How Should Patients with Acute Hip Fractures Be Managed Perioperatively?

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Radiograph of a patient’s right hip showing fracture of the femur neck.

Case

A 91-year-old man with Alzheimer’s dementia presents with severe right hip pain after a fall at his nursing home. His family reports that he is dependent in most of his activities of daily living (ADLs) and can normally ambulate short distances with a walker. He is alert and oriented at baseline but has been more confused since his wife died a week earlier from pneumonia. His only new medication is lorazepam as needed for anxiety. On admission, the patient is diagnosed with a displaced femoral neck fracture, delirium, and healthcare-associated pneumonia, with a new oxygen requirement of 5 L/min. The orthopedic surgery service requests a medicine consult. How should this patient be managed perioperatively?

Overview

Hip fractures are a major health burden on the United States’ geriatric population. The lifetime risk of hip fracture is approximately 17% for Caucasian women and 6% for Caucasian men.¹ In 2010, an estimated 258,000 people aged 65 years and older were hospitalized with hip fractures.² This number is expected to climb to 289,000 by 2030.

In total, hip fractures directly cost the healthcare system about $18 billion per year.¹

Hip fractures, like most other geriatric syndromes, are almost invariably multifactorial in etiology. They occur at the intersection of general frailty, bone fragility, and fall risk. Hip fractures too often trigger a further downward spiral in elderly patients, as deconditioning and acute complications compound chronic comorbidities and compromise any remaining physiologic reserve. Mortality after a hip fracture approaches 25% at one year.³ An excess mortality risk persists for at least 10 years.⁴ Of the patients who survive six months, only 50% can perform their ADLs, and only 25% can perform their instrumental ADLs as well as they could prior to their fracture.^5,6

Unsurprisingly, older adults with hip fractures are five times more likely to require nursing home placement at one year.⁵

Hospitalists frequently encounter patients with hip fractures in the perioperative setting. Given their close collaboration with orthopedic surgeons and emphasis on transitions of care, hospitalists can play an important role in reversing the trajectory of death and disability following hip fractures. Key aspects of inpatient management are outlined below.

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Radiograph of a patient’s right hip showing fracture of the femur neck.

Hip Fracture Repair

Hip fractures can be divided into intracapsular (femoral neck) or extracapsular (intratrochanteric or subtrochanteric) fractures. Their relative frequencies are listed in Table 1.⁷

Surgery types. Femoral neck fractures typically are the most difficult to heal, given a limited regional blood supply.^5,7 Displaced femoral neck fractures require either a hemiarthroplasty or total hip arthroplasty. Over time, hemiarthroplasties tend to cause hip pain from acetabular erosion, so they are better suited for less active, elderly patients. Nondisplaced femoral neck, intratrochanteric, and subtrochanteric fractures are usually managed with open reduction and internal fixation.

The overall goal of surgery is to return patients to their prior level of functioning. In the short term, surgery also provides pain relief and allows for early mobilization. Nonoperative management is generally reserved for patients with very high operative risk or limited life expectancies or those who are bedridden at baseline.

Timing of surgery. In general, hip fracture repair should be performed within 24-48 hours of admission in patients who are medically stable. Though early surgery may not improve functional outcomes or mortality, it has been associated with improved pain control, decreased length of stay, and fewer major complications.⁸ Patients with active medical conditions (e.g. pneumonia) should be medically optimized before proceeding with surgery. A 2011 study found that most of the excess in-hospital mortality associated with surgical delays beyond five days was attributable to the active medical issues rather than to the delay itself.⁹