Care of Elderly Hip Fractures

Question 1

Where are some common sites for fragility fractures?

Answer 1

Neck of femur and humerus, wrist, vertebrae, pelvis

Question 2

What is the ideal patient care outline?

Answer 2

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

Question 3

How quickly should a patient be admitted to an acute orthopaedic ward?

Answer 3

Within 4 hrs = rapid triage through A and E, rapid x-rays, minimise delays in reaching ward, avoid long periods on trolley

Question 4

What are the big 6 interventions that all patients with suspected/confirmed hip fractures should get before leaving ED?

Answer 4

Analgesia (especially for x-ray)
Early warning score
Pressure area inspection
Blood tests
Fluid therapy
Delirium screening

Question 5

What makes up the traditional model of pre-op analgesia?

Answer 5

Strong opioids (e.g morphine) = many side effects

Question 6

What is the newer model for pre-op analgesia?

Answer 6

Local nerve blocks = can last intra and post=operatively, delivered in A and E

Question 7

How is delirium recognised?

Answer 7

By confusion assessment method (CAM)

Question 8

What makes up the confusion assessment method (CAM)?

Answer 8

Acute change/fluctuating cognitive level
Inattention
Altered conscious level or disorganised thinking
4AT tool helps in identification

Question 9

What are some factors that influence delirium?

Answer 9

Predisposing factors = age, dementia
Precipitating factors = pain, drugs, constipation
Propagating factors = change in environment, constipation, infection

Question 10

How is delirium treated?

Answer 10

Treat underlying cause (e.g infection)

Non-pharmacological methods = same nursing team, ensure orientation, use family

Question 11

What should every patient with a hip fracture receive within 24hrs of admission?

Answer 11

Inpatient bundle of care = cognitive, neurological, nutritional, pressure areas, falls

Question 12

When should all patients fit for surgery get to surgery?

Answer 12

Within 36hrs and during working hours

Question 13

What should occur during the pre-operative period?

Answer 13

Assessment, investigations and treatments completed to get fit for surgery
Multidisciplinary communication
Scheduling of surgery and allowing for possible delays
Appropriate antibiotics prophylaxis

Question 14

How does the orthopaedic surgeon assess the patient before surgery?

Answer 14

Senior review of patient and films, appropriate and decisive operative plan

Question 15

How does the medical team assess the patient before surgery?

Answer 15

Assessment of fluid status and starting IV fluids, assessment and management of comorbidities, addressing any acute cause of falls, medication review

Question 16

How does the anaesthetist assess the patient before surgery?

Answer 16

Suitability for type of anaesthetic, assessment of cardio/resp function, other significant comorbidites

Question 17

What are the regulations for fasting a patient before surgery?

Answer 17

No patient should be repeatedly fasted in preparation for surgery and oral fluids should be encouraged up to 2hrs prior to surgery

Question 18

What are the standard hip implants used?

Answer 18

Cemented hemi-arthroplasty implants (unless clinically indicated otherwise)

Question 19

When should every patient identified as being frail be assessed by?

Answer 19

Within three days of being admitted

Question 20

What makes up a comprehensive geriatric assessment?

Answer 20

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

Question 21

What are the syndromes which indicate frailty?

Answer 21

Falls, immobility, delirium, incontinence, susceptibility to side effects of medication

Question 22

How does the CSHA frailty scale work?

Answer 22

Scores patients from 1 (very fit) to 7 (severely frail)

Question 23

How soon can pressure ulcers begin to develop?

Answer 23

After 30 mins of lying on a hard surface = cause pain and immobility limiting rehab, must closely monitor for onset

Question 24

What are risk factors for pressure ulcers?

Answer 24

Delays to surgery, frail/malnourished patients, failure to mobilise

Question 25

What are the main principles of fluid management?

Answer 25

``` Peri-operative period is critical Danger of fluid overloading Continual clinical assessment Appropriate choice of fluids Resuscitation vs maintenance ```

Question 26

When is pain control needed?

Answer 26

On admission, on transferring to x-ray, pre/intra/post-operatively

Question 27

What is the recommended guidelines for pain management post-operatively?

Answer 27

WHO pain ladder

Question 28

What are some options for pain management post-operatively?

Answer 28

Paracetamol is rarely enough NSAIDs rarely tolerated Opiate analgesics can cause drowsiness, confusion, constipation and dizziness

Question 29

What is the step by step approach to analgesia?

Answer 29

``` 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 ```

Question 30

Where should fall assessment be carried out?

Answer 30

Started in orthopaedic ward | Often completed at falls clinic post-op if discharged early into community

Question 31

How should patients be examined in a fall assessment?

Answer 31

Visual assessment Cardio, neurology and MSK/gait assessment Medication review ECG +/- further investigation

Question 32

What should have occurred by the end of the first two days after surgery?

Answer 32

Mobilisation should have begun by end of the first day | Every patient should have physio assessment by end of second day

Question 33

When should patients with a hip fracture be seen by OT for assessment?

Answer 33

By end of day 3 post-admission

Question 34

What should every patient with a hip fracture have before they leave the acute orthopaedic unit?

Answer 34

Assessment of their bone health

Question 35

How is bone health assessed?

Answer 35

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

Question 36

What are some antiresorptive therapies?

Answer 36

Oral (alendronic acid) once weekly, second line treatments include IV bisphosphates or denosumab

Question 37

When is the aim to have patients discharged by?

Answer 37

Within 30 days of the admission date = recovery should be optimised by multi-disciplinary team approach

Question 38

When should patients be transferred to MFE assessment and rehabilitation unit if needed?

Answer 38

After 72hrs