What are the necessary steps for medical clearance in a patient with a hip fracture?

Medical Clearance for Hip Fracture

Medical clearance for hip fracture patients requires a structured assessment of hemoglobin levels, coagulation status, electrolytes, cardiac function, and management of comorbidities to optimize surgical outcomes and reduce mortality. 1

Initial Assessment and Laboratory Testing

• Complete Blood Count:

  • Check hemoglobin (Hb) levels - pre-operative transfusion should be considered if:
    • Hb < 9 g/dL
    • Hb < 10 g/dL with history of ischemic heart disease 1
  • Crossmatch 2 units of blood if Hb is 10-12 g/dL
  • Group and save if Hb is within normal limits
  • Monitor leukocytosis (WBC > 17 × 10^9/L may indicate infection) 1
  • Check platelet count (50-80 × 10^9/L is relative contraindication to neuraxial anesthesia; <50 × 10^9/L requires platelet transfusion) 1

• Electrolytes and Renal Function:

  • Assess for hypokalaemia (risk for new-onset atrial fibrillation)
  • Check for hyperkalaemia (may indicate rhabdomyolysis if patient was immobilized)
  • Evaluate hyponatraemia (present in 17% of patients, may indicate infection or medication effect) 1
  • Assess renal function (40% of hip fracture patients have moderate renal dysfunction) 1

• Cardiac Assessment:

  • ECG required for all elderly hip fracture patients 1
  • Transthoracic echocardiography (TTE) is not routinely needed but should be considered for:
    • Patients with change in clinical status of known heart disease
    • New-onset cardiac symptoms or signs 2

• Chest Radiograph:

  • Not routinely necessary
  • Indicated for patients with newly diagnosed heart failure or pneumonia 1

Management of Special Cases

Anticoagulation Management

• Aspirin:

  • May be withheld during inpatient stay unless indicated for unstable angina or recent/frequent TIAs 1

• Clopidogrel:

  • Generally not stopped on admission, especially with drug-eluting coronary stents
  • Surgery should not be delayed, but expect marginally greater blood loss 1

• Warfarin:

  • Target INR < 2 for surgery and < 1.5 for neuraxial anesthesia
  • Small amounts of vitamin K may be used to reverse effects
  • Supplemental perioperative anticoagulation with heparins usually indicated 1

• Direct Oral Anticoagulants (DOACs):

  • Recent evidence suggests surgery within 24 hours of admission for patients on factor Xa inhibitors does not increase overall blood loss or transfusion rates 3
  • Expedited surgery (≤24 hours) for patients on DOACs is associated with shorter hospital stays and fewer complications 3

Atrial Fibrillation

• Ensure ventricular rate < 100/min
• Address underlying causes: hypokalaemia, hypomagnesaemia, hypovolaemia, sepsis, pain, hypoxaemia
• Consider beta-blockers (metoprolol) or verapamil for rate control if needed 1

Alcohol Dependence

• Recognize as common, under-diagnosed, and a risk factor for falls
• Patients are at risk for significant perioperative morbidity 1

Optimization for Surgery

• Timing of Surgery:

  • Aim for surgery within 24-48 hours of fracture to optimize outcomes 4
  • Delays beyond 48 hours increase mortality and complications 5

• Pain Management:

  • Implement formalized analgesia protocol with regular pain scoring
  • Use paracetamol/acetaminophen as foundation of pain therapy
  • Consider nerve blocks (femoral/fascia iliaca) for effective analgesia without opioid side effects 1, 5
  • Use opioids cautiously, especially with renal dysfunction 1

• Fluid Management:

  • Ensure adequate intravenous fluid therapy
  • Implement warming strategies to prevent hypothermia 1

• Thromboprophylaxis:

  • Implement pharmacological thromboprophylaxis, preferably with low-molecular-weight heparin 5, 6

Perioperative Considerations

• Antibiotic Prophylaxis:

  • Administer prophylactic antibiotics before surgery, particularly against Staphylococcus aureus 6, 4

• Anesthesia Planning:

  • Consider patient comorbidities when choosing between spinal or general anesthesia 4
  • Assess and communicate perioperative risk 1

• Blood Loss Management:

  • Anticipate approximately 2.5 g/dL drop in hemoglobin perioperatively 1
  • Be aware that significant blood loss (0.8-1.2 g/dL) occurs before surgery due to the fracture itself 7
  • Extracapsular fractures typically have greater hidden blood loss than intracapsular fractures 7

Common Pitfalls and Caveats

1. Delaying Surgery Unnecessarily:

   • Avoid unnecessary delays for medical clearance when not clinically indicated
   • Expedited surgery (within 24-48 hours) improves outcomes 4

2. Missing Occult Fractures:

   • If hip fracture is suspected but plain radiography is normal, order MRI 6, 4

3. Overlooking Delirium:

   • Regularly assess cognitive status
   • Optimize hydration, nutrition, pain control, and sleep
   • Minimize medications that can exacerbate confusion 5

4. Neglecting Early Mobilization:

   • Early mobilization is critical to prevent pulmonary complications and improve outcomes 5
   • Plan for rehabilitation early with physiotherapists and occupational therapists 5

5. Underestimating Blood Loss:

   • Remember that significant blood loss occurs before surgery due to the fracture itself 7
   • Monitor hemoglobin closely, especially in extracapsular fractures which have greater hidden blood loss 7