Can you provide an example of a postoperative note for a 73‑year‑old female who underwent repair of a right intertrochanteric fracture with a cephalomedullary nail under spinal anesthesia, including intra‑operative tranexamic acid (1 g intravenous), postoperative vital signs, pain scores, incision and drainage status, neurovascular assessment, enoxaparin (40 mg subcutaneously) for venous thromboembolism prophylaxis, weight‑bearing as tolerated with walker, fall precautions, and the medication regimen (acetaminophen, oxycodone, vitamin D)?

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Postoperative Note Example: Right Intertrochanteric Fracture Repair

Below is a comprehensive postoperative note template for a 73-year-old female who underwent cephalomedullary nail fixation of a right intertrochanteric fracture, incorporating evidence-based elements from the 2022 AAOS Hip Fracture Guidelines 1.

POSTOPERATIVE NOTE

Date/Time: [Insert date and time]
Procedure: Closed reduction and internal fixation of right intertrochanteric femur fracture with cephalomedullary nail
Surgeon: [Name]
Assistant: [Name]
Anesthesia: Spinal anesthesia

PATIENT INFORMATION

  • Age/Sex: 73-year-old female
  • ASA Class: [Insert II/III/IV as appropriate]
  • Preoperative Diagnosis: Right intertrochanteric femur fracture (AO/OTA classification: [specify if stable/unstable])
  • Postoperative Diagnosis: Same

PROCEDURE DETAILS

  • Anesthesia Type: Spinal anesthesia (per AAOS guidelines, both spinal and general anesthesia are acceptable) 1
  • Implant Used: Cephalomedullary nail (short/long nail as appropriate for fracture pattern—unstable intertrochanteric fractures should be treated with cephalomedullary nail fixation per strong AAOS recommendation) 1
  • Estimated Blood Loss: [Insert volume] mL
  • Tranexamic Acid: 1 g intravenous administered intraoperatively (strong AAOS recommendation: TXA should be given to reduce blood loss and transfusion need) 1
  • Operative Time: [Insert] minutes
  • Complications: None

IMMEDIATE POSTOPERATIVE STATUS

Vital Signs (PACU/Floor):

  • Blood Pressure: [Insert] mmHg
  • Heart Rate: [Insert] bpm
  • Respiratory Rate: [Insert] breaths/min
  • Oxygen Saturation: [Insert]% on room air/supplemental O₂
  • Temperature: [Insert]°F

Pain Assessment:

  • Visual Analog Scale (VAS): [Insert 0-10]/10
  • Pain location: Right hip/surgical site
  • Pain character: [Sharp/dull/aching]

SURGICAL SITE ASSESSMENT

Incision:

  • Location: Right lateral thigh
  • Appearance: Clean, dry, and intact
  • Dressing: Sterile dressing applied, dry and intact
  • Drainage: None/minimal serosanguinous drainage (specify volume if present)
  • No signs of hematoma, erythema, or warmth

Neurovascular Examination (Right Lower Extremity):

  • Motor: Able to wiggle toes, dorsiflexion and plantarflexion intact (grade [insert]/5)
  • Sensory: Light touch intact in all dermatomes (L2-S1)
  • Vascular: Dorsalis pedis and posterior tibial pulses palpable/Doppler audible, capillary refill <2 seconds
  • Compartments: Soft, non-tender
  • Skin: Warm, normal color

LABORATORY VALUES

Postoperative Day 1 Hemoglobin: [Insert] g/dL
(Note: Per AAOS moderate-strength recommendation, transfusion is indicated for symptomatic anemia or Hb <8 g/dL in asymptomatic patients; maintain Hb >9 g/dL in frail patients or >10 g/dL in those with ischemic heart disease or failure to mobilize) 1, 2

Transfusion Status: None required / [Insert units] packed red blood cells transfused for [symptomatic anemia/Hb <8 g/dL]

POSTOPERATIVE ORDERS & MANAGEMENT

Weight-Bearing Status:

  • Weight-bearing as tolerated (WBAT) with walker (per AAOS limited-strength option: immediate full weight-bearing to tolerance after surgery) 1
  • Physical therapy consultation for mobilization on postoperative day 1
  • Occupational therapy for activities of daily living assessment

