Medical management of hip fracture.

This article appeared in a journal published by Elsevier. The attached
copy is furnished to the author for internal non-commercial research
and education use, including for instruction at the authors institution
and sharing with colleagues.
Other uses, including reproduction and distribution, or selling or
licensing copies, or posting to personal, institutional or third party
websites are prohibited.
In most cases authors are permitted to post their version of the
article (e.g. in Word or Tex form) to their personal website or
institutional repository. Authors requiring further information
regarding Elsevier’s archiving and manuscript policies are
encouraged to visit:
http://www.elsevier.com/copyright

Author's personal copy
Medical Management
of Hip Fracture
Moises Auron-Gomez, MD, FAAP*, Franklin Michota, MD, FACP
With the expected increase in the US population aged 65 years and older, complica-
tions inherent to the aging population, such as hip fracture, have acquired significant
epidemiologic importance.1 It is estimated that the annual number of hip fractures in
the United States is approximately 250,000, and it is projected that this number will
double by the year 2040.2 Today, the costs associated with hip fracture, including
acute care, rehabilitation, and home care services exceed $5 billion dollars annually,
and it is expected to increase up to $16 billion by the year 2040.3,4
Hip fracture not only causes an increase in mortality, estimated to be 25% on
average at 1 year, but also increases the likelihood of subsequent hospitalization
and functional dependence.5 The mortality and morbidity can be reduced if there is
prompt recognition and treatment of the hip fracture.
There are complications inherent to hip fractures that can occur in almost a predict-
able fashion, and therefore can be described as the ‘‘hip fracture syndrome.’’ As
a result, although hip fracture is considered a surgical disease, the perioperative man-
agement of these patients typically involves medical specialists.6 Issues facing the
medical specialist include surgical-site infection control, venous thromboembolism
(VTE) prophylaxis, delirium prevention and management, nutritional support, urinary
tract management, and rehabilitation. The preoperative examination and optimization
of patient comorbidities as well as the timing of surgery are important in medical
evaluation. Ultimately, the goal is to achieve optimal clinical outcomes and minimize
disability.1 A multidisciplinary approach that includes a hospitalist providing perioper-
ative medical comanagement may offer the best chance for a successful outcome.2,7
EPIDEMIOLOGY
The incidence in adults aged 65 years and older is estimated to be 818/100,000 habi-
tants.8 Women are affected 2 to 3 times more than men, with a proportionately similar
ethnic predominance in Caucasians versus other ethnicities.9
Department of Hospital Medicine, Cleveland Clinic, 9500 Euclid Avenue, S70, Cleveland, OH
44195, USA
* Corresponding author.
E-mail address: auronm@ccf.org (M. Auron-Gomez).
KEYWORDS
� Hip fracture � Surgery � Perioperative care
� Geriatrics � Venous thromboembolism � Delirium
� Postoperative complications � Elderly
Clin Geriatr Med 24 (2008) 701–719
doi:10.1016/j.cger.2008.07.002 geriatric.theclinics.com
0749-0690/08/$ – see front matter ª 2008 Elsevier Inc. All rights reserved.

Author's personal copy
Falls account for 90% of hip fractures in the elderly. Patients’ habitus and the char-
acteristics of the fall (direction, site of impact, and protective response) influence the
risk of hip fracture.10 The lifetime risk for suffering a fragility fracture in 50-year-old
women in the United States is 18%.11 With increase in age, the intensity of the trauma
required to cause a fracture is reduced. Low-energy trauma is the cause of fracture in
53% of patients aged 50 years and older; it is the cause of fracture in 85% of patients
older than 75 years.12 Risk factors for hip fracture include osteoporosis, maternal
history of hip fracture, excessive intake of alcohol and caffeine, sedentary behavior,
low body weight, tall stature, previous hip fracture, use of sedatives, institutional
residence, visual impairment, dementia, and diabetes.2,10,13
As the population continues to age, pathologic fractures secondary to bone metas-
tases are also expected to increase. The most frequent cancers that metastasize to
the bone are breast, lung, kidney, and prostate. Outside of axial skeleton, the hip is
the most frequently affected area by bone metastasis, with 50%, 30%, and 20%
of the fractures occurring in the femoral neck, subtrochanteric region, and intertro-
chanteric region, respectively. Pathologic fractures are particularly challenging as
they require a prolonged time for healing and 50% will never completely heal.14
The mortality rate at 1 year in elderly patients with hip fracture ranges from 14% to
36%,2,5,15 with the highest mortality being found in the first 6 months postfracture.16
After the first year, the mortality rate is similar to that among age- and sex-matched
persons without hip fractures.2 Factors associated with increased mortality after hip
fracture include advanced age, male sex, poorly controlled systemic disease
(metastatic cancer, congestive heart failure, renal failure, liver disease, lymphoma,
and/or weight loss), psychiatric illness, low albumin (<3.0 g/dL), institutional residence,
operative management before stabilization of coexisting medical conditions, poor
baseline functional status, and postoperative complications.2,16,17
Functional recovery after hip fracture is important for prognosis, as hip fracture is
known to increase functional dependence.2,18 Only 60%of patients surviving 6months
after a hip fracture recover to their baseline walking ability, and only 50% of the
patients are able to perform baseline activities of daily living (ADLs).19 Up to 20%
of patients become nonambulatory.2 Factors associated with full recovery of
ambulation and return to baseline ADLs include male sex, younger age, absence of
preexisting dementia (or postoperative delirium in nondemented patients), good social
network, and use of assist devices (walker, cane, and others) before the injury.2,19 The
proportion of patients who are able to return home ranges from 40% to 90%. This wide
range depends on the availability of post–acute care resources, including home health
services, skilled nursing facilities, and an emphasis on returning home. The factors
associated with a discharge to home include younger age, a baseline ability to walk
independently, the ability to independently perform ADLs in the early postoperative
period, and living with another person.2,20 Contributing factors for permanent institu-
tional residence include age more than 80 years, disorientation, the need for assis-
tance with basic ADLs (Box 1), and lack of family member involvement.2
THE ROLE OF THEMEDICAL SPECIALIST
The patient with hip fracture is often medically complex. A multidisciplinary approach
that includes the orthopedic surgeon, anesthesiologist, and the medical specialist is
important if optimal outcomes are to be achieved. To further understand the different
roles of each team member, surgery has been compared with a plane flight where the
patient is the plane.21 The surgeon is the pilot and the anesthesiologist is the copilot.
Together, the pilots and the plane must take off and land safely. The medical specialist
Auron-Gomez & Michota702

