What are the clinical practice guidelines for managing possible hip fractures in elderly patients?

Clinical Practice Guidelines for Managing Hip Fractures in Elderly Patients

Elderly patients with hip fractures should be managed within a multidisciplinary system that ensures prompt surgical treatment within 48 hours of admission, adequate pain management, and early rehabilitation to reduce mortality and improve functional outcomes. 1

Initial Management

Emergency Department Assessment

• Admit patients within 4 hours of arrival to an appropriate clinical ward 1
• Implement fast-track admission pathways with care pathway proformas 1
• Provide appropriate pain management immediately before starting diagnostic investigations 1
  • Consider nerve blocks for acute pain management 1
• Obtain basic investigations: chest X-ray, ECG, full blood count, clotting studies, blood group, renal function 1
• Assess cognitive baseline function 1

Pre-operative Optimization

• Conduct systematic multidisciplinary assessment for common modifiable conditions 1:
  • Malnutrition
  • Electrolyte or volume disturbances
  • Anemia
  • Cardiac or pulmonary diseases
  • Dementia and delirium control

Surgical Management

Timing of Surgery

• Perform surgery within 24-48 hours after admission 1
• Delay surgery only for clear reversible medical conditions 1
• Prioritize hip fracture surgery within operating lists 1

Fracture-Specific Treatment Options

Femoral Neck Fractures

• Stable non-displaced fractures: cannulated fixation in a percutaneous manner 1
• Displaced femoral neck fractures:
  • In healthy, active, independent elderly without cognitive dysfunction: total hip replacement 1
  • In frail patients: hemiarthroplasty (shorter operative time, lower dislocation risk) 1

Trochanteric Fractures

• Stable intertrochanteric fractures: sliding hip screw 1
• Unstable intertrochanteric fractures: antegrade cephalomedullary nail 1
• Subtrochanteric or reverse oblique fractures: cephalomedullary devices 1

Perioperative Care

Pain Management

• Implement multimodal analgesia to reduce opioid requirements 2
• Consider preemptive pain medication and intraoperative periarticular injections 2
• Avoid oversedation with opioids as it can delay mobilization and rehabilitation 2

Post-operative Care

• Provide appropriate pain management 1
• Administer antibiotic prophylaxis 1
• Correct postoperative anemia 1
• Perform regular assessment of:
  • Cognitive function
  • Pressure sore risk
  • Nutritional status
  • Renal function
  • Bowel and bladder function
  • Wound healing 1
• Implement early mobilization 1

Rehabilitation

Early Post-fracture Phase

• Begin physical training and muscle strengthening immediately post-fracture 1
• Identify individual goals and needs for each patient 1
• For shoulder fractures: begin range-of-motion exercises including shoulder, elbow, wrist, and hand motion within first postoperative days 1
• For distal radius fractures: implement early finger motion to prevent edema and stiffness 1

Long-term Rehabilitation

• Continue balance training and multidimensional fall prevention 1
• Aim to restore pre-fracture level of mobility and independence 1

Secondary Prevention

Non-pharmacological Interventions

• Ensure adequate calcium intake (1000-1200 mg/day) 1
• Provide vitamin D supplementation (800 IU/day) 1
• Encourage smoking cessation 1
• Limit alcohol intake 1
• Implement exercise and fall prevention programs 1

Pharmacological Treatment

• Prefer drugs demonstrated to reduce vertebral, non-vertebral, and hip fractures 1
• Consider bisphosphonates (alendronate, risedronate, zoledronic acid) as first-line agents 1
• Monitor regularly for tolerance and adherence 1

Service Organization

Multidisciplinary Team

• Establish a multidisciplinary hip fracture management group including:
  • Orthopaedic surgeons
  • Anaesthetists
  • Orthogeriatricians
  • Nursing staff
  • Physiotherapists
  • Occupational therapists
  • Social workers 1
• Implement orthogeriatric comanagement for frail elderly patients with multiple comorbidities and polypharmacy 1

Healthcare System Requirements

• Provide protected trauma lists daily, including weekends and holidays 1
• Staff lists with appropriately experienced senior medical and theatre staff 1
• Use continuous tracking/live data systems to monitor patient care and identify delays 1

Patient Education

• Educate patients about:
  • Disease burden
  • Risk factors for fractures
  • Follow-up requirements
  • Duration of therapy 1

Common Pitfalls and Caveats

• Delayed surgery beyond 48 hours increases mortality risk 1, 3
• Overly aggressive physical therapy may increase fixation failure risk 1
• Calcium alone has no demonstrated effect on fracture reduction and may cause gastrointestinal side effects 1
• High pulse dosages of vitamin D may increase fall risk 1
• Intracapsular fractures may sometimes allow deceptively maintained mobility with minimal pain 4
• Mortality is highest within the first six months after hip fracture 5