Inpatient Treatment of Hip Fracture
I. What every physician needs to know.
A hip fracture refers to a fracture of the proximal femur. Hip fractures are the most serious consequence of osteoporosis and a catastrophic event. Thirty percent of patients with a hip fracture will die in the following year and up to half will experience significant functional loss, with a five-fold increased risk of institutionalization. A previous hip fracture is associated with a 16% risk of a second fracture which carries a mortality of up to 60%.
A. History Part I: Pattern Recognition:
The typical patient with a hip fracture is an elderly person complaining of severe hip pain and inability to ambulate, usually after a fall. In some instances, however, patients with hip fractures have normal ambulation and complain only of vague pain in their buttocks, knees, thighs, groin or back. In the frailest patients, it is possible for hip fractures to occur with minimal trauma, especially if they have cognitive impairment.
B. History Part II: Prevalence
About 250,000 Americans are hospitalized annually due to hip fractures. Most of these patients are elderly and suffer the fracture in the context of a fall.
C. History Part III: Competing diagnoses that can mimic hip or pelvic fracture.
The differential diagnosis of hip pain is extensive. Because certain types of hip fractures are associated with an increased risk of avascular necrosis of the femoral head, hip pain subsequent to trauma should be considered indicative of hip fracture until proven otherwise. Other lower body fractures must also be excluded. Fractures of the acetabulum and pubic ramus or stress fractures may present with signs and symptoms similar to a hip fracture. Stress fractures symptoms include limping with hip or leg pain worse at night. In older adults, stress fractures are often caused by osteopenic bone, pathologic conditions such as malignancy, malnutrition, or gait impairment.
Once the diagnosis of hip or other lower body fracture has been ruled out, more common but chronic sources of hip and leg pain should be considered. Osteoarthritis is one of the most common causes in patients older than 50 years. Symptoms include limping and hip pain that progresses over time. Other diagnoses to consider include avascular necrosis of the femoral head, primary neoplasm or metastatic disease, inflammatory arthritis, septic arthritis, crystalloid arthritis, acetabular tear, trochanteric bursitis, piriformis syndrome, disorders of the lumbar disc, and referred pain from the knee.
D. Physical Examination Findings.
The classic physical examination in a patient with a hip fracture reveals an abducted and externally rotated hip with leg-length discrepancy. The patient usually has localized tenderness over the hip joint (i.e., localizing to the groin or anterior thigh) and limited range of motion of the affected limb during attempts at passive and active rotation and flexion.
In some instances, however, patients with hip fracture have normal ambulation and complain only of vague pain in their buttocks, knees, thighs, groin, or back. These patients frequently report no antecedent trauma, particularly if cognitive impairment is present. Their physical examination, including assessments of active, passive, and resisted movements of the affected hip joint and limb, may be normal.
E. What diagnostic tests should be performed?
The diagnosis of a hip fracture is typically established with plain films. Antero-posterior (AP) and lateral views should be obtained. The femoral neck is optimally viewed with the hip internally rotated at 15 to 20 degrees. If plain films are indeterminate but suspicion for a fracture remains high, other modalities can be useful. Magnetic resonance imaging (MRI) has gained importance in the diagnosis of occult fractures of the femoral neck; within 24 hours, changes can be seen. Bone scan, though quite sensitive, is less useful in the acute setting because it may take up to 1 week to demonstrate changes, especially in older adults.
1. What laboratory studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?
Laboratory studies do not play a role in diagnosing hip fractures, but are certainly necessary in peri-operative management, and should include complete blood count (CBC), chemistry panel and coagulation profile. A 25-OH vitamin D level should also be obtained at admission for all fragility fractures.
III. Default Management.
In every practical sense, a hip fracture that is severe enough to warrant hospitalization is considered a surgical disease for patients who are ambulatory prior to the event. Urgent consultation with an orthopedic surgeon is required.
Studies show that early surgery (within 24-48 hours of hospital admission) is associated with lower one-year mortality, lower incidence of pressure ulcers, decreased confusion, and lower risk of fatal pulmonary embolism.
Hip fractures are categorized according to anatomic structures affected. They can be classified as femoral neck fractures, intertrochanteric fractures, and subtrochanteric fractures. Surgical approaches are summarized as follows:
For femoral-neck fractures, repair is achieved by either internal fixation with screws or with prosthetic replacement. The former is usually performed in non-displaced or minimally displaced fractures and in younger patients with displaced fractures. The latter approach is typically preferred in older patients with displacement, given higher rates of nonunion and ostenoecrosis.
