What is the appropriate evaluation and management plan for an elderly skilled‑nursing facility resident who sustained a mechanical fall resulting in a femoral neck fracture?

Management Plan for SNF Resident with Femoral Neck Fracture After Mechanical Fall

This patient requires immediate orthopedic surgical consultation and admission for operative management within 24-48 hours, as surgical delay beyond this window dramatically increases complications and mortality. 1, 2, 3

Immediate Evaluation and Stabilization

Clinical Assessment

• Confirm the classic presentation: shortened and externally rotated lower extremity 1, 3
• Document neurovascular status: palpable dorsalis pedis pulse and intact sensation to light touch 1
• Assess pain severity, particularly with attempted weight-bearing or hip movement 3
• Evaluate for skin compromise or redness, which may indicate pressure effects, infection risk, or inflammatory response requiring immediate attention 2

Diagnostic Workup

• Obtain AP pelvis and lateral hip radiographs to confirm fracture displacement 1, 2, 3
• Complete blood count to assess for anemia and infection 2, 3
• Basic metabolic panel to evaluate renal function, electrolytes, and glucose control 1, 2, 3
• ECG if cardiac history present 1

Interdisciplinary Care Initiation

Immediately involve orthogeriatric comanagement team to decrease complications and improve outcomes (strong strength recommendation). 1, 2, 3 The hospitalist should evaluate and optimize the patient for surgery, addressing comorbidities, volume status, cardiac/pulmonary diseases, and malnutrition. 1, 2

Surgical Decision Algorithm

For Displaced Femoral Neck Fractures (Most Common in SNF Residents)

Arthroplasty is the treatment of choice over internal fixation (strong strength recommendation). 1, 2, 3, 4

Choose Hemiarthroplasty if:

• Frail patient with multiple comorbidities 5, 3
• Cognitive dysfunction or dementia present 3
• Limited pre-injury mobility 3
• Higher surgical risk profile 3
• Lower functional demands 5, 6

Choose Total Hip Arthroplasty if:

• Patient is healthy, active, and independent 1, 3
• No cognitive dysfunction 3
• Pre-existing hip osteoarthritis present 1, 3
• Higher functional demands 3, 6

Note: Most SNF residents will meet criteria for hemiarthroplasty given their baseline functional status and comorbidities. 5, 3

For Non-Displaced Fractures

Both internal fixation and hemiarthroplasty remain feasible options, though hemiarthroplasty decreases re-operation rate while internal fixation decreases operative time, blood loss, and infection risk. 4

Surgical Technique Specifications

Implant Selection

Use cemented femoral stem (strong strength recommendation) to improve hip function, reduce residual pain, and decrease periprosthetic fracture risk in osteoporotic elderly patients. 1, 5, 3 Uncemented stems significantly increase periprosthetic fracture risk in osteoporotic bone. 3

Prosthesis Type for Hemiarthroplasty

Either unipolar or bipolar hemiarthroplasty may be equally beneficial (moderate strength recommendation). 1 However, bipolar hemiarthroplasty is preferred in frail patients because operative time is shorter and subsequent dislocation risk is lower while functional outcome is acceptable. 5

Surgical Approach

No preferred approach exists in the general population (moderate strength recommendation). 1, 5 However, in high-risk patients with neurological or cognitive impairment (common in SNF residents), consider avoiding the posterior approach due to increased dislocation risk. 5

Anesthesia

Either spinal or general anesthesia is appropriate (strong strength recommendation). 1, 5, 3 Spinal anesthesia may reduce postoperative confusion in elderly patients. 5

Perioperative Management

Intraoperative

• Administer tranexamic acid at surgery start to reduce blood loss and transfusion requirements (strong strength recommendation) 1, 2, 3
• Provide multimodal analgesia with preoperative nerve block (femoral nerve block) for optimal pain control 5, 3
• Administer prophylactic antibiotics before incision 5

Postoperative Protocol

• Allow immediate weight-bearing as tolerated (limited strength option) 2, 3
• Continue VTE prophylaxis for 4 weeks postoperatively with enoxaparin, fondaparinux, or equivalent (strong strength recommendation) 2, 5, 3
• Begin physical therapy on postoperative day one if medically stable 5
• Use transfusion threshold no higher than 8 g/dL in asymptomatic patients 5
• Administer regular paracetamol throughout perioperative period 5
• Use opioids cautiously, especially with renal dysfunction; avoid codeine due to constipation, emesis, and association with postoperative cognitive dysfunction 5

Critical Postoperative Complications to Monitor

Delirium and Falls

Forty-five percent of patients are delirious the day they fall postoperatively. 7 Delirium after Day 7, male sex, and sleeping disturbances are strongly associated with inpatient falls. 7 Implement fall prevention strategies including delirium prevention/treatment, management of sleeping disturbances, and enhanced supervision of male patients. 7

Fall Event Rate

The postoperative fall event rate is 16.3/1000 days, with 32% of falls resulting in injuries (25% minor, 7% serious). 7

Secondary Prevention

Refer to Fracture Liaison Service or Bone Health Clinic for osteoporosis evaluation and secondary fracture prevention (strong strength recommendation). 2, 3 Arrange outpatient DEXA scan. 5

Post-Discharge Planning

For SNF Residents Returning to Facility

• Conduct comprehensive fall risk assessment within 7 days of return 1
• Develop individual treatment plan addressing medication review, environmental hazards, and mobility aids 1
• Educate SNF staff on fall prevention strategies specific to this patient 1
• Offer hip protectors to prevent future femoral neck fractures (strong recommendation for all nursing home residents) 1
• Implement structured geriatric rehabilitation to prevent functional decline 3

Critical Pitfall to Avoid

Do not delay surgery beyond 48 hours, as this dramatically increases complications and mortality. 3 The target is surgery within 24-48 hours of admission. 1, 2, 3