Author's personal copy
is the chief mechanic, and his or her role is to describe the fitness of the aircraft to the
pilots and provide any needed maintenance before take-off. It is not the mechanic’s
role to tell the pilots when and how to fly the plane. Therefore, the orthopedic surgeon
will determine the most appropriate surgical approach, and the anesthesiologist will
coordinate intraoperative monitoring requirements in addition to fluid and blood
management therapy.22
The medical specialist should thoroughly evaluate the patient for both acute and
chronic disease. Acute conditions that may adversely affect the surgical outcome
need to be fully described with definitive diagnoses and then followed with appropriate
therapy. It is important to understand how the fracture occurred and whether it was the
result of orthostasis from possible infection, acute heart disease, or hemorrhage
versus an innocent fall. A comprehensive history, review of medications and of
body systems is required and will typically involve information gathered from family
members or people who witnessed the original injury. A baseline cognitive and func-
tional assessment should be documented including both basic and instrumental ADLs
(Box 1). Physical examination should focus on other signs of trauma and assess for
decompensated chronic disease. All chronic diseases should be optimized before
surgery in the best possible way (Table 1),23 including attention to nutrition and met-
abolic status before and after surgery. Approximately 20% of patients with hip fracture
suffer from preexistent severe malnutrition,6,24 and hip fracture itself carries a very high
risk for catabolism and protein-calorie malnutrition.25
The medical specialist should also implement available strategies to prevent post-
operative complications frequently encountered in the ‘‘hip fracture syndrome,’’ such
as delirium, VTE, polypharmacy, malnutrition, anemia, and impaired bowel and blad-
der function. A proactive, evidence-based approach targeting potential complications
can decrease the morbidity associated with hip fractures.26
Ideally, medical management should be continuous throughout hospitalization from
admission to discharge. The hospitalist model of care provides a unique opportunity
for comanagement that differs from traditional medical consultation.1,27 It has been
proposed that this model of health care may yield improved quality of care–related
Box1
Activities of daily living
Basic
� Dressing
� Bathing
� Toileting
� Feeding
Instrumental
� Food shopping
� Food preparation
� Housework
� Laundry
� Banking and finance
� Using public transportation or driving
Medical Management of Hip Fracture 703

