Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Review: Recommendations for care of hip fracture are based on sound evidence

ACP J Club. 1998 Nov-Dec; 129:67. doi:10.7326/ACPJC-1998-129-3-067


Source Citation

Morrison RS, Chassin MR, Siu AL. The medical consultant's role in caring for patients with hip fracture. Ann Intern Med. 1998 Jun 15;128:1010-20. Erratum. Ann Intern Med. In press.


Abstract

Question

In patients with hip fractures, what recommendations for care are supported by evidence?

Data sources

Studies were identified by searching MEDLINE (1966 to June 1997) and by scanning the bibliographies of relevant studies.

Study selection

Studies were selected if they focused on medical decisions for patients with hip fractures. Studies on preoperative risk assessment, choice of anesthesia, or type of surgical repair were excluded.

Data extraction

Articles were independently reviewed by 2 investigators. The evidence was summarized, and the quality was rated according to the rating system of the U.S. Preventive Services Task Force. Systematic reviews of randomized controlled trials (RCTs) had the highest quality rating, and opinions of respected authorities had the lowest quality rating. Disagreements were resolved by consensus.

Main results

Study results were not combined because of heterogeneity. Recommendations based on study findings were made for care of patients with hip fractures. It was recommended that all patients receive prophylactic antibiotics and that the first antibiotic dose be given 0 to 2 hours before surgery to reduce postoperative infection (1 systematic review), that patients receive low-molecular-weight or low-dose heparin for thromboembolic prophylaxis unless contraindicated (2 systematic reviews and 6 RCTs), that patients at high risk for bleeding who cannot receive heparin be given aspirin unless contraindicated (1 systematic review and 1 RCT), and that patients use compression stockings(1 RCT). For nutritional management, it was recommended that all patients receive protein supplementation to reduce minor postoperative complications, preserve body protein, and reduce overall length of hospital stay (3 RCTs) and that nocturnal enteral feeding be considered in patients with moderate to severe malnutrition (1 RCT). Recommendations for urinary tract management were that indwelling catheters be removed within 24 hours and that patients be managed with straight catheterization (2 RCTs). For rehabilitation, it was recommended that interdisciplinary rehabilitation be used whenever possible (2 of 4 RCTs). For assessing falls, it was recommended that ambulatory patients exercise and receive balance training after hip fracture (1 systematic review) and that interventions be directed at specific risk factors to help prevent future falls(4 RCTs); these data for rehabilitation were not derived specifically frompatients with hip fractures. Evidence for the management of delirium and for surgical timing was weak.

Conclusion

In patients with hip fractures, evidence from systematic reviews and randomized controlled trials exists to support medical decisions for thromboembolic prophylaxis, nutritional management, urinary tract management, rehabilitation, and assessment of falls.

Source of funding: In part, Agency for Health Care Policy and Research.

For correspondence: Dr. R.S. Morrison,Department of Geriatrics, Box 1070, Mount Sinai School of Medicine, 1 Gustave L. Levy Place, New York, NY 10029, USA. FAX212-860-9737.


Commentary

The available research on the medical care of patients with hip fractures is poor. Morrison and colleagues carefully review and support the known therapies: antibiotic prophylaxis, deep venous thrombosis prophylaxis, nutritional support, rehabilitation, and urinary tract management.

The medical consultant or clinician must address several other difficult issues about what to try to correct before surgery, when to expedite surgery, and when to delay it. These are not well reported in the literature and are, by necessity, left out of this review. Detsky and colleagues' risk score (1) is useful for evaluating the cardiac risk associated with fracture repair.

Choosing not to operate often carries high risks. It is unlikely that delaying surgery for extensive medical or cardiac evaluation is of value, but little evidence exists on this topic. Whether to operate at midnight, within hours of a fracture, or to wait until the morning is also unanswered and must be judged on the basis of local hospital conditions.

The authors do not address the choice of surgical procedure, claiming it is in the surgeon's domain, but the decision should have medical input. Weighing the risks and benefits of pinning compared with hemiarthroplasty depends on the medical stability of the patient as judged by the medical consultant (2).

The evidence summarized by the authors on fall prevention is important, but osteoporosis evaluation and treatment are not covered. Surgeons do not currently evaluate patients with hip fractures for osteoporosis (Earl Bogoch presentation, Women's Health Matters Forum, Toronto, Ontario, Canada; January 1998); however, medical consultants should.

John A. Robbins, MD
University of California, DavisSacramento, California, USA


References

1. Detsky AS, Abrams HB, Forbath N, Scott JG, Hilliard JR. Cardiac assessment for patients undergoing noncardiac surgery. A multifactorial clinical risk index. Arch Intern Med. 1986;146:2131-4.

2. Soreide O, Alho A, Rietti D. Internal fixation versus endoprosthesis in the treatment of femoral neck fractures in the elderly. A prospective analysis of the comparative costs and the consumption of hospital resources. Acta Orthop Scand. 1980;51:827-31.