The document discusses guidelines for the management of hip fractures. It covers topics such as transport to the hospital, assessment in the emergency department, timing of surgery within 48 hours, rehabilitation starting within 24 hours of surgery, and post-discharge management including continued physical therapy. The management of hip fractures is a multidisciplinary process involving services across the healthcare system.

1. Hip Fracture Management
Dr.Darshana Chandrakumara
Supervisor – Mr. Poon Kein Boon

2. • The incidence of hip fractures increases with
age and consists of almost 30% of fall-related
injuries in patients aged 85 years or older.
• Early post-operative mortality is particularly
high, with reported 30-day mortality of 13.3%
• 1 year mortality of 23.8%

3. No more a surgical disease
• Management of patients with hip fracture is
complex and involves a wide multidisciplinary
approach across many different boundaries.
• Ambulance services
• Emergency department,
• Orthopaedic surgeons
• Geriatricians
• Acute services including operating theatre and ICU
• Rehabilitation services
• End-of-life care
• Social services
• Health services in the community

5. Key recommendations
1. Transport to hospital
2. Assessment in the emergency department
3. Physician or orthogeriatrician input
4. Timing of surgery
5. Anaesthetic management
6. Surgical management
7. Early mobilisation
8. Rehabilitation
9. Discharge
10.Post discharge management

6. 1. Transport to hospital
• As quickly as possible
• If necessary pain releif
– IV opioid or entanox
• If long journey consider catheter

7. Communication on admission
• History and examination findings
• Concurrent medical condition and relevant
past medical history
• Current drug therapy
• Pre-morbid functional state, particularly
mobility
• Pre-morbid cognitive function
• Social circumstances and whether the patient
has a carer

8. 2. Early assessment in ED or ward
• Hydration and nutrition
• Pain
• Core body temperature
• Continence
• Coexisting medical problems
• Pressure sore risk
• Mental state AMT
• Patients should be transferred to the ward within
two hours of their arrival in the emergency
department.

10. Long lie
• Lying on the floor for an extended period of
time ( > 1hr) can lead to serious complications
– Pressure ulcers
– Rhabdomyolysis
– Pneumonia
– Hypothermia
– Dehydration
– Even death.

11. Cause for fall
• Illness
• Syncope
• Accident
• Vision
• Epilepsy or other fit
• Drugs (Anti hypertensives)
• Dementia
• Anaemia
• Neurological –Stroke , Neuropathy
• Neurodegenerative – Parkinson’s
I SAVE DAN

12. • Analgesia
• Hydration
• Pressure point care
– Patients judged to be at very high risk of pressure
sores should ideally be nursed on a large-cell,
alternating-pressure air mattress or similar
pressure-decreasing surface.
• Instigate early radiology
• MRI is the investigation of choice where there
is doubt regarding the diagnosis.
Immediate management

13. Analgesia
• Assess the patient's pain:
– immediately upon presentation at hospital
including people with cognitive impairment, and
– within 30 minutes of administering initial
analgesia, and
– hourly until settled on the ward, and
– regularly as part of routine nursing observations
throughout admission.

14. Analgesia
• TWO – Paracetamol 6hrly regular
–Opioid (Tramadol/ Oxynorm/Morphin)
• Ensure analgesia is sufficient to allow
movements necessary for investigations and
for nursing care and rehabilitation.
• NSAIDs are not recommended.
• Consider nerve blocks if pain relief still
insufficient

15. Patient information and support
• Offer (patients and family) verbal and printed
information about:
• Diagnosis
• Choice of anaesthesia
• Choice of analgesia and other medications
• Surgical procedures
• Possible complications
• Postoperative care
• Rehabilitation programme
• Long-term outcomes
• Healthcare professionals involved.

16. 3. Physician or orthogeriatrician input
• All patients presenting with a fragility fracture
should be managed on an orthopaedic ward
with routine access to acute orthogeriatric
medical support.
• Studies reported a reduction in length of stay
• Showed no significant difference in inpatient
mortality and twelve month mortality.

