What steps can reduce morbidity and mortality caused by hip fractures?

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Clinical Inquiries

What steps can reduce morbidity and mortality caused by hip fractures?

J Fam Pract. 2007 November;56(11):944-946

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References

1. Parker MJ, Handoll HH, Bhargara A. Conservative versus operative treatment for hip fractures. Cochrane Database Syst Rev. 2000;(4):CD000337.

2. Dorotka R, Schoechtner H, Buchinger W. The influence of immediate surgical treatment of proximal femoral fractures on mortality and quality of life. Operation within six hours of the fracture versus later than six hours. J Bone Joint Surg Br. 2003;85:1107-1113.

3. Grimes JP, Gregory PM, Noveck H, Butler MS, Carson JL. The effects of time-to-surgery on mortality and morbidity in patients following hip fracture. Am J Med. 2002;112:702.

4. Bottle A, Aylin P. mortality associated with delay in operation after hip fracture: observational study. BMJ. 2006;332:947-951.

5. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(3 Suppl):S338-S400.

6. Handoll HH, Farrar MJ, Mcbirnie J, Tytherleighstrong G, Milne AA, Gillespie WJ. Heparin, low molecular weight heparin and physical methods for preventing deep vein thrombosis and pulmonary embolism following surgery for hip fractures. Cochrane Database Syst Rev. 2002;(4):CD000305

7. Gillespie WJ, Walenkamp G. Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures. Cochrane Database Syst Rev. 2001;(1):CD000244.

8. Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics and the risk of surgical wound infection. N Engl J Med. 1992;326:281-286.

9. March L, Chamberlain A, Cameron I, et al. Prevention, Treatment, and Rehabilitation of Fractured Neck of Femur. report from the Northern sydney Area Fractured Neck of Femur Health outcomes Project. St. Leonards, Australia: Public Health Unit, Northern Sydney Area Health Service; 1996. Available at: www.mja.com.au/public/issues/iprs2/march/fnof.pdf. Accessed on october 11, 2007.

10. Brauer C, Morrison RS, Silberzweig SB, Siu AL. The cause of delirium in patients with hip fracture. Arch Intern Med. 2000;160:1856-1860.

11. Morrison RS, Magaziner J, Gilbert M, et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci. 2003;58:76-81.

12. Edelstein DM, Aharonoff GB, Karp A, Capla EL, Zuckerman JD, Koval KJ. Effect of postoperative delirium on outcome after hip fracture. Clin Orthop Relat Res. 2004;422:195-200.

13. Day H. Postoperative delirium. PIER: Physician’s Information and education resource, American College of Physicians. July 2006. Available at: pier.acponline.org/index.html. Accessed on October 11, 2007.

14. Kalisvaart KJ, de Jonghe JF, Bogaards MJ, et al. Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study. J Am Geriatr Soc. 2005;53:1658-1666.

15. Morrison RS, Magaziner J, Mclaughlin MA, et al. The impact of post-operative pain on outcomes following hip fracture. Pain. 2003;103:303-311.

16. Christmas C. Hip fracture. PIER: Physicians’ Information and Education Resource, American College of Physicians. updated July 2006. Available at: pier.acponline.org/index.html. october 11, 2007.

One study showed that prophylaxis with haloperidol for hip fracture patients did not decrease the incidence of postoperative delirium but did reduce its duration and severity.¹⁴ Haloperidol prophylaxis was also associated with shorter hospital stays. Treatment with haloperidol or risperidone for the agitation of postoperative delirium has been recommended when behavioral interventions fail.¹³

Pain control improves recovery

Providing adequate analgesia is of the utmost importance. In a 2003 prospective cohort study, patients without sufficient analgesia had an increased risk of poor functional recovery and longer hospitalization.¹⁵ In another cohort study, those patients whose pain was inadequately controlled also had an increased risk for delirium (RR=9.0; 95% CI, 1.8–45.2).¹¹ Meperidine use increased the risk for delirium compared with other opioid analgesics (RR=2.4; 95% CI, 1.3–4.5).¹¹

Recommendations of others

The American College of Physicians provides a comprehensive evidence-based guideline for the management of hip fracture patients in their PIER series (Physicians’ Information and Education Resource) (TABLE).¹⁶

FAST TRACK

To prevent delirium after surgery, patients should avoid certain medications, such as meperidine and benzodiazepines

The American College of Chest Physicians has published evidence-based guidelines for the prevention of VTE.⁵ For patients undergoing hip fracture surgery, they recommend routine use of fondaparinux, low-molecular-weight heparin at high-risk dosing, adjusted-dose warfarin (at a target international normalized ratio [INR] of 2.5, range 2.0–3.0), or unfractionated heparin. They recommend against routine use of aspirin alone. If surgery must be delayed, physicians should initiate prophylaxis with unfractionated or low-molecular-weight heparin at the time of hospital admission. Anticoagulation should routinely continue for 10 days after surgery or until the patient is ambulatory. If anticoagulation is contraindicated, mechanical prophylaxis of VTE with foot and calf pumping devices is recommended.^5,6

TABLE
6 steps for managing hip fracture from the American College of Physicians

Consider hospitalization for stabilization and surgical repair for most patients.
Perform surgical repair as soon as the patient is medically stable.
Administer prophylactic antibiotics to patients.
Provide adequate analgesia to all patients with hip fracture, whether or not they undergo surgical repair.
Treat all patients to reduce the rate of thromboembolic complications.
Institute interventions to minimize the risk of postoperative delirium.

Source: PIER: Physicians’ Information and education resource, American College of Physicians, 2006.¹⁶

Evidence-based answers from the Family Physicians Inquiries Network