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Table 7.1 Decision-making criteria for the type of surgery for hip fractures [11, 12]
Fracture type
Femoral neck (intracapsular) fractures
Nondisplaced Garden classication I (nondisplaced
Displaced Garden classication I or II with more
Vertical Vertical orientation of the fracture is
Extracapsular fractures
Basocervical At the boundary between the neck of
Stable trochanteric
fractures
Unstable trochanteric
fractures/
subtrochanteric
fractures
Considerations
impacted or incomplete fracture) or
Garden classication II (nondisplaced
complete fracture)
(These classications imply minimal
disruption of the blood supply to the
head of the femur and low risk of
avascular necrosis)
than 20°tilt
Garden classication III (complete
fracture partially displaced/angulated)
or Garden classication IV (complete
fracture completely displaced)
associated with increased risk for
failure of xation because of greater
instability
the femur and the trochanteric region,
so can be both unstable and prone to
blood supply problems
In the trochanteric region to just below
the lesser trochanter, so outside the
joint capsule
Fractures with the greatest degree of
instability
Example type of surgery
Internal xation with femoral
head retained, e.g. cancellous
hip screws
Age <70years: As for
nondisplaced (see above)
Age >70years:
Hemiarthroplasty or total hip
arthroplasty depending on
local guidelines
Sliding hip screw
Sliding hip screw
Sliding hip screw
Intermedullary nail
C. M. Jensen et al.
trochanters. As the fracture is extracapsular (outside the joint capsule), the blood
supply is less likely to be disrupted, so internal xation with intramedullary nail
or sliding hip screw is preferred (see Fig.7.1).
Subtrochanteric hip fracture: This fracture occurs in the upper part of the femoral shaft with its major extension just below the lesser trochanter. An intramedullary
nail is recommended to internally x a subtrochanteric fracture (see Fig.7.1). It is
also increasingly common for patients admitted to hospital with a fragility fracture
to have sustained a peri-prosthetic fracture (a fracture around an orthopaedic
implant/prosthesis) around previous arthroplasty implants of the hip and knee,
reecting the more widespread conduct of hip and knee arthroplasty for the management of arthritis. Patients who have previously fractured a hip may also sustain
a fracture around the previous xation implant/hemi-arthroplasty. These fractures
are more complex to manage surgically.
Fracture type
Mandatory supervision of junior registrars.
Operation type
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Femoral neck fractures
• Undisplaced
Graden I and II with < 20° post tilt
• Displaced
Graden I and II with
³ 20° post tilt, and Garden III and IV
• Vertical
Extracapsular fractures
• Basocervical
Age < 70 years
Age ³ 70 years
a
Hansson Pins
Prosthesis
b
2-hole DHS
c
• Stable trochanteric
AO/OTA type A1 and A2.1
• Unstable trochanteric
AO/OTA type A2.2, A2.3 and A3
a
Prosthesis is dictated if not fully reducible on the traction table.
b
Femoral Head Removal is dictated if bedridden.
c
Fig. 7.1 How hip fracture surgery decisions are made: an algorithm for hip fracture surgery
(Reproduced with permission from Acta Orthop [12])
4-hole DHS
c
IMHS
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7.4 Emergency andPreoperative Care
Sustaining a hip fracture is a sudden traumatic event, threatening many aspects of
patients’ lives and a forceful reminder of their mortality [6, 13]. Restoring function
is one of the crucial factors affecting the overall outcome after a hip fracture, so
physical care attracts the most attention [4]. The primary goals of care for the older
adult with hip fracture are to maximise mobility and preserve optimal function [1,
2]. Psychosocial factors, however, must be incorporated into a holistic approach to
care, helping patients to nd motivation to rehabilitate [1, 13].
Emergency departments (EDs) are often noisy, busy, overstimulating care settings, with inappropriate care environments for vulnerable older people in a state of
personal and physical crisis. These conditions can expose patients to a risk of acute
delirium (Chap. 12). Reducing the impact of this requires consideration of the following three principles [14]:
• Timeliness—avoid unnecessary and unwanted delay in the ED with rapid trans-
fer to a denitive care environment.
• Effectiveness—aim for optimal outcomes using the best available evidence.
• Patient-centredness—provide care that is respectful of and responsive to indi-
vidual needs.
Patients should fast for up to 6h before the operation and must not drink for up
to 2h before the operation (both depending on local guidance). It is important that
patients do not fast for an unnecessarily long time and are offered clear liquids
(preferably containing sugar and protein) up to 2h before the operation [15, 16].