Fall Precautions:

  • Bed alarm activated
  • Non-slip socks provided
  • Call bell within reach
  • Assist with all transfers and ambulation

VTE Prophylaxis:

  • Enoxaparin 40 mg subcutaneously daily starting [12-24 hours postoperatively], continue for 4 weeks (per AAOS strong recommendation: VTE prophylaxis should be used in hip fracture patients) 1
  • Sequential compression devices (SCDs) to bilateral lower extremities while in bed
  • Early mobilization as tolerated

Pain Management (Multimodal Analgesia):

  • Acetaminophen 1000 mg PO every 8 hours (scheduled, not PRN)
  • Oxycodone 5-10 mg PO every 4-6 hours as needed for breakthrough pain (VAS >4/10)
  • Consider peripheral nerve block if not already administered (AAOS strong recommendation: multimodal analgesia including peripheral nerve blocks) 2
  • Avoid excessive opioids given risk of delirium in elderly patients

Bone Health:

  • Vitamin D 1000-2000 IU daily (initiated postoperatively)
  • Calcium carbonate 1200 mg daily (divided doses with meals)
  • Outpatient DEXA scan ordered
  • Referral to Orthopaedic Bone Health Clinic for osteoporosis evaluation and treatment (AAOS strong recommendation) 1
  • Labs drawn: Vitamin D (25-OH), calcium, parathyroid hormone levels

Additional Medications:

  • Continue home medications as appropriate
  • Stool softener (docusate sodium 100 mg PO BID) to prevent opioid-induced constipation
  • Antiemetic PRN (ondansetron 4 mg IV/PO every 8 hours as needed)

MONITORING & FOLLOW-UP

Daily Assessments:

  • Vital signs every 4 hours
  • Neurovascular checks every 4 hours for first 24 hours, then every shift
  • Pain scores with each vital sign check
  • Incision assessment daily
  • Hemoglobin/hematocrit on postoperative day 1 (and PRN if symptomatic anemia develops)
  • Monitor for signs/symptoms of DVT/PE (leg swelling, chest pain, dyspnea)

Discharge Planning:

  • Target discharge: Postoperative day 2-3 (pending mobilization and medical stability)
  • Anticipated disposition: Home with home health / skilled nursing facility / inpatient rehabilitation
  • Outpatient follow-up: Orthopedic surgery clinic in 2 weeks for wound check and radiographs

POTENTIAL COMPLICATIONS & MANAGEMENT

Common Pitfalls to Avoid:

  • Cut-out is the most common complication with cephalomedullary nails—ensure proper reduction and tip-apex distance <25 mm on intraoperative imaging 3
  • Symptomatic anemia: Monitor for fatigue, dizziness, tachycardia; transfuse if Hb <8 g/dL (asymptomatic) or <9-10 g/dL (symptomatic/frail/cardiac disease) 1, 2
  • VTE: Do not delay enoxaparin >24 hours postoperatively; missing doses increases VTE risk 4
  • Delirium: Minimize opioids, ensure adequate pain control with multimodal approach, early mobilization
  • Delayed mobilization: Physical therapy should begin postoperative day 1; failure to mobilize may indicate need for transfusion or further evaluation

EVIDENCE-BASED RATIONALE

This postoperative management plan incorporates:

  • TXA administration (1 g IV intraoperatively) reduces blood loss and transfusion requirements without increasing thrombotic risk (strong AAOS recommendation) 1, 5, 6
  • Enoxaparin 40 mg subcutaneously for VTE prophylaxis is safe and effective; administration on the morning of surgery does not increase bleeding risk 4
  • Weight-bearing as tolerated promotes early mobilization and functional recovery 1
  • Multimodal analgesia (acetaminophen + opioids ± nerve blocks) optimizes pain control while minimizing opioid-related complications 2
  • Bone health evaluation (vitamin D, calcium, PTH, DEXA scan, specialty referral) addresses underlying osteoporosis and reduces future fracture risk 1

Attending Signature: ___________________________
Date/Time: ___________________________

References

1
Guideline

aaos management of hip fractures in older adults evidence-based clinical practice guideline.

The Journal of the American Academy of Orthopaedic Surgeons, 2022

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