Surgery within 24 hours of hip fracture is a critical step in reducing complications, and may decrease mortality compared with conservative care (strength of recommendation [SOR]: B, cohort studies). Give patients heparin at the time of admission to prevent venous thromboembolism (VTE) (SOR: A, systematic reviews of RCTs). Anticoagulation should be continued in some form for 10 days or until the patient is fully ambulatory (SOR: A). Patients should also get prophylactic antibiotics in the 2 hours before surgery (SOR: A, meta-analysis of RCT)

Edwards, Frederick

Grover, Michael

Hitchcock, Kristin

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944	 vol 56, No 11 / November 2007  The Journal of family PracTiceCliniCal INquIrIes From the Family Physicians Inquiries Network		clinical commentaryevidence-based answerWhat	steps	can	reduce		morbidity	and	mortality	caused	by	hip	fractures?surgery within 24 hours of hip fracture is a critical step in reducing complications, and may decrease mortality compared with conservative care (strength of recommenda-tion [sor]: B, cohort studies). Give patients heparin at the time of admission to prevent venous thromboembolism (vTe) (sor: a, systematic reviews of rCTs). Anticoagula-tion should be continued in some form for 10 days or until the patient is fully ambulatory (sor: a). Patients should also get prophylac-tic antibiotics in the 2 hours before surgery (sor: a, meta-analysis of rCT). reduce the risk of postoperative delirium by avoiding certain medications, minimizing sleep distur-bances, and providing adequate analgesia (sor: B, systematic review of cohort studies). Aggressive pain control should also be top of mind—higher pain scores are associated with longer hospital stays, delayed ambulation, and long-term functional impairment (sor: c, extrapolation from a single cohort study).ensure that proper treatment continues after dischargeAs an FP working in a hospital, I am often asked to consult on cases of hip fracture. It’s important to maximize the patient’s condition quickly in order for the orthopedist to be able to proceed with surgical repair within the first 24 hours of the injury. many hospitals have anticoagulation protocols or standing orders for postop hip fracture management, which should make vTe prevention almost automatic. However, it’s important to ensure that these orders are initiated preoperatively if surgery is delayed, and that treatment gets continued for the appropriate length of time—even after the patient is discharged to their home or to a facility for rehabilitation.  As physicians, we worry about the short-term mortality from vTe and pul-monary embolism, but delirium can be devastating for family members to watch, and carries its own morbidities. I talk to the patient and family preoperatively or immedi-ately postoperatively about this risk so they can be prepared. Mary M. Stephens, MD, MPHeast Tennessee state university, Kingsportz	 Evidence	summaryAlthough most patients undergo sur-gery for hip fracture, family physicians often serve as consultants for periop-erative management and rehabilitation. Several interventions have been studied that influence outcomes for hip fracture patients. Michael Grover, DO,  Frederick Edwards, MDDepartment of Family Medicine, Mayo Clinic Arizona, ScottsdaleKristin Hitchcock, MSiDepartment of Family Medicine, The University of Chicagofast trackDelay in operating after hip fracture was associated with increased  risk of death  in the hospitalfast trackwww.jfponline.com  vol 56, No 11 / November 2007 945Surgical	interventions:		Timing	is	criticalMost ambulatory, medically stable pa-tients elect to have surgical repair of their fractures. A meta-analysis found few ran-domized trials comparing operative with nonoperative therapy; it concluded that surgical treatment seems to be associated with a reduced length of hospital stay and improved rehabilitation.1The timing of surgery appears to be an important variable, particularly whether patients should undergo surgery within 24 hours of the fracture. Some studies found decreased mortality with earlier surgical intervention,2 while others have not.3 A 2006 observational study4 found that de-lay in operating was associated with an in-creased risk of death in the hospital, even after adjusting for comorbidities. For all deaths in the hospital, the odds ratio [OR] for delaying more than 1 day, relative to 1 day or less, was 1.27 (95% confidence interval [CI], 1.23–1.32). Despite the in-consistency regarding mortality rates, complication rates (such as decubitus ul-cers) do increase with a delay in surgery.3Unfractionated	vs	LMW	heparinAfter a hip fracture, patients are at very high risk for VTE. For untreated patients, the rate of deep vein thromboses (DVT) may be as high as 50%, with an associ-ated fatal pulmonary embolism rate as high as 7.5%.5The effectiveness of unfractionated and low-molecular-weight heparin was evaluated in a 2002 Cochrane systematic review.6 While evidence was insufficient to recommend 1 agent over another, both were found to significantly decrease the in-cidence of lower-extremity DVT over pla-cebo (for unfractionated heparin, relative risk [RR]=0.59 [95% CI, 0.49–0.72]; for low-molecular-weight heparin, RR=0.60 [95% CI, 0.50–0.71]). Number needed to treat [NNT] with either agent