How to assess and manage an orthopedic arm issue in an elderly patient with a history of hypernatremia and potential comorbidities?

Assessment of Orthopedic Arm Injury in Elderly Patients

Elderly patients with orthopedic arm injuries require immediate multidisciplinary assessment with specific attention to preoperative optimization, orthostatic blood pressure measurement, correction of hypernatremia if present, and early surgical intervention within 48 hours when indicated. 1

Immediate Assessment Priorities

Orthostatic Blood Pressure Measurement

• Measure blood pressure supine after 5 minutes rest, then at 1 and 3 minutes after standing before any intervention. 2 Orthostatic hypotension (≥20 mmHg systolic or ≥10 mmHg diastolic drop) occurs in approximately 7% of men over 70 and increases age-adjusted mortality by 64%, with strong correlation to falls and fractures. 1, 2
• This measurement is critical because orthostatic hypotension may have contributed to the initial fall causing the arm injury and will affect perioperative management. 2

Hypernatremia Evaluation and Correction

• Check serum sodium immediately in all elderly patients presenting with orthopedic injuries. 3 Hypernatremia is associated with high morbidity and mortality in elderly patients and can contribute to falls through two mechanisms: mild cognitive impairment causing unsteady gait, and direct contribution to osteoporosis through increased bone resorption. 3
• If hypernatremia (>145 mEq/L) is present, calculate fluid deficit and initiate correction at a rate <12 mmol/L per day using hypotonic fluids. 4, 5 Delayed correction is associated with increased hospital stay and mortality. 4
• Hospital-acquired hypernatremia is primarily iatrogenic from inadequate fluid prescription in patients with impaired thirst or restricted water intake. 6

Preoperative Medical Optimization

• Perform comprehensive admission assessment including: chest X-ray, ECG, complete blood count, coagulation studies, renal function, and cognitive baseline. 1 This identifies modifiable variables including malnutrition, electrolyte disturbances, anemia, cardiac or pulmonary disease, and delirium. 1
• Provide adequate pain relief immediately before diagnostic investigations. 1 Nerve blocks reduce acute pain in fracture patients. 1
• Assess for volume depletion, which is a common cause of orthostatic hypotension alongside medications (diuretics, vasodilators, alpha-blockers, beta-blockers). 1, 2

Surgical Timing and Perioperative Care

Early Surgery Protocol

• Proceed to surgery within 24-48 hours of admission when indicated. 1 Early surgery significantly reduces short-term and mid-term mortality rates and reduces complications from immobility (decubitus ulcers, pneumonia). 1
• Delay to optimize acute medical problems must be weighed against effects of prolonging pain and immobility. 1

Orthogeriatric Comanagement

• Implement orthogeriatric comanagement with joint care between orthopedic surgeon and geriatrician on a dedicated ward. 1 This model demonstrates shortest time to surgery, shortest length of stay, and lowest inpatient and 1-year mortality. 1
• The multidisciplinary approach should include comprehensive geriatric assessment to improve functional outcomes and reduce mortality. 1

Medication Review and Fall Risk Reduction

High-Risk Medications to Identify

• Review and consider discontinuing or dose-reducing: benzodiazepines, alpha-1 blockers (doxazosin, prazosin, terazosin), antipsychotics (quetiapine), tricyclic antidepressants, and vestibular suppressants. 7 These are significant independent risk factors for falls in elderly patients. 7
• Beta-blockers and ACE inhibitors have more pronounced orthostatic effects in elderly due to altered pharmacokinetics. 2
• Diuretics and nitrates may aggravate orthostatic hypotension. 1

Antihypertensive Management Considerations

• Do not automatically down-titrate antihypertensives based solely on orthostatic hypotension findings. 2 Intensive blood pressure control actually reduces orthostatic hypotension risk through improved baroreflex function and reduced arterial stiffness. 2
• However, initiation of two antihypertensive agents should be undertaken cautiously with careful monitoring for orthostatic symptoms. 1

Nutritional Support

Oral Nutritional Supplements

• Offer oral nutritional supplements to all elderly fracture patients regardless of nutritional status. 1 Standard ONS increases energy and nutrient intake, reduces postoperative complications, and does not increase adverse effects. 1
• ONS should be combined with fortified foods as part of the multidisciplinary approach. 1

Critical Pitfalls to Avoid

• Never ignore mild hypernatremia in elderly patients with orthopedic injuries. 3 It should be checked and corrected, as it contributes to both the initial fall risk and ongoing complications. 3
• Avoid rapid blood pressure reduction if hypertensive emergency is present. 8 Excessive drops can precipitate cerebral, renal, or coronary ischemia in elderly patients with chronic hypertension and altered autoregulation. 8
• Do not use short-acting nifedipine due to risk of uncontrolled blood pressure falls, stroke, and death. 8
• Avoid chlorpropamide in diabetic patients due to prolonged half-life and increased hypoglycemia risk with age. 1
• Do not delay surgery beyond 48 hours unless acute medical optimization is absolutely necessary. 1 Prolonged immobility increases complications and mortality. 1

Ongoing Monitoring

• Monitor lying and standing blood pressures periodically throughout hospitalization in all patients over 50. 1 Orthostatic hypotension is a common barrier to intensive care that should be clearly documented. 1
• Closely monitor electrolytes during hypernatremia correction to ensure desired correction rate is achieved. 4
• Screen for delirium and cognitive changes, which are common in elderly fracture patients and may be exacerbated by hypernatremia. 1, 3