Management of Hip Fracture in the Elderly
Initial Assessment and Workup
- The American College of Rheumatology recommends performing a comprehensive multidisciplinary assessment including investigations for common modifiable variables: malnutrition, electrolyte/volume disturbances, anemia, cardiac/pulmonary diseases, and cognitive function 3
- Preoperative investigations should include chest X-ray, ECG, full blood count, clotting studies, blood group, and renal function, as suggested by the American College of Rheumatology 3
- Appropriate pain management should be provided immediately, considering nerve blocks for acute pain relief, according to the American College of Rheumatology 3
Surgical Management
- The American Academy of Orthopaedic Surgeons recommends scheduling surgery within 24-48 hours of admission to significantly reduce short-term and mid-term mortality rates 3
- For femoral neck fractures, hemiarthroplasty is preferred in frail elderly patients as operative time is shorter and dislocation risk is lower, as recommended by the American College of Rheumatology 4
- For intertrochanteric fractures, sliding hip screw is recommended for stable fractures, and cephalomedullary device for unstable fractures, according to the American Academy of Orthopaedic Surgeons and the American College of Rheumatology 2, 4
- For subtrochanteric fractures, cephalomedullary device is strongly recommended by the American Academy of Orthopaedic Surgeons 2
- Either spinal or general anesthesia is appropriate, though spinal may have advantages in elderly patients, as suggested by the American Academy of Orthopaedic Surgeons 5
Perioperative Care
- The American College of Rheumatology recommends implementing orthogeriatric comanagement to improve functional outcome and reduce length of hospital stay and mortality 6, 3
- Administering tranexamic acid can reduce blood loss and blood transfusion requirements, as recommended by the American Academy of Orthopaedic Surgeons 2
- Blood transfusion should be considered for symptomatic anemia with a threshold no higher than 8 g/dL, according to the American Academy of Orthopaedic Surgeons 7
Postoperative Management
- The American Academy of Orthopaedic Surgeons recommends implementing multimodal analgesia incorporating nerve blocks 2
- Weight-bearing should be allowed as tolerated to promote early mobilization, as suggested by the American Academy of Orthopaedic Surgeons 7
- Regular assessment of cognitive function should be performed to monitor for delirium, and nutritional status and renal function should be assessed regularly, according to the American College of Rheumatology 1
- Early mobilization and rehabilitation should be begun to improve outcomes, as recommended by the American College of Rheumatology 6