What is the plan of care for an elderly patient with a thumb fracture?

Management of Thumb Fractures in Elderly Patients

Thumb fractures in elderly patients should be managed within a multidisciplinary orthogeriatric care system that includes adequate pain management, appropriate medical optimization, and timely surgical intervention when indicated to improve functional outcomes and reduce mortality. 1

Initial Assessment and Management

• Pain Management:

  • Regular administration of paracetamol as the foundation of pain therapy
  • Consider nerve blocks for effective analgesia without opioid side effects
  • Cautious use of opioids with reduced dosing (typically half standard dose)
  • Avoid codeine due to adverse effects in elderly patients 2

• Medical Optimization:

  • Systematic assessment of medical conditions including:
    • Nutritional status
    • Electrolyte and fluid balance
    • Cardiac and pulmonary function
    • Cognitive baseline function
    • Anemia evaluation 1, 2
  • Preoperative investigations should include chest X-ray, ECG, full blood count, clotting studies, and renal function 1

Treatment Options Based on Fracture Type

Non-displaced/Stable Thumb Fractures:

• Conservative Management:
  • Thumb spica cast immobilization
  • For scaphoid fractures, consider long thumb-spica cast initially (reduces healing time from 12.7 weeks to 9.5 weeks compared to short casts) 3
  • Cast duration typically 6-8 weeks depending on fracture location and healing progress

Displaced/Unstable Thumb Fractures:

• Surgical Management:
  • Open reduction and internal fixation (ORIF) with screws or pins
  • For Bennett fractures (intra-articular base of thumb metacarpal), closed reduction with percutaneous Kirschner wire fixation is often sufficient 4
  • For comminuted intra-articular fractures, external fixation with limited ORIF may be required 4

Orthogeriatric Co-Management

• Implement joint care between geriatrician and orthopedic surgeon on a dedicated orthogeriatric ward 1
• This approach has demonstrated:
  • Shortest time to surgery
  • Shortest length of hospital stay
  • Lowest inpatient and 1-year mortality rates 1

Rehabilitation Protocol

• Early Phase (0-2 weeks):

  • Pain and edema control
  • Protected immobilization
  • Patient education on care of cast/splint

• Intermediate Phase (2-6 weeks):

  • Continue immobilization for fractures being treated conservatively
  • For surgically treated fractures with stable fixation, begin gentle protected range of motion exercises

• Late Phase (6+ weeks):

  • Progressive strengthening exercises
  • Functional activities to restore pinch and grip strength
  • Occupational therapy for activities of daily living 2

Secondary Fracture Prevention

• Systematic assessment of fracture risk in all patients over 50 years with a recent fracture 1
• Consider bone mineral density testing via DXA scan
• Evaluate for secondary osteoporosis and falls risk 1
• Implement fall prevention strategies and home safety assessment 2

Common Pitfalls and Caveats

1. Inadequate Immobilization: Improper casting technique can lead to nonunion; ensure proper thumb immobilization in cases requiring conservative management 5

2. Delayed Surgery: Surgery within 48 hours of injury significantly reduces mortality and complications in elderly patients with fragility fractures 1

3. Overlooking Medical Comorbidities: Elderly patients often have pre-existing conditions that affect management and outcomes; comprehensive assessment is essential 1

4. Insufficient Pain Control: Inadequate pain management can lead to delirium, reduced mobility, and poorer outcomes 2

5. Neglecting Secondary Prevention: Failure to address underlying osteoporosis and fall risk factors increases the likelihood of subsequent fractures 1