The Acute Medical Management of Patients with Fractures Dr Gary Heyburn

Introduction
The modern day management of fracture patients involves close liaison with a variety of specialities especially medicine and anaesthesia. Almost half the patients are over the age of 65 years and are plagued by the twin problems of polypharmacy and significant co morbities. Intense medical involvement is often required to ensure patients receive optimal treatment. This manual highlights common perioperative problems. I hope it will be of some use to junior doctors, medical students and nursing staff.

CONTENTS
1. Introduction 2. Ward Routine 3. Rota 4. Management of hip fracture patients 5. Hip fracture: optimization for surgery 6. The Older Patient with a Hip Fracture : The Medical Perspective 7. Pain Management in the Hip Fracture Patient 8. Pulmonary embolism 9. Fat Embolism 10. Alcohol withdrawal 11. Amiodarone Protocol 12. Protocol for the Prophylaxis of Venous Thromboembolism for
the Trauma Unit

13. Management of the patient admitted on warfarin 14. Current antibiotic guideline 15. Transfusion thresholds 16. Acute Orthogeriatric Care in the Perioperative period 17. Informing the Coroner 18. Model death certificate and covering letter 19. Delirium check list 20. Analgesia for the older patient with a fracture 21. Management of diabetic patients during orthopaedic surgery 22. Management of metastatic bone disease from unknown primary 23. Osteoporosis Management 24. The Renal dialysis patient 25. Transferring an older patient with a fracture

Ward Routine
The working day starts at 8am sharp The Foundation 1 doctors attend the Hospital at Night handover at 8am The F1s then attend the daily fracture unit X ray meeting in the Seminar room in Fracture clinic. After the x ray meeting there is a team meeting with the Physicians During this meeting all the inpatients in the fracture service are discussed The Physicians are particularly interested in patients with hypoxia, hypotension, cardiac arrhythmias(AF) and reduced urinary outputs After this meeting doctors should rapidly go to their wards (not to the canteen !) as the early morning period can be extremely busy. Junior doctors should ensure they get regular breaks throughout the working day and should leave promptly when their shifts are over. The doctor should ensure that tasks such as writing up routine fluids and warfarin prescriptions are done by the end of the day shift. The ward Physician should be informed at the earliest opportunity about any planned leave or unexpected illness involving the ward doctors Remember to review all blood results at the end of the working day and act on any abnormalities detected- this is especially true at weekends Punctuality is essential Endeavour at all times to be a team player and remember the wealth of experience that many of your nursing colleagues possess

Insert sample rota:

Points to remember in the management of hip fracture patients

Take a careful history particularly with regard to the fall. Does the patient fall often? How many falls in the last year? Does the patient blackout? Was the fall witnessed? Was there a postural element? Ensure the patients medications are prescribed promptly. Nursing Homes / GPs and other appropriate sources should be contacted as soon as possible to verify drugs and drug doses. Sedatives and psychotropic medications are associated with falls whilst diuretics and antihypertensives can exacerbate postural hypotension Ensure mini mental scores are recorded on admission. This essential element of the admission can facilitate delirium management or the detection of subdural haematomas. Investigate systolic murmurs by echocardiography ( it is especially important to identify aortic stenosis as this condition can impact on anaesthetic technique) Ensure bloods are done as soon as possible to enable early surgical intervention- older patients will not go to theatre unless the basics have been done Remember to erect intravenous fluids on all the older patients with a hip fracture (unless a contraindication exists) Anaesthetists expect ECGs and (when appropriate) CXRs to be available in the immediate preoperative period Many patients are now on warfarin and the management of their anticoagulation will depend on the indication for taking this medication. Normally surgery can proceed when the INR is less than 1.5. In the preoperative period surgery can rarely proceed if more than enoxaparin 40mg sc bd is used. Older patients with a hip fracture are at risk of thromboembolism and should be prescribed enoxaparin 40 mg sc nocte unless a contraindication exists

Ensure all patients are prescribed appropriate analgesia and AVOID ALL NSAIDS AND COX2 INHIBITORS IN THE PERIOPERATIVE PERIOD

Patients who require inhalers should also be prescribed nebulisers in the perioperative period. Remember alcohol abuse as a cause of falls. Help to confirm the diagnosis with LFTS and remember to check the coagulation screen and platelet count. Prescribe chlordiazepoxide.

Clopidogrel (Plavix) is being increasingly used in cardiovascular disease. It is mandatory to determine why the patient is on plavix. If the patient has had cardiac stents inserted in the last year then cardiology should be contacted prior to stopping the plavix;. Elective patients should if possible be off this medication for 7-10 days. Emergency patients cannot wait this long and currently our hips go to theatre after 72 hours have elapsed.

