01Approach to the Critical Patient/attcp36

Hemorrhagic shock and occult blood loss

›Occult hemorrhage risk

›Intertrochanteric fractures can lose 500-1500 mL into the thigh and retroperitoneum

›Tachycardia may be the sole early sign in elderly patients on beta-blockers

›Hypotension (SBP < 90 mmHg) mandates large-bore IV access and fluid resuscitation

›Two large-bore peripheral IVs or IO access if veins inadequate

›Hemodynamic targets

›MAP >= 65 mmHg

›Heart rate < 100 beats/min

›Urine output >= 0.5 mL/kg/hour

Cardiac precipitant evaluation

›Syncope or pre-fall prodrome

›Chest pain, dyspnea, or palpitations before fall suggest cardiac cause

›12-lead ECG within 10 minutes of arrival for all patients

›Troponin at admission; perioperative MI occurs in 35-41% of hip fracture patients

›New atrial fibrillation or heart block requires cardiology input before anesthesia

›Active cardiac event pathway

›If STEMI pattern on ECG, activate cath lab and defer elective fixation

›If acute decompensated heart failure, stabilize prior to operative planning

›Perioperative MI frequently silent; do not rely on symptoms alone

Immediate stabilization priorities

›Pain and immobilization

›Fascia iliaca compartment block or PENG block as early as possible (Class I, AAOS strong recommendation)

›Position of comfort with pillow support; no traction devices

›NPO immediately for surgical planning

›IV access, monitor, oxygen titrated to SpO2 >= 92%

›Escalation triggers

›Hemodynamic instability not responding to 1-2 L crystalloid — activate trauma/surgical team

02History/hx51

Mechanism and injury context

›Mechanism of injury

›Low-energy fall from standing height (predominant in elderly)

›High-energy trauma in patients under 65 (motor vehicle collision, fall from height)

›Pathologic fracture suspected with minimal trauma or known malignancy

›Pain characteristics

›Anterior groin and lateral hip pain

›Immediate inability to bear weight

›Worsening with any hip movement or log-roll

›Pre-fall prodrome

›Syncope or near-syncope preceding fall

›Chest pain or palpitations (cardiac precipitant)

›Dizziness or presyncope (orthostatic, arrhythmic, or vestibular)

Relevant medical background

›Osteoporosis and bone health

›Prior fragility fractures (wrist, spine, contralateral hip — 10% lifetime risk of second hip fracture)

›Bisphosphonate or denosumab therapy history

›Vitamin D and calcium supplementation status

›Anticoagulation status

›Warfarin with current INR

›Direct oral anticoagulants (apixaban, rivaroxaban, dabigatran) — last dose timing

›Antiplatelet agents (aspirin, clopidogrel)

›Indication for anticoagulation (AF, mechanical valve, DVT/PE history)

›Surgical risk comorbidities

›Coronary artery disease, prior MI, heart failure

›COPD or asthma (respiratory anesthesia risk)

›Chronic kidney disease (contrast, NSAID, antibiotic dosing implications)

›Diabetes mellitus (perioperative glycemic management)

03Physical Exam/exam44

Vitals and hemodynamic assessment

›Vital signs

›Tachycardia > 100 beats/min (occult hemorrhage or cardiac precipitant)

›Hypotension SBP < 90 mmHg (hypovolemic shock)

›Fever > 38.5 C (concurrent infection precipitating fall)

›Oxygen saturation (PE, aspiration, or cardiac event)

›Fluid status

›Dry mucosa and reduced skin turgor (dehydration from prolonged time on ground)

›Peripheral edema (cardiac or chronic venous insufficiency)

Hip and lower extremity exam

›Classic intertrochanteric fracture findings

›Affected limb shortened and externally rotated

›Ecchymosis over the lateral hip and proximal thigh (extracapsular hemorrhage)

›Tenderness on palpation over the greater trochanter and groin

›Severe pain with passive log-roll testing (do not force range of motion)

›Neurovascular assessment

›Distal pedal pulses bilaterally

›Capillary refill at toes

›Sensation over dorsal and plantar foot (sciatic and femoral nerve territories)

›Motor function of ankle and toe extension and flexion

Skin and pressure injury assessment

›Pressure injury screen

›Sacrum and heels examined (prolonged time on ground before discovery)

›Skin breakdown graded (Stage I-IV)

