What is the post-operative management for a patient undergoing right hip intramedullary (IT) nailing?

Post-Operative Management for Right Hip Intramedullary Nailing

Patients should be allowed immediate weight-bearing as tolerated following intramedullary nailing of intertrochanteric fractures, with VTE prophylaxis for 4 weeks and multimodal pain management. 1

Mobilization and Weight-Bearing

• Immediate full weight-bearing as tolerated is recommended postoperatively (limited strength evidence, but represents the standard approach). 1
• Early mobilization should be initiated according to patient tolerance to improve oxygenation, respiratory function, and reduce complications. 1
• The rehabilitation process requires coordinated input from physiotherapists, occupational therapists, and nursing staff to return patients to pre-fracture functional status. 1

Venous Thromboembolism Prophylaxis

• VTE prophylaxis should be used in all hip fracture patients (moderate strength evidence, strong recommendation). 1
• Sequential compression devices should be applied while hospitalized. 1
• Pharmacologic prophylaxis with low molecular weight heparin (Lovenox) or fondaparinux should be continued for 4 weeks postoperatively. 1, 2
• Time LMWH administration between 18:00-20:00 to minimize bleeding risk with neuraxial anesthesia. 2

Pain Management

• Regular paracetamol (acetaminophen) should be continued throughout the perioperative period as the foundation of analgesia. 1, 2
• Peripheral nerve blockade is rarely effective beyond the first postoperative night. 1
• Opioid analgesia should be carefully prescribed and titrated as indicated, particularly during remobilization. 1
• In patients with renal dysfunction, avoid oral opioids and reduce both dose and frequency of intravenous opioids by half. 1, 2
• Codeine should NOT be administered due to constipation, emesis, and association with postoperative cognitive dysfunction. 1, 2
• NSAIDs should be used with extreme caution and are contraindicated in renal dysfunction. 1, 2
• Pain evaluation should be included as part of routine postoperative nursing observations. 1

Respiratory Management

• Supplemental oxygen should be administered postoperatively for at least 24 hours, as older patients are at high risk of postoperative hypoxia. 1
• Oxygenation and respiratory function improve with mobilization. 1

Fluid and Nutritional Management

• Early oral fluid intake should be encouraged rather than routine prescription of intravenous fluids, as hypovolemia is common but oral intake is preferred. 1
• Urinary catheters should be removed as soon as possible to reduce urinary tract infection risk. 1
• Up to 60% of hip fracture patients are clinically malnourished on admission; nutritional supplementation and dietetic support may reduce mortality and length of stay. 1

Blood Transfusion

• Blood transfusion is recommended for symptomatic anemia (moderate strength evidence, moderate recommendation). 1
• Use a transfusion threshold no higher than 8 g/dL in postoperative, asymptomatic hip fracture patients (strong strength evidence, strong recommendation). 1, 2

Monitoring and Complications

• Patients remain at relatively high risk of complications in the early postoperative phase and may require prolonged monitoring in the recovery unit or HDU/ICU. 1
• Ward care should have a nurse:patient ratio of 1:4 with regular input from physicians specialized in geriatric medicine. 1
• Monitor vital signs and neurovascular status of the affected limb. 3
• Postoperative cognitive dysfunction occurs in 25% of patients; treatment involves multimodal optimization including adequate analgesia, nutrition, hydration, electrolyte balance, and identifying/treating complications (chest infection, silent MI, UTI). 1
• Haloperidol or lorazepam should only be used short-term to control acute confusion symptoms; cyclizine should be used with caution due to antimuscarinic side effects. 1

Secondary Prevention

• Outpatient DEXA scan should be ordered and patients referred to bone health clinic for osteoporosis evaluation and treatment (strong strength evidence, strong recommendation). 1, 2
• Secondary prevention of falls and osteoporosis should be actively considered in the early postoperative period, as subsequent fragility fractures carry particularly poor prognosis. 1