Implantable Cardioverter Defibrillators (ICDs) are being used more commonly. These devices often have to be turned off during surgery. Contact Cardiology when patients are admitted with these devices. Do not assume that all subcutaneous devices on the anterior chest wall are just pacemakers they just might be an ICD as well.

Many patients are admitted who are being treated with aspirin. If the condition for which they are taking this medication is stable the aspirin can usually safely be held and enoxaparin substituted

HIP FRACTURE: OPTIMIZATION FOR SURGERY

Is the patient optimized for theatre? The following parameters can be helpful in reaching this conclusion when the orthogeriatrician is unavailable: 1. Oxygen saturations greater than 90 % either off oxygen or on low dose oxygen (28%). 2. Absence of a tachycardia. 3. Satisfactory blood pressure (systolic greater than 90 mmHg) 4. Optimised Haemoglobin 5. Optimised urea + electrolytes. 6. Absence of a significant pyrexia. 7. Does the patient need an ECHO? 8. Are there any anticoagulation problems (INR should be1.5 or less) /is the platelet count satisfactory( remember the effect of drugs such as plavix)?

The Older Patient with a Hip Fracture : The Medical Perspective

The following has been adapted from the following articles with full references : Heyburn G, T Beringer.Hip fracture 1 .Preoperative management GERIATRIC MEDICINE VOL 31 NUMBER 9 SEPTEMBER 2001 PAGES 1721 Heyburn G, T Beringer.Hip fracture 2. Peri- and post-operative management. GERIATRIC MEDICINE VOL 31 NUMBER 10 OCTOBER 2001 PAGES 37-42

INTRODUCTION A recent paper in the BMJ suggested that elderly females would rather die than suffer a hip fracture that resulted in loss of independence and admission to a nursing home.1 Are hip fractures that bad? EPIDEMIOLOGY There were 66 000 hip fracture admissions in England and Wales in 1997/98 2 and this corresponds to an incidence of greater than 1:1000 of the general population. The numbers are rising (see Fig 1) with the majority of patients being female and over the age of 75 years. The lifetime risk of a hip fracture is 16-18% in women and 5-6% in men. At the age of 80 years one in five females has had a hip fracture rising to one in two at 90 years of age.3

Fig. 1. Estimated numbers of hip fractures in people aged over 60 in United Kingdom, 1996-2066, based on rates from 1983 and 1956 4 HISTORY AND EXAMINATION As hip fracture patients tend to be elderly and frail , a full history and examination is essential. Although falls are commonly listed as being simple this is rarely the case and they are usually multifactorial. If the fall has been witnessed the aetiology is easier to ascertain as patients recollection of preceding events may be incorrect. Low velocity falls indoors account for most of the injuries. Despite the difficulty in taking an accurate history some attempt should be made to find the cause of the fall. Risk factors for hip fractures are a combination of the risk factors for falls and those for osteoporosis. Risk Factors for hip fracture5 Female sex Maternal history of hip fracture Excess alcohol Excess caffeine Physical inactivity Low body weight Previous hip fracture Tall stature Certain psychotropic medications

10

Residence in an institution Visual impairment Dementia

Postural hypotension is often an aetiological factor in the fall ,exacerbated by medications such as diuretics and sedatives. The Parkinsonian patient is at particular risk due to postural instability and L dopa induced postural hypotension. The diabetic patient is also prone to falls due to poor vision, hypoglycaemic episodes, peripheral and autonomic neuropathy. A full alcohol history may explain the fall and the presence of osteoporosis. Not all fractures are due to osteoporosis and sometimes hip fracture may be the first presentation of metastatic bone disease . A history of the bone snapping before the fall could be an indicator of this. Five cancers that commonly metastasise to bone are those from the bronchus, breast, kidney, thyroid and prostate. Haematological malignancies also occur such as multiple myeloma and lymphomas. Medications should be assessed on admission and appropriate changes considered. An elderly pre-operative hip fracture patient is unlikely to be able to use an inhaler and therefore should be changed over to nebulisers for the peri-operative period. Non- steroidals are best avoided especially due to their detrimental effect on renal function and bone healing. Patients taking warfarin are a special problem and surgery is deferred until the INR is less than 1.5. A full social history with information on activities of daily living , type of dwelling and other family members at home, as well as the use of outside support agencies, helps to give a fuller picture of the patient. Previous level of mobility should be enquired into and the use of walking aids documented. Abbreviated mini-mental scores help in deciding if a patient can sign their own consent form and for monitoring perioperative confusion which is endemic amongst elderly fracture patients . On examination the classic appearance of a fractured hip is that of a shortened and externally rotated lower limb. However not all presentations are classical, and in the case of an impacted subcapital fracture some patients can actually walk despite their injury. Examination of the cardiovascular system may detect the presence of atrial fibrillation or a murmur. Neurological examination is essential as falls can lead to head injuries that are easily missed. Respiratory examination may detect a chest infection. Examination of the abdomen is important as this group of patients are at risk of developing pseudo-obstruction.

