Hip Fracture Management

Dr.Darshana Chandrakumara

Supervisor – Mr. Poon Kein Boon

• The incidence of hip fractures increases with age and consists of almost 30% of fall-related injuries in patients aged 85 years or older.

• Early post-operative mortality is particularly high, with reported 30-day mortality of 13.3%

• 1 year mortality of 23.8%

No more a surgical disease• Management of patients with hip fracture is complex

and involves a wide multidisciplinary approach across many different boundaries.

• Ambulance services

• Emergency department,

• Orthopaedic surgeons• Geriatricians • Acute services including operating theatre and ICU

• Rehabilitation services• End-of-life care• Social services• Health services in the community

Key recommendations

1. Transport to hospital2. Assessment in the emergency department3. Physician or orthogeriatrician input4. Timing of surgery5. Anaesthetic management6. Surgical management7. Early mobilisation8. Rehabilitation9. Discharge10.Post discharge management

1. Transport to hospital

• As quickly as possible

• If necessary pain releif– IV opioid or entanox

• If long journey consider catheter

Communication on admission

• History and examination findings • Concurrent medical condition and relevant

past medical history • Current drug therapy • Pre-morbid functional state, particularly

mobility • Pre-morbid cognitive function • Social circumstances and whether the patient

has a carer

2. Early assessment in ED or ward• Hydration and nutrition• Pain• Core body temperature• Continence• Coexisting medical problems• Pressure sore risk • Mental state AMT

• Patients should be transferred to the ward within two hours of their arrival in the emergency department.

Long lie

• Lying on the floor for an extended period of time ( > 1hr) can lead to serious complications – Pressure ulcers – Rhabdomyolysis– Pneumonia – Hypothermia– Dehydration– Even death.

Cause for fall

• Illness• Syncope• Accident• Vision• Epilepsy or other fit• Drugs (Anti hypertensives)• Dementia• Anaemia• Neurological –Stroke , Neuropathy• Neurodegenerative – Parkinson’s

I SAVE DAN

• Analgesia• Hydration• Pressure point care– Patients judged to be at very high risk of pressure

sores should ideally be nursed on a large-cell, alternating-pressure air mattress or similar pressure-decreasing surface.

• Instigate early radiology• MRI is the investigation of choice where there

is doubt regarding the diagnosis.

Immediate management

Analgesia

• Assess the patient's pain:– immediately upon presentation at hospital

including people with cognitive impairment, and– within 30 minutes of administering initial

analgesia, and– hourly until settled on the ward, and– regularly as part of routine nursing observations

throughout admission.

Analgesia

• TWO – Paracetamol 6hrly regular –Opioid (Tramadol/ Oxynorm/Morphin)

• Ensure analgesia is sufficient to allow movements necessary for investigations and for nursing care and rehabilitation.

• NSAIDs are not recommended.• Consider nerve blocks if pain relief still

insufficient

Patient information and support• Offer (patients and family) verbal and printed

information about:• Diagnosis• Choice of anaesthesia• Choice of analgesia and other medications• Surgical procedures• Possible complications• Postoperative care• Rehabilitation programme• Long-term outcomes• Healthcare professionals involved.

3. Physician or orthogeriatrician input

• All patients presenting with a fragility fracture should be managed on an orthopaedic ward with routine access to acute orthogeriatric medical support.

• Studies reported a reduction in length of stay

• Showed no significant difference in inpatient mortality and twelve month mortality.

Local policy

• IV fluid – NS 1L/day

• 2 analgesics regular – Para/Tram

• 2 Laxatives regular – Lactulose /senna

• Dulolax suppo if BNO x 2 days

• Fleet if BNO x 3 days or incomplete BO

• Calcium+VitD 2 tab Om for all

• Ergocalciferol weekly 8 doses if Vit D <30ug/L

• BMD if not done in past 1-2 yrs

4. Timing of surgery

• Aim op within 48hrs

• Chasing unrealistic medical goals should not lead to delay. – For example, it may not be appropriate to delay

surgery because of infective pulmonary conditions, as real improvement is unlikely in the presence of continued immobility and pain.

Local policy• Hip fracture is an urgency and not an emergency.

• 48 hrs mean if patient is stable.

• If patient is unstable time starts when the patient is deemed stable.

• Last patient goes to theatre by 5 pm.

• Can cross 48 hours if it is better for the patient.

• Geriatrician cover – international agreed standard is by within 72 hours

• Withholding warfarin combined with administration of oral or intravenous vitamin K is recommended if reversal of the anticoagulant effects of warfarin to permit earlier surgery is deemed appropriate.

• low-dose vitamin K (1-2.5 mg) administered either intravenously (IV) or orally, partially reverses the anticoagulant effect of warfarin over a 24 hour period.

• The onset of reversal is quicker and change in INR value greater in the first four hours when IV vitamin K compared to oral.

• FFP should not be used where there is no contraindication to the use of vitamin K.

Reversal of warfarin anticoagulation

• Surgery should not be delayed in hip fracture patients taking antiplatelet therapy. (Aspirin, Clopidogrel, Dipyridamole)

• Spinal or epidural anaesthesia is not recommended in patients taking dual antiplatelet therapy.

• General anaesthesia is recommended for patients taking dual antiplatelet therapy.

• Treatment with aspirin or dipyridamole alone does not contraindicate spinal or epidural anaesthesia

Antiplatelet therapy

• Recommends stopping antiplatelet drugs for a minimum of five days before elective surgery.

