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Hip Fractures

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Hip Fractures

Take home messages

  • The quicker you fix it, the better the outcome
  • General and regional anaesthesia are both fine, just avoid hypotension
  • 25% will get post-op delirium

LOL FLOF NOF?

Little old lady, found lying on the floor, suspected neck of femur fracture.

This is an increasingly common history, for a few reasons:

  • The population is getting older
  • They're also getting sicker (living with more chronic illness)
  • They're staying sat down inside and getting more osteoporosis
  • They're on more meds that cause dizziness and hypotension
  • They're living more independently (TV and deliveroo) than in care homes
  • We're recognising and responding to more hip fractures
๐Ÿ’ก
There were over 77 000 hip fractures in 2018 in the UK and Ireland.

Why are we operating on such risky patients?

Just north of 48% of patients with a hip fracture who don't have an operation die in hospital.

The number for those who do have an operation is a little over 6%.

"Yeah but clearly those not being operated on are the more comorbid patients who have a higher mortality anyway,"

Very good, however the mortality in ASA 5 patients who were operated on was still less than 25%.

So there.

Putting the bones back where they should be is also the best pain relief, and so operative management should be considered even if only as a palliative procedure.

Extracapsular fractures hurt more than intracapsular because there is significantly more periosteal damage, which is the sore bit.

"Hello, confused elderly person in enormous amounts of pain, we'd like to perform major emergency surgery that carries high mortality and morbidity risk - is that alright?"

Consenting for hip fracture surgery is tricky, because the patients are often confused and don't want to think about how risky the operation they don't want but need is going to be.

  • There is a balance to be struck between 'informing' the patient of the 'relevant' risks pertinent to their own situation, and not scaring the living daylights out of them
  • You should explain the options (regional, general, do nothing) and let them make the choice
  • It is reasonable to encourage towards your institution's preferred technique
๐Ÿ’ก
Use the Notting Hip Fracture Score.

What are the targets?

Absolute classic exam fodder.

Hip fracture targets

  • Surgery within 36 hours of presentation
  • Geriatrician assessment within 72 hours
  • AMTS preop
  • Bone protection assessment
  • Falls assessment
  • Nutritional assessment on admission
  • 4AT post op delirium assessment
  • Physio assessment the day of or day after surgery

The aim is doing surgery as soon and as safely as possible, to reduce pain, confusion and post-operative mortality and morbidity.

Regional or GA?

Ah the classic debate, hotly contested on both sides, with neither coming out on top.

The 2014 Anaesthetic Sprint Audit of Practice in England, Wales and Northern Ireland found relatively 50:50 split between spinal and GA.

There isn't a general rule, there is only what is best for the patient in front of you.

๐Ÿ’ก
The most important thing is to avoid hypotension.

A MAP less than 80 mmHg for more than 10 minutes will increase mortality significantly, so if you're holding much more than 75mg of bupivacaine in your spinal syringe, or 100mg-ish of propofol, maybe squeeze a little out beforehand.

Block it like it's hot

The trauma list is prime time for getting some good block experience in, with several options to choose from:

These don't provide complete anaesthesia so are usually done in addition to a spinal or general anaesthetic, largely because you want to avoid lots of opioids and NSAIDs in elderly patients with fractures and cognitive issues.

What nerves do we care about?

Femoral nerve

  • Longest branch of lumbar plexus
  • Comes from ventral rami of L2 - L4
  • Pops out of lateral border of psoas and descends between psoas and ilicaus
  • Divides into anterior and posterior branches
  • Motor supply to: hip flexors, knee extensors
  • Sensory supply to: anteromedial thigh, medial leg and foot

Obturator nerve

  • The obturator nerve arises from L2, L3 and L4 in the lumbar plexus
  • It then passes through psoas major, posterior to the common iliac artery
  • In the obturator canal it then branches into anterior and posterior branches
  • The anterior branch then heads through the fascia lata to become the cutaneous branch, which supplies the medial thigh

Accessory obturator nerve

  • Only present in up to 30% of patients
  • Originates from L2 - L4 ventral rami
  • Supplies hip joint and adductor longus as well as the medial capsule

Hip capsule

  • Divided into anterior and posterior
  • Anterior has nociceptive fibres
  • Posterior has mechanoreceptors

Fascia iliaca block isn't enough for hip fracture surgery as it doesn't catch the articular branches that leave the femoral nerve higher up.

PENG block also blocks the obturator and accessory obturator nerves.

Bone cement syndrome

Cemented hemiarthroplasty, by definition, carries with it the risk of BCIS, especially given our selected patient cohort is the highest risk group available.

Risk factors for bone cement syndrome

  • Elderly
  • Cardiovascular or respiratory disease
  • On Diuretics
  • Low BMI
  • Osteoporosis
  • Frailty

We won't go into more detail in this article, as we've written about BCIS separately if you're interested:

Bone Cement Implantation Syndrome
How to spot and manage BCIS
AnaestheasierAnaestheasier ltd.

Delirium

Being elderly and falling over with sufficient force to break your hip, then undergoing major emergency surgery involving class A drugs and bone saws can leave one feeling rather confused.

๐Ÿ’ก
25% of NOF patients will get post-op delirium.
  • A third will have some sort of cognitive issue prior to falling as well

Post operative delirium is an independent risk factor for mortality and dependent living.