11

INVESTIGATIONS The hip fracture is usually diagnosed by standard radiographs and a chest X ray should be obtained at that time. In more difficult cases where the clinical picture suggests a fracture but the X rays do not, a bone scan can aid diagnosis. However this investigation takes a number of days to become positive. In the future MRI scans may be helpful as they can accurately detect a fracture within 24 hours of injury. A full blood picture , blood group and hold and urea and electrolytes are mandatory. The fracture often results in blood loss and the patient may need transfusion perioperatively. The platelet count should be scrutinised as a low count is a contra-indication to spinal anaesthesia , the commonest mode of anaesthesia used in elderly hip fracture patients. An electrocardiogram will help to detect arrhythmias and recent infarcts that may have precipitated a fall. The presence of systolic murmurs in the elderly are common 6 but create a special problem in the elderly fracture patient. Aortic stenosis, which can present as syncope, is a contra-indication to spinal anaesthesia. The difficulty arises in clinically distinguishing benign murmurs from more dangerous ones. Echocardiograms are therefore being increasing used to help in the diagnosis of murmurs and to assess cardiovascular function in the pre-operative period. CLINICAL MANAGEMENT ANALGESIA Analgesia is extremely important in the management of hip fracture . Poorly controlled pain will delay early mobilisation and result in the usual complications of prolonged bed rest as well as precipitating perioperative delirium7. Repeated studies show that demented patients or the cognitively impaired receive less analgesia than their non cognitively impaired counterparts.8 This is generally because nursing and medical staff rely on self reporting of pain and rarely consider behavioural ( moaning , sighing, guarded posture) or physiological ( tachycardia, high blood pressure) pointers to the presence of pain. New anaesthetic techniques have added to the tools available in the perioperative period. Intrathecal opioid analgesia involves injection of a small amount of opioid analgesia into the cerebrospinal fluid via the subarachnoid space. This can give prolonged pain relief lasting for between 12 to 24 hours but care is required in the management of breakthrough pain. Local nerve blocks can also be used either separately or in combination with other anaesthetic techniques. Patient controlled analgesia involves the intravenous injection of a small bolus of morphine controlled by the patient , helping to more accurately titrate the

12

analgesia required to obtain optimum pain relief. This type of analgesia is best avoided in the confused patient. Many units now have a dedicated pain team led by a consultant anaesthetist to aid in the management of difficult cases. Remember intravenous paracetamol is a very useful analgesic agent for use in older patients with a fracture. It is far more potent than oral paracetamol and is equivalent to several mg of iv morphine sulphate. It is an attractive agent as it is: Non sedating Non constipating Does not cause respiratory depression Can be safely used in renal impairment

THROMBOPROPHYLAXIS Elderly bed bound hip fracture patients are at high risk for developing thromboembolic events. There are several different types of thromboprophylactic measures available that can be used singly or in combination . These include low molecular weight heparin, intermittent pneumatic leg compression, oral anticoagulants, aspirin and thromboembolic stockings. The optimal regime is unknown due to the relatively small number of trials involving hip fracture patients9. Early surgery, early mobilization and lack of transfusion are also important aspects of an thromboprophylaxis strategy. NUTRITION / HYDRATION / PRESSURE SORE PREVENTION Hydration , nutrition and pressure sore prevention are all closely interlinked. Most patients require intravenous fluid supplementation to maintain fluid balance and satisfactory renal function particularly as hip fracture operations can be repeatedly cancelled at short notice resulting in long periods of fasting. Malnutrition is common in both elderly and orthopaedic patients 11 and is associated with increased morbidity and mortality leading to longer hospital stays, higher infection rates and increased costs.12However it is unclear whether nutritional supplementation either orally or by nasogastric tube feeding improves outcomes.13 . Pressure sore prevention should be considered at the earliest opportunity.Lying on a hard surface, such as a hospital trolley, for as short a time as 30 minutes can result in the development of a pressure sore 14. Special pressure relieving mattresses, heel pads and regular movement should be employed immediately. Early mobilization in the postoperative period will also 13

aid in pressure sore prophylaxis.