›Moisture-associated dermatitis from incontinence

›Wound assessment (if open fracture)

›Skin integrity over fracture site

›Wound size, contamination, and soft tissue compromise

04Differential Diagnosis/ddx46

Life-threatening and high-acuity diagnoses

›Hemodynamic emergencies

›Hemorrhagic shock from hip fracture with retroperitoneal extension

›ICD-10 T79.4 (traumatic shock)

›Occult blood loss up to 1500 mL

›Concurrent pelvic fracture with arterial injury

›High-energy mechanism

›Requires CT angiography and IR consultation

›Cardiac precipitants

›Acute myocardial infarction causing fall

›ICD-10 I21.9

›ECG and troponin diagnostic

›Pulmonary embolism causing syncope

›ICD-10 I26.99

›D-dimer and CT-PA if pretest probability moderate-high

›Acute arrhythmia (atrial fibrillation, heart block)

›ICD-10 I48.91

›Rate or rhythm control prior to anesthesia

Hip and proximal femur fracture differentials

›Intracapsular fractures

›Femoral neck fracture

›ICD-10 S72.00 series

›Surgical management differs (arthroplasty preferred in displaced fractures)

›Avascular necrosis risk higher than intertrochanteric

›Femoral head fracture

›Associated with hip dislocation

›Pipkin classification

›Extracapsular fractures

05Laboratory Tests/lt46

Core preoperative labs

›Complete blood count

›Hemoglobin baseline for transfusion planning

›Transfusion threshold Hgb < 80 g/L (asymptomatic patients)

›Higher threshold (Hgb < 100 g/L) if active cardiac disease or symptoms

›Platelet count for surgical risk

›Thrombocytopenia affects surgical timing and technique

›Basic metabolic panel

›Serum creatinine and eGFR

›Contrast safety for CT if planned

›NSAID avoidance threshold (eGFR < 60)

›Antibiotic dose adjustment

›Serum electrolytes

›Hyponatremia common in elderly and increases delirium risk

›Hyperkalemia may delay anesthesia

Coagulation and type and screen

›Coagulation studies

›PT/INR for warfarin management

›INR > 1.5 associated with increased surgical bleeding

›Reversal with vitamin K +/- 4-factor PCC if urgent surgery

›Anti-Xa level for LMWH monitoring if renally impaired

›Type and screen

›Mandatory for all hip fracture patients

›Blood loss can be significant intraoperatively

›Crossmatch if hemoglobin < 100 g/L or active hemorrhage

Cardiac biomarkers and monitoring labs

›Troponin

›Serial troponin at admission and 3-6 hours

06Diagnostic Tests/dt79

Scoring Systems

›AO/OTA Classification of intertrochanteric fractures

›Type A1: Stable, simple pertrochanteric, two-part fracture

›Intact medial cortex

›Sliding hip screw appropriate implant

›Type A2: Unstable, multifragmentary pertrochanteric

›Medial cortex disrupted

›Cephalomedullary nail strongly preferred

›Type A3: Reverse obliquity or transverse intertrochanteric

›Most unstable pattern

›Long cephalomedullary nail required

›Nottingham Hip Fracture Score (NHFS)

›Predicts 30-day mortality

›Variables: age, sex, MMSE, haemoglobin, comorbidity count, residential status, malignancy

›Score >= 6: high mortality risk; score <= 4: lower risk

›ASA Physical Status Classification

›Preoperative anesthetic risk stratification

›ASA III-IV patients benefit from anesthesia team involvement early

›ASA V: consider goals-of-care discussion

›Parker Mobility Score

›Pre-fracture mobility assessment predicts functional recovery

›Score 0-9 based on ability to walk indoors, outdoors, and shopping

›Score <= 3: unlikely to return to independent ambulation

MRI

›MRI hip indications

›Radiographically occult fracture (normal X-ray with persistent pain and inability to bear weight)

›Approximately 15% of hip fractures are not visible on initial plain films

›MRI sensitivity > 95% for occult fracture detection

›ACR Appropriateness Criteria: usually appropriate for acute hip pain with normal radiograph

›Pathologic fracture evaluation

›Bone marrow signal abnormalities

›Soft tissue mass assessment

›MRI protocol

›Coronal STIR and T1-weighted sequences

›Fracture line appears as low T1 signal with surrounding marrow edema

›Distinguishes fracture from contusion

›Gadolinium not required for fracture detection

›Contrast used if soft tissue neoplasm suspected

›MRI contraindications

›Cardiac pacemakers (unless MRI-conditional)

