What is the treatment for hip fracture?

Treatment for Hip Fracture

The treatment of hip fracture requires prompt surgical intervention within 24-48 hours of injury, followed by comprehensive postoperative care including early mobilization, effective pain management, and structured rehabilitation to optimize outcomes and reduce mortality. 1, 2

Pre-operative Management

• Initial Assessment and Stabilization:

  • Evaluate fracture pattern and stability using radiographic imaging
  • Assess comorbidities, functional status, and mobility
  • Correct hypovolemia with pre-operative fluid therapy 1
  • Provide adequate analgesia (regular paracetamol, cautious use of opioids) 1

• Thromboprophylaxis: Implement early to prevent deep vein thrombosis (DVT) which has a prevalence of 37% in hip fracture patients 1

Surgical Management

Surgical Timing

• Surgery within 24-48 hours of fracture optimizes outcomes and reduces mortality 3

Surgical Approach Based on Fracture Type

1. Intertrochanteric Fractures:

   • Antegrade cephalomedullary nail is preferred due to superior outcomes 2
   • Procedure involves positioning patient supine on fracture table, applying traction for reduction, and inserting nail under fluoroscopic guidance 2

2. Isolated Greater Trochanter Fractures:

   • Conservative management for displacement <2cm and low activity demands
   • ORIF with cable fixation or tension band wiring for displacement >2cm or high physical demands 2

3. Femoral Neck Fractures:

   • Surgical fixation method depends on fracture pattern, displacement, and patient factors 4

Anesthesia Considerations

• Either spinal/regional or general anesthesia can be used
• Regional anesthesia may reduce postoperative confusion 2
• Consider peripheral nerve blockade for supplemental pain control 1, 5

Intraoperative Considerations

• Active warming strategies to prevent hypothermia 1
• Increase inspired oxygen concentration during cementation to reduce risk of bone cement implantation syndrome (BCIS) 1
• Maintain adequate intravascular volume 1

Postoperative Management

Pain Management

• Implement multimodal analgesia to facilitate early mobilization:
  • Regular paracetamol administration 1
  • Cautious use of opioids, especially in patients with renal dysfunction 1, 5
  • Avoid codeine due to constipation, emesis, and cognitive dysfunction 1
  • Consider peripheral nerve blocks for early postoperative pain 1, 5

Early Mobilization and Rehabilitation

• Begin early mobilization to improve outcomes 6, 7
• Weight-bearing restrictions depend on reconstruction stability 2
• For cephalomedullary nails, weight-bearing as tolerated is typically allowed 2
• Progressive return to full activities at 3-4 months based on radiographic healing 2

Respiratory Care

• Administer supplemental oxygen for at least 24 hours postoperatively 1
• Encourage early mobilization to improve oxygenation and respiratory function 1

Fluid and Nutritional Management

• Encourage early oral fluid intake rather than routine IV fluids 1
• Provide nutritional supplementation as up to 60% of patients are malnourished 1
• Remove urinary catheters as soon as possible to reduce infection risk 1

Management of Postoperative Complications

1. Cognitive Dysfunction/Delirium (occurs in 25% of patients):

   • Optimize analgesia, nutrition, hydration, and electrolyte balance
   • Identify and treat complications like chest infection, myocardial ischemia, and UTIs
   • Use haloperidol or lorazepam only for short-term symptom control 1

2. Infection Prevention:

   • Administer prophylactic antibiotics 2
   • Monitor wound healing and implement proper wound care protocols 2

3. Thromboembolic Events:

   • Continue thromboprophylaxis throughout hospitalization 1

Follow-up and Long-term Care

• Radiographic Evaluation: At 6 weeks, 3 months, 6 months, and 1 year to assess healing 2
• Rehabilitation: Coordinate with orthogeriatricians for patient-centered care 1
• Secondary Prevention:
  • Falls prevention assessment
  • Osteoporosis evaluation and treatment if indicated 2
  • Balance training and multidimensional fall prevention 2

Common Pitfalls and Caveats

• Delaying surgery beyond 48 hours increases mortality and complications 3
• Inadequate pain control impairs mobility and delays rehabilitation 5
• Overreliance on opioids can cause oversedation, delayed ambulation, and increased care needs 5
• Failure to address malnutrition increases mortality risk 1
• Neglecting early mobilization increases risk of complications including pneumonia, DVT, and pressure ulcers 6
• Improper implant selection for specific fracture patterns can lead to fixation failure 4