Geriatric Hip Fracture ORIF
Patient phenotype
80-95 years old, falls from standing height, multiple comorbidities (CAD, AF on anticoagulation, CKD, dementia, sarcopenia). Often delirious from pain + opioids before arrival. Mortality 5-10% at 30 days, 25% at 1 year.
Procedure
Cephalomedullary nail (intramedullary device) for intertrochanteric fracture, OR hemi/total hip arthroplasty for femoral neck fracture. Lateral position. ~60-90 min.
Anesthetic plan
Spinal preferred when feasible (less delirium, less DVT). GA acceptable. Pre-op fascia iliaca block at admission for pain control + reduces opioid need. EARLY surgery (< 24-48h) improves outcomes.
Setup
- ·Standard ASA + temp
- ·A-line if any cardiac concern (most have)
- ·Two PIVs
- ·Type & cross 2 units
- ·Fascia iliaca block kit (often done in ED)
- ·Forced air warmer (these patients hypothermic easily)
- ·DVT prophylaxis already started
Biggest concerns by phase
Don't over-optimize — early surgery wins
AHA, ACC, AAOS all agree: surgery within 24-48h of fracture reduces mortality + complications. Don't delay for 'optimization' that won't change. Continue aspirin. Withhold anticoagulants per ASRA + surgeon. Cardiac eval but don't over-test.
Anticoagulation timing for neuraxial
ASRA guidelines: ASA continue, warfarin reverse with PCC (not just hold), DOACs hold 24-48h depending on agent + renal function, LMWH hold 12h prophylactic / 24h treatment dose. If neuraxial impossible, use GA + fascia iliaca block.
Spinal vs. GA — outcome data favors neuraxial
Less delirium, less DVT, less blood loss, possibly less mortality. Spinal: hyperbaric bupi 0.75% 8-12 mg (low dose, lateral fracture-side-down to keep block focal). GA: low-dose etomidate or ketamine + minimal opioid + fascia iliaca block.
Cement fixation — high BCIS risk in elderly
Cemented hemi has highest BCIS risk in this age group. Surgeon may use cementless if comorbidity profile bad. Pre-cementing: optimize volume, vasopressor ready, communicate with surgeon, reduce ventilation pressures briefly.
Positioning — fragile skin, joint flexibility, lateral decub
Padding everywhere. Axillary roll for dependent shoulder. Eye check. Pillow between legs. Safety strap loosely positioned. Don't force range of motion.
Delirium prevention — multimodal pain, early mobilization
Delirium affects 30-60% of geriatric hip fracture patients. Prevention: minimize benzos + opioids, treat pain (multimodal — block + APAP + scheduled), reorient frequently, normal sleep-wake, hearing aids/glasses, family presence, ambulate POD 0-1.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
88-year-old female, intertrochanteric fracture, came from home. AF on apixaban (last dose 18 hours ago), creatinine 1.4. Holding warfarin per orthopedist. Surgeon wants to do ORIF tonight under spinal. What do you do?
What an examiner probes for
- ▹Apixaban + 18h + CrCl ~50 = neuraxial NOT yet safe (ASRA: 24-48h)
- ▹Options: delay surgery 12-24h vs. GA + fascia iliaca block
- ▹Discuss with surgeon + ortho: time-to-OR vs. anesthesia choice
- ▹If GA: consider opioid-sparing technique to reduce delirium
Sources
- AAOS Hip Fracture Clinical Practice Guidelines
- ASRA 2018
- Bateman Anesthesiology 2019 (mortality)
Anatomy reference
Sourced reference images. 4 matches for "hip femur joint".
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