Management of Hip Fracture in a 99-Year-Old Female
Surgical intervention is strongly recommended for this 99-year-old female with a left hip fracture, with surgery performed within 48 hours of admission to reduce mortality and complications. 1
Initial Assessment and Workup
- Perform a comprehensive multidisciplinary assessment including investigations for common modifiable variables: malnutrition, electrolyte/volume disturbances, anemia, cardiac/pulmonary diseases, and cognitive function 1
- Order preoperative investigations including chest X-ray, ECG, full blood count, clotting studies, blood group, and renal function 1
- Provide appropriate pain management immediately, consider nerve blocks for acute pain relief 1
- Evaluate for causes of fall, although unwitnessed, including medication review, orthostatic hypotension, cardiac arrhythmias, and neurological assessment 2
Surgical Management
Schedule surgery within 24-48 hours of admission to significantly reduce short-term and mid-term mortality rates 1
For this patient with a left hip fracture, surgical approach depends on fracture type:
- For femoral neck fractures: Hemiarthroplasty is preferred in frail elderly patients as operative time is shorter and dislocation risk is lower 1
- For intertrochanteric fractures: Sliding hip screw for stable fractures; cephalomedullary device for unstable fractures 1
- For subtrochanteric fractures: Cephalomedullary device is strongly recommended 1
Administer prophylactic antibiotics before surgery, particularly against Staphylococcus aureus 2
Either spinal or general anesthesia is appropriate, though spinal may have advantages in elderly patients 1
Perioperative Care
- Implement orthogeriatric comanagement to improve functional outcome and reduce length of hospital stay and mortality 1
- Provide thromboembolic prophylaxis, preferably with low-molecular-weight heparin 2
- Administer tranexamic acid to reduce blood loss and blood transfusion requirements 1
- Consider blood transfusion for symptomatic anemia with a threshold no higher than 8 g/dL 1
Postoperative Management
- Implement multimodal analgesia incorporating nerve blocks 1
- Allow weight-bearing as tolerated to promote early mobilization 1
- Perform regular assessment of cognitive function to monitor for delirium, which occurs in approximately 19% of patients and is associated with increased mortality 3
- Monitor for common complications including pneumonia, urinary tract infections, and pressure sores 3
- Assess nutritional status and renal function regularly 1
- Begin early mobilization and rehabilitation to improve outcomes 1
Secondary Prevention
- Evaluate systematically for risk of subsequent fractures 1
- Consider referral to a Fracture Liaison Service for secondary fracture prevention 1
- Assess for osteoporosis and consider bisphosphonate therapy unless contraindicated 2
- Implement fall prevention strategies including home safety assessment 4
Special Considerations for Advanced Age
- Age itself is a risk factor for nosocomial infections after hip fracture surgery, requiring vigilant monitoring 5
- Despite advanced age (99 years), surgical management is still recommended as the gold standard treatment, as the risk-reward calculus favors surgical repair in most patients 6
- Family's desire for surgery aligns with evidence-based recommendations, as operative management optimizes outcomes even in nonagenarians 4
Potential Complications
- Overall complication rate after hip fracture surgery is high (approximately 75%), with delirium being the most common complication (19%) 3
- Surgical complications occur in about 9% of cases 3
- Mortality risk increases with complications such as delirium and pneumonia 3
- Early surgery (within 48 hours) and careful anesthesia selection may help reduce preventable complications 3