Author's personal copy
Ta
bl
e
1
Pr
eo
pe
ra
tiv
e
ab
no
rm
al
iti
es
th
at
sh
ou
ld
be
op
tim
iz
ed
be
fo
re
hi
p
re
pa
ir
M
in
or
A
bn
or
m
al
iti
es
a
M
aj
or
A
bn
or
m
al
iti
es
b
BP
Sy
st
ol
ic
BP
R
18
1
m
m
H
g;
di
as
to
lic
BP
R
11
1
m
m
H
g
Sy
st
ol
ic
BP
%
90
m
m
H
g
H
ea
rt
ra
te
an
d
rh
yt
hm
A
F
or
SV
T
10
1–
12
0;
sin
us
ta
ch
yc
ar
di
a
R
12
1;
or
H
R
46
–5
0
be
at
s/m
in
A
F
or
SV
T
R
21
;V
T;
th
ird
-d
eg
re
e
he
ar
tb
lo
ck
or
H
R
%
45
be
at
s/m
in
In
fe
ct
io
n/
pn
eu
m
on
ia
T
R
38
.5
� C
;c
lin
ic
al
di
ag
no
sis
of
pn
eu
m
on
ia
;o
ri
nf
ilt
ra
te
on
CX
R
T
<
35
� C
;T
R
38
.5
� C
w
ith
cl
in
ic
al
di
ag
no
sis
of
pn
eu
m
on
ia
or
in
fil
tr
at
e
on
CX
R
Ch
es
tp
ai
n
Ch
es
tp
ai
n
bu
tn
or
m
al
EC
G
A
ny
ne
w
M
Io
n
EC
G
or
ch
es
tp
ai
n
w
ith
ab
no
rm
al
EC
G
c
CH
F
D
ys
pn
ea
or
pu
lm
on
ar
y
ra
te
so
rs
3
bu
ta
no
rm
al
CX
R;
or
CH
R
on
CX
R
w
ith
a
no
rm
al
ex
am
in
at
io
n
an
d
no
dy
sp
ne
a
Pu
lm
on
ar
y
ed
em
a
on
CX
R;
or
CH
F
on
CX
R
w
ith
dy
sp
ne
a
or
ab
no
rm
al
ex
am
in
at
io
n
Re
sp
ira
to
ry
fa
ilu
re
46
m
m
H
g
<
pC
O
2
<
55
m
m
H
g
Pu
lse
ox
im
et
ry
<9
0%
;p
O
2
<6
m
m
H
g;
or
pC
O
2
R
55
m
m
H
g
IN
R
1.
4–
1.
6
>1
.6
El
ec
tr
ol
yt
es
So
di
um
(N
a)
5
12
6–
12
8
or
15
1–
15
5
m
Eq
/L
;o
rb
ic
ar
bo
na
te
(H
CO
3)
5
18
–1
9
or
35
–3
6
m
Eq
/L
45
1–
60
0
m
g/
dL
N
a
%
12
5
or
>1
55
m
Eq
/L
;K
<
2.
5
or
>6
.1
m
Eq
/L
;o
rH
CO
3
<1
8
or
>3
6
m
Eq
/L
G
lu
co
se
45
1–
60
0
m
g/
dL
gl
uc
os
e
va
lv
e
>6
00
m
g/
dL
BU
N
/c
re
at
in
in
e
BU
N
41
–5
0
m
g/
dL
or
cr
ea
tin
in
e
2.
1–
2.
5
m
g/
dL
w
ith
ou
t
h/
o
ES
RD
BU
N
>
50
m
g/
dL
or
cr
ea
tin
in
e
R
2.
6
m
g/
dL
w
ith
ou
th
/o
ES
RD
A
ne
m
ia
H
b
7.
6–
8
g/
dL
H
b
%
7.
5
g/
dL
A
bb
re
vi
at
io
ns
:A
F,
at
ria
lf
ib
ril
la
tio
n;
BP
,b
lo
od
pr
es
su
re
;B
U
N
,b
lo
od
ur
ea
ni
tr
og
en
;C
H
F,
co
ng
es
tiv
e
he
ar
tf
ai
lu
re
;C
XR
,c
he
st
X
ra
y;
H
R,
he
ar
tr
at
e;
ES
RD
,e
nd
-s
ta
ge
re
na
ld
ise
as
e;
H
b,
he
m
og
lo
bi
n;
IN
R,
in
te
rn
at
io
na
ln
or
m
al
iz
ed
ra
tio
;M
I,
m
yo
ca
rd
ia
li
nf
ar
ct
io
n;
SV
T,
su
pr
av
en
tr
ic
ul
ar
ta
ch
yc
ar
di
a;
T,
te
m
pe
ra
tu
re
;V
T,
ve
nt
ric
ul
ar
ta
ch
yc
ar
di
a.
a
M
in
or
5
m
ild
ly
ab
no
rm
al
bu
tl
es
sl
ik
el
y
to
re
qu
ire
co
rr
ec
tio
n
be
fo
re
su
rg
er
y.
b
M
aj
or
5
m
ar
ke
dl
y
ab
no
rm
al
an
d
m
or
e
lik
el
y
to
re
qu
ire
co
rr
ec
tio
n
be
fo
re
su
rg
er
y.
c
A
bn
or
m
al
EC
G
de
fin
ed
as
ST
de
pr
es
sio
ns
or
el
ev
at
io
ns
.
Fr
om
M
cL
au
gh
lin
M
A
,O
ro
sz
G
M
,M
ag
az
in
er
J,
H
an
na
n
EL
,M
cG
in
n
T,
M
or
ris
on
RS
,e
ta
l.
Pr
eo
pe
ra
tiv
e
st
at
us
an
d
ris
k
of
co
m
pl
ic
at
io
ns
in
pa
tie
nt
sw
ith
hi
p
fr
ac
-
tu
re
.J
G
en
In
te
rn
M
ed
20
06
;2
1(
3)
:2
19
–2
5;
w
ith
pe
rm
iss
io
n.
Auron-Gomez & Michota704

Author's personal copy
outcomes, such as time to consultation, time to surgery, length of hospital stay, and
total hospital costs. Several studies have shown a decrease in these variables without
adversely affecting inpatient deaths or 30-day readmission rates in patients coman-
aged by hospitalists.7,28
SPECIAL CONSIDERATIONS IN THE GERIATRIC PATIENT
Age is not an illness, but it is an independent risk factor for morbidity, mortality, and
perioperative outcome. Age-related changes in physiology and pharmacology might
affect every aspect of perioperative care. The basal function of various organ systems
may be relatively uncompromised, yet functional reserve and the ability to compen-
sate for physiologic stress are reduced (Fig. 1).29 As a result, it is often difficult to
predict the effect of perioperative stress on the geriatric patient.
There are multiple changes secondary to frailty, which is defined as a loss of phys-
iologic reserve that increases the likelihood of disability.29,30
Vascular changes that occur in the elderly include increased systemic vascular
resistance with increased systolic blood pressure (BP) and diastolic dysfunction.
Geriatric patients may be very sensitive to fluid changes and at increased risk for
the development of congestive heart failure without excessive provocation. In addi-
tion, fatty infiltration and conduction abnormalities are more common in the geriatric
patient. As a result, there is a decreased chronotropic response to stress and less sen-
sitivity to catecholamines, all of which increase the risk for perioperative hypotension.
Advanced age (>80 years) is associated with a greater risk of pulmonary complica-
tions. Pulmonary changes with aging include a decrease in thoracic compliance and
lung recoil with increased anatomic and functional dead space. Ciliary function is
reduced and cough is less effective. In addition, there is a diminished response to hyp-
oxia. As a result, the geriatric patient is at increased risk for perioperative atelectasis
and pneumonia. This risk is typically compounded in the hip fracture patient as
medical management includes narcotic analgesia, bedrest, and traction.
Renal function declines with age secondary to diminished renal perfusion, cortical
atrophy, and glomerular sclerosis. In the geriatric patient, serum creatinine will
Fig. 1. Relationship between maximal (broken line) and basal (solid line) physiologic func-
tions. Functional reserve is the difference between maximal and basal functions, and it is
inevitably decreased with aging. (From Muravchick S. Preoperative assessment of the elderly
patient. Anesthesiol Clin North America 2000;18:74; with permission)
Medical Management of Hip Fracture 705

