What is the appropriate management for an elderly patient presenting with a right intratrochanteric (intertrochanteric) fracture?

Hospital Inpatient History and Physical: Right Intertrochanteric Femur Fracture

Chief Complaint

Right hip pain and inability to bear weight following fall.

History of Present Illness

Document the following critical elements:

• Mechanism of injury: Low-energy fall (typical in elderly) versus high-energy trauma 1
• Time of injury: Essential for surgical timing within 24-48 hours 1, 2
• Pre-injury ambulatory status: Independent ambulation, assistive device use, or non-ambulatory 1
• Pain characteristics: Location (hip/groin), severity (typically severe), inability to bear weight 1
• Associated injuries: Head trauma, other fractures, loss of consciousness 1

Past Medical History

Critical comorbidities affecting surgical risk:

• Cardiac disease (ischemic heart disease, heart failure, arrhythmias) 3
• Pulmonary disease (COPD, asthma) 3
• Renal dysfunction (affects medication dosing, particularly opioids and NSAIDs) 1
• Cognitive impairment or dementia (affects consent and delirium risk) 3
• Anticoagulation therapy (requires reversal planning) 1
• Previous hip surgery or hardware 1

Osteoporosis risk factors:

• Previous fragility fractures 4
• Family history of fractures 4
• Low body mass index 4
• Chronic steroid use 4

Medications

• Document all current medications, particularly anticoagulants and antiplatelet agents 1
• Note any medications affecting bone health (steroids, aromatase inhibitors) 4

Social History

• Living situation: Independent, assisted living, nursing home 1
• Support system: Family availability for postoperative care 1
• Baseline functional status: ADL independence level 1
• Fall risk factors: Previous falls, environmental hazards, gait instability 4

Physical Examination

General Appearance

• Overall frailty assessment 4
• Signs of dehydration (many patients are hypovolemic) 1
• Cognitive status and orientation 3

Vital Signs

• Blood pressure (maintain within 20% of baseline intraoperatively) 1
• Heart rate and rhythm 3
• Respiratory rate and oxygen saturation 3
• Temperature (hypothermia risk in elderly) 1

Affected Extremity (Right Lower)

• Inspection: Shortened and externally rotated leg (classic presentation) 1
• Palpation: Tenderness over greater trochanter and proximal femur 1
• Range of motion: Painful with any attempted movement, do NOT attempt passive ROM 1
• Neurovascular status:
  • Dorsalis pedis and posterior tibial pulses 1
  • Capillary refill 1
  • Sensation in all dermatomes (L2-S1) 1
  • Motor function (limited by pain but assess distal function) 1

Skin Examination

• Critical in elderly: Assess for fragile skin, pressure areas, and positioning concerns 1
• Document any pre-existing pressure ulcers 1
• Examine non-operative hip to avoid excessive flexion and internal rotation during positioning 1

Cardiovascular

• Heart sounds, murmurs, irregular rhythm 3
• Signs of heart failure (JVD, peripheral edema) 3

Respiratory

• Breath sounds, wheezing, crackles 3
• Baseline respiratory effort 3

Abdominal

• Soft, non-tender, bowel sounds present 1

Other Extremities

• Assess for additional injuries from fall 1
• Contralateral hip examination 1

Imaging Studies Reviewed

• AP pelvis radiograph: Assess fracture pattern stability 4, 1
• Lateral hip radiograph: Evaluate posterior comminution 4, 1
• Fracture classification:
  • Stable pattern: Intact posteromedial cortex, no subtrochanteric extension 4, 5
  • Unstable pattern: Posteromedial comminution, reverse obliquity, subtrochanteric extension, lesser trochanter avulsion 4, 1

Assessment

Right intertrochanteric femur fracture - specify stable versus unstable pattern based on imaging 4, 1

Plan

Surgical Management

Device selection based on fracture stability:

• Stable intertrochanteric fracture: Sliding hip screw (DHS) is preferred 4, 1
• Unstable intertrochanteric fracture: Cephalomedullary nail is mandatory 4, 1
• Subtrochanteric extension or reverse oblique pattern: Cephalomedullary nail required 4, 1, 3

Surgical Timing

• Target surgery within 24-48 hours of admission to reduce mortality and complications 1, 2

Preoperative Management

• Do NOT use preoperative traction - no benefit and specifically not recommended 1
• Prophylactic antibiotics: Administer within one hour of skin incision 1
• Intravenous fluid resuscitation: Many patients are hypovolemic 1
• Multimodal analgesia: Peripheral nerve block in emergency department or preoperatively 1
• Active warming strategies: Prevent hypothermia intraoperatively and postoperatively 1

Preoperative Testing

• ECG 3
• Chest X-ray 3
• Complete blood count 3
• Renal function tests 1, 3
• Coagulation studies if on anticoagulation 1

Anesthesia

• Either spinal or general anesthesia is appropriate - no preference 1
• BIS monitoring to avoid cardiovascular depression 1

Postoperative Management

• DVT prophylaxis: Fondaparinux or low molecular weight heparin 1
• Pain management:
  • Regular paracetamol throughout perioperative period 1
  • Opioids cautiously, especially with renal dysfunction 1
  • Do NOT use codeine (causes constipation, emesis, cognitive dysfunction) 1
  • NSAIDs with extreme caution, avoid in renal dysfunction 1
• Weight-bearing: Immediate full weight-bearing as tolerated 1
• Early mobilization protocols to reduce complications 1

Secondary Fracture Prevention

• Outpatient DEXA scan for bone mineral density 1
• Referral to bone health clinic for osteoporosis evaluation and treatment 1
• Laboratory evaluation: Vitamin D, calcium, parathyroid hormone levels 3
• Fracture Liaison Service referral for systematic risk evaluation 4

Orthogeriatric Comanagement

• Comprehensive geriatric assessment 3
• Delirium prevention strategies 3
• Cardiac optimization 3
• Pulmonary management 3
• Nutritional assessment 3