SURGERY The vast majority of patients are operated on as conservative treatment involves prolonged bed rest and its subsequent complications. The aims of surgery are to control pain and aid early mobilization. Ideally surgery should occur within 24 hours of injury if the patient is medically fit. Spinal anaesthesia is normally used as it is associated with less thromboembolic complications and reduced perioperative mortality 15. Hip fractures may be simply divided into two categories, intracapsular and extracapsular. The main blood supply to the femoral head is via the capsule and interruption of this can lead to avascular necrosis. Intracapsular fractures can be fixed by insertion of a hemiarthroplasty or by reduction and internal fixation(ie with a dynamic hip screw). Antibiotics are given at the time of surgery to reduce wound, urine and chest infections. Providing there have been no complications the patient can sit out the day after the operation. COMPLICATIONS The major complications specific to the surgery are: Non union of the fracture Avascular necrosis of the femoral head Dislocation of a hemiarthroplasty Subsequent fractures that occur beneath a prosthesis can be extremely difficult to rectify. Increasing numbers of such fractures mean that there is a need for orthopaedic surgeons skilled in their management. Other perioperative complications include Urinary tract infection Pressure sores Chest infection Thrombo-embolism Sepsis Pseudo-obstruction

14

REHABILITATION After a hip fracture operation a variety of options are available for the further care of the patient. Some patients may be suitable for early discharge to their home with appropriate support services,16 others may be discharged back to their nursing homes. Selected patients may benefit from a further period in a rehabilitation unit with early involvement of a multidisciplinary team including medical staff, nursing staff, occupational therapists, physiotherapists, social workers, patients and their families Patients with a good pre-fracture level of mobility and lack of mental impairment tend to benefit most from rehabilitation schemes.17 The period in rehabilitation obviously depends on the individual but can be in excess of 30 days. Specialised units have been shown to improve outcomes in stroke but more studies are required to assess the effectiveness of co-ordinated multidisciplinary inpatient rehabilitation for elderly hip fracture patients. 18,19 PREVENTION Prevention is best considered in two ways: prevention of osteoporosis and prevention of the fall. Prevention of osteoporosis is best started as early as possible by adopting an active lifestyle. Exercise has been shown to increase bone mass, density and strength and is best started in childhood or early adolescence 20. Exercise in later life helps to preserve bone rather than adding to it but also has a dual protective function in the elderly by helping to reduce falls 21. This probably is as a result of improved gait, balance, co-ordination and muscle strength. It appears from the literature that you are never too old to exercise. Bisphosphonates inhibit bone resorption and have been shown to reduce fracture rates at the hip and spine. Various agents are available but the regimes used can be complex or associated with unwelcome side effects such as oesophagitis ( alendronate). Strontium is a relatively new agent which can be used in patients intolerant of bisphosphonates. Selective Estrogen Receptor Modulators ( SERMS) have a role in the prevention of vertebral osteoporosis in postmenopausal women. Calcium and vitamin D have been shown to reduce hip fracture rates in elderly women living in residential accommodation. 23

15

Lifestyle factors such as smoking and alcohol can also have a detrimental effect on bone. Smoking may be responsible for as many as one hip fracture in eight amongst women.24 The impact of a fall may be cushioned by the use of hip protectors 25 but larger trials are required to properly assess this intervention. Compliance can be a problem and the evidence base is insufficient to support their current use. Preventing falls is possible by a number of interventions , such as removing environmental hazards, assessing medications, exercise programs and visual assessment. The evidence base supports the package of interventions but not the individual elements. OUTCOMES One of the most important functional outcomes is the patients ability to walk as this will have implications on future placement. Between 50-65% of patients regain their previous level of mobility, 10-15% do not recover the ability to walk outside the home and up to 20% become immobile. 5 More than half will have returned to their original residence , 30% are more dependent on walking aids and most will have slight or occasional pain in their hip.27 One year after a hip fracture between 12-37% of patients have died and this can rise to almost 50% in patients with significant dementia. Predictive factors for mortality include: Age Reduced mental status Male sex Active medical problems Reduced Barthel score / reduced mobility pre-fracture To give some idea of a patients medical fitness for surgery , anaesthetists often use the American Society of Anaesthetists( ASA ) grade : 1. Completely fit and healthy. 2. Some illness but this has no effect on normal daily activity, that is an asymptomatic condition such as hypertension. 3. Symptomatic illness present, but minimal restriction on life. 4. Symptomatic illness causing severe restriction on life. 5. Moribund. Most elderly hip fracture patients are labeled as Grade 3 ASA CONCLUSION

16

A hip fracture can be a catastrophe for an elderly person with major implications for their physical, psychological and social well being. Numbers are increasing and represent a major socio-economic burden on the health service. Well organized acute and rehabilitative care has the potential to benefit large numbers of elderly patients hopefully improving outcomes and independence. As in all aspects of medicine, prevention is better than cure, especially when preventative strategies are available.

