注: 図が抜けています.
1.
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.
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:
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;
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
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.
