What is the best course of treatment for an elderly patient with a mildly displaced left intertrochanteric hip fracture, chronic kidney disease (CKD), hypothyroidism, hypertension (HTN), and moderate cognitive impairment after a fall?

Surgical Management of Mildly Displaced Intertrochanteric Hip Fracture

This elderly patient with a mildly displaced left intertrochanteric hip fracture requires urgent surgical fixation with a cephalomedullary nail within 24-48 hours of admission, followed by immediate weight-bearing mobilization and comprehensive medical optimization. 1

Immediate Preoperative Management

Surgical Timing

• Surgery should be performed within 24-48 hours of admission to optimize outcomes and reduce mortality 1
• Do not use preoperative traction—this has strong evidence against its use 1

Pain Management

• Administer multimodal analgesia incorporating a preoperative nerve block (iliofascial or femoral nerve block) as part of the pain control strategy 1, 2
• This approach facilitates early mobilization and reduces opioid requirements 2

Medical Optimization

• Despite her multiple comorbidities (CKD, HTN, hypothyroidism, cognitive impairment), she should be medically cleared for surgery expeditiously 1
• The presence of CKD and other comorbidities does not preclude surgical intervention—the case examples specifically demonstrate successful outcomes in patients with similar profiles 1

Surgical Approach

Implant Selection

For this mildly displaced intertrochanteric fracture, either a sliding hip screw OR a cephalomedullary nail is appropriate 1, 2

However, the clinical context favors a cephalomedullary nail for several reasons:

• Her cognitive impairment may limit postoperative compliance 3, 4
• Patients with cognitive impairment show better outcomes with more stable fixation 4
• A nail provides more robust fixation if the fracture proves more unstable intraoperatively 1, 2
• If any comminution or posteromedial instability is present, a cephalomedullary device is strongly recommended 1, 2

Anesthesia Choice

• Either spinal or general anesthesia is equally appropriate—this is a strong recommendation with no preference between the two 1, 2
• The choice should be based on anesthesiologist assessment and patient factors 1

Intraoperative Adjuncts

• Administer tranexamic acid (TXA) at the start of the case to reduce blood loss and transfusion requirements 1, 2
• This is particularly important given her CKD, as minimizing blood loss reduces transfusion risk 1

Postoperative Management

Mobilization

• Allow immediate full weight-bearing as tolerated starting postoperative day 1 1, 2
• Early mobilization is critical to prevent recumbency complications and reduce mortality 2
• Her cognitive impairment should not delay mobilization efforts 3

VTE Prophylaxis

• Provide venous thromboembolism prophylaxis (enoxaparin or other anticoagulant) for at least 4 weeks postoperatively 1
• This is a strong recommendation for all hip fracture patients 1

Transfusion Management

• Monitor hemoglobin postoperatively 1
• Transfuse if symptomatic anemia develops (fatigue, hypotension, tachycardia) or if hemoglobin drops below 8 g/dL in asymptomatic patients 1
• Given her CKD, she may have baseline anemia requiring closer monitoring 1

Osteoporosis Evaluation

• Order outpatient DEXA scan 1, 2
• Check vitamin D, calcium, and parathyroid hormone levels while hospitalized 1, 2
• Refer to bone health clinic or Fracture Liaison Service for long-term osteoporosis management 1, 2
• This is critical for secondary fracture prevention 2

Special Considerations for This Patient

Cognitive Impairment Impact

• Patients with moderate cognitive impairment have shorter presurgery hospital stays but higher risk of delirium 3
• Monitor closely for postoperative delirium, which is common in this population 3
• Cognitive impairment may affect rehabilitation outcomes but should not alter the surgical approach 3, 4

CKD Considerations

• Her CKD does not contraindicate surgery—case examples demonstrate successful outcomes in similar patients 1
• Minimize nephrotoxic medications perioperatively 1
• Coordinate with nephrology if creatinine is significantly elevated 1

Fall Evaluation

• The unwitnessed fall with reported dizziness and recent psychological distress warrants evaluation for syncope, orthostatic hypotension, and medication review 3
• Her multiple comorbidities (HTN, hypothyroidism) may contribute to fall risk 3

Critical Pitfalls to Avoid

• Do not delay surgery beyond 48 hours unless absolutely medically necessary 1
• Do not restrict weight-bearing postoperatively—this increases complications 1, 2
• Do not skip osteoporosis evaluation—this is when secondary prevention must begin 2
• Do not use preoperative traction—strong evidence shows no benefit 1