DEFINITIONS 

Geriatric hip fracture - a patient ≥ 65 years of age with a femoral neck, intertrochanteric, or subtrochanteric femur fracture. Patients < 65 years old and patients with other fractures (e.g., distal femur and tibia shaft) may be appropriate for this protocol and should not be automatically excluded. 

GOALS OF CARE 

Role of the Trauma Team: 

Patients should be initiated on this pathway who meet the following requirements or as per the clinical judgement of the treating clinician: 

• Triage complaint of concern for hip fracture 

OR 

• Patient age > 65 years old or from a facility with either of the following: 

• History of fall and pelvis, hip or lower extremity pain 

OR 

• Inability to bear weight 

When a patient with a suspected hip fracture who meets the above criteria is identified in the Emergency Department, the ED physician’s role is to perform the following: 

• Offer appropriate analgesia prior to obtaining x-rays 

• Minimize IV opioids as much as possible to prevent delirium  

• IV Tylenol and Toradol 

• Perform fascia iliaca block upon presentation, if possible 

• Order appropriate x-rays 

• AP Pelvis 

• AP and cross-table lateral of the affected hip (not frog leg lateral as this can displace a fracture). The femoral head and neck must be visible for adequate interpretation. 

• AP and lateral views of the full femur to exclude distal fracture, presence of total knee arthroplasty, or any other pathology 

• Chest x-ray (one view) 

• Once a hip fracture has been confirmed, multiple actions should be triggered 

• Make NPO and start IV fluids 

• Obtain pre-operative labs/studies including CBC, BMP, Magnesium, Phosphate, Calcium, Vitamin D 25-Hydroxy, PT/INR, PTT, Type and Screen, EKG 

• Place 2 large bore IVs ASAP to run fluid/blood, etc. and avoid delays in the OR 

• Place a foley catheter 

• Contact Medicine and Orthopedic Surgery services  

• Determination of admitting service to be made between Trauma and Medicine services 

• Orthopedic co-management 

• If admitted to Trauma service, a Geriatric Trauma Consult will also be made 

• Write the hospital admission order ASAP 

• If patient remains in the ED for 1 hour without a bed assigned, place a Medical Consult order ASAP and contact the medical consult team (TigerConnect) for urgent preoperative risk stratification and medical optimization recommendations. 

• Consult appropriate medical subspecialty services as needed (i.e. Nephrology for ESRD patient on HD, Cardiology for active cardiac symptoms) 

• If a hip fracture is clinically suspected but x-rays are indeterminant, obtain a non-contrast MRI of the femur (or CT if MRI is contraindicated or unable to be obtained within 24 hours)  

Internal Medicine Responsibilities: 

• See and evaluate patient in a timely fashion 

• If the patient is in the ER and has a pending Medicine admission without a bed assigned within 14 hour, the Medicine consult service will see the patient promptly as above. The nocturnist in the CDU will be expected to see the patient after discussing with the medical consult resident.  

• Pre-operative evaluation and stabilization 

• The goal is to identify and treat correctable co-morbidities as quickly as possible so that surgery is not delayed by: 

• Anemia; goal Hg > 8 

• Anticoagulation: See recommendations below for coumadin reversal, antiplatelet and NOAC management, and heparin bridging 

• Volume depletion 

• Electrolyte imbalance 

• Uncontrolled diabetes  

• Uncontrolled heart failure  

• Correctable cardiac arrhythmia or ischemia 

• Acute chest infection 

• Exacerbation of chronic chest conditions 

• Document H&P including pre-operative risk stratification ASAP and include any outstanding co-morbidities that need to be optimized before surgery 

• Risk Stratification should happen overnight for all AM cases as above. Geriatric hip fractures will be operatively prioritized as soon as risk stratification is complete. 

• See “Risk Stratification Summary Guidelines” below 

• Consult relevant sub-specialty teams deemed critical to preoperative evaluation ASAP.  

• If the patient remains in the ED, the ED is responsible for placing consult orders and contacting consult services as recommended by the Medical Consult team 

• Cardiology for preoperative evaluation ASAP if: 

• Active Acute Coronary Syndrome (i.e. ischemic EKG changes, elevated troponin, anginal symptoms) 

• Unstable arrhythmia 

• Decompensated heart failure (order stat TTE) 

• Known moderate to severe aortic or mitral valve stenosis without TTE in the past 12 months (order stat TTE) 

• Mechanical or recent bioprosthetic heart valve (probably not necessary for bioprosthetic valve – but up to you, we’ll be happy to see the patient).  