The most important modifiable risk factors are:

  • Timely surgery
  • Avoiding hypotension
  • Judicious opioid use
  • Avoiding drugs with central anticholinergic activity
  • Avoid sedation if you can*

*A spinal and a good block will send most customers to sleep, but if you do need to sedate then use something short acting and titratable like propofol TCI.

The controversies

TIVA, gas, des, nitrous, video or direct - Anaesthesia is rife with controversy, because let's face it - we love a spot of drama.

Here are the main areas in hip fracture surgery where we can't quite seem to agree:

Operate or optimise?

  • Delaying surgery is a risk factor for basically every bad outcome
  • However if you delay in order to optimise something, maybe that's a good idea
  • But then again, much of the comorbidity in these patients is rather unmodifiable at this stage
  • The modifiable bits (electrolyte derangement, anaemia) can be fixed very quickly anyway, so shouldn't need a delay in surgery

Transfuse or tolerate?

  • Loads of these patients are anaemic
  • Some of them have then lost more blood from the injury
  • All of them lose more blood in theatre
  • Blood loss and anaemia is bad, but transfusions carry their own risk profile
  • Basically aim for an Hb of 90 in frail patients, and 100 in those with ischaemic heart disease
  • Use tranexamic acid if you're worried about bleeding (duh)

Echo or expedite?

  • A quarter of patients with a hip fracture also have a murmur
  • 10% have actual valve disease
  • ECHONOF-2 suggested a preop echo can influence anaesthetic technique
  • The AoA advise that you're not going to fix anything cardiac until you've fixed the hip, so just get on with it and whack in an arterial line

Bleed or Beriplex?

  • Lots of patients with hip fractures are already on anticoagulants of some sort
  • The 'rules' for neuraxial anaesthesia anaesthesia and anticoagulants are very conservative, and may cause more harm than benefit by delaying surgery
  • For hip fracture repair, single antiplatelet agent (aspirin, clopidogrel) is not a contraindication to spinal anaesthesia
  • If your patient is on dual antiplatelets, and is exceedingly high risk for GA, then neuraxial anaesthesia may still be considered on a case-by-case basis
  • If they're on warfarin, just get their INR below 1.5 with vitamin K - use prothrombin complex concentrate if still >1.5 six hours after vitamin K
  • If they're on a DOAC, you want to wait for two half lives of that agent, assuming their renal function is okay (which is usually the next day)
  • If their renal function isn't okay, measure anti-Xa levels and talk to haematology
  • Atrial fibrillation does not need bridging heparin
  • Metallic valves may need bridging - talk to haematology

How much spinal?

The official guidance is that less is more in elderly hip fractures:

  • Aim for less than 10mg bupivacaine (2ml of 0.5% heavy marcain)
  • If you're using an opioid, use fentanyl

However

  • Most anaesthetists use more (average of 2.5ml)
  • Half of patients get given diamorphine

The evidence suggests

  • 4mg (0.8ml) of bupivacaine diluted with saline to a volume of 2ml, with 20mcg fentanyl is sufficient for 110 min of hip fracture surgery
  • 10mg (2ml) isobaric bupivacaine with no opioid is also enough
  • Especially if you do a fascia iliaca block or equivalent as well

Both of these massively reduce the amount of hypotension and vasopressor requirement.

Just note that you need good communication between surgical and anaesthetic teams at team brief, to anticipate duration of surgery and likelihood of overrunning.

What should I do if the spinal's wearing off and they're still hammering?

Improvise, adapt, overcome.

  • Remain calm
  • Additional local anaesthetic infiltration
  • Cautious systemic analgesics
  • Convert to GA if required

Around three quarters of patients having hip surgery under spinal end up getting some form of sedation.

If you're going for GA

  • Avoid hypotension
  • Use BIS if you've got it
  • Avoid stuff that causes delirium
  • Make sure they're well filled
  • Keep them breathing if you can (use a second generation SGA if you're happy with aspiration risk)
  • Use a peripheral nerve block to reduce anaesthetic requirement

How long is it going to take?

Clearly this is going to vary significantly based on the surgeon, the patient and the fracture.

However, as a general rule, the following tend to apply:

Minimally displaced intracapsular fracture

  • Cannulated hip screws
  • Supine position on a high up traction table
  • 45 minutes ish

Intertrochanteric fracture

  • Dynamic hip screw
  • Supine position on a high traction table
  • 45 minutes ish

Displaced intracapsular fracture

  • Total hip replacement or hemiarthroplasty
  • Lateral or supine on a low table
  • 60 mins for hemi, 90 mins for total

Subtrochanteric

  • IM nail
  • Supine position on high traction table
  • 60 minutes ish

Afterwards

In an ideal world, every hip fracture would go to HDU after theatre, in the same way that in an ideal world, the entire hospital would be an HDU.

Realistically this isn't possible, and most of the time not necessary, but it's good to have a low threshold for HDU referral after surgery if there are any concerns or specific reversible issues that might be improved by HDU level care.

Move it move it

Arguably the most important post-operative interventions are:

  • Early mobilising
  • Rehabilitation
  • Maintaining cognition and avoiding delirium

To do this, you need orthogeriatrics, physiotherapy and cognitive screening in the immediate post op period.

There is a decent argument for having a completely standardised anaesthetic technique for each institution, so the post-op teams know what to expect in terms of post-anaesthetic care.

Useful Tweets and Resources

References and Further Reading

Primary FRCA Toolkit

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