Author's personal copy
probably overestimate renal function as decreased muscle mass is common. The
modified diet in renal disease equation offers a more accurate estimation of glomerular
filtration rate, especially in patients with chronic kidney disease.31 Sodium homeosta-
sis is impaired with aging along with a decrease in renal concentrating ability, alter-
ations in thirst mechanism, and release of antidiuretic hormone.32
The aging process also affects the neurologic system, as there is a decrease in
the number and complexity of neuronal connections over time and a decreased
synthesis of neurotransmitters. Gray matter diminishes through middle age, resulting
in cerebral atrophy. Neuronal loss leads to a decline in visual and auditory function,
impairment of cardiovascular reflexes, decrease in strength, coordination, and fine
motor control, and a decrease in propioception. These changes predispose the ge-
riatric patient to perioperative delirium, increased risk for further falls, and impaired
rehabilitation.
Adverse drug reactions are common in geriatric patients owing to a variety of
physiologic changes. The volume of distribution is altered in addition to the rates of
clearance and elimination of medications. Decrease in lean body mass and in total
body water leads to a higher plasma concentration of water-soluble drugs. Increased
proportion of body fat leads to a prolonged half-life for fat-soluble drugs. In addition,
decreased plasma proteins results in an increased free fraction in plasma of albumin-
bound drugs. These issues are often further complicated by the changes in renal
function and the presence of any comorbidities that can alter drug metabolism.
TYPE OF HIP FRACTURE AND OPERATIVE IMPLICATIONS
Hip fractures are classified according to their anatomic location. They can be intracap-
sular (involving the neck and head of the femur) or extracapsular (intertrochanteric or
subtrochanteric). Approximately 90% of hip fractures occur in equal proportions in the
femoral neck and intertrochanteric regions, generally caused by low-energy trauma,
such as falling from a chair or slipping on the ice.22 Subtrochanteric fractures account
for the remaining 5% to 10%2 and are often associated with higher-energy trauma.22
Patients with osteoarthritis have an increased likelihood of intertrochanteric or subtro-
chanteric fractures after a fall.33
The surgical management of hip fractures will depend on many factors, including
the type of fracture, surgeon preference, severity of the fracture (including involvement
of the pelvis and/or acetabular cup), patient age, and comorbid conditions. Variables
that can affect the biomechanical strength of a fracture repair include bone quality,
which is directly related to age and osteoporosis, and fracture pattern or stability.34
Intracapsular fractures disrupt the vascular supply to the femoral head and can lead
to avascular necrosis with an increased risk of poor union or nonunion.35,36 Therefore,
these fractures are managed preferentially by a hemiarthroplasty and should undergo
surgery as promptly as possible; surgical delay that results in femoral head necrosis
will necessitate a second surgery later for a total arthroplasty.34,36,37 In contrast,
extracapsular fractures require different approaches according to the site of fracture.
Intertrochanteric fractures (including stress fractures) may be repaired by open reduc-
tion and internal fixation, whereas subtrochanteric fractures are typically repaired by
hemiarthroplasty.34,36,37 Damage to the pelvis or acetabular cup will necessitate a total
arthroplasty for repair.
Hip replacement (hemiarthroplasty or total arthroplasty) can be a complicated pro-
cedure, resulting in significant intraoperative fluid shifts and blood loss. Thus, the type
of repair chosen is relevant as it would be expected to stress the patient to varying
degrees. Estimated blood loss and anesthesia time will increase as the procedure
Auron-Gomez & Michota706

