From the Guidelines
Post-surgical management of a neck of femur (NOF) fracture should prioritize a multidisciplinary approach, including pain control, early mobilization, and prevention of complications, with a focus on reducing the risk of subsequent fractures, as recommended by the EULAR/EFORT guidelines 1. The management plan should include a systematic evaluation of the risk of subsequent fractures, as each patient aged 50 years and over with a recent fracture should be assessed for this risk 1.
Key Components of Post-Surgical Management
- Pain management using a multimodal approach, including acetaminophen, NSAIDs, and opioids as needed, while minimizing opioid use
- Early mobilization, with physical therapy beginning within 24-48 hours after surgery
- Deep vein thrombosis prophylaxis using low molecular weight heparin or direct oral anticoagulants for 28-35 days
- Nutritional support with high-protein supplements to aid in wound healing and recovery
- Calcium and vitamin D supplementation to support bone health
- Consideration of anti-osteoporosis medications, such as bisphosphonates, after 2-4 weeks
- Regular wound care and monitoring for infection
- Fall prevention education to reduce the risk of subsequent fractures
Organization of Post-Fracture Care
The EULAR/EFORT guidelines recommend a Fracture Liaison Service (FLS) as the most effective organizational structure for risk evaluation and treatment initiation 1.
- A dedicated coordinator, often a well-educated nurse, should be responsible for identifying patients with a recent fracture, organizing diagnostic investigations, and initiating interventions
- The coordinator should work under the supervision of an orthopaedic surgeon, endocrinologist, or rheumatologist
- The FLS model has been shown to improve the implementation of osteoporosis treatment after a fragility fracture, with 45% of patients receiving appropriate management compared to 26% in the control group 1
Follow-Up and Monitoring
Follow-up appointments should be scheduled at 2 weeks, 6 weeks, 3 months, and 6 months post-surgery to monitor healing, function, and address complications.
- Regular assessments should include evaluation of cognitive function, nutritional status, renal function, and bowel and bladder function
- Patients should be educated about the burden of the disease, risk factors for fractures, and the importance of adherence to treatment plans 1
From the Research
Post-Surgical Management of Non-Operatively Managed Fracture Neck of Femur (NOF)
- The majority of NOF fractures are treated operatively, but a subset is treated non-operatively, with no clear guidance for selection and management of these patients 2.
- A study found that 3.2% of NOF fractures were managed non-operatively, with common reasons being "comfortable mobilisation" or "patient frailty/medically unwell" 2.
- Non-operative management resulted in a 25% 1-year mortality rate and average length of stay of 10.1 days for a select group of patients with stable fractures 2.
- 82% of this group of patients were successfully managed without an operation, indicating a place for non-operative management in a small select subgroup of hip fracture patients with minimally displaced, stable fractures 2.
Surgical Management of NOF
- The fractured neck of femur is a commonly encountered injury in orthopaedic practice, resulting in significant morbidity and mortality 3.
- Operative options include in situ fixation, closed or open reduction and internal fixation, hemiarthroplasty, and total hip arthroplasty 3.
- The Garden and Pauwels classification systems are used to characterize femoral neck fractures and dictate appropriate treatment 3.
- A systematic review found that the Femoral Neck System (FNS) can be a safe and effective operative treatment option for FNF, with similar or significantly lower incidences of postoperative complications, reoperations, and mortality compared to other operative treatments 4.
Pain Management in NOF
- A study found that fascia iliaca compartment block (FICB) reduced the need for additional opioid analgesia and avoided the risk of opioid overdose and respiratory depression in patients with femoral neck fracture 5.
- The use of FICB resulted in significantly lower visual analogue scores (VAS) for pain at rest and on movement compared to standard preoperative analgesia alone 5.