›Ferromagnetic implants

›Severe claustrophobia

›Alternative: CT if MRI unavailable or contraindicated

CT

›CT pelvis and hip indications

›Fracture pattern characterization for surgical planning

›Comminution assessment

›Lesser trochanter fragment size

›Posterior wall integrity

›Alternative to MRI for occult fracture if MRI contraindicated

›Sensitivity 87-94% for occult fractures

›Less sensitive than MRI for bone marrow edema

›High-energy mechanism with suspected concurrent pelvic fracture

›CT pelvis with or without angiography

›Hemorrhage source identification

›CT angiography

›Active arterial hemorrhage evaluation

›Indicated if hemodynamic instability with suspected vascular injury

›Identifies site for interventional radiology embolization

›CT scan limitations

›Radiation exposure (relevant in younger patients)

›Contrast nephropathy risk in CKD (eGFR < 30)

›Not routine — does not change surgical plan for most stable intertrochanteric fractures

Ultrasound

›Point-of-care ultrasound for nerve block guidance

›Fascia iliaca compartment block under ultrasound guidance

›Real-time needle visualization reduces complications

›ACEP ultrasound guidelines support use for regional anesthesia guidance

›Superior to landmark-based technique for local anesthetic spread

›PENG block (pericapsular nerve group block) under ultrasound guidance

›Targets articular branches of femoral and obturator nerves

›Preserves quadriceps strength (motor-sparing)

›JAMA 2025: peripheral nerve blocks reduce opioid use, delirium, and respiratory depression

›DVT ultrasound screening

›Lower extremity venous duplex

›Hip fracture patients have VTE risk > 40% without prophylaxis

›Not routinely recommended in asymptomatic patients but indicated if clinical concern

›Proximal DVT warrants full anticoagulation consideration

›Cardiac point-of-care ultrasound

›Volume status and cardiac function assessment

›IVC collapsibility for fluid responsiveness

›Wall motion abnormalities suggesting perioperative MI

›Pericardial effusion exclusion

07Disposition/dispo30

Admission criteria

›Admission indications

›All confirmed intertrochanteric hip fractures require inpatient admission

›Surgical management within 24-48 hours is standard of care

›Delay beyond 24 hours associated with 38% increase in complications and 74% increase in mortality

›Orthogeriatric co-management recommended for all elderly patients

›Associated with reduced complications, delirium, and length of stay

›ICU admission criteria

›Hemodynamic instability not responding to initial resuscitation

›Active acute coronary syndrome or arrhythmia requiring monitoring

›Severe respiratory compromise

›Need for invasive monitoring (arterial line, central venous access)

Surgical timing

›Target surgical window

›Within 24-48 hours of admission (strong AAOS and NICE recommendation)

›Early surgery reduces pain, delirium, pressure ulcers, and VTE risk

›Ultra-early surgery (< 12 hours) may provide additional benefit (Cochrane 2024)

›Medical optimization does not justify delays beyond 48 hours in most cases

›Correctable conditions (coagulopathy, electrolyte abnormality) should be addressed rapidly

›Non-operative management only for patients refusing surgery or with very limited life expectancy

Discharge destination

›Discharge planning begins at admission

›Most patients require inpatient rehabilitation or skilled nursing facility

›Only 25% of previously independent patients return directly home

›Social work consultation on day of admission

›Discharge criteria

›Pain controlled on oral medications

›Weight-bearing as tolerated with physical therapy clearance

08Treatment/t90

Immediate ED management

›Analgesia protocol

›Nerve block — first line (AAOS strong recommendation)

›Fascia iliaca compartment block

›Ropivacaine 0.5% 30-40 mL or bupivacaine 0.25% 30-40 mL

›Onset 10-20 minutes; duration 12-24 hours

›PENG block (pericapsular nerve group)

›Ropivacaine 0.5% 20 mL or bupivacaine 0.25% 20 mL

›Motor-sparing; preferred for ambulatory patients

›Multimodal systemic analgesia

›Acetaminophen 1 g IV/PO every 6 hours (standing, not PRN)

