Orthogeriatrics

Question 1

What are the classifications of hip #? Draw the boundaries of each.

Answer 1

• Intracapsular
○ Transcervical
○ Subcapital

• Extracapsular
	○ Inter/per trochanteric Sub trochanteric

Question 2

Describe the vascular supply of the femoral head.

Answer 2

majority of vessels enter at joint capsule line of attachment. Fractures proximal to this (especially if displaced) may result in interruption to blood supply to the head and thus increase risk of AVN

Question 3

Signs of hip # on Px

Answer 3

Externally rotated, shortened and abducted due to the unopposed action of the iliopsoas muscle (attaches to the less trochanter of the femur)

Question 4

What are the MMM BOP goals of orthogeriatrics

Answer 4

• M: mobilise early
• M: minimise interventions (IDC, IV lines, restricting to bed etc)
• M: mind the mind (delirium)
• B: bladder, bowels
• O: operate early, osteoporosis treatment
P: pressure care, prophylaxis for VTE, pain relief

Question 5

Aphorisms for orthogeris

Answer 5

• Age > Hb is not a good thing
• Operate early, operate often - operate unless they are actively dying
• If there is no pressure, there can be no pressure sore - heel is the most common and most dramatic - cannot walk and mobilise! Every one with #NOF gets a heel wedge
• No rest for the wicked - mobilise! Don’t get to lie in bed and recover - sit out of bed the next day of op - good for chest, delirium, sense of progression, pressure care and better results overall.
• Not a day goes by - aim for surgery within a day of presentation (if you do not operate, and go by normal theory of resting for 6 weeks, then mortality of not mobilising is almost 100% for the elderly)
- It is your duty to give your patients the shits - reduce constipation (delay recovery and contribute to delirium)- they are less mobile, have analgesia

Question 6

What is ordered in the basic pre-operative work up for hip #?

Answer 6

PRE OP WORK UP

• Bloods: FBE, EUC, coagulation profile, group and hold)
• Imaging: hip and pelvis x-ray, CXR)
• Other: ECG

Question 7

What is assessed if fitness of surgery?

Answer 7

Fitness for surgery -identify and treat any co-morbidities that may delay theatre:

• Significant anaemia, electrolyte abnormalities, volume disturbance or hypoxia
• Cardiac ischaemia, arrhythmias or rate-related problems
• Uncontrolled diabetes
• Anticoagulation –specifically reversal of warfarin. Consider implications of antiplatelet agents such as clopidogrel

Question 8

What does the type of surgical fixation of hip # depend on?

Answer 8

Operative management
» Type of surgical fixation for hip fracture depends on type of fracture, degree of displacement (and therefore risk of damage to blood supply to head of femur), and patient characteristics.

Question 9

List the types of definitive management of hip #?

Answer 9

1. Plates and screws
2. Screws alone - Cannulated Screws.
3. Surgical Nail or Rod – Intramedullary (IM) Nails
4. Partial Hip Replacement - Hemiarthroplasty
5. Total Hip Replacement - Total Hip Arthroplasty

Question 10

What and when are plates and screws used?

Answer 10

Large metal screw across the fracture with a plate then attached to the screw. A number of smaller screws are then used to secure the plate to the femur bone.

• Generally used for non-displaced intracapsular or intertrochanteric fractures

Question 11

When are screws alone used?

Answer 11

• Generally used for non-displaced intracapsular fractures

Question 12

When are surgical rods or nails used?

Answer 12

Surgical Nail or Rod – Intramedullary (IM) Nails

• Generally used for intertrochanteric or subtrochanteric fractures

Question 13

When is a partial hip replacement used (Hemiarthroplasty)

Answer 13

• Generally used for displaced intracapsular fractures

- Older patients, less fit (as the materials last

Question 14

When is a THR used (total arthroplasty)?

Answer 14

• Generally used for displaced intracapsular fractures

- Younger patients

Question 15

What are the types of anaesthesia that can be used in operative management of hip #?

Answer 15

» General: better control for anaethetist - if pt is sick and fragile, this is better and safer operation (this can control hypotension, vasodilation). Higher VTE risk as immobile
» Regional (spinal): awake and more mobile with spinal, shorter operative time

Question 16

In what situations is surgical fixation of the hip should not be done?

Answer 16

NB: If a hip fracture complicates or precipitates a terminal illness, the multidisciplinary team should still consider the role of surgery as part of a palliative care approach that minimises pain and allows for nursing care.

Some reasons to not proceed with surgical fixation of a hip fracture may include:

• Terminal illness where death is imminent
• Inability to undergo anaesthetic (generally due to severe respiratory compromise)
• Impacted fracture where patient able to weight-bear and patient preference not for surgery

Question 17

What are the medical factors to consider with peri-operative management?

Answer 17

» Analgesia
» Diabetic management (especially with fasting and surgery)
» Fluid status and management (especially with fasting and surgery)
» Bowel and bladder management
» Risk assessment and prevention of hospital acquired complications including:
○ Venous thromboembolic disease
- Use of low molecular weight heparin (such as enoxaparin) - For hip fractures this is continued for 28-35 days post-op. NB many private ortho surgeons do not agree with this due to blood pooling and infection of the new joint
○ Pressure injuries
○ Delirium
○ Functional decline associated with fracture and hospitalisation
○ Incontinence
○ Drug and alcohol withdrawal
» Post-operative anaemia (and need for transfusion)

Question 18

What are the surgical factors of perioperative management?

Answer 18

○ » Weight-bearing status (aiming for full weight-bear (FWB) / weight-bear as tolerated (WBAT))

○ » Wound management (bleeding, serous ooze, infection, removal of staples, etc)

○ » Hip precautions (for hemi- and total-arthroplasties via a posterior approach)
- Limited flexion, adduction and internal rotation

Question 19

What are the rehabilitation options for younger v older patients?

Answer 19

• Younger, fitter patients are often able to be discharged directly home from the acute ward with outpatient community-based rehabilitation
• Older, frailer patients from high level residential aged care facilities are generally discharged directly back to these facilities from the acute setting to continue any therapy there
• The majority of older patients will require rehabilitation in an inpatient setting (Rehabilitation or Geriatric Evaluation and Management (GEM) unit).