Lower maximum with liver disease or heavy alcohol use
NSAID option only if low renal and bleeding risk
Ibuprofen PO 400 mg every 6 to 8 hours
Avoid in CKD, active bleeding, high GI risk
Regional anesthesia
Fascia iliaca block
Ropivacaine 0.2% to 0.375% 30 to 40 mL total volume
Maximum local anesthetic dose per kg and product label
If anticoagulated, procedural bleeding risk assessment
Femoral nerve block
Bupivacaine 0.25% 15 to 20 mL
Continuous catheter pathway if available
Opioid rescue
Morphine IV 2 mg increments every 5 to 10 minutes
Hold if respiratory rate low or sedation increasing
Antiemetic option for nausea
Hydromorphone IV 0.2 mg increments every 5 to 10 minutes
Avoid stacking doses in frail older adults
Continuous pulse oximetry if repeated dosing
Perioperative optimization
Medical optimization targets
Fluids and perfusion
Balanced crystalloid bolus if hypovolemia
Avoid fluid overload in CHF
Oxygenation
Supplemental oxygen to maintain target saturation per COPD status
Incentive spirometry planning for admission
Temperature and comfort
Active warming for hypothermia
Shivering reduction to limit oxygen demand
Diabetes management
Sliding scale insulin per local protocol
Avoid hypoglycemia during NPO periods
Anticoagulation and bleeding management
Anticoagulation and reversal
Warfarin
Vitamin K IV 1 to 2 mg for elevated INR with planned surgery
PCC dosing per INR and weight for urgent reversal
DOACs
Last dose timing documentation
Renal function based clearance estimate
If life-threatening bleeding, specific reversal agent per DOAC type and local protocol
Antiplatelets
Aspirin continuation commonly acceptable for hip fracture surgery
P2Y12 inhibitor coordination with surgery and anesthesia
Infection prophylaxis and wound care
Surgical prophylaxis
Cefazolin IV 2 g within 60 minutes of incision
Cefazolin IV 3 g if weight based threshold met per local protocol
Redose interval per operative duration
Severe beta-lactam allergy alternative
Clindamycin IV 900 mg
Vancomycin IV weight based dosing per local protocol
Open fracture adjuncts
Broad spectrum coverage per open fracture grade
Tetanus status update
VTE prophylaxis
Thromboprophylaxis plan
Mechanical prophylaxis
Intermittent pneumatic compression if not contraindicated
Early mobilization planning
Pharmacologic prophylaxis
Enoxaparin 40 mg SC daily
Enoxaparin 30 mg SC daily if renal impairment per local threshold
Hold timing around neuraxial anesthesia per anesthesia protocol
Alternative agent if LMWH contraindicated
Unfractionated heparin 5000 units SC every 8 to 12 hours
DOAC prophylaxis only if explicitly chosen by surgical service
Operative management overview
Definitive management principles
Early surgery target
Surgery within 24 to 48 hours associated with improved outcomes
Delay only for reversible life-threatening medical issues
Femoral neck fracture approach
Nondisplaced fracture options
Percutaneous internal fixation
Weight-bearing plan per surgeon
Displaced fracture options in older adults
Hemiarthroplasty
Total hip arthroplasty in selected patients
Intertrochanteric fracture approach
Cephalomedullary nail for many unstable patterns
Sliding hip screw for selected stable patterns
Subtrochanteric fracture approach
Cephalomedullary nailing common
Plate fixation in selected cases
Special Populations
Pregnancy
Pregnancy considerations
Maternal stabilization priority
Left lateral tilt for late pregnancy to reduce aortocaval compression
Rh status planning if trauma and bleeding concern
Imaging selection
Radiographs with shielding when possible
MRI preferred for occult fracture if available
Medication safety
Acetaminophen preferred baseline
NSAID avoidance in later pregnancy
Consultation
Obstetrics for fetal monitoring based on gestational age
Anesthesia for regional technique planning
Geriatric
Geriatric priorities
Delirium prevention bundle
Vision and hearing aids access
Sleep protection and reorientation
Medication sensitivity
Avoid benzodiazepines when possible
Opioid dose reduction with slow titration
Bone health and secondary prevention
Osteoporosis evaluation planning
Vitamin D and calcium plan per admitting team
Discharge planning early
PT and OT consult timing
Safe home environment assessment
Pediatrics
Pediatric hip fracture approach
High-energy mechanism default
Full trauma evaluation and imaging as indicated
Associated injury screening
Non-accidental trauma consideration
Injury pattern inconsistency
Delay in presentation
Growth plate and AVN risks
Femoral neck fracture AVN risk higher than adults
Urgent orthopedic involvement
Dosing and analgesia
Weight-based acetaminophen
Regional anesthesia only with pediatric expertise
Background
Epidemiology
Epidemiology overview
Older adult fragility fracture predominance
Ground level falls as common mechanism
Female predominance due to osteoporosis burden
Outcomes importance
High 1-year mortality risk in frail older adults
High functional decline risk after fracture
System impact
Early surgery and multidisciplinary care linked to better outcomes
Delirium and immobility as major morbidity drivers
Pathophysiology
Pathophysiology essentials
Intracapsular fracture risk
Femoral head blood supply disruption risk
AVN and nonunion risk in displaced femoral neck fractures
Extracapsular fracture behavior
Greater soft tissue bleeding potential
Mechanical instability patterns in intertrochanteric and subtrochanteric regions
Frailty cascade
Pain leading to immobility
Immobility leading to atelectasis, VTE, pressure injury, delirium
Therapeutic Considerations
Why treatment choices matter
Regional anesthesia benefits
Opioid reduction
Delirium risk reduction signal in older adults
Early surgery rationale
Reduced complications from prolonged bedrest
Earlier mobilization enabling rehabilitation
VTE prophylaxis rationale
High baseline VTE risk from trauma and immobility
Mechanical plus pharmacologic strategies commonly combined
Evidence framing for practice
Multidisciplinary ortho-geriatric models associated with better functional outcomes
Perioperative optimization focuses on reversible risks rather than extensive delay
Patient Discharge Instructions
copy discharge instructions
Discharge instructions
Activity and mobility
Weight-bearing status exactly as prescribed by surgeon
Walker or crutches use until cleared
Wound and hygiene
Keep dressing clean and dry per instructions
Showering guidance per dressing type
Pain control
Acetaminophen schedule with daily maximum
Opioid only as needed with constipation prevention
Blood clot prevention
Anticoagulant or injection schedule if prescribed
Calf swelling or new shortness of breath as emergency signs
Return to ED now
Chest pain
Shortness of breath
Fainting
New leg weakness or numbness
Fever
Increasing redness, drainage, or severe wound pain
New inability to move or bear weight worse than baseline
Follow-up
Orthopedic follow-up date and location
PT appointment scheduling
Primary care follow-up for osteoporosis evaluation
References
Clinical guidelines and evidence sources
Source set and guidelines
AAOS clinical practice guideline for management of hip fractures in older adults
Early surgery and multidisciplinary care themes
Regional anesthesia and multimodal analgesia considerations
NICE guideline on hip fracture management
Orthogeriatric involvement
Early mobilization and delirium prevention
ACCP antithrombotic guidance for VTE prophylaxis in orthopedic surgery
LMWH as common first-line prophylaxis option
Mechanical prophylaxis adjunct
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