AC - Orthogeriatrics & Falls Flashcards
What are the types of intracapsular and extracapsular hip #?
Intracapsular - Subcapital, Transcervical
Extracapsular - intertrochanteric, sub-trochanteric
What are features of intracapsular hip #?
Subcapital - # along junction of femoral head and neck, most common #
Transcervical - # in region of femoral neck
What are features of extracapsular hip #?
Intertrochanteric - fracture in region b/w greater & lesser trochanters
Subtrochanteric - # in shaft of femur, below lesser trochanter
What is the major concern in intracapsular #NOF?
That blood supply is compromised and this can lead to avascular necrosis
What is the prognosis associated with #NOF?
10% mortality within first month
Very poor 12-month mortality
What are principles of treating #NOF?
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
What anaesthetic is typically used for #NOF surgery & why?
Regional block
Reduces risk of VTE
Facilitates early mobilisation
Reduces risk of pre-op delirium
What are some pre-operative Ix you would perform?
FBE, U&Es, coags, G&H
CXR, ECG
What are important post-operative Rx issues?
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
VTE prophylaxis considerations in #NOF
Highest risk of VTE
Must be on prophylaxis for at least 28-35 days
LMWH - enoxaparin, daltoparin or fondaparinux
What prophylactic antibiotics usually given?
1st gen cephlasporin - cefazolin or cephalexin
What are hip precautions following surgery?
Limit flexion >90, internal rotation and adduction for 6 weeks
Tell pt - no crossing legs, twisting leg inwards or outwards
What advice would you give about driving after hip surgery?
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
What is treatment for intracapsular #?
Displaced
- Hemiarthroplasty (most common)
- Total hip replacement (if acetabulum damage also)
Non-displaced (DHS, cannualted screw)
What is treatment for extracapsular #?
Inter-medullary nail
DHS
How can delirium be prevented after hip surgery?
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
What are some falls and injury risk reduction strategies?
- 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
What are some internal risk factors for falls?
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
What are some external risk factors of falls?
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
