Treatment of Subtrochanteric Fracture in Elderly Female with Multiple Comorbidities

Surgical Approach

The American Academy of Orthopaedic Surgeons recommends cephalomedullary nail fixation for subtrochanteric fractures with strong evidence and strong recommendation, as subtrochanteric fractures require intramedullary nailing rather than dynamic hip screw, total hip replacement, or hemiarthroplasty in elderly patients with multiple comorbidities 1, 2
The choice between short versus long nail depends on fracture pattern, though both are acceptable options for subtrochanteric fractures in this population 1
Dynamic hip screw is contraindicated for subtrochanteric fractures—it is only appropriate for stable intertrochanteric fractures, and total hip replacement and hemiarthroplasty are reserved for intracapsular femoral neck fractures, not extracapsular subtrochanteric fractures in elderly patients 1, 2, 3

Surgery should be performed within 48 hours of injury to reduce mortality and complications in elderly patients with subtrochanteric fractures 4
Either spinal or general anesthesia is appropriate for this patient despite her comorbidities, and multimodal analgesia with preoperative nerve block should be administered for pain control 1, 2, 3
Tranexamic acid must be given perioperatively to reduce blood loss and transfusion requirements in elderly patients undergoing subtrochanteric fracture surgery 1, 3

The American Academy of Orthopaedic Surgeons recommends immediate full weight-bearing as tolerated postoperatively, making non-weight bearing for 6 weeks incorrect and potentially harmful in elderly patients with subtrochanteric fractures 1, 2
Early mobilization with immediate weight-bearing prevents recumbency complications including pneumonia, pressure ulcers, and venous thromboembolism in elderly patients with subtrochanteric fractures 2, 4

The patient requires orthogeriatric comanagement given her dementia, hypertension, ischemic heart disease, and COPD, and comprehensive geriatric assessment should address delirium prevention, cardiac optimization, pulmonary management, and nutritional status 4
Preoperative assessment must include ECG, chest X-ray, full blood count, renal function, and cognitive baseline evaluation in elderly patients with subtrochanteric fractures 4
Enoxaparin or other pharmacologic VTE prophylaxis should be prescribed postoperatively to prevent venous thromboembolism in elderly patients with subtrochanteric fractures 1
All patients require systematic osteoporosis evaluation including outpatient DEXA scan, vitamin D level, calcium level, and parathyroid hormone level, and initiate appropriate osteoporosis treatment to prevent subsequent fractures in elderly patients with subtrochanteric fractures 1, 2, 3