›Low-dose opioids for breakthrough

›Morphine 1-2 mg IV every 4-6 hours PRN

›Dose reduce by 50% in patients > 75 years or eGFR < 30

›NSAIDs: avoid in surgical candidates and patients with renal impairment

›Immobilization and positioning

›Pillow support between legs for comfort

›No traction (not recommended — AAOS)

›Pressure offloading for sacrum and heels

Anticoagulation reversal and bridging

›Warfarin reversal

›Target INR <= 1.5 for surgical safety

›Vitamin K 2.5-5 mg PO or 1-2 mg IV for urgent reversal

›4-factor prothrombin complex concentrate (4F-PCC) if surgery within 6-12 hours

›25-50 IU/kg IV based on INR

›Hold warfarin 5 days preoperatively if elective reversal acceptable

›DOAC management

›Last dose timing guides surgical clearance

›Apixaban and rivaroxaban: safe for surgery > 24 hours after last dose (low bleeding risk)

›Dabigatran: 48-72 hours if eGFR >= 50; longer if renal impairment

›No approved reversal agents for routine use; idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors if emergent

Surgical management

›Implant selection by fracture pattern

›Stable patterns (AO/OTA A1)

›Sliding hip screw (SHS)

›Dynamic compression at fracture site

›Lower implant cost than cephalomedullary nail

›Unstable patterns (AO/OTA A2, A3) — cephalomedullary nail (CMN)

›Short versus long nail based on subtrochanteric extension

›A3 and reverse obliquity patterns require long nail

›AAOS strong recommendation for CMN in unstable patterns

›Cephalomedullary nail reduces malrotation and varus collapse

›Anesthesia type

›Spinal versus general anesthesia

›No significant difference in 30-day mortality or ambulation at 60 days

›Spinal anesthesia associated with less postoperative cognitive dysfunction in some series

›Multimodal anesthesia with peripheral nerve block reduces intraoperative opioid requirement

Perioperative pharmacotherapy

›Antibiotic prophylaxis

›Cefazolin 2 g IV 1-2 hours preoperatively

›Repeat cefazolin 2 g IV if surgery > 3 hours or blood loss > 1500 mL

›Continue for 24 hours postoperatively

›Vancomycin 15 mg/kg IV if cephalosporin allergy or MRSA risk

›Infuse over 60 minutes to reduce infusion reactions

›Tranexamic acid (TXA)

›TXA 1 g IV at induction of anesthesia (strong recommendation)

›Reduces intraoperative and postoperative blood loss

›Reduces transfusion requirement

›Safe in most patients including those with renal impairment at standard doses

›Topical TXA 1.5-3 g (alternative or adjunct to IV route)

›VTE prophylaxis

›Chemoprophylaxis preferred over mechanical-only prophylaxis (ACCP and AAOS)

›Enoxaparin 40 mg SC daily (renal dose adjust if eGFR < 30: 20 mg daily)

›Start 12 hours postoperatively

›Continue for minimum 4 weeks

›Aspirin 81-325 mg daily (METRC trial: non-inferior to LMWH for VTE)

›Acceptable alternative in low-moderate risk patients

›Rivaroxaban 10 mg daily for 5 weeks (alternative DOAC)

›Mechanical prophylaxis (compression stockings, IPC devices)

›Use in addition to pharmacoprophylaxis

›Sole therapy only if pharmacoprophylaxis absolutely contraindicated

Blood transfusion

›Transfusion thresholds

›Restrictive strategy preferred

›Hgb < 80 g/L in asymptomatic, hemodynamically stable patients

›Hgb < 100 g/L if symptomatic anemia, active cardiac disease, or hemodynamic instability

›Transfuse packed red blood cells 1 unit at a time; reassess after each unit

Postoperative care

›Delirium prevention

›Minimize opioid dose (nerve blocks reduce opioid need)

›Avoid benzodiazepines as first-line for agitation

›Non-pharmacologic: early mobilization, frequent reorientation, avoid restraints, optimize sleep

›Haloperidol 0.5-1 mg IV for severe agitation if non-pharmacologic measures fail

›Monitor QTc

›Early mobilization

›Weight-bearing as tolerated beginning day of or day after surgery

›Early mobilization (< 24 hours) improves functional outcomes

›Physical therapy and occupational therapy throughout admission

›Nutritional support

›Oral nutritional supplementation high-protein (>= 1.2 g/kg/day protein)

›Reduces infective complications by 50%, pressure ulcers, and hospital length of stay

