Neck Of Femur Fracture

Question 1

An 83-year-old female has been admitted with a proximal femoral fracture and has been listed for an urgent hemi-arthroplasty on the trauma list. She has a history of hypertension and previous breast cancer. She was confused in the emergency department.

What are the key concerns for the perioperative management of this patient?

Answer 1

Comorbidities:
* Cardiac history: The patient has a history of hypertension, which requires further investigation due to the possibility of ischaemic heart disease or previous cardiac events. If treated with ACE inhibitors, these should be stopped as soon as possible prior to surgery to avoid the risk of significant perioperative hypotension but should not be a reason to delay surgery.

• History of breast cancer creates the possibility of a pathological fracture, particularly if recently diagnosed.
• Confusion in the emergency department could indicate a diagnosis of either delirium or dementia, both of which should be managed accordingly during the perioperative period. Capacity to consent for the procedure will need consideration.

Question 2

What are the key concerns for the perioperative management of this patient?

Continued…?

Answer 2

Frailty:
* Multidisciplinary/specialist orthogeriatric team should do a frailty assessment as it increases the risk of perioperative complications.

• Cause of fracture should be determined – falls can indicate frailty and underlying conditions should be identified and managed appropriately to reduce falls risk.

Neck of femur fracture:
* High-risk procedure in high-risk patient; local or national guidelines should direct patient care.

• Surgery should take place within 48 hours of admission into hospital, unless patient presents with reversible and time critical conditions e.g. severe anaemia, electrolyte disturbance and uncontrolled diabetes.
• Multidisciplinary, senior perioperative management is key for safe and optimal management of this patient.

Question 3

What are the key concerns for the perioperative management of this patient?

Continued…?

Answer 3

Anaesthetic management:
* A thorough preoperative history, examination and investigations are crucial but should not delay surgery within the required time.

• Anaesthetic technique should be directed by patient assessment and importantly management should focus on minimising physiological disturbances during the perioperative period.
• Neuraxial blockade should be used where appropriate with calculated risk/benefit balance for an individual patient.
• The evidence supporting regional over general anaesthesia is limited, but dictates careful and judicious use of any anaesthetic or analgesic agents. However, there is an overall increase in mortality with the use of heavy sedation/general anaesthesia together with a regional technique.

Analgesia:
* A multimodal approach to analgesia is key in patients with a proximal hip fracture, avoiding the use of NSAIDs and high doses of opioid- based medications.

• Regional techniques should be used where appropriate but should not limit physiotherapy postoperatively.

Question 4

What is frailty?

Answer 4

• Frailty is described as a group of symptoms that suggest a decline in systemic physiological reserve and function. Typical features of frailty include:
• Loss of muscle mass (sarcopenia).
• Generalised weakness.
• Slow gait.
• Decreased activity levels.

Question 5

How can frailty be assessed?

Answer 5

There are a number of frailty scoring systems that can be used, for example:

• Rockwood Frailty Index – detailed scoring system including assessment of comorbidities, mental health, cognition and functional status.
• Edmonton Frail Scale – patients are scored based on their medication, balance, mobility and cognition.
• Clinical Frailty Scale – patients are scored based on their comorbidities and vulnerability.