• When patients require emergency surgery the recommendation is not to delay and to transfuse platelets only in the event of excessive surgical bleeding.

Antiplatelet therapy

• Transthoracic Echo– Symptoms suggestive of cardiac failure– Any new heart murmur– No need to repeat if done within last 6months and

no change in symptoms

Preoperative cardiac investigations

• The routine use of traction (either skin or skeletal) is not recommended prior to surgery for a hip fracture.

• No evidence of any benefit in pain relief or fracture reduction from the routine use of preoperative traction.

• Cannot exclude possible advantages of traction for specific fracture types.

Preoperative traction

• Hip fracture surgery carries a high risk of venous thromboembolism

• Mechanical and pharmacological prophylaxis may reduce the incidence of thrombosis.

• Heparin (UFH or LMWH) or fondaparinux may be used for pharmacological thromboprophylaxis in hip fracture surgery.

• Aspirin monotherapy is not recommended for patients after hip fracture surgery.

Reducing the risk of venous thromboembolism

• Treatment of asymptomatic bacteriuria is not appropriate in both men and women– the organisms isolated from the urine were not

the same as those from the surgical site infection

• Treat only if symptomatic– Uncomplicated – Ciproflox– Complicated – IV Aug empirically

UTI

• Spinal/epidural anaesthesia should be considered for all patients undergoing hip fracture repair, unless contraindicated.

• Spinal or epidural anaesthesia should be avoided in patients taking dual antiplatelet therapy, as the risk of developing spinal haematoma.

5. Anaesthetic management

• Intracapsular

• Extracapsular

6. Surgical management

• Intracapsular– Undisplaced – Internal fixation– Displaced – Closed reduction and internal

fixation in fit young patients

– Arthroplasty in older biologically less fit patients

• Extracapsular– Sliding hip screws (except in reverse oblique,

transverse or subtrochanteric fractures where an intramedullary device may be considered)

• Pain relief – 2 regular analgesics– Can give addon Tramadol/Oxynorm/Ketoprofen

patch

• Supplementary oxygen is recommended for at least six hours after general or spinal/ epidural anaesthesia, at night for 48 hours postoperatively and for as long as hypoxaemia persists as determined by pulse oximetry.

• FBC and Renal panel

6. Early postoperative management

• If overall medical condition allows, mobilisation and multidisciplinary rehabilitation should begin within 24 hours postoperatively.

• Weight bearing on the injured leg should be allowed, unless there is concern about quality of the hip fracture repair (eg poor bone stock or comminuted fracture).

Early mobilisation

• Prevention by maintaining adequate fluid balance and ensuring adequate pain relief.

• In women - IMC if PVRU >200ml

• In Men - IDC

Urine retention

• In general, catheterisation should be avoided, except in– urinary incontinence – on a long journey – urinary retention – when monitoring renal/cardiac function.

• When patients are catheterised in the postoperative period, prophylactic antibiotics should be administered to cover the insertion of the catheter.

Urinary catheterisation

• Acute confusional state common after a hip fracture.

• Prevention by optimizing,– oxygen saturation– blood pressure– fluid and electrolyte balance – pain control– medication– bowel and bladder function– nutritional intake– early mobilisation– detection and treatment of intercurrent illness

Delirium

• A multidisciplinary team should be used to facilitate the rehabilitation process.

• The initial emphasis should be on walking and activities of daily living (ADL)

• Supplementing the diet with high energy protein preparations containing minerals and vitamins should be considered.

8. Rehabilitation

• Nurse case managers assess patients on admission, to identify those suitable for supported discharge, to facilitate early mobilisation and rehabilitation and arrange appropriate support on discharge and follow up.

• The patient should be central to discharge planning, and their needs and appropriate wishes taken into consideration.

9. Discharge

• TCU in 2weeks for post op patients• TCU 4-6weeks for conservatively managed

patients

• PT is continued

• Refer falls clinic if high risk for future falls

10. Post discharge management

• Streamline and expedite the process• For hip fracture pts over 60 years old.

• Fill the AMT page 7– Pre op screening checklist in page 9– Leave blank Ortho geriatric problem list page 11

– Post op WB status and reason if NWB or PWB (poor bone stock/comminuted fracture)

Hip fracture pathway

– Cardiac risk assessment guide page 45

– Clotting and analgesia guideline page 46

– Diabetic protocol page 47

– Antibiotic prohylaxis page 48

• Get enough calcium and vitamin D. Men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.

• Exercise to strengthen bones and improve balance.

• Avoid smoking or excessive drinking.

• Use a walking stick or walker.

Prevention of hip fracture

• Assess home for hazards. Remove throw rugs, keep electrical cords against the wall and clear excess furniture and anything else that could trip you. Make sure every room and passageway is well-lit.

• Correct poor vision

• Optimize medications

• Stand up slowly. Getting up too quickly can cause your blood pressure to drop and make you feel wobbly.

Prevention of hip fracture

• Hip protector

Prevention of hip fracture

In summary • IV fluid – NS 1L/day• 2 analgesics regular – Para/Tram• 2 Laxatives regular – Lactulose /senna• Dulolax suppo if BNO x 2 days• Fleet if BNO x 3 days or incomplete BO• Calcium+VitD 2 tab Om for all• Ergocalciferol weekly 8 doses if Vit D <30ug/L• BMD not done in past 1-2 yrs

• Do not routinely treat asymptomatic bacteriuria.

• Chemical DVT prophylaxis if surgery is delayed >48hrs

• Post op FBC, RP, BMD

In summary