AC - Orthogeriatrics & Falls

Question 1

What are the types of intracapsular and extracapsular hip #?

Answer 1

Intracapsular - Subcapital, Transcervical

Extracapsular - intertrochanteric, sub-trochanteric

Question 2

What are features of intracapsular hip #?

Answer 2

Subcapital - # along junction of femoral head and neck, most common #

Transcervical - # in region of femoral neck

Question 3

What are features of extracapsular hip #?

Answer 3

Intertrochanteric - fracture in region b/w greater & lesser trochanters

Subtrochanteric - # in shaft of femur, below lesser trochanter

Question 4

What is the major concern in intracapsular #NOF?

Answer 4

That blood supply is compromised and this can lead to avascular necrosis

Question 5

What is the prognosis associated with #NOF?

Answer 5

10% mortality within first month

Very poor 12-month mortality

Question 6

What are principles of treating #NOF?

Answer 6

Should ALWAYS operate - otherwise difficult to manage and poor prognosis

Operate as early as possible - ideally within 36 hrs

Only delay if systemically unwell i.e. septic

Question 7

What anaesthetic is typically used for #NOF surgery & why?

Answer 7

Regional block
Reduces risk of VTE
Facilitates early mobilisation
Reduces risk of pre-op delirium

Question 8

What are some pre-operative Ix you would perform?

Answer 8

FBE, U&Es, coags, G&H

CXR, ECG

Question 9

What are important post-operative Rx issues?

Answer 9

Pain 
DVT prophylaxis
Infection prophylaxis 
Monitoring Hb 
Hydration & nutrition
Early mobilisation
Pressure area monitoring 
Assessment of osteoporosis & Rx 
Falls risk reduction and injury prevention
Hip precautions
Delirium prevention
Early discharge planning 
Driving advice

Question 10

VTE prophylaxis considerations in #NOF

Answer 10

Highest risk of VTE
Must be on prophylaxis for at least 28-35 days
LMWH - enoxaparin, daltoparin or fondaparinux

Question 11

What prophylactic antibiotics usually given?

Answer 11

1st gen cephlasporin - cefazolin or cephalexin

Question 12

What are hip precautions following surgery?

Answer 12

Limit flexion >90, internal rotation and adduction for 6 weeks

Tell pt - no crossing legs, twisting leg inwards or outwards

Question 13

What advice would you give about driving after hip surgery?

Answer 13

Do not drive until hip precautions lifted (~6 weeks) as can increase risk of dislocation

Inform insurance company

Caution if pain medications cause sedation

If other concerns identified during recovery may require OT assessment

Question 14

What is treatment for intracapsular #?

Answer 14

Displaced

• Hemiarthroplasty (most common)
• Total hip replacement (if acetabulum damage also)

Non-displaced (DHS, cannualted screw)

Question 15

What is treatment for extracapsular #?

Answer 15

Inter-medullary nail

DHS

Question 16

How can delirium be prevented after hip surgery?

Answer 16

Orientating aids visible - clocks, calendars
Always introduce yourself and your role/purpose
Avoid a lot of staff and room changes and encourage family/friends to be present as often as possible
Optimise sleep and normal routine - lights on during day and off at night, minimise noises and disruptions during night

Question 17

What are some falls and injury risk reduction strategies?

Answer 17

• Identify internal and external falls risk factors and address

STO(2)P(2) M(2)E

Single focal lenses

Toileting schedule - frequent opportunity to use toilet - increase mobility and decrease risk of falls associated with urgency and incontinence

Orientate, reassure and supervise

Osteoporosis mangagement

Physical activity - weight bearing, gait retraining, balance exercises

Protectors (hip) - can have issues with compliance but have been shown to reduce injury in aged care facilities

Medication review

Mobility & environmental aids (physio, OT assessment & modification/equipment, gait aids)

Education - behavioural/risk issues, reduce fear of falling

Question 18

What are some internal risk factors for falls?

Answer 18

Age 
Cognitive impairment
sensory impairment
physical/functional impairment 
Joint problems - knee, ankle, foot i.e. OA
Vestibular issues
Myopathy - drug induced, malnutrition 
Gait/mobility issues 
Neurological disease
Peripheral neuropathy 
Hx of falls, fear of falling 
Incontinence 
Behavioural issues - i.e. rushing, risky behaviours (ladder climbing)
Autonomic dysfunction - postural hypotension

Question 19

What are some external risk factors of falls?

Answer 19

Bifocal lenses
Inadequate footware
Environment - uneven ground, hazards in path, dim lighting
Polypharmacy and specific drugs (i.e. sedatives, benzos, antihypertensives, alpha-blockers)
House set up - stairs