What is the best course of treatment for an elderly patient with a fracture of the proximal third of the left femur, considering the likelihood of underlying osteoporosis and the need to minimize complications?

Management of Proximal Femur Fracture in Elderly Patients

Elderly patients with proximal femur fractures require urgent surgical fixation within 24 hours, followed by immediate full weight-bearing mobilization and interdisciplinary orthogeriatric care to minimize mortality and complications. 1, 2

Immediate Pre-operative Management

Pain Control

• Administer regular paracetamol immediately and continue throughout the peri-operative period 1, 2
• Implement multimodal analgesia incorporating a preoperative nerve block 2
• Use opioids with extreme caution, reducing both dose and frequency by half in patients with renal dysfunction; avoid oral opioids entirely in this population 1
• Never use codeine as it causes constipation, emesis, and peri-operative cognitive dysfunction 1
• Avoid NSAIDs entirely in elderly patients, particularly those with renal dysfunction 1, 2

Fluid and Blood Management

• Prescribe pre-operative fluid therapy routinely as elderly patients commonly become hypovolaemic before surgery 1
• Consider pre-operative blood transfusion if hemoglobin is <9 g/dL, or <10 g/dL with history of ischemic heart disease 1
• Crossmatch two units of blood if hemoglobin is 10-12 g/dL 1
• Use point-of-care hemoglobin analyzers at the end of surgery to guide transfusion decisions 1

Timing of Surgery

• Operate within 24 hours of the decision that the patient is fit for surgery 1
• Do not use preoperative traction as this is strongly contraindicated 2
• Expedited surgery reduces DVT risk and improves outcomes 1, 3

Surgical Treatment Selection

For Femoral Neck Fractures

The choice depends on fracture displacement and patient biological age, not chronological age 3:

• Non-displaced fractures (Garden I-II) in biologically young patients: Closed reduction with percutaneous cannulated screw fixation 4
• Displaced fractures (Garden III-IV) in biologically old patients: Total hip arthroplasty or hemiarthroplasty (Austin-Moore or bipolar) 3, 5, 4
• Bedridden patients: Consider osteosynthesis to establish transferability from bed to chair and restroom 3
• Active elderly with acetabular disease or severely displaced fractures: Primary total hip arthroplasty provides superior functional outcomes 4

For Intertrochanteric and Subtrochanteric Fractures

• Intramedullary cephalomedullary nail (Gamma nail) is the preferred method for both stable and unstable fractures, allowing immediate full weight-bearing and early mobilization 3, 5, 6
• For severely comminuted fractures in patients >60 years with poor bone quality: Consider primary proximal femur replacement, which allows immediate weight-bearing and reduces complications from prolonged bed rest 6

Intra-operative Management

Monitoring

• Maintain continual presence of anaesthetist with pulse oximetry, capnography, ECG, and non-invasive blood pressure monitoring 1
• Monitor core temperature routinely as elderly patients are highly susceptible to hypothermia 1
• Consider invasive blood pressure monitoring for patients with limited left ventricular function or valvular heart disease 1
• Consider central venous pressure monitoring for patients with limited left ventricular function or undergoing revision surgery 1

Infection Prevention

• Administer antibiotics within one hour of skin incision per hospital protocols 1

Pressure Care and Thermoregulation

• Position patients sympathetically to avoid pressure sores and neuropraxia; elderly skin is thin and easily damaged 1
• Employ active warming strategies throughout surgery and continue postoperatively 1

Immediate Post-operative Management

Mobilization Protocol

• Allow full weight-bearing as tolerated immediately after surgery, regardless of fracture pattern (stable intertrochanteric, unstable intertrochanteric, subtrochanteric, or reverse obliquity fractures) 2
• Do not restrict weight-bearing based on fracture pattern as cephalomedullary nails provide sufficient stability 2
• Oxygenation improves with early mobilization 2

Respiratory Support

• Administer supplemental oxygen for at least 24 hours post-operatively as older patients are at high risk of hypoxia 2

Fluid and Nutrition Management

• Encourage early oral fluid intake rather than routine IV fluids 2
• Monitor for hypovolemia, which is common in these patients 2
• Provide dietetic support as up to 60% of hip fracture patients are malnourished on admission; nutritional supplementation reduces mortality and may decrease length of stay 2

Catheter Management

• Remove urinary catheters as soon as possible to reduce infection risk 2

Pain Management

• Continue regular paracetamol administration 2
• Include pain evaluation as part of routine nursing observations 2

Thromboembolism Prevention

• Administer pharmacologic VTE prophylaxis (fondaparinux or low molecular weight heparin) for at least 4 weeks post-operatively 1, 2
• Time low molecular weight heparin administration between 18:00-20:00 to minimize bleeding risk with neuraxial anaesthesia 1
• Use thromboembolism stockings or intermittent compression devices intra-operatively 1, 2
• Ensure patient remains warm and well-hydrated 1

Interdisciplinary Care Requirements

• Implement interdisciplinary care programs involving orthogeriatrics, physical therapy, occupational therapy, and nursing to decrease complications and improve outcomes 2, 7
• Maintain ward nurse-to-patient ratio of 1:4 2
• Ensure regular physician input from geriatric medicine specialists 2

Prevention of Cognitive Dysfunction and Delirium

• Optimize analgesia, nutrition, hydration, and electrolyte balance 2
• Identify and treat silent complications including chest infection, myocardial ischemia, and urinary tract infection 2
• Use haloperidol or lorazepam only for short-term symptom control if delirium develops 2
• Avoid cyclizine due to antimuscarinic effects in elderly patients 2

Osteoporosis Management

• Draw vitamin D, calcium, and parathyroid hormone levels during hospitalization 2
• Order outpatient DEXA scan 2
• Refer to bone health clinic for osteoporosis management 2
• Implement fall prevention strategies through education and environmental modification 2

Critical Pitfalls to Avoid

• Never delay mobilization as prolonged bed rest increases complications and mortality 2
• Never use preoperative traction 2
• Never restrict weight-bearing after cephalomedullary nail fixation 2
• Never use codeine for pain management 1
• Never use cyclizine for nausea 2
• Never use NSAIDs in elderly patients with renal dysfunction 1, 2