What is the initial management for an older adult with a femur fracture proximal to the knee joint and potential comorbidities?

Initial Management of Proximal Femur Fracture in Older Adults

Immediate Pain Control (First Priority)

Pain control is the absolute first priority in managing proximal femur fractures, as these are extremely painful injuries requiring immediate analgesia before any other intervention. 1

• Administer regular paracetamol immediately unless contraindicated, as this is the foundation analgesic for all femur fractures 2, 1
• Titrate intravenous morphine cautiously after checking renal function, as approximately 40% of older patients with hip fractures have moderate renal dysfunction (GFR <60 ml/min/1.73m²) 2
• Reduce opioid dose and frequency by half in elderly patients or those with any renal impairment 3
• Avoid oral opioids, codeine, and tramadol entirely, as these cause constipation, cognitive dysfunction, and nausea without superior analgesia 2, 3
• Do not use NSAIDs until renal function is confirmed normal, as they are relatively contraindicated in this population with high rates of renal dysfunction 2, 1

Regional Analgesia

• Consider femoral nerve block or fascia iliaca block for superior pain control, though these may not reliably block all three nerves (femoral, obturator, lateral cutaneous) 2, 1
• Document pain scores at rest and on movement before and after analgesia administration to guide ongoing management 2

Immobilization and Stabilization

• Immobilize the limb immediately in the position found (characteristically shortened and externally rotated) to minimize pain and prevent further soft tissue injury 2, 1
• Straighten the deformity only if necessary to facilitate safe transport 1

Rapid Assessment and Admission

• Admit to an orthogeriatric ward within 4 hours of hospital arrival, utilizing fast-track triage systems that enable early radiography and diagnosis 2, 4
• Continue attention to analgesia, IV fluid therapy, warming, and pressure care throughout emergency department stay, particularly if ward admission is delayed beyond 4 hours 2

Pre-operative Optimization

Essential Investigations

• Obtain full blood count and urea/electrolytes routinely before surgery 2
• Check hemoglobin concentration, as approximately 40% of patients are anemic pre-operatively and will drop approximately 2.5 g/dL peri-operatively, risking myocardial and cerebral ischemia 2
• Coagulation studies and chest radiography only if clinically indicated 2

Comorbidity Assessment

• Assess cardiovascular disease (35%), respiratory disease (14%), cerebrovascular disease (13%), diabetes (9%), malignancy (8%), and renal disease (3%) as these are the most common comorbidities 2
• Review all medications carefully for inappropriate dosing and drug interactions, as 20% of patients over 70 take more than five medications 2
• Calculate Nottingham Hip Fracture Score to predict postoperative mortality and discuss prognosis with patient/family 2

Anticoagulation Management

• For warfarin: administer vitamin K early to allow surgery within 24 hours; reserve prothrombin complex concentrate (PCC) only for extreme cases 5
• For direct oral anticoagulants: discontinue 24-48 hours prior to surgery depending on drug type and renal function 5
• For antiplatelet therapy (aspirin/clopidogrel): do not discontinue as surgery can proceed safely without stopping these medications 5

Surgical Timing

Plan for surgical fixation on the day of or day after admission, within 24-48 hours maximum, as this is the standard that reduces mortality and morbidity 2, 4, 5

• Prioritize surgery within 6 hours for undisplaced femoral neck fractures to preserve femoral head viability 6
• Do not delay surgery beyond 48 hours unless there are clear reversible medical conditions 4
• Utilize protected daily trauma lists with consultant-delivered care to ensure timely surgery 2

Critical Perioperative Considerations

Anesthesia

• Consider regional anesthesia (spinal/epidural) for all patients unless contraindicated, as this may reduce DVT risk 2, 4
• If general anesthesia required: use reduced doses of induction agents and consider peripheral nerve blockade for perioperative analgesia 4

Monitoring and Support

• Use minimum monitoring: pulse oximetry, capnography, ECG, non-invasive blood pressure, and core temperature routinely 2
• Consider invasive blood pressure monitoring for patients with limited left ventricular function or valvular heart disease 2
• Maintain theatre temperature at 20-23°C and employ active warming strategies to prevent hypothermia 2

Infection and Thrombosis Prevention

• Administer prophylactic antibiotics within one hour of skin incision per hospital protocol 2, 4
• Prescribe fondaparinux or low molecular weight heparin between 18:00-20:00 to minimize bleeding risk with neuraxial anesthesia on daytime trauma lists 2, 4
• Apply thromboembolism stockings or intermittent compression devices intra-operatively 2

Common Pitfalls to Avoid

• Do not delay pain assessment while focusing on imaging or other interventions 2, 1
• Do not use standard opioid dosing without considering age and renal function 2, 3
• Do not prescribe NSAIDs empirically without confirming normal renal function 2
• Do not delay surgery for antiplatelet therapy as aspirin and clopidogrel do not require discontinuation 5
• Do not allow surgery to be delayed beyond 48 hours for non-critical medical optimization, as delayed surgery increases mortality 7

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