What is the best treatment approach for a 72-year-old female with a closed fracture (fx) of the right femur?

Treatment for Closed Femur Fracture in a 72-Year-Old Female

Surgery within 24-48 hours of admission is strongly recommended for a 72-year-old female with a closed femur fracture to improve outcomes, reduce mortality, and optimize functional recovery. 1

Initial Assessment and Management

• Preoperative Preparation:
  • Avoid preoperative traction (strong recommendation) 1
  • Ensure adequate pain relief with multimodal analgesia
  • Provide appropriate fluid management 1
  • Consider peripheral nerve blockade (femoral nerve/fascia iliaca block) as an adjunct to reduce opioid requirements 1

Surgical Timing and Approach

• Timing: Surgery within 24-48 hours of admission is associated with:

  • Reduced mortality rates 2
  • Shorter hospital stays 1
  • Better functional outcomes 1
  • Lower complication rates 3

• Anesthesia Options:

  • Either spinal or general anesthesia is appropriate (strong recommendation) 1
  • For spinal anesthesia:
    • Use lower doses of intrathecal bupivacaine (<10 mg) to reduce hypotension
    • Consider intrathecal fentanyl for postoperative analgesia
    • Provide supplemental oxygen during procedure 1
  • For general anesthesia:
    • Use reduced doses of induction agents
    • Consider inhalational induction to maintain spontaneous ventilation 1

Surgical Treatment Based on Fracture Location

Femoral Neck Fractures

• Unstable (displaced) fractures:
  • Arthroplasty is strongly recommended over fixation 1
  • Options include:
    • Hemiarthroplasty (unipolar or bipolar equally beneficial) 1
    • Total hip arthroplasty (THA) in properly selected patients 1
  • Use cemented femoral stems (strong recommendation) 1

Intertrochanteric Fractures

• Stable fractures:
  • Either sliding hip screw or cephalomedullary device (strong recommendation) 1
• Unstable/reverse obliquity fractures:
  • Cephalomedullary device is strongly recommended 1

Subtrochanteric Fractures

• Cephalomedullary device is strongly recommended 1

Distal Femur Fractures

• Consider distal femoral replacement arthroplasty for comminuted intra-articular fractures, as it may provide better ambulatory outcomes than open reduction internal fixation in elderly patients 4

Perioperative Care

• Monitoring:

  • Standard monitoring (pulse oximetry, ECG, non-invasive BP)
  • Core temperature monitoring
  • Consider invasive monitoring for patients with significant cardiac comorbidities 1

• Pain Management:

  • Multimodal approach:
    • Regular paracetamol
    • Cautious use of opioids (reduced dose and frequency in renal dysfunction)
    • Peripheral nerve blocks when possible
    • Avoid NSAIDs in patients with renal dysfunction 1

• Thromboprophylaxis:

  • Low molecular weight heparin or fondaparinux
  • Mechanical prophylaxis (compression stockings/devices)
  • Early mobilization 1

• Antibiotic Prophylaxis:

  • Administer within one hour of skin incision 1

Postoperative Management

• Early Mobilization:

  • Begin physical therapy as soon as possible after surgery
  • Progressive muscle strengthening and balance training 1

• Orthogeriatric Co-management:

  • Strongly recommended to improve functional outcomes and reduce mortality 1, 5
  • Regular assessment of cognitive function, nutritional status, and wound healing 1

• Prevention of Future Fractures:

  • Evaluate for osteoporosis and fall risk 1
  • Ensure adequate calcium and vitamin D intake 1

Pitfalls and Caveats

• Delaying surgery beyond 48 hours significantly increases mortality risk and complications 2
• Avoid preoperative traction as it provides no benefit 1
• Be vigilant for bone cement implantation syndrome during cemented arthroplasty procedures 1
• Monitor for postoperative delirium, which is common in elderly patients
• Recognize that femoral fractures in the elderly have similar mortality risks as hip fractures and should be treated with similar urgency 2

By following these evidence-based recommendations, optimal outcomes can be achieved for elderly patients with femur fractures, minimizing mortality risk and maximizing functional recovery.