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<div class="Section1"> 1. </div> <span lang="EN-US" style= "FONT-SIZE: 10pt; FONT-FAMILY: Century; mso-fareast-font-family: "ＭＳ明朝"; mso-bidi-font-family: "Times New Roman"; mso-font-kerning: 1.0pt; mso-ansi-language: EN-US; mso-fareast-language: JA; mso-bidi-language: AR-SA"> <div class="Section2"> 東京消防庁の統計によると, 家庭内で発生した不慮の救急事故のため救急車を呼んだ人のうち全体の約45％が 転倒, 約10% が 転落 でした. 65歳以上の高齢者で検討したところ, 家庭内事故の統計では約7割は 転倒 が原因でした. 事故の発生場所は家の中の居室が全体の約７割, 階段, 廊下, 庭などが転倒・転落場所となっています. </div> <span lang="EN-US" style= "FONT-SIZE: 10pt; FONT-FAMILY: Century; mso-fareast-font-family: "ＭＳ明朝"; mso-bidi-font-family: "Times New Roman"; mso-font-kerning: 1.0pt; mso-ansi-language: EN-US; mso-fareast-language: JA; mso-bidi-language: AR-SA"> <div class="Section3"> 高齢者 (65歳以上) の家庭内事故 受傷形態の割合: 総数14,915人, 平成11年 東京消防庁調べ. 2. Faculty Comments Falling is a serious public health problem among elderly people because of its frequency, morbidity and cost associated with these falls. Injuries resulted from falls ranks as the sixth leading cause of death among people over 65 years of age. The non-fatal results of falls include physical injury and fear which can lead to functional deterioration and institutionalization. The yearly cost for acute care associated with fall-related fractures is estimated at $10 billion. 3. Falls are not a normal part of the aging process. There are physical and environmental factors that make falls more common in the elderly. 4. Faculty Comments 1. Impaired vision (e.g. from cataracts) 2. Decreased hearing 3. Impairment in balance and gait

<div class="Section1"> 注: 図が抜けています. 1. </div> <span lang="EN-US" style= "FONT-SIZE: 10pt; FONT-FAMILY: Century; mso-fareast-font-family: "ＭＳ明朝"; mso-bidi-font-family: "Times New Roman"; mso-font-kerning: 1.0pt; mso-ansi-language: EN-US; mso-fareast-language: JA; mso-bidi-language: AR-SA"> <div class="Section2"> 東京消防庁の統計によると, 家庭内で発生した不慮の救急事故のため救急車を呼んだ人のうち全体の約45％が転倒, 約10% が 転落 でした. 65歳以上の高齢者で検討したところ, 家庭内事故の統計では約7割は転倒 が原因でした. 事故の発生場所は家の中の居室が全体の約７割, 階段, 廊下, 庭などが転倒・転落場所となっています. </div> <span lang="EN-US" style= "FONT-SIZE: 10pt; FONT-FAMILY: Century; mso-fareast-font-family: "ＭＳ明朝"; mso-bidi-font-family: "Times New Roman"; mso-font-kerning: 1.0pt; mso-ansi-language: EN-US; mso-fareast-language: JA; mso-bidi-language: AR-SA"> <div class="Section3"> 高齢者 (65歳以上) の家庭内事故 受傷形態の割合: 総数14,915人, 平成11年東京消防庁調べ. 2. Faculty Comments Falling is a serious public healthproblem among elderly people because of its frequency, morbidityand cost associated with these falls. Injuries resulted from falls ranksas the sixth leading cause of death among people over 65 years of age.The non-fatal results of falls include physical injury and fear which can leadto functional deterioration and institutionalization. The yearly cost for acutecare associated with fall-related fractures is estimated at $10billion. 3. Falls are not a normal part of the agingprocess. There are physical and environmental factors that make falls morecommon in the elderly. 4. Faculty Comments 1. Impaired vision (e.g. fromcataracts) 2. Decreasedhearing 3. Impairment in balance andgait �　 sensory changes (e.g.diabetic neuropathy, vascular insufficiency) �　 muscleweakness �　 arthritis, ParkinsonDisease and other medical conditions 4. Slowed reactiontime 5. Faculty Comments Falls can be caused by both extrinsicand intrinsic or physiologic causes. Extrinsic causes are those causes that can be found about the patient'sliving environment, such as poor lighting, loose rugs or floor boards,unstable furniture, absent handrails, wet or slippery or uneven surfaces, longhousecoat or pants, or over-size clothing. Intrinsic or physiologic causes can be due to decreased visual acuity, eitherdue to cataracts or other visual disturbances, or causes due to the agingprocess, diminished hearing, impaired balance due to any numberof causes, and reduced strength and slowed reaction time due tothe aging process. It is important to note that many falls can be due to acombination of factors of both intrinsic and extrinsic causes binding in such away to cause the person to fall. 6. Faculty Comments Many medications we prescribe can causeside effects which can increase the patient's risk of falling.Antihypertensive medication can cause postural hypotension. Painmedication and sleeping pills can cause sedation. It has been shownthat patients on four or more medications are at an increased risk offalling. 