Day 2 Post-Operative Management of an Internally Fixated Femoral Diaphysis Fracture
Early mobilization with physical therapy and multimodal pain management including peripheral nerve blocks should be implemented on day 2 post-operatively for patients with internally fixated femoral diaphysis fractures to improve outcomes and reduce complications. 1
Pain Management
Multimodal Analgesia
- Regular paracetamol (acetaminophen) administration should continue throughout the post-operative period 2
- Avoid non-steroidal anti-inflammatory drugs (NSAIDs) in elderly patients or those with renal dysfunction 2
- Use opioids cautiously, with reduced dosing in patients with renal dysfunction 2
- Avoid codeine due to its constipating effects, emetic properties, and association with post-operative cognitive dysfunction 2
Regional Anesthesia Options
- Peripheral nerve blocks provide superior analgesia compared to systemic pain therapy 3
- Consider femoral nerve or fascia iliaca compartment block to:
- Ultrasound-guided techniques improve accuracy and safety 2
- Options include:
Mobilization Protocol
- Begin physical therapy on day 2 post-operatively 1
- Progressive weight-bearing as tolerated (unless otherwise specified by surgeon)
- Focus on:
- Muscle strengthening exercises
- Balance training
- Range of motion exercises for the hip and knee 1
- Monitor for signs of malrotation or limb length discrepancy during mobilization 5
Thromboprophylaxis
- Continue low molecular weight heparin or fondaparinux as prescribed 2, 1
- Timing: Administer LMWH between 18:00-20:00 to minimize bleeding risk 2
- Mechanical prophylaxis:
- Thromboembolism stockings
- Intermittent compression devices 2
- Early mobilization further reduces DVT risk 2
- Monitor for clinical signs of DVT/PE, recognizing that symptoms are only seen in 1-3% of DVTs and 0.5-3% of PEs 2
Fluid Management
- Continue optimized fluid management to reduce morbidity and hospital stay 2
- Consider cardiac output-guided fluid administration in high-risk patients 2
- Monitor for signs of hypovolemia or fluid overload
Wound Care and Infection Prevention
- Continue antibiotic prophylaxis as per hospital protocol 2
- Inspect surgical wound daily for:
- Erythema
- Drainage
- Dehiscence
- Signs of infection
- Maintain sterile technique during dressing changes
Monitoring and Prevention of Complications
Delirium Prevention
- Peripheral nerve blocks reduce risk of acute confusional state 2
- Minimize opioid use to prevent cognitive dysfunction 2
- Ensure adequate hydration, oxygenation, and early mobilization
Pressure Care
- Reposition patient regularly to prevent pressure sores
- Use pressure-relieving mattresses
- Protect thin skin from trauma during repositioning 2
Thermoregulation
- Continue active warming strategies as needed 2
- Monitor core temperature
Respiratory Care
- Encourage deep breathing exercises
- Early mobilization to prevent atelectasis and pneumonia
- Provide supplemental oxygen if indicated
Special Considerations
For Elderly Patients
- Orthogeriatric co-management is strongly recommended 1
- More vigilant monitoring for complications
- Consider evaluation for osteoporosis and fall risk 1
- Ensure adequate calcium and vitamin D intake 1
For Patients with Comorbidities
- More intensive monitoring for patients with cardiac disease
- Adjust pain management for patients with renal dysfunction
- Consider more frequent vital sign monitoring for frail patients
Discharge Planning
- Begin discharge planning on day 2
- Assess need for rehabilitation services
- Evaluate home safety requirements
- Ensure adequate social support
- Plan for follow-up appointments to monitor for:
- Fracture healing
- Functional recovery
- Potential complications such as nonunion or infection 5
Warning Signs Requiring Immediate Attention
- Excessive pain not controlled by prescribed analgesics
- Signs of compartment syndrome
- Neurovascular compromise
- Fever or other signs of infection
- Significant swelling or hematoma formation
- Signs of venous thromboembolism