Surgery should not be delayed by more than 48 hours unless early identified and reversible medical comorbidities present. 2īritish Orthopaedic Association Standards for Trauma However, nerve blockade is recommended, irrespective of the type of anaesthesia administered. 2 No evidence promoting general or regional anaesthesia exists. 2 The surgery should only be delayed if the benefits of additional medical treatment outweigh the risks of delaying surgery. 23, 26, 31Īnaesthesiologists are fundamental to the multi-disciplinary approach. 25 These patients suffer from a clustering of comorbidities 30 which have been shown in multiple studies to be a predictor of poor outcomes. The orthogeriatric unit should assess the patient prior to surgery. 29 As many as 50% of FNFs will be complicated by one or more grave and potentially avertible early complications such as venous thromboembolism (VTE), 7 delirium, pressure ulcers, cardiovascular events and infections such as urinary tract infections, surgical site infections and pneumonia. 2Ĭomprehensive, multi-disciplinary peri-operative care is essential. 25 The pain itself can lead to delirium however, caution should be taken in administering analgesia. Adequate prompt analgesia should be provided according to a pain management hierarchy throughout the patient hospital stay. Intravenous fluids are essential as up to 500 ml blood loss and subsequent hypovolemia, resultant fluid shifts 27 and electrolyte imbalances 28 occur with this injury. On admission, a thorough record of the patient’s cognitive status, 2, 25 pre-injury medical history, mobility and the use of walking aides must be taken to determine optimal operative intervention 25 and to predict patient outcomes. 24 The aim of pre-operative management is to ensure medical optimization and expedite surgical intervention. 22įNFs constitute an orthopaedic emergency. 17 A FNF in itself is a marker of systemic decline 23 and sub-clinical physiological changes which impair the body’s response to the trauma of the injury. 21 Elderly patients fall, 30–50% suffer from at least one fall per year, 22 which increases the risk of sustaining a FNF. 20 Alcohol consumption of more than 14 glasses per week in men aged 30–59 years increases the risk of sustaining a FNF. 19 There is a general increased fracture risk 19 which is five times in FNFs. 17 Globally there are currently over 36 million people living with human immunodeficiency virus (HIV), 18 the disease and antiretroviral therapies reduce bone mineral density. 6 Patients are often on systemic glucocorticoids treatment of more than three months, or at a dose of prednisolone of 5 mg daily or more increases the risk of sustaining a fracture. 6 The mean age is 80 years old and less than 5% occur before the age of 60 years. 10, 16 Females account for 80% of patients, and have an 11.4% lifetime risk at 50 years of age of sustaining a FNF, which is comparable to breast cancer. Advanced age is an independent risk factor for poor outcomes in FNFs.
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