment in early terms promote achievement of good results .
It is known that these traumas meet more often at women that is caused by avalanche hormonal reorganization in the post-menopausal period. With age the ratio the woman/man decreases with 9/2 at the age of 60-69 years to 3/2 at 70-79 and 1/1 in 80 and is more senior.
That fact is interesting also that at women the absolute number of changes constantly grows with age, and at men, reaching a maximum in 80-84 years, then decreases .
Estimating the economic party of a question, it should be noted constantly increasing expenses of the budget on treatment of these patients. For example, according to Health Insurance Review Agency review, in Korea only from 2001 to 2004 a factor medical cost increased from $62 707 697 in 2001 to $65 200 035 in 2004 (for $2 492 338), respectively national medical expenses for this group of patients increased by 4,5 % . On the basis of the research which has been carried out in Germany, it was revealed that, 2 billion 736 million Euros were spent for treatment of 108 341 changes of proksimalny department of a hip in 2002, and indirect losses made at least 262 million Euros . In Belgium in 1996 a factor cost on treatment of the same changes, including the stationary and out-patient help, made $126 159 323 a year on 10 million inhabitants . Many authors note also that the earlier the patient was operated from the moment of receiving a trauma, the there passed rehabilitation quicker and terms of stay of the patient in a hospital decreased, and also expenses on treatment [13, 14], therefore, were cut down.
Thus, surgical treatment of changes of proksimalny department of a femur at persons of advanced and senile age in the shortest terms is «a gold standard» in the countries with the developed economy and health care. It not only reduces terms of rehabilitation of the patient, but also essentially reduces total costs of treatment. According to the tasks set forth above this instruction intended for unification and standardization of approaches to treatment of patients of advanced and senile age with fractures of a proksimalny hip in our country also is developed.
Change of proksimalny department of a hip at persons of advanced and senile age call complete violation of integrity of a bone in or out of the joint capsule, arisen owing to action of the injuring agent of small energy and bringing, as a rule, to loss of possibility of maintaining a former way of life. These changes happen, generally against osteoporosis when falling from height of own growth. They lead to the compelled hypodynamia, a fast decompensation of already available somatic diseases and very high probability of development of a lethal outcome.
Fractures of a proksimalny hip at persons of young and middle age against a trauma of high energy here are not considered.
According to classification joint stock company/OTA fractures of a proksimalny hip belong to a segment 31 and share on 3 types – And, In, S.Pri etom treat type A extra capsular (lateral) changes of a vertelny z
one: А1 А2 А3
As change 31А1 is called as simple (not splintered) a chrezvertelny change. Distinctive feature of these changes is the high level of stability reached after a repozitsiya and connected with absence of damage both lateral, and medial (a small spit) support.
31А2 the splintered chrezvertelny change is called as a change. Distinctive feature of these changes is the smaller level of stability reached after a repozitsiya and connected with damage of a medial support (a change of a small spit).
31А3 the mezhvertelny change, both simple, and splintered is called as a change.
Distinctive feature of these changes is the low level of stability reached after a repozitsiya and connected with damage both medial, and lateral support.
Intra capsular fractures of a neck of a femur belong to type B: В1 В2 В3
The intra capsular subcapital fracture of a neck of a hip with small shift is called as change В1. Distinctive feature of these changes is that they have the driven or linked character.
The intra capsular transtservikalny fracture of a neck of a hip is called as change В2. Thus the change relating to this group and with the line, a neck passing through the basis, call bazistservikalny.
The intra capsular subcapital not driven fracture of a neck of a hip with shift is called as change В3. Distinctive feature of these changes, as well as follows from the name of this group, that all of them have not driven character is.
Intra articulate a change of a head (Pipkina) of type C treat a high-energy trauma of patients of young and middle age and in this instruction are not considered.
3. Pre-hospital stage.
Suspicion on a change of proksimalny department of a hip – the direct indication for hospitalization of the patient in a hospital an emergency medical service brigade. An exception patients in a terminal stage of somatic diseases and with the expressed mental disorders make only, the approaches which have lost still to the fact of a trauma ability to movement, including by means of a wheelchair.
In default the patient from hospitalization he and his relatives should be warned about possible consequences with the corresponding entry in medical documentation. Transportation of the patient by an ambulance crew is carried out in a prone position on a stretcher with an immobilization the transport tire or situation (easy bending and assignment with fixing by rollers). For anesthesia not narcotic analgetics are entered.
Diagnostics actually and its specification according to classification in the conditions of a hospital, as a rule, difficulties does not cause a fracture of a proksimalny hip and is based on data of the anamnesis, survey and a standard rentgenografiya. However, it is necessary to remember that the most part of changes В1 has the driven character and the change line on standard roentgenograms at such damages can not be traced distinctly and the patient thus keeps ability to independent walking. If, despite the carried-out volume of inspection at the patients complaining of pain who have appeared after a trauma in the field of a coxofemoral joint, the diagnosis remains not clear, the emergency computer tomography of a coxofemoral joint for the purpose of an exception of the driven fracture of a neck should be executed.
In a reception, after survey by the traumatologist and diagnostics of a change of proksimalny department of a hip, within one hour since receipt, to the patient should be carried out the following researches: Electrocardiogram, thorax rentgenografiya, clinical analysis of blood, general analysis of urine, blood type and Rhesus factor, and as glucose and blood bilirubin, electrolits, time of coagulability and duration of bleeding. All patients of advanced and senile age with the diagnosed change of proksimalny department of a hip in a reception look round the therapist. The therapist, if necessary, can invite for emergency consultation of experts of a narrow profile, as a rule – the endocrinologist (in case of a diabetes decompensation), the cardiologist or (and) the neurologist – for an exception of a sharp myocardial infarction or violation of brain blood circulation in the presence of the relevant kliniko-laboratory data. Additional diagnostic actions and the procedures not entering into the specified list and directed on identification of chronic diseases, including oncological if they did not lead to development of the complications listed in points
5.1. – 5.6., are carried out after surgical stabilization of a change (joint replacement).