17

Pain Management in the Elderly Hip Fracture Patient

Introduction Elderly patients probably occupy at least half the beds in our central fracture service and hip fracture operations alone account for between 20-25% of theatre cases. The number of hip fracture cases could possibly double in the next 50 years 1 which would have huge implications for an already over burdened health service. The vast majority of hip fracture patients are operated on despite many being very frail and elderly. The two major principles of surgery are to control the patients pain and to aid early mobilisation. Without surgery the patient is at risk of developing the complications of prolonged bed rest such as chest and urinary infections, thromboembolism, pressure sores and pseudo obstruction. Early mobilisation in the post operative period is dependent upon effective analgesia and is therefore one of the major mainstays in the management of the elderly fracture patient.2 The Effects of Pain There is no consensus in the literature concerning decreased perception of pain with aging . However the effects of pain on an elderly patients physical, psychological and social well being can be immense. If pain is not treated promptly this can lead to pain sensitisation where pain is experienced at lower thresholds than usual. Delirium is a common perioperative complication of hip fracture surgery and can be caused by both pain and its treatment. Multifactorial interventions by both nurses3 and doctors4 which include effective pain management can reduce the levels of this distressing complication. Acute pain together with the stress response to surgery can have multisystem consequences. Tachycardia, hypertension and increased peripheral resistance are common changes in the cardiovascular system. A fall that has resulted in bruised ribs as well as a hip fracture can result in respiratory complications such as hypoxia and an inability to deep breathe. Pain and its treatment can lead to pseudo-obstruction especially when combined with bed rest. The immune response is also modified due to a reduction in both humeral and cellular immunity5 18

Psychologically , depression and anxiety together with social isolation can result if pain is not adequately treated.

Pharmacokinectics and Pharmacodynamics in the Elderly It is important to understand the physiological changes associated with aging and their consequent effects on drug handling. Adverse drug reactions are more common in the elderly normally due to a combination of polypharmacy and multiple co- morbidities superimposed on the normal changes associated with aging. Adsorption There is no major reduction in drug absorption with rising age 6 despite reductions in intestinal epithelium, gut motility, splanchnic blood flow and possibly gastric acid secretion7 Distribution The volume of distribution of many drugs is reduced due to reduced lean body mass, reduced total and percentage body water and increased percentage body fat. Serum albumin levels are also reduced which can result in adverse effects with highly protein bound drugs such as diazepam Metabolism There is a reduction in size and liver blood flow with age and the ability of the liver to recover from injury (ischaemia/ congestive heart failure). The reduction in first pass metabolism can result in higher bioavailability of certain drugs such as opiates. Excretion The most important pharmacokinectic change associated with aging is the reduction in glomerular filtration rate and creatinine clearance which can result in tissue concentrations of some drugs being increased by 50% 8 Pharmacodynamics Pharmacodynamics may be altered in the elderly largely due to a reduction in the number and response of receptors. In the case of opioids this can mean an increase in their anaesthetic, sedative and analgesic effects as well as making adverse effects such as respiratory depression more pronounced 6 Pain Assessment Under-recognised and unrelieved pain in elderly patients is a major problem mainly due to a lack of systematic assessment and documentation 9 .Elderly patients tend to receive less analgesia than younger patients and cognitively impaired adults receive less analgesia than their cognitively intact

19

colleagues10 . Perioperative hip fracture patients have been noted to experience unacceptable levels of pain.11 Pain can be detected by three major means: 1. Self report 2. Behavioural characteristics 3. Physiological response Self report is probably the commonest way medical and nursing staff detect and treat pain but this method is unsatisfactory when used in isolation.Some patients may be reluctant to report pain for cultural or social reasons In particular demented patients who are normally agitated and vocal may become quiet and withdrawn. In the cognitively impaired patient behavioural characteristics , both verbal and non verbal , can be used. Moaning , groaning , crying and sighing are common verbal responses to pain. Clutching and rubbing affected areas together with guarded postures and reluctance to move are useful non verbal clues. The physiological response to pain may be manifested by a rise in blood pressure and respiratory rate or the development of a tachycardia. Obviously these changes are non specific. Various tools are available to help in pain assessment including visual analogue scores and verbal descriptor scales . Other tools include using pictures of facial responses to pain which patients then point at to indicate their personal level of discomfort.12 These tools can be difficult for the elderly to use as a result of visual or hearing impairment together with musculoskeletal or cerebrovascular disease. The absence of pain behaviour does not rule out the presence of pain 13 More research is required into pain assessment especially in the cognitively impaired. Lessons could be learned from are Paediatric colleagues where there appears to be an abundance of assessment tools for a group of patients with similar problems at the other extreme of life.

