Medical Care of Patients with Hip Fractures

1
Medical Care of Patients with Hip Fractures
2
Epidemiology and Survival Data

• Lifetime risk of hip fracture
• women 17.5
• men 6.0
• in 1990, approximate 281,000 hip fractures
  occurred in the United States, and the
  associative cost was more than 8 billion

Osteoporosis Int. 1992 2 285-289
3
Epidemiology and Survival Data

• All-cause mortality rates for patients
  hospitalized with hip fractures
• 4.9 during index hospitalization
• 7 at one month
• 13 at three months
• 24 at 12 months

Am J Public Health 1994 84 1287-1291
4
Recovery or Functional Status in Elderly Patients
after Hip Fracture

• 6 mo () 1 y ()
• Walked unaided 60 54
• Nonambulatory 22
• Perform activities of daily living (ADL) 50 40
• Performed instrumental ADL 25 ...
• institutionalized 29 ...

Am J Public Health 1997 87 398-403
5
Timing of Surgery

• Early repair (within 24-48 hr) is associated with
  a reduction in 1-year mortality and lower
  incidence of pressure sores, confusion, and fatal
  pulmonary embolism
• in a cohort study of patients older than 80
  years, the mortality rate was
• 0 in those with early fixation (lt 24 hr)
• 25 in those whose surgery was delayed gt3 days

Ann Intern Med 1998 128 1010-1020 J Bone Joint
Surg Br 1992 74 2 61-2 64
6
Antibiotic Prophylaxis for Surgical Infection

• A meta-analysis of 7 studies found a 44
  reduction in postoperative infection
• first-or second-generation settles warns party
  anybody of choice for prevention of these
  infections
• first dose 0-2 hours before surgery
• continue for total duration of 24 hours
• ex. Cefazolin 1 g q8h x3 doses

Ann Intern Med 1998 128 1010-1020 N Engl J Med
1992 326 281-286
7
Thromboembolic Prophylaxis

• Most DVT occur in the 1st week after a hip
  fracture
• The Fifth Am College of Chest PhysiciansConsensus
  Conference on Antithrombotic Therapy
• pooled total prevalence of DVT of 48
• high-risk of fatal pulmonary embolus, with rates
  of 4 to 14

Chest 1998 114 561S -578S Clin Orthtoop 1989
212-231
8
Thromboembolic Prophylaxis

• No predictor treatment is distinctly superior
  warfarin, low molecular weight heparin (LMWH),
  unfractionated heparin, aspirin, sequential
  compression devices
• LMWH may decrease the incidence of DVT more
  effectively than other therapies however, this
  is disputed as the most cost-effective choice
• compression stockings, with added
  thromboprophylactic benefit and negligible risk,
  should be used in combination with other treatment

9
Nutritional Assessment and Support

• protein depletion may lead to poor wound healing
  and increased potential for postoperative
  complications
• enteral nutrition within 12-24 hrs
  postoperatively
• oral protein supplements may be beneficial
• nocturnal nasogastric tube feeding may also
  improve nitrogen balance and caloric intake

10
Urinary Retention

• prolonged use of an indwelling urinary catheter
  is associate with an increased risk of urinary
  retention and infection
• catheters should routinely be removed within 24
  hrs
• intermittent straight catheterization should be
  used to maintain low bladder volumes and decrease
  the risk of infection
• when scanned volume exceeds 200 mL
• when patient reports physical discomfort

11
Impaired Sensorium

• Treatable causes
• hypoxia, infection, fluid and electrolyte
  abnormalities, drug toxicity, and hypotension
• Other Risk factors for delirium
• advanced age, dementia, alcohol use, and
  prehospitalization functional status
• medications opioids, sedative-hypnotics,
  anticholinergics, and anti-come
  Olsensanticonvulsants
• fat embolism
• urinary retention, uncontrolled pain, medications
  used for pain, changed in environment from home
  to hospital

12
Rehabilitation, Recovery, and Prevention of
Recurrences

• Early mobilization and ambulation within 24 hours
  of surgical repair is standard practice
• Treatment of osteoporosis or osteopenia
• medical regimens should be reviewed for use of
  calcium and vitamin D
• diphosphonates or calcitonin
• estrogen therapy should be reserved until after
  convalescence
• assessments of lifestyle and other risk factors
  diet, exercise, alcohol, caffeine, tobacco, and
  visual or balance impairments

13
Thromboembolic Prophylaxis

• In high-risk, frail, elderly patients, aspirin
  (325 mg/d) or only mechanical measures such as
  pneumatic compression boots may be effective
• LMWH should be held 12 hours preoperatively
• duration of VT prophylaxis postoperatively is
  unclear at a minimal, patients should continue
  with at least a daily dose of aspirIn and wear
  compression stockings for 6 wks postoperatively