Update on medical management of acute hip fracture

Lily Ackermann; Eric S. Schwenk; Yair Lev; Howard Weitz

doi:10.3949/ccjm.88a.20149

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TABLE 1

Preoperative evaluation of acute hip fracture

Preoperative condition or organ system	Interventions and comments
Fall	Evaluate the cause of the fall, including cardiac and neurologic syncopal episodes. Correct complications from the fall such as rhabdomyolysis, dehydration, and acute renal failure.
Diabetes	Patients with severe hyperglycemia (glucose levels > 400 mg/dL), ketoacidosis, or on an insulin pump: treat with an insulin infusion preoperatively with a target glucose level of 140–180 mg/dL. Patients with glucose levels > 180 mg/dL: the recommended total daily dose of insulin is 0.1–0.15 U/kg, given mainly as basal insulin, with correctional insulin coverage for glucose levels > 180 mg/dL before meals and at bedtime.
Anemia, thrombocytopenia	Evaluate anemia with a hemoglobin below 8 g/dL and thrombocytopenia with a platelet count < 100 × 10⁹/L, and correct as needed.
Anticoagulation before admission	Evaluate an international normalized ratio (INR) > 1.5 and correct if needed. It is not necessary to have a normal INR or partial thromboplastin time before surgery. Assess continuation or reversal of anticoagulants.
Respiratory	Bronchospasm and hypoxemia require evaluation. For a patient with known asthma or chronic obstructive pulmonary disease, an exacerbation identified on preoperative evaluation may require acute bronchodilator therapy and consideration for surgical delay. Consider spinal anesthesia.
Renal	Discontinue angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers preoperatively, and provide adequate hydration with isotonic fluid.
Cardiovascular	High-risk cardiac conditions should not disqualify surgery. Emphasis is on shared decision-making with the patient and family.

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TABLE 2

Pain control in acute hip fracture

	Dose	Comments
First line: nonopioid analgesia
Peripheral nerve block (femoral nerve block, fascia iliaca block)	Ropivacaine 0.5%, 15–20 mL in primary block; if catheter placed, infusion may be run with ropivacaine 0.2% at 8–10 mL/hour	Quadriceps weakness can be a limitation
Acetaminophen	1,000 mg intravenously or orally every 6 hours	For patient weighing < 50 kg, orally 650 mg every 6 hours
Celecoxib	200 mg orally twice a day	Use if glomerular filtration rate is > 60 mL/min
Ibuprofen	400 mg by mouth every 6 hours	Use if glomerular filtration rate is > 60 mL/min
Opioids
Tramadol	50 mg orally every 6 hours as needed for mild to moderate pain	Use 25 mg if creatinine clearance rate is < 60 mL/min
Oxycodone	2.5–5 mg orally every 4–6 hours as needed for severe pain	Start with 2.5 mg if creatinine clearance rate is < 60 mL/min
Hydromorphone	0.25 mg intravenously every 4–6 hours as needed	Preferable to morphine, since morphine’s metabolites can accumulate in patients with impaired renal function Respiratory depression, delirium, urinary retention, sedation, nausea and vomiting, and constipation are side effects of all opioids. Elderly patients may be particularly vulnerable to changes in mental status with opioids

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TABLE 3

Surgical repair of acute hip fracture: Indications for bridging therapy

Mechanical valves

Mechanical mitral valve

Mechanical aortic valve in a patient with atrial fibrillation

Mechanical tricuspid valve

Mechanical aortic valve in a patient in sinus rhythm if it is anticipated that warfarin will not be promptly

resumed after surgery

Atrial fibrillation

CHA₂DS₂–VASc^a score 7–9 without additional bleeding risks: major bleeding event or intracerebral hemorrhage < 3 months ago; international normalized ratio above the therapeutic range; prior bleeding event from previous bridging

Any history of stroke or transient ischemic attack (ischemic or cardioembolic)

Venous thromboembolism (VTE)

VTE event within 3 months

Severe thrombophilia with history of VTE or recurrent VTE (protein C or S deficiency, antithrombin deficiency, antiphospholipid antibodies, homozygous factor V Leiden, or multiple abnormalities); consider bridging for VTE in other thrombophilias (heterozygous factor V Leiden, heterozygous factor II mutation)

History of VTE during discontinuation of anticoagulation

↵a CHA₂DS₂–VASc = 1 point each for congestive heart failure, hypertension, age 65–74, diabetes mellitus, vascular disease (coronary artery disease, peripheral arterial disease, aortic aneurysm), female sex; 2 points for age ≥ 75 and for prior stroke or transient ischemic attack (total possible points 9).
Based on information in references 38.

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TABLE 4

Prophylaxis of venous thromboembolism in elderly hip fracture patients

Drug	Dosing and route of administration	FDA-approved for VTE prophylaxis?
Low-molecular-weight heparin	Enoxaparin 40 mg subcutaneously daily	Yes
Fondaparinux	2.5 mg subcutaneously daily	Yes
Warfarin	3–5 mg by mouth daily for goal international normalized ratio 2–3	Yes
Unfractionated heparin	5,000 U every 8 hours, every 12 hours for patients weighing < 50 kg Use if creatinine clearance rate is < 230 mL/min	Yes
Aspirin	Unclear, dosing ranges from 81 mg orally twice a day for creatinine clearance rate < 30 mL/min, to 325 mg orally twice a day	No
Apixaban	2.5 mg orally twice a day	No
Dabigatran	150 mg orally daily	No
Rivaroxaban	10 mg orally daily	No