What is the appropriate management for an elderly patient with a mildly displaced left intertrochanteric hip fracture, scalp hematoma, and complex medical history including chronic kidney disease (CKD), moderate cognitive impairment, and history of costochondritis, who presented after an unwitnessed fall?

Neurology-Specific Evaluation and Management

From a neurological standpoint, this patient requires no specific neurological intervention beyond standard fall risk assessment and cognitive monitoring, as the CT brain shows no intracranial injury and her mild confusion is likely multifactorial (baseline cognitive impairment, pain, stress from recent trauma). 1

Neurological Assessment Findings

The neurological examination is reassuring:

• Alert and oriented x2-3 with mild confusion about location is consistent with her baseline moderate cognitive impairment 1
• No loss of consciousness reported 1
• CT brain negative for intracranial hemorrhage, showing only scalp subgaleal hematoma 1
• The discrepancy in fall location reporting (kitchen vs. washing room) is expected given her documented cognitive impairment 1

Key neurological considerations:

• The scalp hematoma is superficial (subgaleal) and does not require neurosurgical intervention 1
• Her recent dizziness episodes reported by family warrant attention but are likely multifactorial (anxiety from recent home invasion, orthostatic changes, baseline cognitive issues) 1
• The mild confusion does not represent acute delirium requiring specific treatment beyond addressing the underlying hip fracture and pain 1

Primary Management Focus: Orthopedic Intervention

The mildly displaced left intertrochanteric hip fracture requires urgent orthopedic surgical management within 24-48 hours of admission, as this timing is associated with better outcomes. 1

Surgical Approach

This patient should undergo closed reduction and cephalomedullary nail fixation:

• Intertrochanteric fractures, even if mildly displaced, should be treated with cephalomedullary nail fixation 1
• Either short or long cephalomedullary nail may be used (limited strength option) 1
• Spinal or general anesthesia are both appropriate options 1

Perioperative Pain Management

Multimodal analgesia incorporating a preoperative peripheral nerve block (iliofascial block) is strongly recommended:

• This approach significantly reduces pain and opioid requirements 1
• Continue regular acetaminophen throughout the perioperative period 1
• Use opioids cautiously given her CKD—reduce both dose and frequency (e.g., halve the dose), avoid oral opioids, and avoid codeine entirely 1
• NSAIDs are contraindicated due to her CKD 1

Surgical Adjuncts

Tranexamic acid should be administered at the start of surgery to reduce blood loss and transfusion need (strong strength recommendation). 1

Postoperative Management

Mobilization

Allow immediate weight-bearing as tolerated postoperatively:

• This approach prevents deconditioning and reduces complications 1
• Do not prescribe bed rest, as immobility increases complications in elderly patients 2, 3

Anemia Management

Monitor hemoglobin postoperatively and transfuse if symptomatic anemia develops:

• Transfusion is recommended for symptomatic anemia (fatigue, hypotension) 1
• The transfusion threshold should be no higher than 8 g/dL in asymptomatic patients 1

VTE Prophylaxis

Administer VTE prophylaxis for 4 weeks postoperatively:

• Low molecular weight heparin (enoxaparin) or fondaparinux should be used 1
• Sequential compression devices should be used intraoperatively 1
• Timing: administer LMWH between 18:00-20:00 to minimize bleeding risk with neuraxial anesthesia 1

Antibiotic Prophylaxis

Administer prophylactic antibiotics within one hour of skin incision, particularly against Staphylococcus aureus. 1, 4

Bone Health and Secondary Prevention

Refer to Fracture Liaison Service or Bone Health Clinic for osteoporosis evaluation:

• Draw vitamin D, calcium, and parathyroid hormone levels during hospitalization 1
• Order outpatient DEXA scan 1
• Initiate bisphosphonate therapy to reduce future fracture risk 1, 4

Cognitive and Fall Risk Management

Address modifiable fall risk factors:

• The recent home invasion and anxiety may have contributed to this fall 1
• Her reported dizziness episodes require evaluation for orthostatic hypotension, medication effects, and cardiac causes 1
• Implement fall prevention strategies given her cognitive impairment and now-documented fall risk 3

Monitoring for Delirium

Monitor closely for postoperative delirium, which is common in elderly patients with baseline cognitive impairment:

• Avoid medications that worsen cognition (codeine, excessive opioids, anticholinergics) 1
• Maintain adequate hydration and electrolyte balance 1
• Encourage early mobilization 1

Special Considerations for CKD

Her chronic kidney disease requires specific modifications:

• Reduce opioid dosing by half and avoid oral formulations 1
• Avoid NSAIDs entirely 1
• Monitor fluid status carefully—optimize preoperative volume status and consider cardiac output-guided fluid administration 1
• Adjust medication dosing for renal function throughout hospitalization 1

Critical Pitfalls to Avoid

Do not delay surgery for "medical optimization" beyond 24-48 hours:

• Early surgery (within 24-48 hours) improves outcomes 1
• Preoperative traction should NOT be used 1

Do not assume the scalp hematoma requires neurosurgical consultation:

• Subgaleal hematomas without intracranial injury are managed conservatively 1

Do not attribute all confusion to "just dementia":

• Monitor for superimposed delirium, which requires different management 1
• Ensure pain is adequately controlled, as uncontrolled pain worsens confusion 1

Do not prescribe bed rest or restricted weight-bearing:

• Immediate weight-bearing as tolerated is the standard of care 1