Analgesic agents and Techniques A long bone fracture normally results in severe pain and it is a priority that effective analgesia is given at the earliest opportunity which usually means in the Accident and Emergency department. Strong analgesics such as morphine sulphate should not be denied to elderly patients due to inappropriate fears of addiction or over emphasis on side

20

effects such as respiratory depression. It should be remembered that there are a variety of ways of effectively delivering these drugs: Oral Intramuscular Intravenous Intrathecal Subcutaneous Transdermal Rectal*

*The rectal bioavailability of morphine is similar to its oral bioavailability 14 The gold standard is probably morphine sulphate given intravenously at a dose of 1mg/min titrated for effect. Patient controlled analgesia involves morphine sulphate being given as an intravenous bolus on demand. This type of analgesia may be appropriate for a highly select group of cognitively intact elderly patients but the high prevalence of perioperative delirium makes its use limited. More commonly morphine sulphate is given intramuscularly at a dose of 5-10mg in the perioperative period. In recent years anaesthetic techniques have become more sophisticated. Spinal anaesthesia is being use increasingly as it is meant to reduce perioperative mortality and morbidity.15. Epidural analgesia involves a continuous infusion of analgesia continued into the postoperative period or it can be given as a single bolus. Intrathecal analgesia uses lower doses of opioids and involves the injection of a small amount of opioid into the subarachnoid space at the time of surgery. It can produce prolonged pain relief lasting up to 24 hours but respiratory depression can develop. Nerve blocks involve the infiltration of local anaesthetic usually to the femoral nerve and can be use in combination with other techniques such as general anaethesia. Paradoxically pain may increase after a hip fracture is fixed as patients begin to mobilise and sit out. Postoperatively sevredol (an oral morphine derivative) can be used. Pain should be anticipated and analgesia given in advance of expected painful episodes ( such as sitting out or walking practice). In the days following surgery analgesia should be appropriately assessed and step down analgesia used. Tramadol is an opioid used for moderate to severe pain and can be given orally, intramuscularly or intravenously. It is said to be less constipating and to cause less respiratory depression than other opioids but psychiatric reactions have been reported. Paracetamol can be used for mild pain either alone or in combination with codeine. Remember intravenous paracetamol is a very useful analgesic agent for use in older patients with a fracture. It is far more potent than oral paracetamol

21

and is equivalent to several mg of iv morphine sulphate. It is an attractive agent as it is: Non sedating Non constipating Does not cause respiratory depression Can be safely used in renal impairment

Most of the analgesics employed can cause constipation and nausea and both these side effects should be anticipated and appropriate measures undertaken. Non Steroidal Anti-inflammatory Drugs are very effective agents for controlling bone pain but their side effect profile means they should be avoided or used with great caution in the peri-operative period. Those patients at increased risk of nephrotoxicity16 are: The elderly Pre-existing renal impairment Volume contraction - diuretics - cardiac failure - cirrhosis - hypertension - perioperative

The cox 2 inhibitors cause less gastro-intestinal side effects but nephrotoxicity remains a problem. Non pharmacological pain management should not be forgotten and can range from massage or stretching exercises for muscle spasm to relaxation or distraction techniques for decreasing pain perception . Conclusion Pain management is of paramount importance in the elderly fracture patient. More research is required to develop better pain assessment tools for the elderly ( especially the cognitively impaired) to ensure their smooth passage through the peri-operative period into rehabilitation. All members of the multi disciplinary team should be involved in pain management from its early detection to its successful treatment. The 10 principles of pain management stated by Ferrell in 199117 should be borne in mind: 1. Always ask elderly patients about pain. 2. Accept the patients word about pain and its intensity. 3. Never underestimate the potential effects of chronic pain on a patients overall condition and quality of life.

22

4. Be compulsive in the assessment of pain. An accurate diagnosis will lead to the most effective treatment. 5. Treat pain to facilitate diagnostic procedures. Dont wait for a diagnosis to relieve suffering. 6. Use a combined approach of drug and non-drug strategies when possible. 7. Mobilize patients physically and psych-socially. Involve patients in their therapy. 8. Use analgesic drugs correctly. Start doses low and increase slowly. Achieve adequate doses and anticipate side effects. 9. Anticipate and attend to anxiety and depression. 10. Reassess responses to treatment. Alter therapy to maximize functional status and quality of life.