Some patients will have been lying on the oor at home for a long time after their
fall. Consequently, they are at risk of dehydration and other complications of a ‘long
lie’ after the fall including pressure ulcers/injuries, incontinence, compartment syndrome and rhabdomyolysis (release of toxins from muscle damage into the bloodstream). In accordance with local guidelines, intravenous uid therapy should be
commenced soon after admission to the ED [17]. EKG/ECG and initial blood tests
should include, as a minimum, BAC test (blood typing, antibody screen and computer control test), uid and electrolyte balance and haemoglobin. Identication of
signs of a urine infection such as pyrexia, frequency, cloudy/foul-smelling urine and
incontinence may instigate a urine sample being sent for microbiology.
Providing emergency care to older people following trauma must follow the
same principles as for all age groups, using the ABCDE approach. The normal and
abnormal changes of ageing, compounded by active comorbidities, mean that morbidity and mortality are increased concerns. Examples of physiological considerations relating to ageing include the following [18]:
Airway—ageing causes degeneration of the physiological airway, and musculoskeletal pathology, such as osteoarthritis, can reduce neck and spine exibility,
making airway management difcult. Any pre-existing dysphagia increases the risk
of aspiration and pneumonia. Hypostatic pneumonia is an increased risk due to
immobility and limited coughing reexes.
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Breathing—depleted respiratory resilience leads to loss of hypoxic reserve and
potential hypoventilation with oxygen administration; oxygen therapy is still needed
but requires closer monitoring in recognition of this. Older people are more at risk
of respiratory failure because of the increased work of breathing.
Circulation—reduction in cardiopulmonary reserve means that there is increased
risk of uid overload when administering intravenous uids (particularly colloids),
requiring closer monitoring. Normal heart rate and blood pressure are not a guarantee of normal cardiac output and use of beta-blockers, and antihypertensive agents
can mask the signs of deterioration. Blood loss from the fracture site can vary from
a few millilitres for an un-displaced intracapsular fracture to over a litre for a multifragment or subtrochanteric fracture. All patients should have intravenous saline
from the time of presentation, with the rate of infusion adjusted according to the
estimated blood loss and degree of dehydration. Older people have an increased risk
of heart failure, so infusion needs to be carefully prescribed and monitored.
Disability—prolonged inactivity and disuse limit nal functional outcome and
impact survival.
Exposure—skin and connective tissue undergo extensive changes with ageing,
resulting in diminished thermoregulation, increased risk of infection, poor wound
healing and increased susceptibility to hypothermia. Prevention of these risks
should begin from arrival in the ED.The patient’s skin should be examined from
head to toe to identify any skin damage or redness and recorded in the patient record
(see Chap. 9 for further information about pressure ulcer/injury prevention). A
pressure- redistributing mattress should be in place on the trolley/bed; older people
who are suspected to have hip fracture should preferably be immediately admitted
to a hospital bed (rather than ED trolley) with a pressure-relieving/redistributing
mattress. Clothing should be replaced with a gown as soon as possible so that zippers or buttons do not create pressure, leading to skin injuries [15, 19]. Adequate
pain assessment and management should be in place to enable position changes.The
admission to the ED is the point at which comprehensive geriatric assessment
(CGA) should begin (see Chap. 6). A full and comprehensive history should be
taken that includes relevant comorbidities, medication history and previous functional ability as well as personal and social history. This will form the initial CGA
assessment to be built on in the following hours and days. Further detailed assessment can then take place following hospital admission and surgery. It is important
to get an overview of the patient’s overall history from various sources on arrival at
the ED.Many older people, with and without cognitive impairment, are unable to
provide an accurate history in this stressful situation so the history should also be
sought from a relative, caregiver or general practitioner [20, 21].
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7.4.1 Pain Management
A hip fracture is very painful, but good pain management is a frequently neglected
aspect of care. Unresolved pain contributes to worse outcomes for the patient. Good
collaboration among the orthogeriatric team is essential for achieving good pain
management, particularly so that mobilisation can take place soon after surgery.
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One signicant reason for inadequate analgesia is poor assessment, particularly
in those who have difculty in or are unable to communicate [22]. Acute pain should
be continuously assessed by the clinical care team at the time of presentation and
then regularly throughout the care pathway so that effective pain management can
be implemented. Every patient should receive frequent, accurate pain assessment
using an evidence-based tool, beginning at the admission interview [23]. A review
of health records should be conducted to detect pre-existing painful conditions and
prescribed analgesia, noting its impact and any side effects and reporting these to
the clinical team.