7. Faculty Comments: There have been several programsdesigned for the elderly people living in the community that have shown a 30%risk reduction. Things that were effective in preventing fallsinclude: <ul style="MARGIN-TOP: 0mm" type="disc"> <li class="MsoNormal" style= "MARGIN: 0mm 0mm 0pt; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt"> physicaltherapy for gait, balance and strength training </li> <li class="MsoNormal" style= "MARGIN: 0mm 0mm 0pt; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt"> use cane andwalker if needed </li> <li class="MsoNormal" style= "MARGIN: 0mm 0mm 0pt; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt"> wearrubber-soled shoes to improve traction </li> <li class="MsoNormal" style= "MARGIN: 0mm 0mm 0pt; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt"> reviewpatient's medications with patient's primary care physician to discontinue orsubstitute medications which can cause hypotension andsedation </li> <li class="MsoNormal" style= "MARGIN: 0mm 0mm 0pt; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt"> educate thepatient of potential side effects of his/her medications and the appropriateuse of sedative-hypnotic agents </li> <li class="MsoNormal" style= "MARGIN: 0mm 0mm 0pt; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt"> environmentalmodification - well-lit halls/stairways, removal of hazards (anchoring rugs),safer furniture (correct height, more stable) installation of structures suchas grab bars or handrails on stairs </li> </ul> 8. Faculty Comments Before we assume the patient's fall wasdue to environmental factors, we must rule out intrinsic causes of her fallsuch as arrhythmia, vertebrobasal insufficiency, seizure disorders. Thesecauses when missed will lead to serious consequences and/or repeatedfalling. Lab data; </div> <span lang="EN-US" style= "FONT-SIZE: 10pt; FONT-FAMILY: Century; mso-fareast-font-family: "ＭＳ明朝"; mso-bidi-font-family: "Times New Roman"; mso-font-kerning: 1.0pt; mso-ansi-language: EN-US; mso-fareast-language: JA; mso-bidi-language: AR-SA"> <div class="Section4"> Acid Phosphatase = 0.5 (0.3-0.7U/L) Amylase=86 IU/L [20-90IU/L] Creatinine=1.5 [0.8-1.4mg/dl] BUN=23 [8-22mg/dl] Complete Blood Count withDifferential: WBC= 6.8[4.6-10.8] K/�L HGB= 14.7[14-18] g/dL HCT= 39.7[40-50] % MCV= 85[82-96] fL MCH= 29[28-33] pg MCHC= 33.1 [32-36]% Differential: Band Neutrophil 2.0[0-0.7] Neutrophil 7.1[1.7-7.0] Lymphocyte 0.5[1.2-4.9] Eosinophil 0.0[0-0.7] Chest X-Ray: Normal exam EKG: Sinus tachycardia at rate of 105, no ST-T waveabnormalities. Erythrocyte Sedimentation Rate = 15 mm/h[0-20 mm/h] Fasting Glucose = 107 [70-120mg/dl] Liver Profile: Total Bilirubin=0.8 [0.1-1.2mg/dl] Alk Phosphatase=180 [40-130U/L] AST (SGOT) = 63 [10-40U/L] Lumbar SpineSeries: X-Ray of thelumbo-sacral spine demonstrates moderate degenerative changes and moderateosteopenia. No fractures noted. Platelet Count = 200,000/uL[100,000-500,000/uL] Serum Calcium andPhosphorus: Calcium=9.0 [8.4-10.6mg/dl] Phosphorus=2.6[2.4-4.5] Serum Total Protein andAlbumin: Total Protein = 7.4 [6.5-8.3gm/dl] Albumin = 3.6 [3.5-5.5gm/dl] Serum Uric Acid = 6.2 mg/dl [2.5-8.0mg/dl] Thyroid Profile: T3 Resin Uptake = 30%[25-35%] T4 = 8ug/dl[4-11 ug/dl] TSH = 2.0 �U/ml [0.6-4.6�U/ml] U/S of theAbdomen: Normalstudies Liver, spleen appearsnormal Pancreas was poorly visualized dueto bowel gas. No evidence of gall bladder disease Kidney of normal size, no stonenoted Urinalysis: Dipstick Glucose = none Bilirubin =none Ketones = none Protein =none Blood = none Micro No cast NoCrystals 0-1 WBC-hpf 0 RBC/hpf 0 Bacteria </div> <span lang="EN-US" style= "FONT-SIZE: 10pt; FONT-FAMILY: Century; mso-fareast-font-family: "ＭＳ明朝"; mso-bidi-font-family: "Times New Roman"; mso-font-kerning: 1.0pt; mso-ansi-language: EN-US; mso-fareast-language: JA; mso-bidi-language: AR-SA"> X-Ray of RightKnee: Clinical History: Statuspost-fall, contusion to left knee. Impression: There is a minimallydepressed lateral tibial plateau fracture. Mild osteopenia isnoted. PA projection of the leftknee　　　　　 Lateral projection　　　 　　　　　　 Enlargement of PAprojection 9. 心疾患, 神経疾患による失神, 意識障害, 運動障害を鑑別するため. 10. FacultyComments Patientfell due to slippery floor that is wet from the snow. The intrinsic factorsinclude the patient's impaired vision due to cataracts and was unable to seethe water on the floor. With her age, her reaction time is slow. Theophylinetoxicity (level of 22) may possibly be a secondary factor. Extrinsic factorsinclude slippy floor, poor fitting and worn slippers that gave little traction.There was no handrail to help break the fall. 11 転移が少ない骨折: 関節を穿刺して血腫を排除し, 膝関節を軽度に屈曲して3-4週間のギプス包帯固定をする. その後, 屈伸運動に移る. 