›Calcium 800-1000 mg/day and vitamin D 800-1000 IU/day

›Osteoporosis secondary prevention

›Bisphosphonate initiation typically 2 weeks post-surgery

›Alendronate 70 mg PO weekly or zoledronic acid 5 mg IV annually

›DEXA scan referral within 3 months for formal osteoporosis assessment

09Special Populations/sp74

Pregnancy

›Epidemiology in pregnancy

›Intertrochanteric hip fractures extremely rare in pregnancy

›When they occur, usually due to high-energy trauma or transient osteoporosis of pregnancy

›Pelvic and hip stress fractures more common than complete intertrochanteric fractures

›Imaging considerations in pregnancy

›Radiograph with abdominal shielding as first-line

›Fetal radiation dose from hip X-ray approximately 0.001-0.01 mSv (well below 50 mSv threshold)

›MRI preferred over CT for occult fracture in pregnancy

›No ionizing radiation

›Gadolinium avoided unless benefit clearly outweighs risk

›CT only if MRI unavailable and surgical planning requires it

›Treatment modifications in pregnancy

›Multidisciplinary team: orthopedics, obstetrics, anesthesia, perinatology

›Gestational age determines anesthesia approach

›Regional anesthesia (spinal) preferred over general anesthesia when possible

›Surgical fixation not delayed for stable pregnancy

›Fetal monitoring perioperatively

›Left lateral tilt positioning to relieve aortocaval compression

›VTE prophylaxis

›LMWH preferred (enoxaparin 40 mg SC daily adjusted for weight)

›Warfarin and DOACs contraindicated in pregnancy

Geriatric

›Epidemiology and outcomes in elderly

›Peak incidence in patients > 80 years

›30-day mortality approximately 10%; 1-year mortality 24-30%

›Men have higher excess mortality than women despite lower incidence

›Only 50% regain pre-fracture ADL function at 6 months

›Delirium is the most common postoperative complication in elderly

›Incidence 15-50% after hip fracture surgery

›Associated with increased mortality, hospital length of stay, and functional decline

›Modified assessment approach

›Frailty assessment (Clinical Frailty Scale or FRAIL scale)

›Frailty independently predicts 30-day mortality

›Modified goals of care discussion in severely frail (CFS 7-9)

›Delirium baseline assessment (CAM instrument)

›Pre-operative cognitive status determines reference point

›Medication reconciliation

›Polypharmacy (>= 5 medications) increases fall risk and adverse drug events

›Deprescribe fall-risk medications at discharge

›Analgesia modifications

›Nerve blocks particularly beneficial in elderly

›Reduces opioid requirement and opioid-related adverse effects

›Motor-sparing PENG block preferred to preserve early mobilization

›Opioid dose reduction

›Start at 25-50% of standard adult dose

›Titrate carefully; avoid PRN scheduling in cognitively impaired

›Orthogeriatric co-management

›Associated with 25-30% reduction in postoperative complications

›Shared care model: orthopedics primary with geriatric medicine input daily

›Targets: early surgery, early mobilization, delirium prevention, nutritional support

Pediatrics

›Epidemiology in pediatric patients

›Intertrochanteric fractures in children are uncommon

›Account for < 1% of pediatric hip fractures

›Typically require high-energy mechanism (motor vehicle collision, fall from height)

›Pathologic fractures possible with bone cysts or fibrous dysplasia

›Classification in children

›Delbet classification for pediatric hip fractures

›Type I: Transphyseal (includes intertrochanteric region)

›Type II: Transcervical (most common)

›Type III: Cervicotrochanteric

›Type IV: Intertrochanteric

›Physeal involvement must be assessed carefully

›Premature physeal closure can cause leg length discrepancy

›MRI helpful to assess physis

›Treatment approach in children

›Operative fixation for most displaced fractures

›Smooth pins or cannulated screws to cross physis only if necessary

›Avoid implants that violate growth plate when possible

›Avascular necrosis risk significantly higher in children than adults

›Risk 15-50% depending on fracture type and displacement

›Early surgery reduces AVN risk

›Weight-based dosing for pain management

›Acetaminophen 15 mg/kg PO/IV every 6 hours (max 75 mg/kg/day)

›Morphine 0.05-0.1 mg/kg IV every 4-6 hours PRN (max 5 mg/dose)

