An 84-year-old woman is brought to the emergency department for hip pain after a fall from her bed. Her medical problems include hypertension, type 2 diabetes mellitus, coronary artery disease, and mild cognitive impairment. She is ambulatory and lives on her own, requiring only a home health aide to drive her around. The patient's temperature is 36.1 C (97 F), blood pressure is 160/85 mm Hg, pulse is 102/min, and respirations are 18/min. Physical examination shows an obese and alert elderly woman. She has an ecchymotic area on the lateral aspect of the left thigh. Her left leg is rotated outward and looks shorter than the right leg. X-ray of the hip reveals a left-sided intertrochanteric hip fracture. The patient's family members call for a meeting with the treating team to discuss whether surgical repair should be performed. Which of the following is the most appropriate statement about the patient's condition?

Question

An 84-year-old woman is brought to the emergency department for hip pain after a fall from her bed.  Her medical problems include hypertension, type 2 diabetes mellitus, coronary artery disease, and mild cognitive impairment.  She is ambulatory and lives on her own, requiring only a home health aide to drive her around.  The patient's temperature is 36.1 C (97 F), blood pressure is 160/85 mm Hg, pulse is 102/min, and respirations are 18/min.  Physical examination shows an obese and alert elderly woman.  She has an ecchymotic area on the lateral aspect of the left thigh.  Her left leg is rotated outward and looks shorter than the right leg.  X-ray of the hip reveals a left-sided intertrochanteric hip fracture.  The patient's family members call for a meeting with the treating team to discuss whether surgical repair should be performed.  Which of the following is the most appropriate statement about the patient's condition?

Quizplus · Accepted Answer

Explanation: Hip fractures due to falls are common in the elderly and are classified as either intracapsular (femoral head and neck) or extracapsular (intertrochanteric or subtrochanteric). Femoral neck fractures typically present with pain without significant ecchymoses and have a higher risk of avascular necrosis. Extracapsular fractures are at higher risk for displacement and usually have visible ecchymosis, as in this patient. Both types of fractures should be evaluated by an orthopedic surgeon as most require surgical correction with either arthroplasty or open reduction with internal fixation. In elderly patients who are stable and ambulatory prior to the fracture, surgery within 48 hours is associated with lower mortality and a lower risk of pressure ulcers and pneumonia (Choice E). (Choice A) Studies have shown no benefit of traction in reducing pain or improving the quality of hip fracture reduction. Routine use of traction in hip fracture is not advised. (Choice B) Nonoperative management is reserved for patients who are nonambulatory, are demented, have end-stage terminal illness, have an old nondisplaced or impacted fracture, or are unstable with major comorbidities. Advanced age alone is not a contraindication to surgery. (Choice C) Surgery may be delayed briefly (up to 72 hours) to stabilize acute, life-threatening medical conditions, but longer delays are associated with an increased risk of complications. Preoperative cardiac stress testing prior to non-cardiovascular surgery is generally advised only if it would otherwise be indicated in the absence of surgery. medical conditions Educational objective: Hip fractures in the elderly are common and should be managed with early surgery (<48 hours) in patients who are ambulatory and stable. Nonoperative management is reserved for those who are nonambulatory, have advanced dementia, or are medically unstable. References: Management of hip fracture: the family physician's role. (http://www.ncbi.nlm.nih.gov/pubmed/16836036) Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/20837683)

An 84-Year-Old Woman Is Brought to the Emergency Department for Hip