What is the next step in managing a 92-year-old female with a left trochanteric fracture causing mild discomfort, confirmed on X-ray (XR)?

Management of Left Trochanteric Fracture in a 92-Year-Old Female

The next step for this 92-year-old female with a left trochanteric fracture causing mild discomfort should be surgical intervention with cephalomedullary nail fixation. 1

Surgical Management Approach

• Trochanteric fractures in elderly patients require surgical intervention, as they have often devastating effects and conservative management is associated with dangerous complications of prolonged recumbency 1, 2
• For unstable intertrochanteric fractures, cephalomedullary nail fixation is strongly recommended based on high-quality evidence 1
• Surgery should be performed promptly, ideally within 48 hours of admission, as delays beyond this timeframe are associated with significantly higher mortality 3

Preoperative Considerations

• Thorough medical optimization without unnecessarily delaying surgery is essential 3
• Appropriate pain management should be provided while awaiting surgery 1
• Preoperative traction should not be used for hip fracture patients (strong evidence, strong recommendation) 1
• An orthogeriatric comanagement approach should be implemented to improve outcomes and reduce mortality 3

Surgical Technique Details

• For unstable intertrochanteric fractures, an antegrade cephalomedullary nail is the preferred fixation method 1
• Either short or long cephalomedullary nail may be used (limited evidence, limited strength option) 1
• The procedure should aim for good reduction from both anteroposterior and lateral views to minimize the risk of excessive postoperative sliding 4
• Proper placement of the lag screw with appropriate tip-apex distance is critical to prevent fixation failure 4

Special Considerations for High-Risk Patients

• In extremely high-risk patients who cannot tolerate general or spinal anesthesia, external fixation under local anesthesia may be considered as an alternative approach 2, 5
• External fixation offers advantages of being quick, simple, with minimal blood loss, and allows early ambulation in high-risk patients 2

Postoperative Management

• Immediate full weight-bearing to tolerance after surgery should be allowed (limited evidence, limited strength option) 1
• VTE prophylaxis should be used for 4 weeks postoperatively (moderate evidence, strong recommendation) 1
• Monitor for postoperative anemia and provide blood transfusion for symptomatic anemia 1
• Early mobilization is essential to prevent complications such as pneumonia, deep vein thrombosis, and pressure ulcers 3

Rehabilitation and Secondary Prevention

• An appropriate rehabilitation program should include early physical training, muscle strengthening, and long-term balance training 1, 3
• Systematic evaluation for the risk of subsequent fractures should be performed 1, 3
• Referral to an Orthopedics Bone Health Clinic for osteoporosis evaluation and treatment is strongly recommended 1, 3
• Non-pharmacological measures including adequate calcium and vitamin D intake should be implemented 1

Potential Complications to Monitor

• Watch for excessive sliding of the fracture fragments, which is more common in females, unstable fracture types, greater tip-apex distance, and poor reduction 4
• Monitor for pin tract infection if external fixation is used 2
• Assess for postoperative anemia, which may require blood transfusion if symptomatic 1
• Regular assessment of cognitive function, nutritional status, and pressure sore risk is essential 3