What is the best course of action for an elderly patient with dementia who has fallen on her hip/butt, is unable to put weight on her left leg, and is experiencing increased limping and generalized pain, making it difficult to determine the presence of a bony injury?

Immediate Management of Suspected Hip Fracture in Elderly Patient with Dementia

This elderly patient with dementia who cannot bear weight on her left leg after a fall requires immediate imaging with AP pelvis and lateral hip radiographs, followed by urgent orthopedic consultation for likely hip fracture, with surgery planned within 24-48 hours to reduce mortality and complications. 1, 2

Immediate Diagnostic Approach

Obtain AP pelvis and lateral hip radiographs immediately as the first-line imaging modality to identify femoral neck fractures, intertrochanteric fractures, or other hip fractures. 1 The inability to bear weight after a fall in an elderly patient is highly suspicious for hip fracture, and this represents a medical emergency requiring urgent evaluation. 1

Critical Caveat About Imaging

• If initial radiographs appear normal but clinical suspicion remains high (inability to bear weight, increased limping, pain with movement), obtain MRI of the hip within 2-3 days to identify occult fractures, as plain films can be falsely negative in up to 10% of hip fractures. 1, 2
• The patient's dementia and generalized pain complaints make clinical examination unreliable, so imaging becomes even more critical for diagnosis. 1

Immediate Pain Management

Implement multimodal analgesia immediately before and during diagnostic workup, including peripheral nerve block (such as fascia iliaca block) and intravenous acetaminophen to reduce opioid requirements. 1 This is particularly important in elderly patients with dementia who are at increased risk for delirium with opioid use. 1

• Avoid relying solely on opioids due to increased risk of delirium, respiratory depression, and falls in elderly patients with dementia. 1

Urgent Multidisciplinary Activation

Immediately activate interdisciplinary care with orthogeriatric or hospitalist consultation to decrease complications and improve outcomes. 1, 2, 3 This should occur simultaneously with imaging, not after fracture confirmation.

Comprehensive Medical Assessment

The orthogeriatric team should perform systematic multidisciplinary assessment including: 4, 2

• Complete blood count to assess for anemia and leucocytosis (which may indicate underlying infection such as pneumonia or UTI that precipitated the fall). 2, 3
• Basic metabolic panel to identify electrolyte disturbances (hypokalemia, hyponatremia), volume status, and renal function. 4, 2
• ECG in all elderly patients with hip fracture. 4, 2
• Chest X-ray as part of preoperative workup. 4
• Assessment of cognitive baseline function and delirium screening, particularly important in this patient with known dementia. 4
• Evaluation for malnutrition, cardiac/pulmonary diseases, and medication review. 4, 2

Surgical Planning and Timing

Surgery should be performed within 24-48 hours of admission once the patient is medically optimized, as this significantly reduces short-term and mid-term mortality rates and reduces complications from immobility. 4, 1, 2, 3

Surgical Approach Based on Fracture Pattern

• For displaced femoral neck fractures: Arthroplasty (hemiarthroplasty or total hip arthroplasty) is the treatment of choice, using cemented femoral stem. 3
• For intertrochanteric/subtrochanteric fractures: Cephalomedullary nail fixation is recommended. 1
• Administer tranexamic acid at the start of surgery to reduce blood loss and transfusion requirements. 1, 3

Perioperative Management Specific to Dementia

For patients with dementia specifically, zoledronic acid (intravenous) or denosumab (subcutaneous) are preferred alternatives to oral bisphosphonates for osteoporosis treatment due to issues with oral compliance and malabsorption. 4

VTE Prophylaxis

• Initiate VTE prophylaxis with sequential compression devices during hospitalization and pharmacological prophylaxis (LMWH or UFH) for 4 weeks postoperatively, adjusted for renal function. 1, 2, 3

Postoperative Care and Secondary Prevention

Allow immediate weight-bearing as tolerated after surgery to promote early mobilization. 1, 2, 3

Refer to Fracture Liaison Service for comprehensive secondary fracture prevention, including: 2, 3

• DXA scan of spine and hip for bone mineral density assessment. 4
• Vitamin D supplementation (800 IU/day) with adequate calcium intake (1000-1200 mg/day). 4, 2
• Pharmacological treatment with bisphosphonates (zoledronic acid or denosumab preferred in dementia patients). 4, 2
• Multifactorial falls risk assessment and intervention. 2

Key Clinical Pitfall

The most critical error would be delaying imaging or dismissing the fracture possibility because the patient has dementia and "notes generalized pain." The inability to bear weight after a fall is a red flag that supersedes the unreliable history and examination in dementia patients. 1 Even patients with minimally displaced fractures can sometimes maintain some weight-bearing ability initially, so any increased limping or functional decline after a fall warrants immediate imaging. 3