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.

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

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

commence pain chart early
fascia lata / fascia iliacus nerve block within 60 minutes of clinical diagnosis and ideally BEFORE going for X-ray
parenteral / oral analgesics as appropriate and with care
remember, either untreated pain or parenteral opiates and opioids may cause delirium

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
Western Health P&P: Pressure ulcer prevention (WH intranet only)

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