What is the recommended management for patients with proximal femur fractures?

Management of Proximal Femur Fractures

Proximal femur fractures require surgical intervention within 48 hours of hospital admission through a multidisciplinary approach led by orthogeriatricians to reduce mortality, morbidity, and improve functional outcomes. 1, 2

Initial Management

• Implement protocol-driven, fast-track admission through the emergency department 2
• Complete monitoring including oximetry, respiratory rate, ECG, non-invasive blood pressure, central temperature, and pain scales 1
• Provide adequate analgesia while awaiting surgery (surgery is considered the best analgesic) 2
• Evaluate and optimize comorbidities without unnecessarily delaying surgery 1

Surgical Timing and Approach

• Surgery within 24-48 hours of admission is strongly associated with:
  • Reduced mortality
  • Shorter hospital stay
  • Fewer respiratory complications
  • Lower overall morbidity 1, 2
• For femoral neck fractures with potential for head preservation, surgery within 6 hours may be advantageous 3

Surgical Treatment by Fracture Type

Femoral Neck Fractures

• Non-displaced fractures: Osteosynthesis (screw fixation) is preferred, especially in biologically younger patients 4
• Displaced fractures:
  • Total hip arthroplasty (THA) for active patients with good pre-fracture function
  • Hemiarthroplasty for very elderly or less active patients 1, 4
  • Consider osteosynthesis in bedridden patients to facilitate transfers 4

Intertrochanteric Fractures

• Proximal femur nailing (PFN) is the preferred surgical treatment 1, 3
• Provides superior stability allowing early mobilization 1

Subtrochanteric Fractures

• Long proximal femoral nail is recommended 1, 3
• For pathologic fractures, consider adjuvant radiotherapy 2-4 weeks postoperatively 1

Anesthesia Considerations

• Both spinal and general anesthesia are appropriate 1
• Spinal anesthesia recommendations:
  • Low-dose bupivacaine (<10 mg)
  • Consider adding fentanyl for postoperative analgesia 1
• General anesthesia recommendations:
  • Reduced doses of induction agents for elderly patients
  • Higher inspired oxygen concentrations may be required 1
• Peripheral nerve blockade should be considered as an adjunct to either technique 1

Special Considerations for Patients on Antithrombotic Therapy

• Antiplatelet therapy:
  • Acetylsalicylic acid (ASA) and clopidogrel can be continued through surgery 5
  • Consider antifibrinolytic therapy if bleeding occurs 5
• Warfarin therapy:
  • Early administration of vitamin K to reverse effects and allow surgery within 24 hours 5
  • Prothrombin complex concentrate reserved for extreme cases 5
  • Resume warfarin 24 hours after surgery 5
• Direct oral anticoagulants:
  • Discontinue 24-48 hours prior to surgery (depending on drug type and renal function) 5
  • Resume 24-48 hours after surgery 5

Postoperative Care

• Early mobilization with physical therapy starting from the first postoperative day 1, 2
• Allow full weight-bearing with stable fixation 1
• Regular monitoring of vital signs and cognitive function 1
• Provide supplemental oxygen for at least 24 hours postoperatively 1
• Encourage early oral fluid intake 1
• Remove urinary catheters as soon as possible to reduce UTI risk 1
• Nutritional assessment and supplementation (60% of patients are malnourished on admission) 1

Pain Management

• Regular paracetamol (1g every 6 hours) 1
• Peripheral nerve blocks as needed 1
• Minimize opioid use to prevent confusion in elderly patients 1

Complications Prevention and Management

• Thromboprophylaxis:
  • Low-molecular-weight heparin started on admission and continued through perioperative period 1
  • Consider mechanical prophylaxis (compression stockings) as adjunct 1
• Delirium prevention:
  • Avoid medications that may worsen confusion (e.g., cyclizine)
  • Maintain proper hydration, nutrition, and electrolyte balance
  • Use haloperidol or lorazepam only for short-term symptom control if necessary 1
• Monitor for common complications:
  • Postoperative cognitive dysfunction (occurs in 25% of patients) 1
  • Respiratory infections
  • Myocardial ischemia
  • Urinary tract infections 1

Expected Outcomes

• Mortality rate is approximately 8-10% at 30 days, higher in patients with ASA scores 3-4 1, 2
• Implementation of comprehensive protocols significantly reduces morbidity and mortality 1