患肢への荷重は少なくとも2か月は禁ずる. Faculty Comments Minimally displaced fractures in thecase of reliable patients may be managed with a few days of splinting in aJones dressing or plaster splint followed by active knee movement if follow-upX-ray shows no change in position of the fracture. In patients who areunreliable, a long-leg cast for a few weeks is a more satisfactoryapproach. Weight bearing is recommended to bedelayed until there is evidence of fracture healing on X-ray. This usuallyoccurs within 6-8 weeks. In terms of active exercise, this shouldbe done in order to ensure that there is significant retained strength in thequadriceps mechanism. The goal is to have at least 90 degrees of motionwithin 3-4 weeks. Prognosis in the casesof minimally displaced tibial plateau fractures is generallygood, except when aligamentous injury is not initially diagnosed, and therefore, has not beenrepaired. Other complications include the possibility of a gradual varus orvalgus angulation resulting from progressive deformity of the fracture, andthis generally occurs within the first few weeks. This mostly occurs infractures that extend from the intercondylar area to the medial or lateraltibial cortices. One is strongly urged to reexamine the patients clinically andradiographically in the early phase of fracture healing to promptly detect lossof position, and thereby be able to institute corrective measurespromptly. If there is articular depression inexcess of 8 millimeters, the preferred method of treatment is generally openreduction. Open reduction may also be used when there is lesser depressions ifthe clinical stress testing shows a five degree or more instability inextension. 12. FacultyComments In the case of this patient, thepatient was placed in a long-leg cast in view of the patient's need to returnto her home in Florida . Probably one ofthe most overlooked but extremely important aspects of patients' care whenpatients are being transported to another facility for follow-up is to includeappropriate records and to arrange, if possible, for person-to-personcommunication between the referring physician and the consultant. Thepatient must also understand what treatment she needs when she gets home andhow soon she needs to seek follow-up care. Other issues which should becarefully considered include the patient's ability to deal with thedisability due to her injury as her daily activities will clearly be affecteddue to the cast and she may need assistance with a visiting nurse,physical therapist, and orthotic devices. 13. FacultyComments Withimmobility from the cast and long plane ride, this patient is at risk fordeveloping deep venous thrombosis. She may also develop muscleweakness/atrophy, stiffness, making physical therapycrucial. 14. FacultyComments As yourpatient approaches menopause, her risk of osteoporosis increases. Knowing themother has osteopenia and a history of fall resulting in fracture, the primarycare physician must counsel the daughter of the causes and prevention ofosteoporosis. She should be counseled on adequate calcium intake,regular weight-bearing exercise, avoid smoking, moderatealcohol use to maintain the health of her bones. The protective effectof estrogen replacement treatment should be discussed along with the potentialrisk of breast and uterine cancer. For women without risk factors forestrogen replacement therapy, therapy should begin soon after menopause tomaximize the protective effects of estrogen. 15. FacultyComments A bonedensitometry, such as dual-energy x-ray absorptiometry (DEXA) is a good way tomeasure a patient's bone mineral density. It will help make the diagnosis ofosteoporosis and is a good predictor for risk offracture. Even ifMrs. Martin has osteoporosis, there is still much we can offer her. It isnever too late to start estrogen replacement therapy (ERT). Studies haveshown that bone mineral density increases even if ERT was started after age 60.An alternative to ERT is Calcitonin, an antiresorptive hormone which canprovide pain relief of osteoporosis, as well as inhibiting bone resorption.Alendronate (オンクラスト�), athird-generation amino-bisphosphonate, is a nonhormonal treatment forosteoporosis. Since it is not a hormone, Alendronate may be suitable for menand for women who have a personal or family history of breast cancer. BothCalcitonin and Fosamax are more expensive than ERT.

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