• Also order stat TTE if: 

• Known HFrEF, extensive cardiac history, and no recent cardiac workup (within 12 months). This has downstream value to the anesthesiology team and can affect post-op location. 

• If requested by cardiology service. 

• Echocardiogram is not necessary in patients when there is no reasonable level of clinical concern that the patient has significant cardiac dysfunction, as it will likely delay surgery. May forgo TTE if deemed unnecessary by cardiology consultation.  

• Stress tests may be indicated in the setting of symptoms that suggest ACS or impending ACS. In such cases, cardiology consultation is advised to expedite care and decision making.  

• Prompt optimization of co-morbidities 

• Prompt communication with the orthopedics team regarding consults called and remaining 

• Start discharge planning at the time of admission. 

• Consult social work, PT and OT 

• Verify emergency department orders entered or completed upon admission to the floor. 

Patients on Coumadin1: 

Risk of thrombosis during an interruption in anticoagulation must be weighed against the risk of bleeding intraoperatively and postoperatively. In general, surgical repair of a hip fracture, particularly with arthroplasty, is considered high bleeding risk (can be further stratified by Orthopedic Surgery based upon intervention required for repair).  

Inclusion criteria for Coumadin reversal: 

Patients taking Coumadin for Atrial fibrillation with: 

• CHA2DS2-VASc < 7 

• No stroke/TIA within 3 months PE/DVT:  

• Not within 3 months 

• No severe thrombophilia history 

• No recurrent VTE, particularly with prior discontinuation of anticoagulation 

All other patients (including those with mechanical or prosthetic heart valves and those  not meeting inclusion criteria above) need to be evaluated with the medicine and/or cardiology service on a case-by-case basis.  

Coumadin Reversal Guidelines: 

• Goal INR is </= 1.5 

• If INR > 2.0, hold coumadin and give phytonadione (vitamin K) 2.5mg – 5mg po stat x1 and repeat stat INR in 8-12 hours. Repeat dose of phytonadione if INR remains above 2.0.  

• If INR </= 2.0, FFP can be used on the way to the OR  

Bridging Guidelines1: 

• Bridging therapy is indicated when INR is below goal in the following situations considered to be high thromboembolic risk, unless major bleed/ICH within 3 months: 

• For mechanical heart valves (Consider Cardiology consultation) 

• Any mechanical mitral valve prosthesis 

• Caged-ball or tilting disc aortic valve prosthesis 

• Stroke or TIA within 6 months 

• Consider with bileaflet aortic valve prosthesis and additional thromboembolic risk factor 

• Recent (within 3mo) surgical bioprosethetic heart valves on VKA
   

• For atrial fibrillation: 

• CHA2DS2-VASc >/= 7 

• Stroke/TIA within 3 months 

• For PE/DVT (Consider Hematology consultation):  

• Within 3 months 

• For recurrent VTE, particularly with prior discontinuation of anticoagulation 

• For severe thrombophilia 

Patients on dual antiplatelet therapy/DAPT (Aspirin + clopidogrel, prasugrel, ticagrelor, cilostazol): 

• Continue aspirin 

• Continue DAPT if: 

• Acute Coronary Syndrome 

• Drug-eluting stent/DES placement within 6 months and no ACS 

• Bare metal stent/BMS placement within 1 month and no ACS 

Patients on NOACs (apixaban, rivaroxaban, edoxaban, dabigatran)1:  

• Hold and document date and time of last dose as accurately as possible 

• To reduce risk of bleeding, the ideal timing of the last dose should be: 

• For rivaroxaban, apixaban, edoxaban: >/= 48hours 

• For dabigatran: >/=48hrs if CrCl >/= 50mL/min or >/= 96hrs if CrCl </= 50mL/min 

1Refer to “Adult Perioperative Anticoagulation Management” guideline posted on the CCH intranet 

Patients on dialysis:  

• Investigate normal dialysis schedule and most recent dialysis 

• Contact renal/dialysis team ASAP to coordinate next session  

• Dialysis is typically needed prior to urgent/emergent surgery, unless last session was within 24-48 hours 

Delirium prevention: 

• A) Minimize opioids/benzodiazepines  

• B) Do not take away glasses, hearing aids, false teeth etc. 

• C) Allow relatives to stay with patient  

• D) Use room lighting to mimic normal night/day cycle 

Orthopedic Surgery Responsibilities: 

• See and evaluate patient in a timely fashion 

• Consult H+P – at a minimum: 

• Laterality 

• Age 

• Mechanism 

• Preoperative functional status and ambulatory aids 

• Presence of antecedent hip pain 

• Additional injuries 

• Comorbidities 

• Social situation (i.e. - lives alone, with family, in nursing home) 

• If patient does not have capacity, identify and appropriate contact information for medical decision maker  

• Verify appropriate imaging ordered/obtained  

• Discuss patient with chief resident and attending on call 

• OR logistics 

• Post case to surgical schedule and contact OR coordinator 

• Contact implant companies (IMN, ORIF, hemi/THA, cement, etc.) 

