Fragility fractures in the elderly
As a junior doctor on call, in geriatrics or in orthopaedics - you will frequently look after frail and elderly patients with multiple co-morbidities admitted with fragility fractures providing input on their pre & post-operative care. Fragility fractures are fractures that result from mechanical forces that would not ordinarily result in fracture e.g. low energy trauma such as falling from standing height.

Neck of femur (NOF) fractures are very serious for elderly patients. At 12 months: 30% mortality, 30% reduction in function & 30% return to baseline.alert-warning
Types of NOF fractures & Management


Extracapsular Intracapsular
Blood supply to femoral head not affected Blood supply to the femoral head may be affected (particularly if displaced)
Management
Internal fixation for trochanteric (as blood supply preserved)
Management
Displaced: Hemiarthroplasty or total hip replacement
Undisplaced: Internal fixation using dynamic hip screw


Current Standards of Care
Early surgery, appropriate analgesia & minimising post-operative complications and length of stay is best for our patients. The Best Practice standards are set by NHS England, they include
  • Operation to start within 36 hours (of ED arrival)
  • Geriatrician review within 72 hours
  • Fracture prevention assessment (bone health & falls)
  • Nutritional assessment
  • Abbreviated Mental Test Score pre-operatively
  • Delirium assessment (4AT)
  • Physiotherapy assessment on the day of or after surgery
Pre-operative considerations

Assessment
Ensure they've had an adequate falls history & appropriate investigations. Ensure an AMTS is completed. Pre-operative echos are not usually required unless insisted on by an anaesthetist (aortic stenosis can limit anaesthetic options). 

VTE Prophylaxis
This needs to be adjusted to weight & renal function. It is often held the day before operating with advice from the orthopaedic team on when to restart & how long to continue after discharge (often 28 days).

Do consider reasons for additional fluids above maintenance e.g. vomiting or rhabdomyolysis. 

Adequate analgesia reduces the risk of delirium & allows patients to mobilise faster. Do give regular paracetamol but avoid NSAIDs. Elderly, frail patients often require less opiates & ensure you check their renal function to prevent accumulation. Fascia iliac block works very effectively and should be considered in all patients.

Ensure these are written up on the PRN side!

Regular Medication Changes
The anaesthetists and other teams should advise on which medications to continue as pre-operative changes are becoming increasingly complex. They, together with the surgical team, will also advise on antibiotic prophylaxis. 
  • Anticoagulation policies vary and benefits of lower bleeding risk need to be weighed against the risks of delayed operations. Therefore it may not be possible to hold Clopidogrel for 7 days or DOACs for 36-48 hours. Platelets or other blood products may be given to reduce delays. Warfarin is more easily reversible. 
  • Antihypertensives are usually withheld on the day of surgery. ACE inhibitors or b blockers may reduce a patient's BP during a spinal anaesthetic but this is controversial
  • Oral antihyperglycaemics and metformin are usually withheld. 
Post-operative considerations

Bloods
Monitor their haemoglobin & inflammatory markers post-operatively. Whilst a modest rise in white cells & CRP is expected, these might be associated with an infection

Mobility
They really must mobilise on "Day 1" post-operatively. The orthopaedic team should state the weight-bearing status clearly and the physiotherapists must review within 24 hours. 

Bladder & Bowels
Ensure the patient is opening their bowels prior to aiming to TWOC a patient (trial without catheter i.e. remove the catheter). Mobility, laxatives, adequate hydration and privacy can all help. It can be quite embarrassing to use a commode behind a thin curtain, so taking them to the toilet can really help. 

Delirium
Monitor for this with the 4AT score and manage appropriately: "PINCHME"

Bone Health Assessment

Assessment
Treatment
  • Vitamin D can be supplemented as per trust policies (usually high dose once weekly for 6 weeks followed by maintenance therapy)
  • Routine calcium supplementation (e.g. adcal) in those who are not deficient may cause hypercalcaemia. Consider whether they are getting adequate supplementation from their diet (discussing with the dietician as necessary)
  • Consider the role of a DXA scan & bisphosphonate therapy (e.g. Alendronic acid 70mg once weekly)
    • Ensure you counsel them on how to take bisphosphonates - standing with a whole glass of water on an empty stomach (i.e. 30 mins before breakfast)
DXA Scan & Bisphosphonate therapy
This depends on the patient. For a male under 75 years, you would want to do a DXA scan as potentially they could potentially be on a bisphosphonate for a long time which is not always a good thing. Whereas both may not be useful in someone with limited life expectancy, for example, in a frail, multi-comorbid 90-year-old the risks may outweigh the benefits. Finally, those of any age, who are not very mobile, may not get optimised bone remodelling due to not being sufficiently weight-bearing. 

Discharge
Discharge planning - it is important that the patient & family appreciate what the patient will achieve during the admission. Many services will continue rehab therapy at home so it can be tailored to their usual environment. However, this takes extensive MDT planning. 

Discharge Summary: Ensure you include the new medications to be started, VTE on discharge & that the GP should review their fracture risk. 

Further Reading & References
Written by Swati Vara (FY2) & Dr Corrinne Quah (Geriatric Consultant)
Edits by Dr Akash Doshi (CT2)