Falls are common among older people, often resulting in fractures, particularly the neck of femur. Hip fractures can have serious consequences, with a mortality of 10% at 1 month after fall, 20% at 4 months and 30% at 1 year. The average age of patients who fall and fracture their femur neck is over 80 and 75% of these are females. Recent evidence finds that a delay in surgery beyond 48h after injury is associated with higher risk of mortality and an increase in length of postoperative recovery¹.

Fractures cause significant pain which can be exacerbated by movement. Several factors can make pain control in the elderly more difficult than in younger patients ANZCA chapter 11.2.4., p 402.

• Co-morbid diseases and concurrent medications
• Diminished functional status
• Age-related changes in pharmacodynamics and pharmacokinetics
• Altered pain responses
• Difficulties in pain assessment, including problems related to cognitive impairment and communication.

Evidence based recommendations specific to hip fracture in the elderly

There is little research into postoperative analgesic regimens targeted specifically at fractured neck of femur surgery. However, there is a large systematic review by the PROSPECT group on postoperative analgesia after hip replacement. It may be possible to apply many of the recommendations to fractured neck of femur surgery. PROSEPCT/Total hip arthroplasty/PROSPECT final recommendations

Pre-& intraoperative:

Whenever possible, patients should be given multimodal pain management therapy.

• COX-2 selective NSAIDs, nonselective NSAIDs, and calcium channel α-2-δ antagonists (gabapentin and pregabalin) should be considered as part of a postoperative multimodal pain management regimen.
• Unless contraindicated, patients should receive an around-the-clock regimen of NSAIDs, COXIBs, or acetaminophen. ASA section V Multimodal techniques for Pain Management, p 253-254.

Spinal anaesthesia is the preferred choice. Adding 0.1 mg morphine to the local anaesthetic solution can provide up to 24h postoperative pain relief.

If general anaesthesia is used, postoperative pain should be controlled with continuous peripheral nerve block (psoas or femoral block) French section 10.3.2, page 408

Postoperative

Strong opioids (i.v opioid PCA). Opioids are effective analgesics but older patients generally require less opioid than younger patients, therefore, careful titration at appropriate dose intervals is required to prevent undesirable side-effects such as increased sedation, confusion, nausea, constipation and respiratory depression French section 5.4, p 405; ANZCAchapter 11.2.4 p 403.

Issues related to nursing /monitoring of patients

• Avoidance of dehydration.
• Early surgery 24-48 after injury
• Avoidance of over transfusion
• Early ambulation.
• Monitoring effects of opioids.

Summary

There is little evidence targeted specifially at managmenet of pain in patients after head of femur fractures. Much of the evidence from management of hip replacement is probably transferable. Thus, spinal anaethesia is the recommended mode of anaesthesia and analgeisa. If not available, strong systemic opioids and non-opioid analgesia should be provided with appropriate monitoring of patients. Surgery should not be delayed.

Supplementary reading

1. Griffiths R, Alper J, et al Management of proximal femoral fractures 2011: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia. 2012 Jan;67(1):85-98.
2. Khan SK, Kalra S, Khanna A et al. Timing of surgery for hip fractures: a systematic review of 52 published studies involving 291,413 patients. Injury 2009;40:692-7
3. National Hip Fracture database. www.nhfd.co.uk
4. Ummenhofer W, Suhm N. Fractured neck of femur: guidelines and beyond. Anaesthesia. 2012 Jan;67(1):2-4.