Management of Hip Fractures in Elderly Patients

Preoperative Management

The American Academy of Orthopaedic Surgeons recommends urgent orthopedic surgical management within 24-48 hours of admission for mildly displaced left intertrochanteric hip fractures, as this timing is associated with better outcomes 2
The American Academy of Orthopaedic Surgeons suggests that multimodal analgesia incorporating a preoperative peripheral nerve block (iliofascial block) significantly reduces pain and opioid requirements 1, 2, 4
Anaesthesia guidelines recommend continuing regular acetaminophen throughout the perioperative period 3
For patients with chronic kidney disease, opioids should be used cautiously, with reduced dose and frequency, and NSAIDs are contraindicated 3

The American Academy of Orthopaedic Surgeons recommends closed reduction and cephalomedullary nail fixation for intertrochanteric fractures, even if mildly displaced 1, 4
Either short or long cephalomedullary nail may be used, with limited strength option 1, 4
Spinal or general anesthesia are both appropriate options 2
Tranexamic acid should be administered at the start of surgery to reduce blood loss and transfusion need, with strong strength recommendation 2, 4

The American Academy of Orthopaedic Surgeons recommends allowing immediate weight-bearing as tolerated postoperatively to prevent deconditioning and reduce complications 1, 2, 4
Monitor hemoglobin postoperatively and transfuse if symptomatic anemia develops, with transfusion threshold no higher than 8 g/dL in asymptomatic patients 1, 4
Administer VTE prophylaxis for 4 weeks postoperatively, using low molecular weight heparin or fondaparinux 1, 2, 3, 4
Administer prophylactic antibiotics within one hour of skin incision, particularly against Staphylococcus aureus 3

The American Academy of Orthopaedic Surgeons recommends referring patients to Fracture Liaison Service or Bone Health Clinic for osteoporosis evaluation, including drawing vitamin D, calcium, and parathyroid hormone levels during hospitalization, and ordering outpatient DEXA scan 1, 4
Initiate bisphosphonate therapy to reduce future fracture risk 2

Address modifiable fall risk factors, including evaluation for orthostatic hypotension, medication effects, and cardiac causes 3
Implement fall prevention strategies given cognitive impairment and documented fall risk 1, 3
Monitor closely for postoperative delirium, which is common in elderly patients with baseline cognitive impairment, and avoid medications that worsen cognition 3

Reduce opioid dosing by half and avoid oral formulations in patients with chronic kidney disease 3
Avoid NSAIDs entirely in patients with chronic kidney disease 3
Monitor fluid status carefully and adjust medication dosing for renal function throughout hospitalization 3

Do not delay surgery for "medical optimization" beyond 24-48 hours, as early surgery improves outcomes 2
Do not assume the scalp hematoma requires neurosurgical consultation, as subgaleal hematomas without intracranial injury are managed conservatively 1
Do not attribute all confusion to "just dementia", and monitor for superimposed delirium, which requires different management 3
Do not prescribe bed rest or restricted weight-bearing, as immediate weight-bearing as tolerated is the standard of care 1, 2, 4