›Ultrasound-guided fascia iliaca block: bupivacaine 0.25% 0.5-1 mL/kg (max 20 mL)

10Background/b71

Epidemiology

›Incidence and demographics

›Approximately 300,000 hip fractures occur annually in the United States

›Intertrochanteric fractures account for approximately 50% of all hip fractures

›Global incidence projected to increase 3-fold by 2050 due to aging populations

›Age and sex distribution

›Predominantly affects women > 65 years (3:1 female-to-male ratio)

›Mean age at presentation approximately 80 years

›Risk doubles every 5-6 years after age 50

›Mortality and morbidity

›30-day mortality approximately 10%

›1-year mortality 24-30% even with optimal treatment

›Men have disproportionately higher excess mortality than women

›Functional outcomes

›Only 50% of patients regain pre-fracture ADL function at 6 months

›25% never return to independent ambulation

›25% of previously independent patients return directly home from hospital

›Economic burden

›Average hospitalization cost exceeds USD 30,000

›Hip fractures account for majority of fracture-related healthcare expenditure globally

Pathophysiology

›Fracture mechanism

›Low-energy falls in elderly

›Combination of osteoporosis (reduced bone quality) and fall risk (reduced neuromuscular protection)

›Impact typically on the greater trochanter or lateral hip

›Fracture propagates along lines of least resistance between trochanters

›High-energy trauma in younger patients

›Requires substantial force given normal bone density

›Associated injuries (pelvic, abdominal, thoracic) more likely

›Anatomy of the intertrochanteric region

›Extracapsular location between greater and lesser trochanters

›Abundant blood supply from circumflex femoral arteries

›Avascular necrosis risk much lower than intracapsular (femoral neck) fractures

›Cortical and cancellous bone mix

›Medial calcar femorale integrity determines fracture stability

›Loss of posteromedial cortical support creates unstable pattern

›Osteoporotic bone biology

›Reduced trabecular density and cortical thickness

›T-score < -2.5 corresponds to > 2.5 SD below peak bone mass

›Each SD reduction in T-score approximately doubles fracture risk

›Impaired bone remodeling

›Uncoupling of osteoclast resorption and osteoblast formation

›Accelerated in postmenopausal women due to estrogen withdrawal

›Hemorrhage physiology

›Intertrochanteric region contains medullary cavity and perforating vessels

›Blood loss 500-1500 mL typical (extracapsular hematoma)

›Intraoperative blood loss adds to total; TXA reduces this significantly

Therapeutic Considerations

›Evidence base for surgical timing

›Surgery within 24-48 hours reduces mortality and complications (Class I, AAOS)

›Delay > 24 hours: 38% increase in complications, 74% increase in mortality

›Ultra-early surgery (< 12 hours): emerging evidence from Cochrane 2024 meta-analysis

›Medical optimization should not delay surgery beyond 48 hours

›Correctable conditions (coagulopathy, electrolytes) addressed rapidly

›Non-operative management reserved for those refusing surgery or with terminal illness

›Implant selection evidence

›Cochrane 2022 network meta-analysis

›Cephalomedullary nail superior to sliding hip screw for unstable (A2/A3) patterns

›Sliding hip screw equivalent to CMN for stable (A1) patterns with fewer implant failures

›No advantage to cemented versus uncemented implants for intertrochanteric region

›Regional anesthesia evidence

›Fascia iliaca block and PENG block

›JAMA 2025 clinical evidence review: peripheral nerve blocks reduce opioid use, delirium, and respiratory depression

›Motor-sparing PENG block facilitates early post-block mobilization

›VTE prophylaxis evidence

›METRC trial (NEJM 2023): aspirin 81 mg non-inferior to enoxaparin for VTE prevention after fracture

›No significant difference in DVT, PE, or bleeding events

›Aspirin preferred option in some guidelines for lower-risk patients

›Duration: minimum 4 weeks recommended regardless of agent

›Nutritional supplementation evidence

›Oral protein supplementation (>= 1.2 g/kg/day)

›Cochrane-level evidence: reduces infective complications by approximately 50%

›Reduces pressure ulcers and hospital length of stay

›Vitamin D 800-1000 IU/day combined with calcium reduces refracture risk

11Patient Discharge Instructions/pdi44

copy discharge instructions

›Understanding your hip fracture surgery

›You had an intertrochanteric hip fracture — a break in the upper femur (thigh bone) just below the hip joint