Common instruments used for pain assessment are the verbal rating scale
(VRS) and the visual analogue scale (VAS) (particularly useful for patients with
cognitive decline) [24]. Older people are often reluctant to acknowledge and
report pain, so practitioners should be alert to signs of pain in older people including behavioural and autonomic signs of pain, e.g. facial grimaces/frowns; writhing or constantly shifting while in bed, moaning, whimpering or groaning;
restlessness; or agitation.
Administration of nerve blocks preoperatively (including in pre-hospital care by
paramedics in some countries) for patients with hip fracture is increasingly common
as they have been shown to have a signicant positive effect on the pain experience
and minimise the need for opioid analgesics, which have multiple risk factors in
older frail patients [25, 26]. Advanced and specialist nurses increasingly have a role
in the administration of nerve blocks both in the ED and inpatient units [26].
Immediate analgesia should be offered to all patients presenting with suspected hip fracture, including those with cognitive impairment. The choice and
dose of analgesia should be age-appropriate, with close monitoring for associated side effects. Analgesia should be sufficient to allow movements necessary
for investigations (indicated by the ability to tolerate passive external rotation
of the leg) and for nursing care. Multimodal analgesia can be used to maximise
the positive effect of the selected medications while limiting the associated
adverse effects [27]. Older people are more susceptible to adverse medication
reactions. However, analgesics can be used safely and effectively when agerelated differences in absorption and distributions of these medications are
considered alongside individual risk factors [22]. Comorbidities, especially
kidney disease, and polypharmacy must be considered, and pain management
in those with cognitive difficulties is challenging because of communication
problems.Attention to patient comfort using support and positioning is an additional element of pain management. Turning the patient with a hip fracture onto
the affected side should be avoided until it has been surgically fixed; gently
‘tipping’ the patient may be unavoidable when performing care and checking
the skin on the patient’s back. Pillows should be used between the thighs and
knees to help manage pain. Adduction or rotation of the affected leg should be
avoided. Changing the patient’s position should always be performed by two
experienced nurses using good manual handling practice.
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7.5 Post-operative Care
Post-operatively, orthogeriatric care aims to mitigate the effects of the fracture and
surgery and remobilise, re-enable and re-motivate patients in preparation for discharge, ideally back to their place of residence before the fracture (Chaps. 8, 14 and
16). The fundamental principles of post-operative care include:
• Early mobilisation
• Management of pain
• Post-operative hypotension management
• Optimisation of hydration
• Management of anaemia
• Assessment for delirium
• Nutritional optimisation
Mobilising the patient soon after surgery has proven to be benecial in prevention of the complications of mobility and in assisting recovery (see Chap. 8 for more
information about mobility, remobilisation and exercise following fragility fractures). The early post-operative phase is crucial, as delayed remobilisation is associated with prolonged hospital stay [11]. Following surgery, it should be standard
practice to sit the patient out of bed for them to begin to stand on the day after surgery, providing that this is not medically contraindicated. Attention should be paid
to the potential for the patient’s blood pressure to drop (orthostatic hypotension) on
standing in the rst few days. Progress thereafter varies considerably depending on
the individual patient and the type of fracture or surgery. Patients with extracapsular
fractures tend to take longer to remobilise than those with intracapsular fractures
[4]. Initially, they may be afraid of weight bearing on the operated leg and should be
motivated by the care team while ensuring effective pain management.
Creating good outcomes in rehabilitation after a hip fracture requires motivation,
so understanding a patient’s anxiety, feelings of vulnerability and concerns for the
future should be considered as barriers for recovery [28].
7.5.1 Pain Management
Pain assessment, evaluation, reassessment and appropriate administration of analgesia should be central to routine care and to promote rehabilitation. Most patients
have constant pain in the days following surgery, which worsens when they move,
so they want to lie still to avoid pain, increasing the impact of immobility. The same
principles of pain assessment and pain management discussed earlier apply in the
post-operative period. If pain is poorly controlled, mobilisation will be delayed,
increasing the risk of the complications of prolonged immobility and leading to
increased dependency and associated rise in the risk of delirium [29, 30]. Pain also
inhibits the ability to receive and understand given information.