Author's personal copy
advances from open reduction and internal fixation, to hemiarthoplasty, to total
arthroplasty.
TIMING OF SURGERY
Hip fracture repair should occur as soon as possible once the patient is optimized for
the operating room. Delay in hip fracture repair does negatively affect the return
to weight bearing and overall functional recovery. Case series and observational stud-
ies suggest that early surgical repair (within 24–48 hours) can decrease 1-year
mortality1,2,6,27,38 in addition to decreasing postoperative pain, length of hospital
stay, and major complications.39 Early mobilization will enhance recovery and help
prevent VTE, pulmonary complications, urinary tract infection, and skin breakdown.1,2
However, serious perioperative complications may arise if preexistent medical prob-
lems are not stabilized before surgery.1,6,22,27 Current evidence suggests that a brief
delay in surgery (up to 72 hours) for optimization of uncontrolled medical conditions
will not adversely affect health or functional outcomes in patients with hip fracture.40
The final decision about the timing of surgery should be determined after a full evalu-
ation and review by the multidisciplinary team.
PREVENTION OF COMPLICATIONS
Surgical-Site Infections
The use of perioperative antibiotics before surgery has dramatically decreased the
incidence of wound infections in hip fracture patients.2 A Cochrane review of 22 trials
(n 5 8,307) demonstrated that preoperative antibiotic prophylaxis decreased deep-
wound and urinary tract infections by 64% and 44%, respectively.41
Coagulase-negative staphylococci (Staphylococcus epidermidis) and methicillin-
sensitive Staphylococcus aureus are the most frequently isolated organisms in hip
fracture surgical-site infections.42 The optimal time for antibiotic administration is
within 2 hours of surgery and continued for another 24 hours.22,36,43 Thus, the antibi-
otics of choice include first-, second-, and third-generation cephalosporins, with
vancomycin or clindamycin being reserved for patients with b-lactam allergy.22,36
Cefazolin, 1 g intravenously every 8 hours for 3 doses, is the dominant strategy.
Patients allergic to b-lactams or those admitted to centers with a high prevalence of
methicillin-resistant S aureus, should receive vancomycin, 1 g intravenously every
12 hours for 24 hours.
Venous Thromboembolism
Over 30 years of randomized trial evidence confirms that VTE prophylaxis is one of the
highest safety practices for hospitalized patients with hip fracture and is considered
a standard of care in this setting.44 Pooled data from multiple trials suggest pharma-
cologic prophylaxis with heparin (unfractionated), low molecular weight heparin
(LMWH), aspirin, and coumadin can decrease the incidence of VTE.45 Currently, fon-
daparinux, a synthetic indirect inhibitor of factor Xa, has the best evidence for efficacy
in hip fracture patients.46 Extended (4-week) prophylaxis with fondaparinux can pro-
duce a 96% reduction in venographic deep venous thrombosis and an 89% reduction
in symptomatic VTE events relative to perioperative (1-week) prophylaxis.47 A large
retrospective database analysis of 144,806 patients in more than 500 hospitals in
the United States found a significant decrease in VTE events in patients receiving
fondaparinux (1.5%) compared with those receiving enoxaparin (2.3%), dalteparin
(2.1%), and unfractionated heparin (4.2%). After controlling for baseline covariates,
the odds of experiencing a VTE were significantly higher for other treatments
Medical Management of Hip Fracture 707

Author's personal copy
compared with fondaparinux (dalteparin 5 odds ratio: 1.22, 95% CI, 1.01–1.46,
P 5 .0370; enoxaparin 5 odds ratio: 1.39, 95% CI, 1.19–1.62, P < .0001; unfractio-
nated heparin 5 1.98, 95% CI, 1.67–2.34, P < .0001).48
The American College of Chest Physicians recommends routine prophylaxis for all
patients undergoing hip fracture surgery, beginning preoperatively and continuing until
full ambulation is reached.22,45 This will typically require some form of out-of-hospital
prophylaxis. The agents of choice include fondaparinux, heparin (unfractionated or
low molecular weight), or vitamin K antagonists with a target international normalized
ratio (INR) of 2.5 (between 2 and 3) (Table 2).45 Of the recommended strategies, fon-
daparinux carries the highest level of evidence (1A). The American College of Chest
Physicians does not support aspirin as a strategy for VTE prevention in hip fracture.
Patients on heparin or LMWH should have platelet count examination periodically to
monitor for heparin-induced thrombocytopenia.
Renal function and the use of neuraxial anesthesia are important considerations
when choosing the prophylaxis agent and timing of administration. Patients with renal
impairment are at greater risk for bleeding complications when using anticoagulants
compared with non-renally impaired patients.49 Fondaparinux is contraindicated in
patients with a serum creatinine of 2.0 mg/dL or more. LMWH may bioaccumulate
in the renally impaired patient leading to a greater risk for bleeding if dose adjustments
are not made. Enoxaparin is the only available LMWH with specific dose adjustments
for renal insufficiency supported by the Food and Drug Administration (creatinine
clearance % 30 mL/min; Table 2).
Neuraxial anesthesia is associated with a lower incidence of VTE.49 The use of
anticoagulants in combination with neuraxial anesthesia increases the risk of spinal
hematoma, which can lead to devastating neurologic injury. The American Society
of Regional Anesthesia recommends a 12- to 24-hour window between pharmaco-
logic prophylaxis dose and spinal needle insertion.22,49 For patients who have
a continuous epidural postoperatively, the American Society of Regional Anesthesia
suggests that pharmacologic prophylaxis may continue but that the catheter should
not be manipulated or pulled out within 2 hours of any pharmacologic injection. Use
of full-dose anticoagulation (such as with coumadin or weight-adjusted LMWH) is
not compatible with neuraxial anesthesia.
Delirium
Most patients with hip fracture (up to 62%) will develop delirium.50 Delirium is defined
as an acute disruption in attention and cognition. The most common risk factors for
delirium are advanced age, dementia, alcohol and tobacco use, sensory impairment,
vision impairment, dehydration and electrolyte imbalance, use of psychotropic medi-
cations, and changes in sleep–wake cycle.1,50,51 Delirium usually develops on the first
Table 2
Prophylactic anticoagulation recommendations for patients with hip fracture
Drug Dose (glomerular filtration rate)
> 30 ml/min/1.73 m2 > 30 ml/min/1.73 m2
Fondaparinux 2.5 mg subcutaneous once daily Not approved
Enoxaparin subcutaneous
once daily
40 mg subcutaneous once daily 30 mg
Warfarin Target INR 2–3 Target INR 2–3
Auron-Gomez & Michota708

