What is the management of a closed comminuted proximal femur fracture in a 73-year-old female?

From the Guidelines

Surgical management with either intramedullary nailing or hip arthroplasty is the recommended treatment for a closed comminuted proximal femur fracture in a 73-year-old female, as it significantly improves outcomes and functional recovery. The patient should be stabilized immediately with pain control using multimodal analgesia (acetaminophen 1000mg every 6 hours, plus opioids as needed) and DVT prophylaxis with low molecular weight heparin (enoxaparin 40mg subcutaneously daily) 1. Pre-operative optimization should include assessment of comorbidities, correction of anemia if present, and evaluation of bone health.

Key Considerations

• Surgery should be performed within 24-48 hours to reduce complications and mortality risk 1.
• Post-operatively, early mobilization with physical therapy is crucial, starting the day after surgery with weight-bearing status determined by the specific surgical procedure.
• Calcium (1200mg daily) and vitamin D (800-1000 IU daily) supplementation should be initiated, and osteoporosis treatment considered after appropriate screening.
• Rehabilitation should continue for 3-6 months with regular follow-up appointments at 2 weeks, 6 weeks, 3 months, and 6 months post-surgery.

Additional Recommendations

• The use of cemented femoral stem is recommended, and a unipolar femoral head may be used 1.
• Tranexamic acid (TXA) should be administered at the start of the case to decrease bleeding and the need for transfusion 1.
• The choice of surgical procedure, either intramedullary nailing or hip arthroplasty, depends on the fracture pattern and location, and should be determined by an orthopedic specialist.

Rationale

This approach is recommended because elderly patients with proximal femur fractures have high morbidity and mortality rates, and prompt surgical intervention with comprehensive perioperative care significantly improves outcomes and functional recovery 1.

From the Research

Treatment Options for Closed Comminuted Proximal Femur Fracture

• The treatment of proximal femoral fragility fractures, including closed comminuted proximal femur fractures, is primarily surgical with either arthroplasty or internal fixation 2.
• Intramedullary nailing is used in the treatment of some types of proximal femoral fragility fractures and may be associated with unique complications that become evident on postoperative follow-up radiographs 2.
• Hip arthroplasty is an alternative in older patients with intertrochanteric femur fractures at high risk of fixation failure or with concomitant intraarticular pathologies 3.

Considerations for Surgical Management

• The choice of surgical technique mainly depends on the surgeon's preferences and the fracture characteristics 3.
• Bipolar hemiarthroplasty is the most common type of prosthesis used with primary or revision femoral stems 3.
• Strategic patient positioning is key to the reduction and fixation of proximal femur fractures without complications 4.
• The use of intramedullary devices for the fixation of proximal femur fractures has led to an increased use of the modern fracture table, but recent evidence has suggested increased risk of malrotation associated with its use 4.

Biomechanical Considerations

• The biomechanics that dictate fracture site stability and implant stress depend on fracture type as well as implant features such as nail length, nail diameter, presence of distal fixation screws, and material composition of the implant 5.
• Filling the reamed canal with the largest fitting nail diameter reduced axial and shear interfragmentary motion for all fracture types 5.
• Nail length was less predictive of shear interfragmentary motion for most simulated fracture types than other construct variables 5.