• Select correct OR table/position  

• Obtain surgical consent from patient or authorized representative 

• Mark patient for laterality 

• Discuss plan of care with patient and family and provide educational materials 

• Consider crossmatching PRBCs for significantly anemic patient, particularly if requiring arthroplasty 

• Traction is not indicated for geriatric hip fractures. For subtrochanteric fractures or patients that remain uncomfortable despite adequate medical pain control, discuss placement of traction pin with chief resident and/or attending 

• Wound care recommendations including suspected post op bleeding in wound area 

• Weight bearing status 

• Physical and occupational therapy orders  

• Perioperative medication orders:  

• Surgical antibiotic prophylaxis 

• Cefazolin IV (weight based) infused 30 minutes prior to incision 

• Minimization of blood loss 

• Tranexamic acid (1 gram) infused 30 minutes prior to incision  

• Hold if patients have family/personal history of unprovoked VTE or are at increased risk of VTE  

• DVT prophylaxis  

• Sequential compression devices should be used for all patients while an inpatient  

• Subcutaneous heparin or low molecular weight heparin upon arrival and prior to surgery 

• Hold if dose will be administered less than 12 hours before surgery  

• Postoperatively, patients should be discharged with low molecular weight heparin and then transitioned to aspirin when fully ambulatory 

Anesthesiology Responsibilities:  

• The Anesthesia team should consult the Acute Pain Service (TigerConnect) as soon as the consult is called by the ED service and let them know (situation dependent) that we are planning an urgent/emergent case within 24hrs. 

• Information to be provided to APS resident: 

• Date/time of anticipated surgery and attending surgeon’s name. 

• Patient’s current anticoagulation status (i.e., pharmacological, coagulopathy, liver failure) and anticipated postoperative anticoagulation plan (i.e., DVT prophylaxis, therapeutic anticoagulation for underlying comorbidities). 

• NPO status (specific time and type of last PO intake). 

• Once the patient is admitted, the Anesthesia resident will evaluate the patient ASAP and follow up medical con follow up medical consult and/or cardiology recommendations  

• Consent patient as soon as they are aware of the patient 

• Recommendations to be staffed with attending and note published in chart within 6 hours or prior to 6am if overnight 

• Any regional blocks for pain control may be performed on the floor or in preoperative holding area prior to surgery, per the available resources of the Acute Pain Service. This is in addition/supplementation to the regional block (fascia iliaca) performed by the ED service upon initial presentation. The intraoperative primary anesthetic for the case will either be general anesthesia or a spinal/epidural as per the discretion of the attending orthopedic surgeon and attending anesthesiologist for the case. 

Risk Stratification Summary Guidelines 

1. Hip Fractures are not elective; they are urgent operative cases with a goal of surgical stabilization in less than 24 hours to reduce the risk of mortality and morbidity. 

2. Identify any acute medically modifiable risks that can be mitigated within a short window (e.g. improved status within 1-2 days). A delay of surgery is not appropriate unless there are clearly modifiable concerns that can be addressed within a 24- 48 hour time window.  Ultimately, the surgical team is responsible to present these risks and benefits to the patient as part of the informed consent process. 

3. Provide a comprehensive medical summary for all teams to reference (in the form of the H&P). Anesthesiologists refer to these notes to assess risk and identify all the salient points that may affect perioperative management. The comprehensive perspective of internists has downstream value to other providers.   

4. Echocardiograms should be performed on anyone with a low EF, extensive cardiac history and no recent cardiac workup, and whenever indicated by clinical assessment (through history and exam). This has downstream value to the anesthesiology team and can affect post-op location. A recent echocardiogram or any other cardiac workup from our hospital system or outside hospital is acceptable. Every effort should be done to provide this information in the patient record or include it in the consulting risk stratification note. 

• Echocardiogram is not necessary in patients when there is no reasonable level of clinical concern that the patient has significant cardiac dysfunction, as it will likely delay surgery.  

5. Stress tests are indicated in the setting of symptoms that suggest ACS or impending ACS, but the surgery is not elective, and the AHA/ACC guidelines therefore only apply tangentially.  