For intertrochanteric and subtrochanteric fractures, repair is by and large achieved with internal fixation, involving some combination of screws, plates or nails.
The decision surrounding surgical repair in the non-ambulatory or terminally ill patient is more complex. However, depending on goals of care, even patients enrolled in hospice are not necessarily precluded from surgery, which may improve symptoms of pain or salvage bed and chair mobility. Decisions in complex cases should be individualized; consultation with geriatrics or palliative care services may be helpful in such instances.
A. Immediate management.
For the hospitalist, immediate management of a hip fracture consists of ensuring adequate analgesia, careful assessment of pre-operative cardiac risk assessment, and meticulous peri-operative medical management.
Most hip fractures severe enough to warrant hospitalization are extremely painful; opioids are appropriate in the acute setting. Although many physicians may hesitate to use them given the frailty of the typical hip fracture patient, opioids, when dosed and monitored appropriately, are associated with decreased incidence of delirium in hip fracture. Pre-operatively, morphine 2-4 mg IV q4 hrs, or the oral equivalent, is reasonable for the opioid-naive patient. Scheduled dosing, with appropriate holding parameters, may be preferable if as-needed (prn) orders result in significantly delayed medication administration. In patients with chronic kidney disease, hydromorphone or oxycodone at the equivalent dose should be considered, as morphine is renally cleared. In patients for whom the physician wishes to minimize opioids (e.g., patients with sleep apnea), acetaminophen around-the-clock, up to 3 grams daily, can be effective. A breakthrough dose of opioids should be made available if this approach is utilized, however. Finally, a standing bowel regimen, such as senna/docusate twice daily orally, should accompany any regular use of opioid pain medication.
Although the diagnosis of hip fracture is typically straightforward, careful history taking surrounding the circumstances of the fracture should be obtained. Since hip fractures commonly occur in the context of falls, the hospitalist should assess whether other serious medical conditions coexist, such as syncope or alcohol intoxication, as these will have major implications for peri-operative management.
Pre-operative cardiac risk assessment is beyond the scope of this article, but certainly medical stability must be achieved prior to surgical repair. Orthopedic surgeries pose intermediate cardiac risk according to American College of Cardiology/American Heart Association (ACC/AHA) guidelines.
Of the many peri-operative issues that may arise, management of anticoagulation is among the most common and complex. Because delay of surgical repair is associated with poorer outcomes, reversal of therapeutic INR for patients on warfarin is often warranted. Vitamin K is typically effective. Patients who are taking novel oral anticoagulants (NOACs) pose challenges, as high-quality data surrounding best practices peri-operatively are lacking. Discussion with pharmacists is advised; in practice, NOACs are typically held at least 24-48 hours prior to operation.
Finally, hospitalists should ensure prophylaxis against common hospital-acquired conditions, including deep venous thrombosis (DVT), pressure ulcers, delirium and catheter associated urinary tract infection (UTI). Pre-operatively, pharmacologic DVT prophylaxis with either a low molecular weight heparin or unfractionated heparin can be administered up until 12 hours prior to the procedure.
IV. Management with Co-Morbidities
A. Diabetes or other Endocrine issues
In most experts’ opinions, a fragility fracture indicates osteoporosis. The National Osteoporosis Foundation recommends treatment of osteoporosis in all patients with a hip or vertebral fracture, regardless of bone mineral density.
Bisphosphonate therapy is the current first-line treatment and has been shown to decrease the rate of refracture by up to 35%.
Initiation of bisphosphonate therapy as an inpatient is advocated by some experts. Intravenous zoledronic acid is an attractive option, needing only annual dosing in osteoporosis. If not initiated as an inpatient, therapy is warranted within 90 days of surgical repair. Contraindications to bisphosphonate therapy include CrCl <30 mL/min and hypocalcemia.
Treatment for osteoporosis can be summarized as follows:
Vitamin D level less than 10 ng/ml: 50,000 units oral vitamin D twice weekly and calcium. NO bisphosphonate yet.
Vitamin D level 10-20 ng/ml: 50,000 units oral vitamin D once weekly and calcium. Start bisphosphonate.
Vitamin D level 21-30 ng/ml: 1,000 IU oral vitamin D and calcium. Start bisphosphonate.
Vitamin D level greater than 30 ng/ml: 800 IU oral vitamin D and calcium. Start bisphosphonate.
