Should we work up an unwitnessed fall in an elderly patient with a hip fracture?

Workup of Unwitnessed Falls in Elderly Patients with Hip Fractures

Yes, a thorough workup of an unwitnessed fall in an elderly patient with a hip fracture is essential as it can reveal occult injuries and prevent increased morbidity and mortality.

Rationale for Fall Workup

• Unwitnessed falls in the elderly can result in multisystem injuries that may be missed without comprehensive evaluation, especially in patients with cognitive impairment 1
• Hip fractures are typically associated with falls directly onto the greater trochanter (76% of cases), but may be accompanied by other injuries that are not immediately apparent 2
• Patients with reduced cognitive function should undergo full trauma assessment to identify all potential injuries 1

Components of Fall Workup

Initial Assessment

• Perform comprehensive multidisciplinary assessment including investigations for common modifiable variables: malnutrition, electrolyte/volume disturbances, anemia, cardiac/pulmonary diseases, and cognitive function 3
• Obtain complete blood count, as leucocytosis >17 × 10^9/L may indicate underlying infection (commonly chest or urinary) 4
• Check electrolytes, as hypokalemia is associated with new-onset atrial fibrillation, and hyponatremia (present in 17% of patients) may indicate infection or medication effects 4
• Obtain ECG in all elderly patients with hip fracture 4

Advanced Imaging

• If plain radiographs are normal but clinical suspicion for fracture remains high, obtain MRI to identify occult fractures 4
• Consider more liberal use of advanced imaging such as full-body CT scan in patients with cognitive impairment who cannot reliably report pain or other symptoms 1

Fall Risk Assessment

• Perform multifactorial falls risk assessment incorporating evaluation of gait, mobility, balance, lower limb strength, medication review, cognitive capacity, footwear, and environmental factors 4
• Use standardized tests such as the Timed Up and Go test to evaluate mobility 4

Post-Fracture Management

• Implement orthogeriatric comanagement to improve functional outcomes and reduce length of hospital stay and mortality 3
• Provide appropriate VTE prophylaxis with sequential compression devices during hospitalization and pharmacological prophylaxis (e.g., LMWH) for 4 weeks postoperatively 4
• Allow weight-bearing as tolerated to promote early mobilization 4
• Refer to a Fracture Liaison Service or Orthopaedics Bone Health Clinic for secondary fracture prevention 4, 3

Secondary Prevention

• Evaluate systematically for risk of subsequent fractures 3
• Implement multicomponent interventions including exercise, fall prevention strategies, and education about bone health 4
• Recommend weight-bearing impact exercise and/or resistance training to promote bone health and improve physical performance 4
• Ensure adequate calcium intake (1000-1200 mg/day) and vitamin D supplementation (800 IU/day) 4
• Consider pharmacological treatment with bisphosphonates (alendronate or risedronate as first-choice agents) to reduce risk of subsequent fractures 4

Clinical Pitfalls to Avoid

• Do not dismiss unwitnessed falls as minor events, as they can result in multiple injuries beyond the obvious hip fracture 1
• Avoid delaying surgical management, as surgery within 24-48 hours of admission significantly reduces short-term and mid-term mortality rates 3
• Do not overlook the possibility of occult fractures in other locations, particularly in patients with cognitive impairment who may not report pain 1
• Remember that mortality is highest within the first six months after hip fracture (50% of deaths), with sepsis being a common cause 5

By thoroughly investigating unwitnessed falls in elderly patients with hip fractures, clinicians can identify all injuries, address underlying medical conditions, and implement appropriate preventive measures to reduce the risk of future falls and fractures.