Key Interventions Summary 

1. Identify geriatric hip fracture patients early in the ED and flag them to be screened for inclusion in this protocol 

1. Trigger this protocol as soon as a candidate is identified: 

1. Early notification of orthopedics, medicine, and anesthesiology 

2. Notification to OR Charge RN of anticipated surgery date/time, and request for immediate notification of anesthesiologist on call (or anesthesiology clinical coordinator if weekday) 

2. Perioperative medications 

1. Surgical antibiotic prophylaxis 

1. Cefazolin IV (weight based) infused 30 minutes prior to incision 

2. Minimization of blood loss 

1. Tranexamic acid (1 gram) infused 30 minutes prior to incision  

1. Hold if patients have family/personal history of unprovoked VTE or are at increased risk of VTE  

3. DVT prophylaxis  

1. Sequential compression devices should be used for all patients while an inpatient  

2. Subcutaneous heparin or low molecular weight heparin upon arrival and prior to surgery 

3. Hold if dose will be administered less than 12 hours before surgery  

4. Postoperatively, patients should be discharged with low molecular weight heparin and then transitioned to aspirin when fully ambulatory 

3. Early interactions between patient/family and DC planning 

1. Education/ material in the ED on likelihood of DC to SNF by MD’s and RN’s 

2. Continued education on floor 

3. Early interactions with DC planning during hospital stay 

4. Standardized pain control: 

1. Standing IV Acetaminophen started in the ED 

2. Fascia iliaca block (by ED service) if possible, and repeated as needed perioperatively +/- the use of an epidural catheter for perioperative analgesia 

3. Minimize narcotics 

5. Delirium control: 

1. Assess delirium 

2. Avoid delirium 

3. Treat delirium 

6. Standardized order set 

7. Clear delineation of orthopedic surgery and internal medicine roles  

8. Improved communication between all disciplines of health care professional involved in the care of these patients 

GOALS OF CARE 

Timing and sequence for the treatment of long bone fractures in multiply injured patients: 

• Response to resuscitation, lactate/ABG trends should be closely monitored 

• Hemodynamically stable patients 

• definitive fixation/reduction/splinting within 24 hours of clearance by the trauma team 

• Hemodynamically unstable patients 

• external fixation/reduction/splinting at first OR visit or once cleared by the trauma team 

• temporary splinting for all fractures in the Emergency Department 

Time to wound coverage:  

• Timing of definitive soft tissue coverage will vary per patient based on complexity of wound and burden of other traumatic injuries. Ideally, this should occur at the time of definitive fixation. The latest time to coverage from definitive fixation should be 5 days afterwards.  

Sequence for fractures associated with Vascular Injury requiring repair  

• External fixation or provisional skeletal stabilization first 

• Provisional vascular repair or shunt 

• Definitive skeletal stabilization and/or vascular repair/reconstruction when appropriate  

DEFINITIONS - Since it is common to underestimate the time from injury to restoration of blood flow, by default, all complicated extremity injuries will receive a complete fasciotomy unless all involved faculty members believe the fasciotomy is unnecessary based on known ischemic time and physiology. The involved faculty should have a brief but focused discussion regarding priorities of care and the need for fasciotomy. Ultimately, the final decision to perform a fasciotomy is the responsibility of the attending trauma surgeon. At the conclusion of the case, the primary surgeon will call the trauma faculty if a fasciotomy was not performed prior to leaving the OR. 

GOALS OF CARE 

Absolute indications for fasciotomy: 

• ischemic time of >4 hours or unknown ischemic time 

• compartment syndrome unequivocally diagnosed on physical exam 

Relative indications for fasciotomy: 

• combined skeletal and vascular trauma 

• ischemic vascular injury associated with shock 

• combined arterial and venous injury 

• crush injury 

Which service performs the fasciotomy: 

• Orthopedic service – any extremity with a fracture or dislocation 

• Trauma service – all other patients 

• Vascular service – will perform the fasciotomy at the time of vascular repair 

Potential pitfalls: 

• Failure to recognize in compartments other than the calf – i.e., thigh 

• Incomplete fasciotomy 

• Damage to nerves 

• Complications of rhabdomyolysis and severe electrolyte derangements – i.e., hyperkalemia, hyperphosphatemia 

CROSS REFERENCE 

• Leg (calf) compartment syndrome: 

• https://www.orthobullets.com/trauma/1001/leg-compartment-syndrome 

• https://www.wheelessonline.com/bones/tibia-fibula/fasciotomy-of-the-leg/ 

• Thigh compartment syndrome: 

• https://www.orthobullets.com/trauma/1063/thigh-compartment-syndrome 

• Hand and forearm compartment syndrome: 

• https://www.orthobullets.com/trauma/1064/hand-and-forearm-compartment-syndrome 

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