Management of Hip Fracture in Patients Who Are Not Candidates for Surgery
For patients who are not candidates for surgery, hip fracture management should focus on comprehensive pain control, early mobilization when possible, prevention of complications, and multidisciplinary care with orthogeriatric comanagement to reduce mortality and morbidity. 1
Pain Management
Pain control is critical and should be implemented immediately:
- Regular paracetamol (acetaminophen) should be the foundation of pain management 1
- Nerve blocks (femoral or fascia iliaca) provide effective analgesia without the side effects of opioids 1
- Cautious opioid use with reduced dosing in elderly patients (typically half the standard dose) 1
- Avoid codeine as it causes constipation, nausea, and cognitive dysfunction 1
Medical Management
Initial Assessment and Stabilization
- Complete systematic assessment of medical conditions including:
- Nutritional status
- Fluid and electrolyte balance
- Cardiac and pulmonary function
- Cognitive status
- Anemia 1
Fluid Management
- Optimize fluid balance to prevent hypovolemia
- Consider cardiac output-guided fluid administration when available 1
- Encourage early oral fluid intake when possible 1
Thromboprophylaxis
- Implement pharmacological thromboprophylaxis, preferably with low-molecular-weight heparin 1
- Consider mechanical methods (compression stockings, intermittent pneumatic compression) for those with contraindications to anticoagulation
Oxygen Therapy
- Provide supplemental oxygen for at least 24 hours to prevent hypoxia 1
- Monitor oxygen saturation regularly
Mobilization and Positioning
- Implement careful positioning to minimize pain and prevent pressure ulcers
- Use pressure-relieving mattresses
- Consider limited weight-bearing with assistive devices if tolerated
- Early physiotherapy assessment to maximize remaining function
Complication Prevention
Delirium Management
- Regular cognitive assessment
- Optimize hydration, nutrition, pain control, and sleep
- Minimize use of medications that can exacerbate confusion
- Treat underlying causes (UTI, pneumonia, etc.) 1
- Use haloperidol or lorazepam only for short-term symptom control if necessary 1
Pressure Ulcer Prevention
- Regular repositioning (every 2-4 hours)
- Early mobilization when possible
- Skin assessment and care
Nutritional Support
- Nutritional assessment and supplementation
- Consider dietetic consultation
- Up to 60% of hip fracture patients are malnourished on admission 1
- Nutritional supplementation may reduce mortality 1
Multidisciplinary Approach
A multidisciplinary approach is essential and should include:
- Orthogeriatric comanagement - shown to reduce length of hospital stay and mortality 1
- Regular nursing care with appropriate nurse-to-patient ratio (1:4 recommended) 1
- Physiotherapy and occupational therapy input
- Social services involvement for discharge planning
- Regular multidisciplinary meetings to coordinate care 1
Monitoring and Follow-up
- Regular vital signs monitoring
- Pain assessment as part of routine observations
- Regular reassessment of cognitive status
- Monitor for complications (pneumonia, UTI, pressure ulcers, thromboembolism)
Prognosis
It's important to note that non-operative management of hip fractures carries significant mortality risk. Surgical fixation within 24-48 hours of admission significantly reduces short-term and mid-term mortality rates and reduces medical complications due to immobility 1. Therefore, non-surgical management should only be considered when surgery is absolutely contraindicated.
Discharge Planning
- Early discharge planning
- Assessment of home environment and support needs
- Consider rehabilitation facility placement when appropriate
- Implement fall prevention strategies
- Consider osteoporosis assessment and treatment if appropriate
The management of hip fracture patients who cannot undergo surgery requires careful attention to all aspects of care to minimize complications and optimize outcomes in this high-risk population.