Author's personal copy
or second postoperative day and symptoms are worse at night. Despite its preva-
lence, delirium is often misdiagnosed or unrecognized.6
Delirium is associated with increased morbidity along with a decrease in rehabilita-
tion potential and return to prefracture functioning.52 The relative risk of mortality in
patients with cognitive impairment is similar to that found in other chronic diseases,
and there is a compound effect of cognitive impairment and chronic medical illness
on mortality.53 Dementia by itself significantly increases the costs of hospitalization
in patients with hip fracture.54
Precipitant factors for delirium include impaired mobility; use of physical restraints;
medical complications (pneumonia, sepsis, urinary tract infections, disturbance in
fluid and electrolyte balance, and myocardial infarction); unfamiliar environment; mal-
nutrition; and use of new drugs, especially sedatives, narcotics, and anticholinergics
(Table 3).55 Most cases of delirium will be multifactorial. Alcohol or benzodiazepine
withdrawal may present in the hip fracture patient approximately 2 to 3 days from
the original injury.50,55
A proactive approach to prevent and minimize the risk for delirium is an important
and routine part of postoperative hip fracture care (Box 2).51
Oxygen delivery
Incentive spirometry and deep-breathing exercises should be encouraged as soon as
possible in the postoperative period to prevent atelectasis and other pulmonary com-
plications. Oxygen delivery depends on cardiac output, hemoglobin concentration,
and arterial oxygen saturation (SpO2). Therefore, oxygen supplementation should be
Table 3
Medications associated with an increased risk of delirium
Medicationa NegativeAction Alternative
Amitriptyline Potent anticholinergic
side effects
Serotonin uptake inhibitors
in low doses (sertraline)
Diphenhydramine Potent anticholinergic
side effects with sedation
Short-acting benzodiazepine
in low doses (temazepam)
Chlordiazepoxide Long half-life with prolonged
sedation
Short-acting benzodiazepine
in low doses (temazepam)
Chlorpromazine Potent anticholinergic
side effects
Mirtazapine of olanzapine are
preferred; haloperidol in low doses
Diazepam Long half-life with prolonged
sedation
Short-acting benzodiazepine
in low doses (temazepam)
Doxepin Potent anticholinergic
side effects
Serotonin uptake inhibitors
in low doses (sertraline)
Hydroxyzine Potent anticholinergic
side effects with sedation
Nonsedating antihistamine
(loratidine)
Imipramine Potent anticholinergic
side effects
Serotonin uptake inhibitors
in low doses (sertraline)
Indomethacin CNS side effects Acetaminophen
Meperidine Neurotoxicity from
accumulated metabolites
Morphine sulfate in low doses
a All medications with known psychoactive side effects should be used in the lowest doses possible.
From Michota FA, Frost SD. Perioperative management of the hospitalized patient. Med Clin
North Am 2002;86(4):731–48, with permission.
Medical Management of Hip Fracture 709

Author's personal copy
Box 2
Recommendations for proactive geriatric assessment
Module/recommendation
1. Adequate oxygen delivery to the central nervous system (CNS)
(a) Supplemental oxygen to keep saturation > 90%, preferably >95%
(b) Treatment to raise systolic BP > 2/3 baseline or >90 mm Hg
(c) Transfusion to keep hematocrit > 30%
2. Fluid/electrolyte balance
(a) Treatment to restore serum sodium, potassium, glucose to normal limits
(glucose < 300 mg/dL, <16.5 mmol/L for diabetics)
(b) Treat fluid overload or dehydration detected by examination or blood tests
3. Treatment of severe pain
(a) Around-the-clock acetaminophen (1 g 4 times daily)
(b) Early-stage breakthrough pain: low-dose subcutaneous morphine, avoid meperidine
(c) Late-stage breakthrough pain: oxycodone as needed
4. Elimination of unnecessary medications
(a) Discontinue/minimize benzodiazepines, anticholinergics, antihistamines
(b) Eliminate drug interactions, adverse effects, modify drugs accordingly
(c) Eliminate medication redundancies
5. Regulation of bowel/bladder function
(a) Bowel movement by postoperative day 2 and every 48 h
(b) Discontinue urinary catheter by postoperative day 2, screen for retention or
incontinence
(c) Skin care program for patients with established incontinence
6. Adequate nutritional intake
(a) Dentures used properly, proper positioning for meals, assist as needed
(b) Supplements: 1 can Ensure and 3 cans Ensure for poor oral intake
(c) If unable to take food orally, feed through temporary nasogastric tube
7. Early mobilization and rehabilitation
(a) Out of bed on postoperative day 1 and several hours daily
(b) Mobilize/ambulate by nursing staff as tolerated, such as to bathroom
(c) Daily physical therapy; occupational therapy if needed
8. Prevention, early detection, and treatment of major postoperative complications
(a) Myocardial infarction/ischemia—electrocardiogram, cardiac enzymes if needed
(b) Supraventricular arrhythmias/atrial fibrillation—appropriate rate control, electrolyte
adjustments, anticoagulation
(c) Pneumonia/chronic obstructive pulmonary disease—screening, treatment, including
chest therapy
Auron-Gomez & Michota710

