What is the recommended treatment for an elderly patient with a hip fracture?

Hip Fracture Management in Elderly Patients

Elderly patients with hip fractures require surgical intervention within 48 hours of admission, with the specific surgical approach determined by fracture type: stable intertrochanteric fractures are treated with either sliding hip screw or cephalomedullary device, displaced femoral neck fractures in active patients receive total hip arthroplasty with cemented stems, and frail patients receive hemiarthroplasty. 1, 2

Timing of Surgery

• Surgery must occur within 48 hours of admission to minimize mortality risk 1, 2
• Preoperative optimization should include adequate pain relief and fluid management but should not unnecessarily delay surgery 1, 2
• Hip fracture is a surgical urgency, and operation should proceed even in patients with serious comorbidities unless they are bed-ridden or moribund 3, 4

Surgical Approach by Fracture Type

Stable Intertrochanteric Fractures

• Either a sliding hip screw or cephalomedullary device is recommended 1
• Both options are equally effective for stable patterns 1, 5

Unstable Intertrochanteric Fractures

• Cephalomedullary nail is the preferred device 5

Subtrochanteric or Reverse Obliquity Fractures

• Cephalomedullary device is mandatory 1, 5
• This is a strong recommendation with no alternative 1

Displaced Femoral Neck Fractures

• In healthy, active, independent elderly patients without cognitive dysfunction: total hip arthroplasty (THA) is preferred 2
• THA provides functional benefit over hemiarthroplasty but carries increased complication risk 1
• In frail patients: hemiarthroplasty is preferred due to shorter operative time and lower dislocation risk 2
• Unipolar or bipolar hemiarthroplasty are equally beneficial 1
• Cemented femoral stems must be used for all arthroplasty procedures 1

Stable (Non-displaced) Femoral Neck Fractures

• Options include hemiarthroplasty, internal fixation with percutaneous cannulated screws, or nonsurgical care 1, 2
• The choice depends on patient functional status and comorbidities 1

Perioperative Management

Pain Control

• Multimodal analgesia incorporating a preoperative nerve block is mandatory 1, 5
• This optimizes pain control and facilitates early mobilization 5

Blood Loss Prevention

• Tranexamic acid must be administered perioperatively to reduce blood loss and transfusion requirements 1, 5

Anesthesia

• Either spinal or general anesthesia is appropriate 5

Antibiotic Prophylaxis

• Prophylactic antibiotics, particularly against Staphylococcus aureus, must be given before surgery 6

Thromboembolism Prevention

• Thromboembolic prophylaxis is required, preferably with low-molecular-weight heparin 6

Orthogeriatric Comanagement

• Interdisciplinary care programs involving orthogeriatric comanagement must be used for all elderly hip fracture patients 1, 2
• This approach decreases complications, improves functional outcomes, reduces hospital stay, and decreases mortality 1, 2
• Regular assessment during the perioperative period must include: cognitive function, nutritional status, renal function, bowel and bladder function, pressure sore risk, and wound status 1, 2

Postoperative Care

• Immediate full weight-bearing mobilization is essential unless contraindicated 2, 5
• Early mobilization prevents pneumonia, deep vein thrombosis, and pressure ulcers 2
• Correction of postoperative anemia is required 1, 2
• Comprehensive wound assessment and care must be performed 1

Rehabilitation Program

• Early postfracture physical training and muscle strengthening must begin immediately 1, 2
• Long-term balance training and multidimensional fall prevention should continue after discharge 1, 2
• The program should be tailored to the patient's prefracture functional status 2

Secondary Fracture Prevention

• Every patient aged 50 years and over with a hip fracture requires systematic evaluation for subsequent fracture risk 1, 2, 5
• Evaluation includes: clinical risk factors review, DXA of spine and hip, spine imaging for vertebral fractures, falls risk assessment, and identification of secondary osteoporosis 1
• A Fracture Liaison Service (FLS) model is the most effective organizational structure for this evaluation 2, 5
• Pharmacological treatment with bisphosphonates or other agents proven to reduce vertebral, non-vertebral, and hip fractures must be initiated 2, 5
• Regular monitoring for tolerance and adherence is required 1, 2
• Ensure adequate calcium and vitamin D intake, smoking cessation, and alcohol limitation 1

Common Pitfalls to Avoid

• Delaying surgery beyond 48 hours significantly increases mortality 2
• Failing to use cemented stems in arthroplasty leads to increased complications 1
• Omitting preoperative nerve blocks results in suboptimal pain control 1
• Not administering tranexamic acid increases transfusion requirements 1
• Underestimating the importance of orthogeriatric comanagement leads to worse outcomes 2
• Neglecting secondary fracture prevention increases the risk of subsequent fractures 2
• Common surgical complications after internal fixation include cut-out, nonunion, Z-effect/medial migration, periimplant failure, and avascular necrosis—high quality surgical technique is critical 7