17. Local policy
• IV fluid – NS 1L/day
• 2 analgesics regular – Para/Tram
• 2 Laxatives regular – Lactulose /senna
• Dulolax suppo if BNO x 2 days
• Fleet if BNO x 3 days or incomplete BO
• Calcium+VitD 2 tab Om for all
• Ergocalciferol weekly 8 doses if Vit D <30ug/L
• BMD if not done in past 1-2 yrs

18. 4. Timing of surgery
• Aim op within 48hrs
• Chasing unrealistic medical goals should not
lead to delay.
– For example, it may not be appropriate to delay
surgery because of infective pulmonary
conditions, as real improvement is unlikely in the
presence of continued immobility and pain.

19. Local policy
• Hip fracture is an urgency and not an emergency.
• 48 hrs mean if patient is stable.
• If patient is unstable time starts when the patient
is deemed stable.
• Last patient goes to theatre by 5 pm.
• Can cross 48 hours if it is better for the patient.
• Geriatrician cover – international agreed standard

20. • Withholding warfarin combined with administration of
oral or intravenous vitamin K is recommended if reversal
of the anticoagulant effects of warfarin to permit earlier
surgery is deemed appropriate.
• low-dose vitamin K (1-2.5 mg) administered either
intravenously (IV) or orally, partially reverses the
anticoagulant effect of warfarin over a 24 hour period.
• The onset of reversal is quicker and change in INR value
greater in the first four hours when IV vitamin K
compared to oral.
• FFP should not be used where there is no contraindication
to the use of vitamin K.
Reversal of warfarin anticoagulation

21. • Surgery should not be delayed in hip fracture patients
taking antiplatelet therapy. (Aspirin, Clopidogrel,
Dipyridamole)
• Spinal or epidural anaesthesia is not recommended in
patients taking dual antiplatelet therapy.
• General anaesthesia is recommended for patients
taking dual antiplatelet therapy.
• Treatment with aspirin or dipyridamole alone does not
contraindicate spinal or epidural anaesthesia
Antiplatelet therapy

22. • Recommends stopping antiplatelet drugs for a
minimum of five days before elective surgery.
• When patients require emergency surgery the
recommendation is not to delay and to
transfuse platelets only in the event of
excessive surgical bleeding.
Antiplatelet therapy

23. • Transthoracic Echo
– Symptoms suggestive of cardiac failure
– Any new heart murmur
– No need to repeat if done within last 6months and
no change in symptoms
Preoperative cardiac investigations

25. • The routine use of traction (either skin or
skeletal) is not recommended prior to surgery
for a hip fracture.
• No evidence of any benefit in pain relief or
fracture reduction from the routine use of
preoperative traction.
• Cannot exclude possible advantages of
traction for specific fracture types.
Preoperative traction

26. • Hip fracture surgery carries a high risk of venous
thromboembolism
• Mechanical and pharmacological prophylaxis may
reduce the incidence of thrombosis.
• Heparin (UFH or LMWH) or fondaparinux may be
used for pharmacological thromboprophylaxis in
hip fracture surgery.
• Aspirin monotherapy is not recommended for
patients after hip fracture surgery.
Reducing the risk of venous thromboembolism

27. • Treatment of asymptomatic bacteriuria is not
appropriate in both men and women
– the organisms isolated from the urine were not
the same as those from the surgical site infection
• Treat only if symptomatic
– Uncomplicated – Ciproflox
– Complicated – IV Aug empirically
UTI

28. • Spinal/epidural anaesthesia should be
considered for all patients undergoing hip
fracture repair, unless contraindicated.
• Spinal or epidural anaesthesia should be
avoided in patients taking dual antiplatelet
therapy, as the risk of developing spinal
haematoma.
5. Anaesthetic management

29. • Intracapsular
• Extracapsular
6. Surgical management

30. • Intracapsular
– Undisplaced – Internal fixation
– Displaced – Closed reduction and internal
fixation in fit young patients
– Arthroplasty in older biologically less fit patients

31. • Extracapsular
– Sliding hip screws (except in reverse oblique,
transverse or subtrochanteric fractures where an
intramedullary device may be considered)

