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Terms of Use The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-forprofit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. 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Unauthorized use of the In the Clinic slide sets constitutes copyright infringement. © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View menu, select the Slide Show option * To help you as you prepare a talk, we have included the relevant text from ITC in the notes pages of each slide © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. in the clinic Hip Fracture © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. What medical comorbid conditions increase the risk for falls and hip fracture? Advanced age (>75 years) Sensory impairments (i.e., hearing or vision loss) Conditions causing gait instability or abnormal proprioception Depression Muscular weakness Orthostatic hypotension Impaired cognition Using ≥4 medications long-term, alcohol, or benzodiazepines Osteoporosis © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. What are the mechanical risk factors for hip fracture? Mechanical risk factors Gait instability Foot deformities Environmental hazards at home Home safety evaluations recommended for older people who have fallen or have risk factors for falls © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. What is the role of bone densitometry in assessing risk for hip fracture? To diagnose osteoporosis and predict fracture risk 1-SD decrease BMD at femoral neck = 2.6 RR hip fracture Risk factors warranting bone densitometry: History of fracture Glucocorticoid use Family history of fracture Cigarette smoking Excessive alcohol intake Low bodyweight Note: Repeated screening is no more predictive of subsequent fracture than original measurement © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. Fracture risk assessment tool (FRAX): Predicts 10-y risk for hip fracture in untreated men and women 40-90 yrs (w/ or w/out BMD) FRAX Tool: Estimate 10-yr risk for fracture: Free calculation tool: www.shef.ac.uk/FRAX • Age • Sex • Height • Weight • Ethnicity (US calculator only) • Optional item: femoral neck BMD Yes/no: • Previous fracture • Parent with hip fracture • Current smoking • Glucocorticoid use • Rheumatoid arthritis • 2° osteoporosis • ≥3 units of alcohol/day Factors most predictive of osteoporotic fracture: History previous low-impact fracture Low BMD © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. What pharmacologic interventions can prevent hip fracture? Calcium and vitamin D Bisphosphonates (alendronate, risedronate, ibandronate, zoledronic acid) HRT: estrogen (*several health risks) Selective estrogen-receptor modulators: raloxifene, risedronate Anabolic: parathyroid hormone, strontium renelate Calcitonin (less potent than others) Monoclonal antibody: denosumab © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. What is the role of exercise in preventing hip fracture? Can reduce risk factors* for falls and fractures Particularly balance training, t'ai chi *Risk factors Physical inactivity Inability to rise from chair w/o using the arms Gait instability Lower-extremity weakness Hip protectors may also reduce risk Effectiveness unclear, compliance poor © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. Screening and Prevention © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. What is the differential diagnosis of hip fracture? History & physical exam and X-rays usually distinguish fracture from other conditions Pathologic fracture Septic hip joint Pelvic fracture Dislocation Osteoarthritis Soft tissue injury Osteonecrosis Trochanteric bursitis Rheumatoid arthritis affecting hip Meralgia paresthetica (nerve entrapment) Lumbar spine disease(spinal stenosis, arthritis, disk disease) Paget disease of bone © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. What are the important elements of the history when hip fracture is suspected? Trauma (esp fall from standing with impact on hip) Hip pain (in groin, buttock; referred to knee or thigh) Inability to bear weight or pain with weight-bearing Circumstances surrounding fall Previous minimal trauma fracture or loss of height Risk factors for osteoporosis and fracture CVD and other comorbid conditions Premorbid function © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. What are the important elements of the physical when hip fracture is suspected? Position and length of limb + gentle ROM determination ? leg shortened, externally rotated, abducted when supine Musculoskeletal and neurologic survey ? evidence concomitant injury; ? head trauma Distal motor, sensory, and vascular integrity of affected limb ? interruption of neurovascular blood supply Cardiac and general physical exam ? unstable comorbid illness: may need presurgical management ? conditions associated with osteoporosis Mental status testing Delirium present in up to 60% with hip fracture © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. What are the different types of hip fracture? Classified by area of upper femur affected Intracapsular at level of head and neck of femur Intertrochanteric between neck of femur and lesser trochanter Subtrochanteric below lesser trochanter Classified by whether displacement present © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. What other injuries commonly occur with hip fracture? Soft tissue injuries Other sites of fracture Head trauma DVT, skin ulceration, pneumonia, rhabdomyolysis If patient remained on the ground for prolonged time © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. What radiographs and other imaging studies are used? Radiographs For diagnosis and determining if surgical