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The highly variable nature of pain and an individual’s response to it make accurate assessment a central element in facilitating individualised pain management
and monitoring. Many studies have shown that cognitively impaired and acutely
confused patients receive less analgesia than their unimpaired counterparts. To help
staff understand the individual needs of a person with dementia, the use of an assessment tool such as the ‘this is me’ tool [31] encourages relatives and carers to share
individual information, characteristics and behaviour.
Paracetamol can be offered every 6h unless contraindicated with additional opioids if paracetamol alone does not provide sufcient pain relief. Nonsteroidal antiinammatory drugs are often contraindicated in older adults and should only be
considered in selected cases. Opioid analgesia is a key component in managing hip
fracture pain, but there remains wide variability in individual need; opioid requirements decrease with ageing, and side effects can impede mobility, impair cognition
and interfere with recovery. Other medications such as sedatives, anti-emetics and
neuroleptics may increase opioid sedation, and adverse effects need to be considered when dosing and titrating opioids. It is essential to anticipate and monitor common side effects such as sedation, constipation, nausea and vomiting and instigate
preventive treatment as appropriate [32]. Older people have increased risk of respiratory depression with opioids, so regularly monitoring sedation levels is
recommended.
Non-pharmacological therapies are also an integral part of the treatment plan. A
variety of options have been shown to be effective individually or in combination
with appropriate medications [1]. Selecting strategies that the patient believes to
enhance the effectiveness is helpful. Recommended therapies include, but are not
limited to:
C. M. Jensen et al.
• Ensuring that the patient feels warm using blankets
• Cognitive-behavioural strategies: breathing exercises, relaxation therapy,
humour, music therapy and socialisation/distraction
• Repositioning regularly with supportive pillows, engaging the patient in decision-
making about comfortable positions
• Using an interdisciplinary approach: occupational therapists may provide cus-
tom seating, splints or adaptive devices; physiotherapists will assist in individual
mobility, exercise and strengthening programmes
• Physical activity to improve range of motion, mobility and strength (Chap. 8)
7.5.2 Preparation forDischarge
Discharge planning should be a coordinated effort between the patient, the patient’s
family, the interdisciplinary team and staff in the destination setting, if the patient is
to be discharged to another care facility (discharge and post-hospital care are considered in more detail in Chap. 16). This process should begin as soon as possible
following admission.
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Education of the patient and family or other carers is an important aspect of preparing for discharge both in terms of their continued recovery and rehabilitation and
in relation to prevention for future falls (Chap. 4) and secondary fracture prevention
(Chap. 5). This can be a challenge for healthcare providers because of decreasing
lengths of stay and the need to deliver increasingly complex information. So, providing patients with alternative ways of receiving information is valuable. This may
include printed written information and various forms of electronic information and
education using mobile phone apps, for example. Providing patients with an information booklet or automated pictographic illustration of discharge instructions has
been proven valuable [33–35]. Healthcare professionals can also support information and education for patients with a hip fracture using an app that accommodates
different learning styles. This way of dissemination of health knowledge can be
used by elderly hip fracture patients even if they are not used to technology [36].
There are numerous factors to consider when preparing the patient for discharge.
The responsibility for the patient’s care after discharge from the hospital is often
delegated to the patient and their family (Chap. 15) along with the general practitioner and, sometimes, community care staff. Therefore, the patient and their caregivers must be able to understand the discharge advice so that they can recall aftercare
instructions and recognise that the information they require for their post-discharge
care can be found in these (written or other) instructions. There are several reasons
for supporting oral information or education with written or virtual illustrations:
with ageing visual clarity and auditory acuity decreases, making it difcult for older
people to assimilate information, and poor lighting, noise levels and room temperatures can inhibit the learning process. Managing multiple messages can be difcult
for older people, and their personal perception of the severity of their injury and
subsequent surgery will limit their ability to receive and understand information.
Anticipation, anxiety and fear all contribute to diminished reception of knowledge.
Fear and preconceived notions of the consequences of acquiring a hip fracture also
block patients’ ability to take in information [6].
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7.6 Fundamentals ofPerioperative Care
Maintaining mobility, energy and participation in self-care during an older person’s
hospital stay can help to maintain their independence, reduce the likelihood of falls
and fall-related injuries and minimise loss of condence due to fear of falling (Chap.
4). The underlying principle of high-quality care is empathy; this is a complex mul-
tidimensional aspect of the therapeutic relationship that involves understanding the
needs, meanings, fears, priorities and perspectives of patients [37, 38] (Chap. 12).