Author's personal copy
used as needed to keep SpO2 at more than 90%. Systolic BP should be maintained at
more than 90 mm Hg, and transfusions should be considered to keep hematocrit at
more than 30%.51
Fluid and electrolytes
Intravenous fluids should be discontinued as soon as adequate oral fluid intake is
established and the diet should be advanced to regular as tolerated. Intravenous
access can be removed once prophylactic antibiotics are complete and both wound
drain and urinary catheter have been removed.56 Fluid overload or dehydration should
be corrected, and electrolytes (sodium and potassium) and glucose should be re-
stored to normal limits.51
TREATMENT OF PAIN
Inadequate pain control increases length of hospital stay, delays ambulation, and
decreases overall mobility at 6 months. There is little evidence regarding the best
analgesic approach.57 Narcotic analgesia can worsen mental status and precipitate
delirium, but suboptimal analgesia should be avoided.33 Non-narcotic analgesia
with acetaminophen should be scheduled, 1 g every 6 hours around the clock; opioids
should provide breakthrough pain (early-stage breakthrough pain with low-dose mor-
phine and late-stage breakthrough pain with oxycodone).51 After the second postop-
erative day, most patients will be comfortable on oral analgesics alone, and parenteral
analgesia can be discontinued.56
Epidural analgesia has been associated with decreased perioperative cardiac
complications, including acute coronary syndromes, heart failure, arrhythmias, and
sudden cardiac death.57 This form of analgesia has not been shown to improve overall
outcomes in hip fracture and it may complicate VTE prophylaxis management.
ELIMINATE UNNECESSARYMEDICATIONS
Sedative hypnotics, such as benzodiazepines (except in the case of alcohol with-
drawal), anticholinergics, and antihistamines should be avoided if possible and used
at the lowest effective dose. Narcotic use (intravenous or by mouth) should also be
(d) Pulmonary embolus—appropriate anticoagulation
(e) Screening for and treatment of urinary tract infection
9. Appropriate environmental stimuli
(a) Appropriate use of glasses and hearing aids
(b) Provision of clock and calendar
(c) If available, use of radio, tape recorder, and soft lighting
10. Treatment of agitated delirium
(a) Appropriate diagnostic workup/management
(b) For agitation, calm reassurance, family presence, and/or sitter
(c) For agitation, if absolutely necessary, low-dose haloperidol 0.25–0.5 mg every 4 h as
needed; if contraindicated, use lorazepam at same dose
From Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture:
a randomized trial. J Am Geriatr Soc 2001;49(5):516–22; with permission.
Medical Management of Hip Fracture 711

Author's personal copy
minimized; these medications increase the likelihood of delirium owing to direct CNS
effects and any resultant urinary retention or constipation. All medications should be
adjusted accordingly to renal function, and polypharmacy should be specifically
avoided.51
REGULATION OF BOWEL/BLADDER FUNCTION
Constipation is commonly seen after the second postoperative day as a result of
decreased mobility and perioperative use of narcotic analgesia. A bowel regimen of
stool softeners and laxatives should be routine and titrated to bowel motions at least
every 48 hours.51,56
Bladder catheter removal should be prompted as early as possible, typically on
postoperative day 1 when patients begin to mobilize out of bed. If urinary retention
is encountered (patients unable to void 8 hours post–catheter removal with bladder
scan urine volumes more than 200 mL, or when patient expresses physical discom-
fort), intermittent bladder catheterization is preferable to reinsertion of an indwelling
bladder catheter.1,56 Benefits of intermittent catheterization compared with indwelling
catheters include early resumption of spontaneous voiding, decreased risk for bladder
infection, improved patient mobility, and reduced risk for delirium.6 Indwelling cathe-
ters prevent incontinence screening, which should also be evaluated in the postoper-
ative setting. Urinary incontinence is a significant risk factor for skin breakdown.
Patients with urinary incontinence require a skin care program to protect skin integ-
rity.51 Skin breakdown should be prevented with frequent mobilization and use of
foam or alternating pressure mattresses.57
ADEQUATE NUTRITIONAL INTAKE
Malnourishment occurs in up to 20% of patients with hip fractures.6,24,33 The hip frac-
ture patient is predisposed to catabolism with an increased risk for protein-calorie
malnutrition.25 Protein depletion is associated with poor wound healing and increased
postoperative complications, including reduced survival at 1 year.1,58 Low serum albu-
min (<3.5 g/dL) and low total lymphocyte count (1,500 cells/mL) are associated with
increased resource consumption, length of hospital stay and operative time in joint
arthroplasty.59 Albumin levels below 3 g/dL are associated with increased in-hospital
mortality.17
Most patients tolerate enteral nutrition within 12 hours postoperatively. This can be
achieved by means of oral or nasogastric tube feedings. Patients should be encour-
aged to resume oral intake; this can be achieved by proper use of dentures, adequate
positioning for meals, and assistance as needed.51
Aggressive postoperative protein supplementation has been associated with weight
gain, decreased length of hospitalization, and decreased postoperative complica-
tions.1,6 Daily supplements with protein and calorie-dense formulations, such as
Ensure or Sustacal, are recommended in all patients.51,60 Lean elderly women with
femoral neck fracture demonstrated increased albumin levels, maintained lean
body mass, improved ADLs and better health-related quality of life after receiving
oral protein supplementation in combination with nandrolone given for 6 months
postfracture.61
Most low-impact hip fractures occur in the setting of osteopenia and/or osteoporo-
sis. Nutritional assessment should review intake of calcium and vitamin D, in addition
to counseling to avoid caffeine, alcohol, and tobacco to reduce osteoporosis risk.1
Auron-Gomez & Michota712