›This was repaired with a metal implant (sliding hip screw or nail) that holds the bone while it heals

›Bone healing typically takes 3-6 months; the implant remains permanently

›Activity instructions

›Weight-bearing as tolerated with your walker or crutches as instructed by your physiotherapist

›Do not put more weight than advised on the operated leg until your surgeon clears you

›Avoid high-impact activities (running, jumping) for at least 3 months

›Gentle walking with your walking aid is encouraged from day one after surgery

›Hip range-of-motion restrictions: follow your surgeon's specific instructions

›Avoid extreme hip flexion, adduction, or internal rotation until advised

›Wound care

›Keep wound dry until sutures or staples are removed (typically 10-14 days)

›Waterproof dressing for showering once advised by your nurse

›No submerging in bath, pool, or hot tub until wound fully healed

›Pain management at home

›Acetaminophen (Tylenol) 500-1000 mg every 6 hours as needed for pain (maximum 4 g/day)

›Take with food if it upsets your stomach

›Prescribed opioid pain medication: use only as needed for severe pain not controlled by Tylenol

›Opioids cause constipation — take stool softener (docusate 100 mg twice daily) while using them

›Do not drive or operate heavy machinery while taking opioid medications

›Blood clot prevention

›Take your prescribed blood thinner (aspirin, enoxaparin, or rivaroxaban) exactly as directed

›Blood clot prevention medication is typically required for 4-6 weeks after surgery

›Signs of deep vein thrombosis: leg swelling, redness, warmth, or pain in the calf or thigh

›Signs of pulmonary embolism: sudden chest pain, shortness of breath, or coughing blood

›Both require immediate return to the emergency department

12References/r30

Guidelines and key sources

›Schroeder JD, Turner SP, Buck E. Hip Fractures: Diagnosis and Management. American Family Physician. 2022

›Comprehensive primary care and emergency reference for hip fracture diagnosis and management

›PMID 36521464

›Switzer JA, O'Connor MI. AAOS Management of Hip Fractures in Older Adults Evidence-Based Clinical Practice Guideline. Journal of the American Academy of Orthopaedic Surgeons. 2022

›Definitive North American orthopedic guideline for hip fracture management

›Covers implant selection, surgical timing, VTE prophylaxis, perioperative care

›Bhandari M, Swiontkowski M. Management of Acute Hip Fracture. New England Journal of Medicine. 2017

›Classic NEJM clinical practice review covering all aspects of acute hip fracture care

›PMID via NEJM: 10.1056/NEJMcp1611090

›Liu YT, Tovar Hirashima E, Yadav K. Peripheral Nerve Blocks for Hip Fractures. JAMA. 2025

›JAMA evidence review confirming opioid reduction, delirium reduction, and respiratory benefit from nerve blocks

›10.1001/jama.2025.0999

›METRC, O'Toole RV et al. Aspirin or Low-Molecular-Weight Heparin for Thromboprophylaxis after Fracture. NEJM. 2023

›Non-inferiority trial: aspirin 81 mg equivalent to enoxaparin for VTE prevention post-fracture

›Informs VTE prophylaxis choice in hip fracture patients

Cochrane reviews

›Lewis SR et al. Cephalomedullary Nails Versus Extramedullary Implants for Extracapsular Hip Fractures in Older Adults. Cochrane Database of Systematic Reviews. 2022

›Supports CMN for unstable intertrochanteric fracture patterns; SHS equivalent for stable patterns

›Viamont-Guerra MR et al. Ultra-Early Versus Early Surgery for Hip Fracture. Cochrane Database of Systematic Reviews. 2024

›Emerging evidence supporting surgery within 12 hours for additional benefit

›Handoll HH et al. Multidisciplinary Rehabilitation for Older People With Hip Fractures. Cochrane Database of Systematic Reviews. 2021

›Evidence base for orthogeriatric co-management and multidisciplinary rehabilitation

Additional references

›Guasti L et al. Cardiovascular Diseases, Prevention, and Management of Complications in Older Adults After Hip Orthopaedic Interventions. European Journal of Preventive Cardiology. 2025

›ESC consensus statement on cardiac management in hip fracture patients

›PMID 39812215

›Bartolotta RJ et al. ACR Appropriateness Criteria Acute Hip Pain: 2024 Update. Journal of the American College of Radiology. 2025

Evidence & Review

Evidence & Review