What is the management for a patient with a hip fracture if no surgery is performed?

Management of Hip Fracture Without Surgery

Nonsurgical management of hip fracture should only be considered in patients with stable (nondisplaced) femoral neck fractures, bed-ridden or moribund patients, or those with very limited life expectancy and extensive comorbidities that prohibit safe anesthesia. 1, 2

When Nonsurgical Management May Be Appropriate

The AAOS guidelines indicate that nonsurgical care may be considered only for stable (nondisplaced) femoral neck fractures as a limited-strength option, though this carries lower quality evidence. 1 Surgery is not advisable for bed-ridden or moribund patients, nor for those with very osteoporotic bones and extensively comminuted fractures where fixation would be impossible. 2

It is critical to understand that avoiding surgery in most hip fracture patients significantly increases mortality and morbidity. Delaying or avoiding surgery beyond 48 hours is associated with prolonged hospital stay, increased complications (pressure sores, pneumonia, thromboembolic events), and increased mortality. 1

Essential Components of Nonsurgical Management

Pain Control

• Implement multimodal analgesia immediately, including nerve blocks for acute pain relief. 1
• Continue regular paracetamol (acetaminophen) administration as the foundation of pain management. 1
• Use carefully titrated intravenous opioids with reduced dose and frequency, particularly in patients with renal dysfunction. 1
• Avoid codeine entirely due to constipating, emetic, and cognitive dysfunction effects. 1
• Include pain evaluation as part of routine nursing observations. 1

Fluid and Nutritional Management

• Correct hypovolemia with appropriate fluid resuscitation using cardiac output-guided administration when possible. 1
• Encourage early oral fluid intake rather than routine intravenous fluids once the patient can tolerate oral intake. 1
• Address malnutrition aggressively, as up to 60% of hip fracture patients are malnourished on admission. 1
• Provide nutritional supplementation and dietetic support to reduce mortality and length of stay. 1

Thromboprophylaxis

• Administer thromboprophylaxis, preferably with low-molecular-weight heparin, given the 37% prevalence of deep vein thrombosis and 6% prevalence of pulmonary embolism in hip fracture patients. 1, 3

Respiratory Support

• Provide supplemental oxygen for at least 24 hours, as older patients are at high risk of postoperative hypoxia even without surgery. 1
• Monitor respiratory function closely and improve oxygenation through mobilization when possible. 1

Prevention of Immobility Complications

• Implement aggressive pressure care protocols to prevent decubitus ulcers. 1, 2
• Remove urinary catheters as soon as possible to reduce urinary tract infection risk. 1
• Monitor for and treat pneumonia aggressively. 1, 2

Cognitive Function Management

• Expect postoperative cognitive dysfunction in 25% of patients and implement multimodal optimization including adequate analgesia, nutrition, hydration, and electrolyte balance. 1
• Identify and treat complications such as chest infection, silent myocardial ischemia, and urinary tract infection that contribute to delirium. 1
• Use haloperidol or lorazepam only for short-term symptom control. 1
• Avoid cyclizine due to antimuscarinic side effects in older persons. 1

Interdisciplinary Care

• Provide orthogeriatric comanagement with comprehensive geriatric assessment to improve functional outcomes and reduce mortality. 1
• Ensure ward care with a nurse-to-patient ratio of 1:4 with regular input from physicians specialized in geriatric medicine. 1
• Conduct systematic multidisciplinary assessment of medical conditions including malnutrition, electrolyte disturbances, anemia, cardiac or pulmonary diseases, and dementia. 1

Mobilization Attempts

• Attempt early mobilization as tolerated to improve respiratory function and reduce complications, though this will be severely limited without surgical stabilization. 1
• Recognize that most patients will not regain their baseline independence and function without surgical repair. 4

Critical Prognostic Information

Patients managed nonsurgically face devastating outcomes. Up to 50% of patients with hip fracture die within six months, with the highest mortality occurring in the first six months. 4 The major causes of death include sepsis (35%), pneumonia, and cardiovascular events. 2, 4 Post-operative medical complications (which also occur in nonsurgical patients due to immobility) are associated with 78.5% mortality at 4 years. 5

Secondary Fracture Prevention

• Systematically evaluate all patients aged 50 years and older for osteoporosis using DXA scanning of spine and hip. 1
• Initiate bisphosphonate therapy unless contraindicated to reduce risk of subsequent fractures. 3
• Ensure adequate calcium and vitamin D intake. 1
• Conduct fall-prevention assessment and implement multidimensional fall prevention strategies. 3

Common Pitfalls to Avoid

• Do not delay considering surgical consultation even in high-risk patients, as the risks of nonsurgical management often exceed surgical risks. 1
• Do not use oral opioids or codeine in this population. 1
• Do not allow prolonged immobilization without aggressive prevention of complications. 1
• Do not overlook the need for antibiotic prophylaxis against Staphylococcus aureus even if surgery is not performed, as infection risk remains high. 3