23

Points on the management of suspected pulmonary embolism

A pulmonary embolism is not an uncommon event in fracture patients All patients should have their thromboembolic risk assessed on admission Presentation will depend on the extent of the embolism. A small clot might just cause transient breathlessness whilst a huge clot can cause a cardiorespiratory arrest Symptoms to look out for include shortness of breath, pleuritic chest pain (pain worse on inspiration- sharp like a knife) and coughing up blood (haemoptysis) Signs can be few and may be manifested solely by the presence of a tachycardia If suspected the following tests should be done: ECG CXR Arterial blood gas Remember that fractures are associated with bleeding and blood clotting. A d Dimer is therefore unhelpful in this setting Treatment should be commenced with enoxaparin either 1 mg per Kg bd or 11/2 mg/KG once daily Spinal patients need special consideration and treatment in the early post injury/surgery period should involve close liaison with a spinal surgeon In the absence of lung disease a V/Q scan can aid diagnosis. If a V/Q Scan is not appropriate (or comes back with an indeterminate result) then a CTPA should be ordered. Interventional radiology can help in difficult cases by inserting vena caval filters or by actually helping to physically remove the clot

24

Fat Embolism Syndrome Fat embolism is usually asymptomatic and develops in nearly all patients with bone fractures Fat embolism syndrome(FES) develops in the minority of patients and is associated with dysfunction of the lungs, skin and brain FES most commonly occurs in closed long bone and pelvic fractures Incidence after long bone fractures varies from 1-20% FES usually occurs 24-72 hours after the initial insult The classic triad is hypoxaemia neurological abnormalities petechial rash Respiratory manisfestations can vary from mild dyspnoea through to ARDS Neurological abnormalities consist of altered levels of consciousness, seizures or focal deficits The petechial rash is usually observed on the head, neck, anterior thorax, subconjunctiva and axillae Aetiology is uncertain and opinions vary that FES is caused by direct entry of fat globules from disrupted tissue into the bloodstream or the production of toxic intermediaries No test is diagnostic and the diagnosis of fat embolism remains a clinical one.

Adapted from an Editorial in CHEST : Georgopoulos :2003 vol:123 iss:4 pg:982

25

ALCOHOL WITHDRAWAL
Alcohol is a major cause of morbidity and mortality on the acute fracture ward.It has been implicated as a contributing factor in: 40 % of road traffic accidents 30% of fatal road traffic accidents 20-30% of all hospital admissions It is not always apparent that a patient abuses alcohol and problems may not develop until after an expensive operative procedure has been carried out. If full blown delirium tremens develops then the potential cost in extra nursing / medical intervention can be huge. Preventiion is better than cure! 1. All patients admitted to the fracture ward should have an alcohol history documented. Safe weekly limits are 14 units for females and 21 units for males.Remember that alcohol abuse is not limited to the young. 2. History and examination may detect signs and symptoms of alcohol withdrawal: anxiety , tremor , tachycardia , hypertension , agitation , anorexia , nausea , hyper-reflexia , insomnia , nightmares , sweating , hyperthermia , disorientation , seizures , hallucinations , delirium . 3. Simple blood investigations such as a raised gamma GT and a MCV (greater than 100) can detect as many as 75% of problem drinkers. Other less sensitive markers that may be a pointer to alcohol abuse include a low urea and low platelet count. 4.The liver is the centre for the manufacture of some clotting factors (2,7,9 AND 10) and if damaged coagulation times may be dangerously deranged. Therefore it is worthwhile doing a coagulation screen as a baseline investigation. 5. Delirium Tremens is a potentially dangerous complication of alcohol withdrawal due to the development of fits, hypothermia, dehydration, electrolyte imbalance, shock and chest infection. Mortality can approach 10%. 6.If alcohol abuse is suspected commence chlordiazepoxide- the dose can vary and is made on an individual assessment. A typical starting dose would be 30mg t.i.d. Lower doses may be needed if the patient has respiratory disease.The dose is then tapered off over the following seven days. 7. Deficiency of thiamine ( vit B1 ) can lead to syndromes such as Wernicke's Encephalopathy and Korsakoff's Syndrome. These may be prevented by giving thiamine. If this is given orally the usual dose is 200mg daily for about a month. 8.High risk patients may need parenteral thiamine-this comes as Pabrinex. Treatment may need to last for 3-6 days. Due to the risk of anaphylaxis it should be given slowly over 10 minutes.Intravenous dextrose should not be given before parenteral thiamine because of the risk of precipitating Wernicke's Encephalopathy.

26

Amiodarone
Baseline; 1. Clinical history & physical examination 2. Diagnostic investigation (12 lead ECG, U&E, Ca, Mg, LFTs, TFTs, CXR, Echocardiogram, PFTs if considering long-term usage) 3. Look for common predisposing or precipitating factors, e.g;

Primary Cardiac causes

1. IHD, acute coronary syndromes, previous MI 2. Congestive heart failure 3. Cardiomyopathy 4. Congenital heart disease e.g. atrial septal defect 5. Valvular disease 6. Accessory pathway 7. Hypertension 1. 2. 3. 4. 5. 6.