repair warranted Obtain plain anteroposterior pelvis and lateral radiographs MRI Evaluate for occult fracture if clinical suspicion high despite negative plain radiographs Bone scan To diagnose fracture in patients who cannot undergo MRI May take up to 72 hours to register as positive © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. Diagnosis © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. When should conservative therapy be considered? Consider for Patients too ill for surgery or anesthesia Patients bed- or wheelchair-bound before injury If modern surgical facilities unavailable Do not use skeletal or skin traction No evidence beneficial and associated with risks Conservative vs. surgical therapy Similar mortality, medical complications, long-term pain But surgery offers better chance for functional recovery © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. During what time frame should surgery be performed? As soon as patient is medically stable Postpone if ≥ 1 unstable medical condition Active heart failure Ongoing angina Serious infection Hemodynamic instability (correct before surgery) © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. How is the appropriate surgical approach determined? Fracture location & severity of displacement Femoral neck fracture Internal fixation with screws (if nondisplaced or minimally displaced in younger patient) Prosthetic replacement (if displaced or poor bone quality, joint disease, or excessive propensity to fall) Intertrochanteric fracture Sliding screws or similar devices (minimally invasive surgery lowers blood transfusion rate but not mortality) Subtrochanteric fracture Intramedullary nail or screw-plate fixation (intramedullary nail may provide better outcomes) © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. Should preoperative cardiac risk be assessed in all patients having surgery? Only in patients with comorbid cardiac conditions Unstable coronary syndromes Decompensated heart failure Significant atrial arrhythmias or ventricular arrhythmia Severe valvular disease Revascularization before surgery Beneficial if cardiac conditions severe or unstable β-blockers for patients with CAD or high cardiac risk © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. What is the expected mortality of hip surgery? Surgical-specific mortality: 2%-3% most U.S. hospitals However…hip fracture confers 5-fold increase in all-cause mortality for women 8-fold increase in all-cause mortality for men (in first 3 months after fracture, compared with age- and sex-matched controls) © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. What are the major postoperative complications of hip fracture? Infection Dislocation and failure of prosthesis Delirium DVT Skin breakdown Bladder problems Complications may occur years after repair Osteonecrosis of femoral head after internal fixation Loosening of the prosthesis after arthroplasty Persistent pain © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. When should rehabilitation begin following surgery and what are the goals? Patients should get out of bed on 1st postoperative day Progress to ambulation as soon as tolerated Prevents pressure ulcer formation, atelectasis, pneumonia, muscle weakness Goal: Regain ambulation and independence ? best strategies Studies mostly small, methodologically limited © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. What is the role of prophylactic antibiotics for patients having surgery for hip fracture? Decrease deep wounds, superficial wounds, UTI Give 1st dose before surgery Continue for 24 hours after surgery Cephalosporins commonly used 44% lower risk infectious complications with antibiotic use vs. placebo 40% reduction of infection with multiple vs. single doses © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. What are the major components of pain management for hip fracture? Use adequate analgesia Improves patient comfort Facilitates rehabilitation Decreases the risk for delirium Avoid meperidine strong risk factor for delirium © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. How common is thromboembolism following a hip fracture, and should it be prevented and treated? DVT: up to 50% if not treated prophylactically Fatal PE: 1.4%-7.5% within 3 months after surgery Use prophylaxis unless contraindicated Fondaparinux, low-dose unfractionated heparin, adjusted-dose vitamin K antagonist, or LMWH Begin before surgery if procedure likely to be delayed Restart once postop hemostasis demonstrated Use up to 28-35 days after surgery © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. What is the correct approach to secondary prevention in patients with hip fracture? Evaluation return of function Monitor for late postop complications Institute secondary prevention measures Osteoporosis education and treatment Fall prevention Modify risk factors: Poor vision, muscular weakness, certain medications, environmental factors 2.5% have 2nd hip fracture in the first year 8.2% have 2nd hip fracture within 5 years © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. Treatment and Management © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. What should patients be told about immediate care after a fall and the detection of hip fracture? Fracture repair: usually on day 1 or 2 of hospitalization Rehabilitation: usually begun 1st day after surgery Rehab facility: for 2 weeks before return home Assistance at home: required for several months Further therapy: required for several months ≈50% regain ambulatory status Function gains mostly in first 6 months © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1. Patient Education © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (11): ITC6-1.