Author's personal copy
EARLYMOBILIZATION AND REHABILITATION
Early mobilization within 24 hours after hip surgery is a standard practice. Self-mobi-
lization should be encouraged depending on the clinical circumstances; an overhead
trapeze frame may assist the patient in regaining earlier functional independence. In
addition, overhead trapeze will reduce the force exerted on the hips upon patient
transfer to a bedpan; these forces can be significant, estimated to be 4 times the
body weight.56 Early mobilization not only reduces the risk for complications, such
as VTE, atelectasis, skin breakdown, and delirium but also has a significant psycho-
logic impact.56 Physical therapy should begin on postoperative day 1 with a focus
on bed mobility and range of motion with weight-bearing as tolerated. Goals for
ambulation are progressive: day 1––15 ft with moderate assistance (supervised ambu-
lation using parallel bars, advancing to a walker); day 2––20 ft with minimal assistance
(walker to crutches to a cane); day 3––40 ft (independent ambulation as tolerated); day
4––begin stair climbing as tolerated.62 Hip abductor and quadriceps strengthening
correlates with independent ambulation56 and should also be started on the first post-
operative day.62 Occupational therapy should be used as needed to help patients re-
learn adaptive skills, such as toileting, bathing, dressing, and cooking. Use of adaptive
equipment, such as bedside commode, walkers, and wheelchairs, will help patients
regain mobility and independence.56
EARLY DETECTION AND TREATMENT OFMAJOR COMPLICATIONS
Delirium may be the only manifestation of a life-threatening condition in the elderly
patient. Clinicians must take a standardized approach to postoperative delirium
such that myocardial infarction, hemorrhage, pneumonia, urosepsis, or VTE are not
missed.51,55 In a large study of 8,930 patients with hip fracture, 19% had postoperative
complications, and cardiac and pulmonary complications occurred in 8% and 4%,
respectively. Serious cardiac and pulmonary complications occurred in 2% and 3%,
respectively; gastrointestinal bleeding occurred in 2%, VTE in 1%, and stroke in 1%.
For serious cardiac or pulmonary complications, mortality was 20% and 40% at 30
days and 1 year, respectively.63 Although delirium postoperatively will typically bemul-
tifactorial and associated in some degree with medication use, patients should gener-
ally have ancillary studies that include serum chemistries, complete blood cell count,
SpO2 determination, electrocardiogram, and urinalysis. Depending on the results of
these initial studies and in conjunction with the history and physical examination,
further testing may be warranted, such as chest radiography, blood and urine cultures,
cardiac enzymes measurements, and a radiologic assessment for VTE.55
Environmental Stimuli
The hospital environment is by itself a disorienting stimulus. Reassurance and contin-
uous reorientation should be provided at every patient encounter. Environmental mod-
ifications to avoid sleep deprivation are important. Interventions include turning lights
on during the day and off at night, using natural light whenever possible (keep patients
near a window), and limiting noise at night. Use of clocks and calendars will help pro-
vide time orientation. Patients with vision or hearing impairment should have access to
their eyeglasses and hearing aids. Family involvement will further reinforce orientation
and may help with other important activities, such as feeding and physical therapy.
Treatment of Agitation
Agitation is a symptom of delirium and should be approached with identification and
treatment of the underlying cause. However, the symptoms of delirium (agitation) may
Medical Management of Hip Fracture 713

Author's personal copy
need treatment as well. Patients who are frightened or anxious may simply need reor-
ientation and reassurance by a family member or health care personnel. Physical
restraints should only be used if the patient’s agitation poses an immediate and seri-
ous threat; this is rarely the case. If reorientation and reassurance are unsuccessful,
pharmacologic therapy should be used for a brief period of time to minimize injury
and allow for further evaluation and treatment. Low-dose haloperidol (0.25–0.5 mg)
every 4 hours (intravenously or orally) as needed is the most common treatment
approach. Care should be taken to monitor electrocardiograms for QRS prolongation.
Benzodiazepines should generally be avoided unless anxiety is a significant compo-
nent to the agitation, or withdrawal is suspected.51 Atypical antipsychotics, such as
risperidone, 0.25 to 0.5 mg orally twice a day, or olanzapine, 2.5 mg orally once
a day, can be used as well (Table 4).
REHABILITATION AND RECOVERY
Rehabilitation is fundamental after hip fracture and should start as soon as possible in
the postoperative period. Early rehabilitation is associated with shorter hospital stay
and decreased medical costs.1 After hospital discharge, ongoing long-term rehabili-
tation in a skilled nursing facility, a dedicated acute rehabilitation hospital, or on an
outpatient basis is beneficial. Intense physical therapy (twice daily sessions) may
help improve long-term outcomes.62 The intensity and length of rehabilitation will
depend on a variety of factors, including patient tolerability, prognosis for recovery,
and insurance coverage. The ultimate goal for posthospital discharge rehabilitation
is to return the hip fracture patient to the prefracture level of function and minimize
risk for further injury.
Weight-bearing exercise, balance training, muscle strengthening, cognitive-behav-
ioral learning, and reduction of sedative medications are among the most effective
fall-prevention interventions.64 Specific risk factors for falling, such as postural hypo-
tension or gait instability, should be identified and treated.
Hip protectors may help prevent hip fractures, although the evidence is limited.
Patient compliance is an issue due to physical discomfort and poor practicality.
Some investigators suggest that up to 50% of low-impact hip fractures are potentially
preventable with routine use of hip protectors.65 Despite the controversy, many inves-
tigators advocate the use of hip protectors in nursing home residents, patients with
increased risk for falls (with or without osteopenia), and patients with osteoporosis.66
Virtually all patients with hip fracture have underlying osteoporosis or osteopenia,
and are at increased risk for future fractures. For previously mobile patients, evaluation
with bone densitometry should be sought as a baseline to follow-up long-term
therapy. Up to 30% of patients with hip fractures will have a T score above �2.5.
Pharmacologic treatment of osteoporosis includes calcium and vitamin D, and may
Table 4
Medications suggested for acute management of delirium in hip fracture patients
Medication Route Dose (mg) Frequency
Haloperidol iv/im/po 0.25�0.5 qid
Risperidone po 0.25�0.5 bid
Olanzapine po 2.5 mg qhs
Abbreviations: bid, twice daily; im, intramuscular; iv, intravenous; po, oral; qhs, at bedtime; qid,
4 times daily.
Auron-Gomez & Michota714