Medical Management of Hip Fracture
Section snippets
Epidemiology
The incidence in adults aged 65 years and older is estimated to be 818/100,000 habitants.8 Women are affected 2 to 3 times more than men, with a proportionately similar ethnic predominance in Caucasians versus other ethnicities.9
Falls account for 90% of hip fractures in the elderly. Patients' habitus and the characteristics of the fall (direction, site of impact, and protective response) influence the risk of hip fracture.10 The lifetime risk for suffering a fragility fracture in 50-year-old
The role of the medical specialist
The patient with hip fracture is often medically complex. A multidisciplinary approach that includes the orthopedic surgeon, anesthesiologist, and the medical specialist is important if optimal outcomes are to be achieved. To further understand the different roles of each team member, surgery has been compared with a plane flight where the patient is the plane.21 The surgeon is the pilot and the anesthesiologist is the copilot. Together, the pilots and the plane must take off and land safely.
Special considerations in the geriatric patient
Age is not an illness, but it is an independent risk factor for morbidity, mortality, and perioperative outcome. Age-related changes in physiology and pharmacology might affect every aspect of perioperative care. The basal function of various organ systems may be relatively uncompromised, yet functional reserve and the ability to compensate for physiologic stress are reduced (Fig. 1).29 As a result, it is often difficult to predict the effect of perioperative stress on the geriatric patient.
Type of hip fracture and operative implications
Hip fractures are classified according to their anatomic location. They can be intracapsular (involving the neck and head of the femur) or extracapsular (intertrochanteric or subtrochanteric). Approximately 90% of hip fractures occur in equal proportions in the femoral neck and intertrochanteric regions, generally caused by low-energy trauma, such as falling from a chair or slipping on the ice.22 Subtrochanteric fractures account for the remaining 5% to 10%2 and are often associated with
Timing of surgery
Hip fracture repair should occur as soon as possible once the patient is optimized for the operating room. Delay in hip fracture repair does negatively affect the return to weight bearing and overall functional recovery. Case series and observational studies suggest that early surgical repair (within 24–48 hours) can decrease 1-year mortality1, 2, 6, 27, 38 in addition to decreasing postoperative pain, length of hospital stay, and major complications.39 Early mobilization will enhance recovery
Surgical-Site Infections
The use of perioperative antibiotics before surgery has dramatically decreased the incidence of wound infections in hip fracture patients.2 A Cochrane review of 22 trials (n = 8,307) demonstrated that preoperative antibiotic prophylaxis decreased deep-wound and urinary tract infections by 64% and 44%, respectively.41
Coagulase-negative staphylococci (Staphylococcus epidermidis) and methicillin-sensitive Staphylococcus aureus are the most frequently isolated organisms in hip fracture
Treatment of pain
Inadequate pain control increases length of hospital stay, delays ambulation, and decreases overall mobility at 6 months. There is little evidence regarding the best analgesic approach.57 Narcotic analgesia can worsen mental status and precipitate delirium, but suboptimal analgesia should be avoided.33 Non-narcotic analgesia with acetaminophen should be scheduled, 1 g every 6 hours around the clock; opioids should provide breakthrough pain (early-stage breakthrough pain with low-dose morphine
Eliminate unnecessary medications
Sedative hypnotics, such as benzodiazepines (except in the case of alcohol withdrawal), anticholinergics, and antihistamines should be avoided if possible and used at the lowest effective dose. Narcotic use (intravenous or by mouth) should also be minimized; these medications increase the likelihood of delirium owing to direct CNS effects and any resultant urinary retention or constipation. All medications should be adjusted accordingly to renal function, and polypharmacy should be specifically
Regulation of bowel/bladder function
Constipation is commonly seen after the second postoperative day as a result of decreased mobility and perioperative use of narcotic analgesia. A bowel regimen of stool softeners and laxatives should be routine and titrated to bowel motions at least every 48 hours.51, 56
Bladder catheter removal should be prompted as early as possible, typically on postoperative day 1 when patients begin to mobilize out of bed. If urinary retention is encountered (patients unable to void 8 hours post–catheter
Adequate nutritional intake
Malnourishment occurs in up to 20% of patients with hip fractures.6, 24, 33 The hip fracture patient is predisposed to catabolism with an increased risk for protein-calorie malnutrition.25 Protein depletion is associated with poor wound healing and increased postoperative complications, including reduced survival at 1 year.1, 58 Low serum albumin (<3.5 g/dL) and low total lymphocyte count (1,500 cells/μL) are associated with increased resource consumption, length of hospital stay and operative
Early mobilization and rehabilitation
Early mobilization within 24 hours after hip surgery is a standard practice. Self-mobilization should be encouraged depending on the clinical circumstances; an overhead trapeze frame may assist the patient in regaining earlier functional independence. In addition, overhead trapeze will reduce the force exerted on the hips upon patient transfer to a bedpan; these forces can be significant, estimated to be 4 times the body weight.56 Early mobilization not only reduces the risk for complications,
Early detection and treatment of major complications
Delirium may be the only manifestation of a life-threatening condition in the elderly patient. Clinicians must take a standardized approach to postoperative delirium such that myocardial infarction, hemorrhage, pneumonia, urosepsis, or VTE are not missed.51, 55 In a large study of 8,930 patients with hip fracture, 19% had postoperative complications, and cardiac and pulmonary complications occurred in 8% and 4%, respectively. Serious cardiac and pulmonary complications occurred in 2% and 3%,
Rehabilitation and recovery
Rehabilitation is fundamental after hip fracture and should start as soon as possible in the postoperative period. Early rehabilitation is associated with shorter hospital stay and decreased medical costs.1 After hospital discharge, ongoing long-term rehabilitation in a skilled nursing facility, a dedicated acute rehabilitation hospital, or on an outpatient basis is beneficial. Intense physical therapy (twice daily sessions) may help improve long-term outcomes.62 The intensity and length of
Summary
Medical management of the hip fracture patient has multiple components. Preoperative assessment and optimization along with appropriate timing of surgery and implementation of risk-reducing therapies should maximize outcomes. Postoperative complications are common, yet close monitoring and attention to the “hip fracture syndrome” should reduce morbidity. A process of care that includes hospitalist comanagement may be a useful model that addresses clinical issues in both the preoperative and
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