What are the admitting orders for an adult patient presenting with a traumatic fracture, potentially with underlying conditions such as osteoporosis?

Admitting Orders for Fractures

For adult patients with traumatic fractures, particularly those over 50 years, admitting orders must prioritize rapid multidisciplinary assessment, early surgical intervention within 24-48 hours, and immediate initiation of secondary fracture prevention pathways to reduce mortality and morbidity. 1

Immediate Admission Orders

Diagnostic Investigations

Upon admission, the following investigations should be ordered immediately to identify and treat acute medical conditions that could delay surgery: 1

• Chest X-ray 1
• ECG 1
• Complete blood count (CBC) 1
• Coagulation studies 1
• Type and screen/crossmatch 1
• Renal function tests (BUN, creatinine) 1
• Basic metabolic panel 1
• Cognitive baseline assessment (abbreviated mental test score) 1

Admission Location and Timing

• Admit to orthogeriatric ward within 4 hours of emergency department arrival 1
• Transfer to a dedicated ward with nursing, orthogeriatric medicine, and surgical expertise appropriate for elderly patients 1

Pain Management and Supportive Care

• Adequate pain relief - this is a critical component of preoperative care 1
• Appropriate fluid management to optimize medical status 1
• Avoid delays that prolong pain and immobility, as these increase complications 1

Multidisciplinary Care Coordination

Orthogeriatric Comanagement (Level IA Evidence)

Orthogeriatric comanagement should be initiated immediately upon admission, as this has the strongest evidence for reducing mortality, length of stay, and improving functional outcomes. 1

• Joint care model between geriatrician and orthopedic surgeon on a dedicated orthogeriatric ward demonstrates shortest time to surgery, shortest inpatient stay, and lowest 1-year mortality 1
• Hospitalist or geriatrician should evaluate patient in emergency department and provide medical clearance for surgery 1
• Comprehensive geriatric assessment should be performed 1

Surgical Timing

Surgery should be performed within 24-48 hours of admission unless there are clear reversible medical conditions. 1

• Early surgery within this window significantly reduces short-term and mid-term mortality rates 1
• Reduces major and minor medical complications from immobility (decubitus ulcers, pneumonia) 1
• The risk of delaying surgery to optimize acute medical problems must be weighed against prolonging pain and immobility 1

Secondary Fracture Prevention Orders (For Patients ≥50 Years)

Immediate Risk Assessment

Every patient aged 50 years and over with a fracture must have systematic evaluation for subsequent fracture risk initiated during admission. 1

Metabolic Bone Disease Workup

Order the following investigations before discharge or arrange outpatient follow-up: 2

• Calcium level 2
• 25-hydroxyvitamin D level 2
• Parathyroid hormone (PTH) 2
• Thyroid function tests (TSH) 2
• DXA scan of spine and hip (can be arranged as outpatient) 1
• Spine imaging (radiography or vertebral fracture assessment) to detect subclinical vertebral fractures 1

Fracture Liaison Service Referral

Arrange referral to Fracture Liaison Service (FLS) with a dedicated coordinator, as this is the most effective organizational structure for preventing subsequent fractures (Level IA evidence). 1, 2, 3

• FLS significantly improves implementation of osteoporosis treatment (45% vs 26% in control groups) 1
• If FLS unavailable, arrange direct referral to endocrinology, rheumatology, or orthopedic bone health clinic 2

Common Pitfall: Approximately 70% of patients who could benefit from osteoporosis treatment do not receive it - this represents a critical care gap that must be addressed through systematic FLS referral. 2

Perioperative Medication Orders

Tranexamic Acid (TXA)

Administer tranexamic acid at the start of surgery to reduce blood loss and transfusion requirements (Level IA evidence). 1

Antibiotic Prophylaxis

• Routine antibiotic prophylaxis should be administered perioperatively 1

Calcium and Vitamin D Supplementation

• Initiate calcium (1000-1200 mg/day) and vitamin D (800 IU/day) supplementation 1, 4, 5

Postoperative Orders

Monitoring and Assessment

• Pain management - appropriate analgesia regimen 1
• Correction of postoperative anemia 1
• Regular cognitive function assessment 1
• Pressure sore assessment 1
• Nutritional status evaluation 1
• Renal function monitoring 1
• Bowel and bladder function assessment 1
• Wound assessment and care 1

Early Mobilization

Early mobilization should be initiated as soon as medically appropriate to reduce complications. 1

Discharge Planning

Documentation Requirements

The discharge summary must explicitly document: 2

• Presence of fragility fracture 2
• Need for osteoporosis evaluation and treatment 2
• Specific outpatient referrals arranged (FLS, endocrinology, rheumatology) 2
• Patient education provided about fracture risk 2

Rehabilitation Program

• Arrange early postfracture physical training and muscle strengthening 1
• Long-term continuation of balance training and multidimensional fall prevention 1

Critical Pitfall to Avoid: Even when osteoporosis is diagnosed, evaluation and pharmacological intervention is only offered to a small percentage of patients. The discharge summary must include explicit documentation and arranged follow-up to prevent this treatment gap. 2