Attending to comfort and hygiene is a fundamental care activity. This includes,
for example, acknowledging that the patient often does not feel hunger or thirst and
therefore may have a dry mouth, needing effective and frequent mouth care. Many
other aspects of fundamental nursing care during the perioperative period are covered in other chapters including the following:
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Cognitive impairment and acute delirium—The nursing team is most likely to
recognise and act on the signs of altered cognitive function and/or signs of delirium.
Interaction between care providers and a patient with cognitive impairment can be
a source of stress, particularly if the individual with cognitive impairment resists the
efforts of the care provider (Chap. 12).
Pressure ulcer/injury prevention—Pressure injuries are serious complications of
immobility, hospitalisation and surgery and can affect up to one-third of hip fracture
patients (Chap. 9).
Hydration and nutrition—Fluid management in older people can be difcult as
they may reduce/self-regulate uid intake to control incontinence or urinary frequency and to manage difculties in accessing toilet facilities. Close monitoring of
uid balance is essential to prevent or identify renal injury. Often patients do not
like or want to drink uids or nutritional supplements. Nutrition is closely linked to
all recovery outcomes. Although it is the responsibility of the whole team, the 24-h
presence of the nursing team makes them central to adequate uid and dietary intake
(Chap. 11).
Constipation—Either acute or chronic constipation is a signicant and common
complication for patients following fracture and during periods of ill health and
immobility. Prevention should be considered early in the care pathway; this should
involve:
• Regular assessment of bowel function including frequency and consistency of
defecation
• Titration of opioids as pain diminishes—opioid analgesia is a signicant cause of
constipation
• Providing and encouraging a bre-rich but palatable diet and sufcient oral
uid intake
• Careful but early use of prescribed aperients
Nurses should also educate patients about how to diminish aperients after discharge according to their changed mobility, regained privacy and, eventually,
regained appetite.
Healthcare-associated infection—Prevention, recognition and management of
infection are the responsibility of the whole orthogeriatric team but are central to
24-h nursing care, which includes coordination of care provided by the other team
members. Nurses in leadership roles can be instrumental in ensuring adherence of
staff to infection prevention guidelines and monitoring rates of infection. Prevention
of surgical site (Chap. 10), pulmonary and urinary tract infections and thromboembolism are also important in perioperative care.
Secondary fracture prevention—When preparing the patient for discharge, it is
important to consider secondary prevention of the fracture. This is described in
detail in Chaps. 2 and 5 and should be a focus during the entire patient’s stay in
hospital. This includes referral for investigation and—when needed—treatment of
osteoporosis together with assessment and prevention of fall risk (Chap. 4).
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Summary of Key Points
• The care of the orthogeriatric patient following hip fracture and subsequent
surgery presents signicant challenges for the healthcare team.
• Effective evidence-based nursing care is crucial in optimising patient outcomes following hip fracture.
• Nurses need to understand different types of hip fracture and their management so that they can deliver evidence-based acute and perioperative care
to patients with hip fracture based on each person’s specic needs.
• Much of the pre-, peri- and post-operative care of the patient in need of hip
fracture surgery is aimed at maintaining safety and preventing and recognising the complications of the fracture and surgery.
• Patients have existential concerns and worries about the future as they
know that a hip fracture is a serious injury with complications that can be
life-threatening or threaten their mobility.
• Even once the patient has recovered from surgery, there remains the need
to comprehensively prepare them for discharge.
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7.7 Suggested Further Study andIdeas forReflections
After reading this chapter, consider the following case example:
Mrs. Ito has been admitted to the ED in her local city hospital following an intertrochanteric hip fracture. You are the practitioner who receives her on arrival at the
orthopaedic unit. Her daughter is with her.
Mrs. Ito is transferred from the ED trolley to a bed. She is clearly in pain, so you
administer the pain medication she is due immediately. While you are making her
comfortable, you chat with her about how she is feeling. At rst, she seems a little
uncertain in her answers, and you notice that she seems anxious.
• What do you think may be going on in her mind? What might be her worries?
• How might you nd out more about what her experiences and worries are? And
how can you comfort her?
The following day, after Mrs. Ito’s surgery for internal xation of her fracture,
you are responsible for her personal care.
• Write a reection about what you think is important for patients in their post-
operative care.
7.7.1 General Suggestions forFurther Reflection
• Talk with your colleagues about what you have learned and the ways you could
use this to address the problems identied. Have you noted any areas of good
practice in this chapter that do not currently happen in your own area that you
might consider implementing?
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