From the Guidelines
Management of a possible hip fracture requires prompt evaluation and treatment, with surgical intervention within 24-48 hours to reduce complications, as recommended by the most recent guideline 1. The initial management includes pain control with appropriate analgesics such as acetaminophen, NSAIDs if not contraindicated, or opioids like morphine 2-5mg IV or hydromorphone 0.5-1mg IV for severe pain.
- The patient should be kept non-weight bearing on the affected side and transported for immediate imaging, typically plain radiographs of the hip and pelvis.
- If radiographs are negative but clinical suspicion remains high, MRI or CT scan should be obtained.
- Laboratory tests including CBC, basic metabolic panel, coagulation studies, and type and screen should be ordered in preparation for potential surgery.
- Medical optimization before surgery is essential, addressing issues like anemia, electrolyte abnormalities, and cardiac status. Some key considerations in the management of hip fractures include:
- The type of anaesthesia used may not be as important as the careful delivery of anaesthesia, with a focus on age-appropriate doses and careful management of intra-operative blood pressure 1.
- Early mobilization post-surgery is crucial to prevent complications like pneumonia, deep vein thrombosis, and pressure ulcers.
- Thromboprophylaxis with low molecular weight heparin or direct oral anticoagulants should be initiated.
- Post-discharge rehabilitation and fall prevention strategies are vital components of recovery, along with calcium (1000-1200mg daily) and vitamin D (800-1000 IU daily) supplementation and consideration of osteoporosis treatment if appropriate. It is also important to note that:
- Patients with hip fractures require multidisciplinary care, led by orthogeriatricians 1.
- High-quality communication between clinicians and allied health professionals is essential 1.
- Continuous audit and targeted research is required to inform and improve the management of patients with hip fracture 1.
From the Research
Management Approach for Possible Hip Fracture
The management of a possible hip fracture involves a multidisciplinary approach, including medical specialists and rehabilitation. Key aspects of management include:
- Preoperative care: correcting medical abnormalities, considering the appropriateness, timing, and type of surgical repair in the context of the patient's life expectancy and goals of care 2
- Perioperative care: prophylaxis with antibiotics, chemoprophylaxis for venous thromboembolism, and correction of major clinical abnormalities prior to surgery 2
- Pain control: using multimodal pain control for early mobility and decreased narcotic requirement 3
- Rehabilitation: early mobilization followed by rehabilitation exercises in institutional, home, and group settings to maximize restoration of locomotive abilities 2
Surgical Interventions
Surgical interventions for hip fracture include:
- Arthroplasty
- Internal fixation
- External fixation
- Intramedullary devices
- Extramedullary devices The choice of surgical intervention depends on the type and severity of the fracture, as well as the patient's overall health and mobility 4
Thromboprophylaxis
Thromboprophylaxis is an important aspect of hip fracture management, with low-molecular-weight heparin (LMWH) being a common choice. The timing of thromboprophylaxis is controversial, with some studies suggesting that postoperative start of LMWH may reduce the risk of intraoperative bleeding complications 5. Other studies have investigated the efficacy and safety of different anticoagulant regimens, including rivaroxaban and LMWH 6
Rehabilitation and Recovery
Rehabilitation and recovery from hip fracture are critical aspects of management, with the goal of maximizing restoration of locomotive abilities and reducing the risk of complications. A multidisciplinary approach, including medical specialists and rehabilitation, is essential for optimal recovery 2. Rehabilitation strategies should be tailored to the patient's needs and may include early mobilization, rehabilitation exercises, and home-based rehabilitation 2, 4