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fracture neck of femur (#NOF)

introduction

  • fracture NOF is a common ED presentation and timely recognition, analgesia, referral, ward admission for previon of decubitis ulcers, and care of comorbidities are required to ensure early surgery (preferably within 36 hours) which is required if one wishes to avoid increased risk of morbidity or mortality.

ED management of probable #NOF

  • oxygen - some evidence to support routine oxygen use in first 72 hours
  • nil orally
  • iv access
  • FBE, U&E, Glucose, LFT, clotting profile, calcium, phosphate, vitamin D levels
  • iv analgesia as needed
  • consider early fascia lata nerve block if patient distressed with pain
  • iv fluids as needed
  • 12 lead ECG
  • fascia lata block (see below under pain management) ASAP on clinical diagnosis and preferably before going to X-ray
  • CXR
  • AP and lateral hip XR
  • AP pelvis XR

if #NOF is confirmed

  • if fracture is subtrochanteric or extends inferiorly, then also do AP and lateral femur XR

early referral

  • medical or orthogeriatric team:
    • to optimise co-morbidities, ensure usual medications are given, etc.
    • to coordinate care and liaise with orthopaedic, anaesthetic and allied health teams
  • orthopaedic registrar - to arrange theatre time, etc.
  • anaesthetic registrar - early pre-op assessment and planning + can assist with analgesia / nerve block

pain management

nursing care

  • avoid urinary catheters unless indicated
  • regular urinary bladder scan post-void and if retention, consider in/out catheter rather than IDC
  • pillow under legs to ensure heels do not contact bed
  • early admission to a ward with pressure-relieving mattress ASAP to prevent decubitus ulcers
  • no evidence to support pre-operative traction

early theatre with early optimisation of medical care

  • aim for following afternoon or evening surgery
  • commence fasting (keep as short as possible) for theatre BUT give most of their usual meds, in particular, do NOT with-hold medications for Parkinson's or regular antipsychotics, BUT with-hold metformin, raloxifene and hormone replacement therapy
  • peri-operative diabetic Mx protocol
  • peri-operative warfarin Mx protocol for those patients on warfarin - need INR < 1.5 for ortho surgery
  • peri-operative anti-platelet agent Mx protocol
  • optimise medical care pre-op
  • thromboprophylaxis to prevent DVT
  • prophylactic antibiotics at induction - eg. 1g iv cephazolin followed by 2 further doses 8hrly.
  • consider blood transfusion if Hb < 80?
  • early recognition, Ix and Mx of delirium
nof.txt · Last modified: 2014/01/21 01:26 by gary1