Care of Elderly Hip Fractures Flashcards
Where are some common sites for fragility fractures?
Neck of femur and humerus, wrist, vertebrae, pelvis
What is the ideal patient care outline?
Prompt admission to orthopaedic care and rapid comprehensive assessment
Minimal delay to surgery, and accurate and well-performed surgery
Prompt mobilisation and prevention of complications
Early multidisciplinary management rehabilitation
Early supported discharge
Secondary prevention including falls and bone health assessment
How quickly should a patient be admitted to an acute orthopaedic ward?
Within 4 hrs = rapid triage through A and E, rapid x-rays, minimise delays in reaching ward, avoid long periods on trolley
What are the big 6 interventions that all patients with suspected/confirmed hip fractures should get before leaving ED?
Analgesia (especially for x-ray) Early warning score Pressure area inspection Blood tests Fluid therapy Delirium screening
What makes up the traditional model of pre-op analgesia?
Strong opioids (e.g morphine) = many side effects
What is the newer model for pre-op analgesia?
Local nerve blocks = can last intra and post=operatively, delivered in A and E
How is delirium recognised?
By confusion assessment method (CAM)
What makes up the confusion assessment method (CAM)?
Acute change/fluctuating cognitive level
Inattention
Altered conscious level or disorganised thinking
4AT tool helps in identification
What are some factors that influence delirium?
Predisposing factors = age, dementia
Precipitating factors = pain, drugs, constipation
Propagating factors = change in environment, constipation, infection
How is delirium treated?
Treat underlying cause (e.g infection)
Non-pharmacological methods = same nursing team, ensure orientation, use family
What should every patient with a hip fracture receive within 24hrs of admission?
Inpatient bundle of care = cognitive, neurological, nutritional, pressure areas, falls
When should all patients fit for surgery get to surgery?
Within 36hrs and during working hours
What should occur during the pre-operative period?
Assessment, investigations and treatments completed to get fit for surgery
Multidisciplinary communication
Scheduling of surgery and allowing for possible delays
Appropriate antibiotics prophylaxis
How does the orthopaedic surgeon assess the patient before surgery?
Senior review of patient and films, appropriate and decisive operative plan
How does the medical team assess the patient before surgery?
Assessment of fluid status and starting IV fluids, assessment and management of comorbidities, addressing any acute cause of falls, medication review
How does the anaesthetist assess the patient before surgery?
Suitability for type of anaesthetic, assessment of cardio/resp function, other significant comorbidites
What are the regulations for fasting a patient before surgery?
No patient should be repeatedly fasted in preparation for surgery and oral fluids should be encouraged up to 2hrs prior to surgery
What are the standard hip implants used?
Cemented hemi-arthroplasty implants (unless clinically indicated otherwise)
When should every patient identified as being frail be assessed by?
Within three days of being admitted
What makes up a comprehensive geriatric assessment?
Ongoing analgesia
Fluid and electrolyte management including blood transfusions
Comorbid condition management including medication review
Prevention, identification and management of delirium
Prevention of complications = DVT, infection, pressure ulcers
Early identification and treatment of complications
Falls assessment
What are the syndromes which indicate frailty?
Falls, immobility, delirium, incontinence, susceptibility to side effects of medication
How does the CSHA frailty scale work?
Scores patients from 1 (very fit) to 7 (severely frail)
How soon can pressure ulcers begin to develop?
After 30 mins of lying on a hard surface = cause pain and immobility limiting rehab, must closely monitor for onset
What are risk factors for pressure ulcers?
Delays to surgery, frail/malnourished patients, failure to mobilise
What are the main principles of fluid management?
Peri-operative period is critical Danger of fluid overloading Continual clinical assessment Appropriate choice of fluids Resuscitation vs maintenance
When is pain control needed?
On admission, on transferring to x-ray, pre/intra/post-operatively
What is the recommended guidelines for pain management post-operatively?
WHO pain ladder
What are some options for pain management post-operatively?
Paracetamol is rarely enough
NSAIDs rarely tolerated
Opiate analgesics can cause drowsiness, confusion, constipation and dizziness
What is the step by step approach to analgesia?
1 = paracetamol regularly oral or IV 2 = codeine starting at 15mg dose but can be increased 3 = morphine as required or regular oxycodone if confused on morphine, maybe small doses of both
Where should fall assessment be carried out?
Started in orthopaedic ward
Often completed at falls clinic post-op if discharged early into community
How should patients be examined in a fall assessment?
Visual assessment
Cardio, neurology and MSK/gait assessment
Medication review
ECG +/- further investigation
What should have occurred by the end of the first two days after surgery?
Mobilisation should have begun by end of the first day
Every patient should have physio assessment by end of second day
When should patients with a hip fracture be seen by OT for assessment?
By end of day 3 post-admission
What should every patient with a hip fracture have before they leave the acute orthopaedic unit?
Assessment of their bone health
How is bone health assessed?
Basic assessment should be done whilst inpatient (with follow-up arrangement)
Calcium/vitamin D intake should be assessed (most get supplemented)
Dual x-ray bone densitometry if required as out-patient
Antiresorptive therapy
What are some antiresorptive therapies?
Oral (alendronic acid) once weekly, second line treatments include IV bisphosphates or denosumab
When is the aim to have patients discharged by?
Within 30 days of the admission date = recovery should be optimised by multi-disciplinary team approach
When should patients be transferred to MFE assessment and rehabilitation unit if needed?
After 72hrs
