CDHB
The patients who are most at risk of complications are elderly males, patients with dementia, institutionalized patients, insulin and non-insulin dependent diabetics, and patients who are underweight. All of these patients are at increased risk of cardio respiratory complications as well as infection.
A detailed history must be obtained to ascertain the contributing factors to the fall, and in particular whether there was a secondary cause such as arrhythmia, silent myocardial infarction, postural hypotension, drug effect, neurological event.
It is important to record pre-morbid level of functioning as this will provide important information for rehabilitation and discharge planning.
Many drugs are recognized as having an association with hip fractures including benzodiazepines, tricyclic antidepressants, SSRIs, antipsychotics, and polypharmacy. Please discuss with the Orthopaedic Medicine Registrar or Consultant or seek advice from Psychiatric Services for the Elderly (PSE) as to how these drug regimens might be optimized.
Refer to the guidelines on analgesia. Please note regular low dose analgesia should be used rather than PRN analgesia. Avoid tramadol as first line analgesia due to its side effect profile.
Where there is concern or if a patient is unstable from cardio-respiratory problems, early consultation should be made to the cardiology or respiratory services. Early anaesthetic consultation must be made if the patient is awaiting surgery.
Deep vein thrombosis occurs commonly in patients with fractures of the lower limbs. Refer to Surgical VTE Prophylaxis.
Refer to the Thrombosis section for management of patients on oral anticoagulant therapy undergoing surgery.
Reduces deep and superficial wound infections.
All patients undergoing surgery for fracture fixation should receive antibiotic prophylaxis perioperatively.
Delirium occurs in up to 2/3 of older patients with hip fracture and can last up to several months. It carries an adverse prognosis with increased length of stay, mortality, and institutionalization. It is more common in patients with pre-existing dementia and memory loss. Secondary causes of delirium must be excluded i.e. alcohol and drug withdrawal, infection, analgesia, hypoxia.
Refer to the guidelines for management of delirium. The delirium service is available (contact through the operator at TPMH) for consultation and advice.
Oral protein supplementation is beneficial in reducing minor post-operative complications, preserving body protein stores, and decreasing length of stay. All patients should receive protein supplementation before and after surgery. For further information, refer to Nutrition Support.
Constipation is very common in these patients. Please ensure early and optimal use of laxatives as outlined in Constipation. When prescribing regular opioid analgesia, regular laxative therapy should generally be prescribed at the same time.
Refer to management of osteoporosis.
If the patient is very independent, discharge home directly from Christchurch Hospital may be possible. However most elderly people will require a period of rehabilitation following an orthopaedic injury. If they are medically and surgically stable, then transfer to the Orthopaedic Rehabilitation Unit at Burwood Hospital is recommended. Those with ongoing medical problems are best rehabilitated on the medical wards at TPMH.
Topic Code: 3666