was 7.Reduce	infections		with	antibiotic	prophylaxisAntibiotic prophylaxis has been support-ed by a Cochrane review, which conclud-ed that single-dose antibiotic prophylaxis before surgery significantly reduced the risk of deep wound infections (RR=0.40; 95% CI, 0.24–0.67; NNT=55), as well as superficial wound, urinary, and respira-tory tract infections.7 Patients should receive antibiotics less than 2 hours before surgery to reduce the risk of infection.8 Classen et al found that patients treated less than 2 hours before surgery had a 0.6% rate of infec-tion (10/1208), compared with a 3.85% rate for those treated 2 to 24 hours ahead (14/369) (NNT=31).8 It is unclear whether multiple-dose therapy provides additional benefit when administered over the first 24 to 36 hours after surgery9 (OR=0.60; 95% CI, 0.18–2.02). First- or second-generation cephalosporins were used in most studies. Delirium:	A	common		but	avoidable	complication	Delirium is a common complication seen after hip fracture, affecting approximately 10% to 16% of patients.10,11 Delirium may increase the duration of hospitalization, and may be associated with an increased mortality at 1 year.12 Delirium can be avoided by looking at each patient’s risk factors.13 Studies suggest avoiding use of meperidine, benzodiazepines, and medica-tions with anticholinergic side effects.11,13 Sleep deprivation, delayed mobility, and inadequate pain control are also associ-6	steps	for	managing	hip	fracture	from		the	American	College	of	Physicians1.  Consider hospitalization for stabilization and surgical repair for most patients.2. Perform surgical repair as soon as the patient is medically stable.3. Administer prophylactic antibiotics to patients.4.  Provide adequate analgesia to all patients with hip fracture,  whether or not they undergo surgical repair.5. Treat all patients to reduce the rate of thromboembolic complications.6. Institute interventions to minimize the risk of postoperative delirium.Source: PIer: Physicians’ Information and education resource,  American College of Physicians, 2006.16 tablEInadequate  pain control is  associated with longer hospital stays and deliriumHip fracturefast track946	 vol 56, No 11 / November 2007  The Journal of family PracTiceCliniCal INquIrIesated with the development of delirium.13One study showed that prophylaxis with haloperidol for hip fracture patients did not decrease the incidence of postop-erative delirium but did reduce its duration and severity.14 Haloperidol prophylaxis was also associated with shorter hospital stays. Treatment with haloperidol or ris-peridone for the agitation of postoperative delirium has been recommended when be-havioral interventions fail.13Pain	control	improves	recovery	Providing adequate analgesia is of the ut-most importance. In a 2003 prospective cohort study, patients without sufficient analgesia had an increased risk of poor functional recovery and longer hospital-ization.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 de-lirium compared with other opioid analge-sics (RR=2.4; 95% CI, 1.3–4.5).11Recommendations	of	othersThe 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 The American College of Chest Physi-cians has published evidence-based guide-lines for the prevention of VTE.5 For pa-tients undergoing hip fracture surgery, they recommend routine use of fondaparinux, low-molecular-weight heparin at high-risk dosing, adjusted-dose warfarin (at a tar-get 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 de-layed, physicians should initiate prophy-laxis with unfractionated or low-molecu-lar-weight heparin at the time of hospital admission. Anticoagulation should rou-tinely continue for 10 days after surgery or until the patient is ambulatory. If an-ticoagulation is contraindicated, mechani-cal prophylaxis of VTE with foot and calf pumping devices is recommended.5,6   nreferences 1.  Parker mJ, Handoll HH, bhargara A. Conservative versus operative treatment for hip fractures. Co-chrane Database Syst Rev 2000; (4):CD000337  2.  Dorotka r, schoechtner H, buchinger W. The influ-ence of immediate surgical treatment of proximal fem-oral 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, Car-son 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 Con-ference on Antithrombotic and Thrombolytic Thera-py. Chest 2004; 126(3 suppl):s338–s400. 6.  Handoll HH, Farrar mJ, mcbirnie J, Tytherleigh-strong 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. Co-chrane 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. Preven-tion, 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, North-ern 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. rela-tionship 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 In-formation 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. Hal-operidol 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 fol-lowing hip fracture. Pain 2003; 103:303–311. 16.  Christmas C. Hip fracture. PIer: Physicians’ Infor-mation and education resource, American College of Physicians. updated July 2006. Available at: pier.acponline.org/index.html. october 11, 2007. To prevent  delirium after  surgery,  patients should avoid certain  medications, such as meperidine and benzodiazepines

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

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