Workup and Management of Unwitnessed Falls in Elderly Patients with Hip Fractures

Initial Assessment and Workup

The American Academy of Orthopaedic Surgeons recommends performing comprehensive multidisciplinary assessment including investigations for common modifiable variables: malnutrition, electrolyte/volume disturbances, anemia, cardiac/pulmonary diseases, and cognitive function 1
A complete blood count should be obtained, as leucocytosis may indicate underlying infection, commonly chest or urinary 2
Electrolytes should be checked, as hypokalemia is associated with new-onset atrial fibrillation, and hyponatremia may indicate infection or medication effects 2
An ECG should be obtained in all elderly patients with hip fracture 2

If plain radiographs are normal but clinical suspicion for fracture remains high, an MRI should be obtained to identify occult fractures 3
A multifactorial falls risk assessment should be performed, incorporating evaluation of gait, mobility, balance, lower limb strength, medication review, cognitive capacity, footwear, and environmental factors 4
Standardized tests such as the Timed Up and Go test should be used to evaluate mobility 4

Orthogeriatric comanagement should be implemented to improve functional outcomes and reduce length of hospital stay and mortality 1
Appropriate VTE prophylaxis should be provided with sequential compression devices during hospitalization and pharmacological prophylaxis for 4 weeks postoperatively 5
Weight-bearing should be allowed as tolerated to promote early mobilization 3
Patients should be referred to a Fracture Liaison Service or Orthopaedics Bone Health Clinic for secondary fracture prevention 1, 5
A systematic evaluation for risk of subsequent fractures should be performed, and multicomponent interventions including exercise, fall prevention strategies, and education about bone health should be implemented 1, 4
Weight-bearing impact exercise and/or resistance training should be recommended to promote bone health and improve physical performance 4
Adequate calcium intake and vitamin D supplementation should be ensured 6
Pharmacological treatment with bisphosphonates may be considered to reduce risk of subsequent fractures 6

Surgery within 24-48 hours of admission significantly reduces short-term and mid-term mortality rates 1