V. Transitions of Care
A. Anticipated Length of Stay
The average length of stay for persons with hip fractures varies but averages approximately 5-6 days. About 52% of patients in the United States are discharged to a skilled nursing facility for ongoing rehabilitation, necessitating at least a stay of 3 days per Medicare requirements.
B. When is the Patient Ready for Discharge
Post-operatively, the patient should be evaluated by physical therapy services. Barring no major surgical complications, patients may attempt to bear weight as soon as the first post-operative day. Discharge is appropriate once the patient has been evaluated by physical therapy, has analgesia adequate enough to allow participation in ongoing rehabilitation, and is functioning at baseline mental status.
C. Arranging for Clinic Follow-up
1. When should clinic follow up be arranged and with whom.
Patients should follow-up with their primary care provider within 1-2 weeks of discharge and with their orthopedic surgeon within 1 month of discharge.
2. What tests should be ordered as an outpatient prior to, or on the day of, the clinic visit.
Although many experts consider the presence of a fragility fracture enough to make a diagnosis of osteoporosis, a bone density test should be scheduled following discharge. This is done to determine osteoporosis severity and establish a baseline to monitor treatment response. If vitamin D level is found to be low in the hospital, a vitamin D level should be checked in 4-6 weeks after therapy is begun. If treatment with IV bisphophonates is administered, the hospitalist should note this in the discharge summary to avoid duplication of therapy.
VI. Patient Safety and Quality Measures
A. Core Indicator Standards and Documentation.
Foley catheter should be removed on post-operation day 1.
B. Appropriate Prophylaxis and Other Measures to Prevent Readmission.
Owing to the post-operative state and decreased mobility, hip fracture patients are at increased risk for DVT, and pharmacologic prophylaxis is often recommended after discharge. Low molecular weight heparin, unfractionated heparin, vitamin K antagonists and NOACs are all potential options and usually may be resumed 12-24 hours post-operatively.
The optimal duration of pharmacologic DVT prophylaxis is not well-established. Prophylaxis for up to 7-14 days post-operatively is common, but lengths of up to 35 days has been recommended in some guidelines. In the face of inconclusive evidence, length of administration may be tailored to bleeding risk as well as the rate at which functional mobility is recovered.
VII. What's the Evidence?
Zuckerman, JD. “Hip fracture”. N Engl J Med. vol. 334. 1996 Jun 6. pp. 1519-25.
“National Hospital Discharge Survey (NHDS), National Center for Health Statistics. Health Data Interactive, Health Care Use and Expenditures”.
Hung, WW, Egol, KA, Zuckerman, JD, Siu, AL. “Hip fracture management: tailoring care for the older patient”. JAMA. vol. 307. 2012 May 23. pp. 2185-94.
Morrison, RS, Magaziner, J, Gilbert, M, Koval, KJ, McLaughlin, MA, Orosz, G, Strauss, E, Siu, AL. “Relationship between pain and opioid analgesics on the development of delirium following hip fracture”. J Gerontol A Biol Sci Med Sci. vol. 58. 2003 Jan. pp. 76-81.
Forster, R, Stewart, M. “Anticoagulants (extended duration) for prevention of venous thromboembolism following total hip or knee replacement or hip fracture repair”. Cochrane Database of Systematic Reviews 2016.
Brauer, CA, Coca-Perraillon, M, Cutler, DM, Rosen, AB. “Incidence and Mortality of Hip Fractures in the United States”. JAMA. vol. 302. 2009. pp. 1573-1579.
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- I. What every physician needs to know.
- A. History Part I: Pattern Recognition:
- B. History Part II: Prevalence
- C. History Part III: Competing diagnoses that can mimic hip or pelvic fracture.
- D. Physical Examination Findings.
- E. What diagnostic tests should be performed?
- III. Default Management.
- A. Immediate management.
- IV. Management with Co-Morbidities
- A. Diabetes or other Endocrine issues
- V. Transitions of Care
- A. Anticipated Length of Stay
- B. When is the Patient Ready for Discharge
- C. Arranging for Clinic Follow-up
- 1. When should clinic follow up be arranged and with whom.
- 2. What tests should be ordered as an outpatient prior to, or on the day of, the clinic visit.
- VI. Patient Safety and Quality Measures
- A. Core Indicator Standards and Documentation.
- B. Appropriate Prophylaxis and Other Measures to Prevent Readmission.