32. • Pain relief – 2 regular analgesics
– Can give addon Tramadol/Oxynorm/Ketoprofen
patch
• Supplementary oxygen is recommended for at
least six hours after general or spinal/ epidural
anaesthesia, at night for 48 hours
postoperatively and for as long as hypoxaemia
persists as determined by pulse oximetry.
6. Early postoperative management

33. • If overall medical condition allows,
mobilisation and multidisciplinary
rehabilitation should begin within 24 hours
postoperatively.
• Weight bearing on the injured leg should be
allowed, unless there is concern about quality
of the hip fracture repair (eg poor bone stock
or comminuted fracture).
Early mobilisation

34. • Prevention by maintaining adequate fluid
balance and ensuring adequate pain relief.
• In women - IMC if PVRU >200ml
• In Men - IDC
Urine retention

35. • In general, catheterisation should be avoided,
except in
– urinary incontinence
– on a long journey
– urinary retention
– when monitoring renal/cardiac function.
• When patients are catheterised in the
postoperative period, prophylactic antibiotics
should be administered to cover the insertion
of the catheter.
Urinary catheterisation

36. • Acute confusional state common after a hip
fracture.
• Prevention by optimizing,
– oxygen saturation
– blood pressure
– fluid and electrolyte balance
– pain control
– medication
– bowel and bladder function
– nutritional intake
– early mobilisation
– detection and treatment of intercurrent illness
Delirium

37. • A multidisciplinary team should be used to
facilitate the rehabilitation process.
• The initial emphasis should be on walking and
activities of daily living (ADL)
• Supplementing the diet with high energy
protein preparations containing minerals and
vitamins should be considered.
8. Rehabilitation

38. • Nurse case managers assess patients on
admission, to identify those suitable for
supported discharge, to facilitate early
mobilisation and rehabilitation and arrange
appropriate support on discharge and follow
up.
• The patient should be central to discharge
planning, and their needs and appropriate
wishes taken into consideration.
9. Discharge

39. • TCU in 2weeks for post op patients
• TCU 4-6weeks for conservatively managed
patients
• PT is continued
• Refer falls clinic if high risk for future falls
10. Post discharge management

40. • Streamline and expedite the process
• For hip fracture pts over 60 years old.
• Fill the AMT page 7
– Pre op screening checklist in page 9
– Leave blank Ortho geriatric problem list page 11
– Post op WB status and reason if NWB or PWB
(poor bone stock/comminuted fracture)
Hip fracture pathway

41. – Cardiac risk assessment guide page 45
– Clotting and analgesia guideline page 46
– Diabetic protocol page 47
– Antibiotic prohylaxis page 48

44. • Get enough calcium and vitamin D. Men and
women age 50 and older should consume
1,200 milligrams of calcium a day, and 600
international units of vitamin D a day.
• Exercise to strengthen bones and improve
balance.
• Avoid smoking or excessive drinking.
• Use a walking stick or walker.
Prevention of hip fracture

45. • Assess home for hazards. Remove throw rugs,
keep electrical cords against the wall and clear
excess furniture and anything else that could trip
you. Make sure every room and passageway is
well-lit.
• Correct poor vision
• Optimize medications
• Stand up slowly. Getting up too quickly can cause
your blood pressure to drop and make you feel
wobbly.
Prevention of hip fracture

46. • Hip protector
Prevention of hip fracture

47. In summary
• IV fluid – NS 1L/day
• 2 analgesics regular – Para/Tram
• 2 Laxatives regular – Lactulose /senna
• Dulolax suppo if BNO x 2 days
• Fleet if BNO x 3 days or incomplete BO
• Calcium+VitD 2 tab Om for all
• Ergocalciferol weekly 8 doses if Vit D <30ug/L
• BMD not done in past 1-2 yrs

48. • Do not routinely treat asymptomatic
bacteriuria.
• Chemical DVT prophylaxis if surgery is delayed
>48hrs
• Post op FBC, RP, BMD
In summary