What is the most appropriate treatment for an elderly female with a subtrochanteric fracture, dementia, hypertension (High Blood Pressure), ischemic heart disease, and Chronic Obstructive Pulmonary Disease (COPD) after a fall?

Treatment of Subtrochanteric Fracture in Elderly Female with Multiple Comorbidities

For this elderly patient with a subtrochanteric fracture, cephalomedullary nail fixation is the definitive treatment, as subtrochanteric fractures require intramedullary nailing rather than dynamic hip screw, total hip replacement, or hemiarthroplasty. 1, 2

Surgical Approach

Implant Selection

• Subtrochanteric fractures mandate cephalomedullary nail fixation with strong evidence and strong recommendation. 1, 2
• The choice between short versus long nail depends on fracture pattern, though both are acceptable options for subtrochanteric fractures. 1
• Dynamic hip screw (option 1) is contraindicated for subtrochanteric fractures—it is only appropriate for stable intertrochanteric fractures. 2, 3
• Total hip replacement (option 2) and hemiarthroplasty (option 4) are reserved for intracapsular femoral neck fractures, not extracapsular subtrochanteric fractures. 1

Timing and Perioperative Management

• Surgery should be performed within 48 hours of injury to reduce mortality and complications. 1
• Either spinal or general anesthesia is appropriate for this patient despite her comorbidities. 1, 2
• Multimodal analgesia with preoperative nerve block (iliofascial block) should be administered for pain control. 1, 3
• Tranexamic acid must be given perioperatively to reduce blood loss and transfusion requirements. 1, 3

Postoperative Weight-Bearing Protocol

Immediate full weight-bearing as tolerated is recommended postoperatively, making option 3 (non-weight bearing for 6 weeks) incorrect and potentially harmful. 1, 2

Rationale for Early Mobilization

• Early mobilization with immediate weight-bearing prevents recumbency complications including pneumonia, pressure ulcers, and venous thromboembolism. 2
• Delayed mobilization increases mortality risk in elderly patients with hip fractures. 1
• The patient should be allowed to weight-bear as tolerated starting postoperative day 1. 1

Critical Management Considerations

Multidisciplinary Orthogeriatric Care

• This patient requires orthogeriatric comanagement given her dementia, hypertension, ischemic heart disease, and COPD. 1
• Comprehensive geriatric assessment should address delirium prevention, cardiac optimization, pulmonary management, and nutritional status. 1
• Preoperative assessment must include ECG, chest X-ray, full blood count, renal function, and cognitive baseline evaluation. 1

Venous Thromboembolism Prophylaxis

• Enoxaparin or other pharmacologic VTE prophylaxis should be prescribed postoperatively. 1

Osteoporosis Evaluation

• All patients require systematic osteoporosis evaluation including outpatient DEXA scan, vitamin D level, calcium level, and parathyroid hormone level. 1, 2, 3
• Initiate appropriate osteoporosis treatment to prevent subsequent fractures. 2

Common Pitfalls to Avoid

• Do not use preoperative traction—this has strong evidence against its use and does not improve outcomes. 1, 3
• Do not delay surgery beyond 48 hours unless acute medical optimization is absolutely necessary, as delay increases mortality. 1, 4
• Do not restrict weight-bearing postoperatively—this increases complications and mortality in elderly patients. 1, 2
• Do not select dynamic hip screw for subtrochanteric fractures—this leads to fixation failure due to high mechanical stresses in the subtrochanteric region. 1, 2