Other causes
Alcohol Hyperthyroidism Electrolyte disturbance Certain drugs (antiarrhythmic, stimulants) COPD Fever, chest infection

4. Management with amiodarone

Add amiodarone 300mg to 250ml 5% Dextrose. Infuse over 20mins 2hrs followed by amiodarone 900mg in 500ml 5% Dextrose over 24hrs **Amiodarone must be infused via a large bore vein peripherally or via central line if available. Do not use NaCl 0.9% as a diluent**
Changeover from IV amiodarone to oral dosing As soon as adequate response is obtained, oral therapy can be initiated concomitantly with IV therapy (the IV amiodarone can be phased out gradually) at usual loading dose i.e. 200mg tid for one week, 200mg bd for one week then 200mg od. If long-term therapy is indicated, refer to monitoring requirements / patient information in Amiodarone Trust Policy (N.B. patients started on IV amiodarone for control of ventricular response to AF during acute illness often do not need to remain on amiodarone long-term please check with cardiology staff).

5. Monitoring requirements - Perform hourly pump checks, BP, HR and venflon site. The patient needs to be on an ECG monitor during period of amiodarone infusion. Inform Medical Staff immediately if patient experiences: Bradycardia (HR <60 bpm & symptoms of hypotension) Hypotension (i.e. marked drop in BP from baseline) Tachycardia (HR >170 / min) if unsure, check with Cardiology Staff Broad complex rhythm Any pain/erythema at venflon site especially tracking along arm resite venflon immediately!! 6. Amiodarone interactions: - for full list see BNF;
1. 2. 3. 4. Digoxin level doubled Flecainide level doubled Warfarin - INR increased Phenytoin level increased

27

Protocol for the Prophylaxis of Venous Thromboembolism for the Trauma Unit Redrafted: 25/06/09 This protocol has been developed as required by the new trust policy on the prevention of venous thromboembolism.. There is some disagreement between the producers of the major set of guidelines in this area as to the most effective and efficacious treatment. This has not been resolved by the publication of guidelines by NICE in 2007. The protocol has purposely been kept simple (using one main chemical thromboprophylaxis agent, given at one particular time) to aid implementation and compliance. Objective To reduce the incidence of venous thromboembolism in patients admitted to the trauma unit Every patient admitted to the trauma unit should have their thromboembolic risk assessed on admission. (See Appendix 1 + 2) Methods to reduce thromboembolism may involve the use of chemical agents (such as low molecular weight heparin), mechanical agents (graduated elastic compression stockings) or patient lifestyle measures ( early mobilisation, leg exercises, adequate hydration). These measures may be used singly or in combination. All fracture patients with a medium to high risk of venous thromboembolism should be commenced on enoxaparin 40mg given subcutaneously at 10pm unless a contraindication exists (see Appendix 3) The half life of enoxaparin is 10-12 hours and its peak effect occurs at 4-6 hours post administration. This should not interfere with spinal anaesthesia if given at 10pm the night before surgery.

28

Doctors should be aware of heparin associated thrombocytopenia (HAT). This usually occurs between 5-10 days (up to 20 days) after initiation of heparin. HAT should be considered in any patient whose platelet count falls by 50% or more.

If the patient is admitted on other drugs( such as aspirin or clopidogrel) which could increase the risk of bleeding perioperatively, these should be with-held in the perioperative period depending on the clinical picture.If the patient has had a cardiac stent in the last year cardiology should be consulted regarding discontinuation of the clopidogrel - -in this case aspirin can be continued

NICE recommends mechanical methods of thromboprophylaxis such as graduated elastic compression stockings should be used in conjunction with chemical prophylaxis. The use of this intervention should be clearly documented in the nursing or medical notes.( for cautions and contraindications see Appendix 4)

If the patient is admitted on warfarin , the protocol in appendix 5 should be consulted. If urgent reversal of the anticoagulation is required vitamin K can be used. Vitamin K takes 6-8 hours to work. Any further advice needed can be obtained from the ward based orthogeriatric team. In certain circumstances prothrombinase complex (Octaplex) can be given to rapidly reverse the effects of warfarin this should always be discussed with a Consultant Haematologist

If a venous thromboembolic event occurs prompt investigation and treatment should occur. Care should be taken when trying to interpret d dimmer results when trauma or surgery has occurred(as the d dimmer will be elevated by the associated blood clotting). This test should rarely be ordered in the setting of the acute trauma ward in the perioperative period.

29

The use of interventional radiology should not be forgotten in the management of difficult cases (ie the insertion of vena caval filters in the actively bleeding patient with diagnosed thromboembolic disease).Vascular surgery should also be involved in any discussions about vena caval filters

In those patients whose thromboembolic risk remains high at discharge, arrangements should be put in place with the General Practitioner to ensure the continuation of thromboprophylaxis for the appropriate period. Examples of when to use extended thromboprophylaxis for 6 weeks include post: - pelvic surgery - bilateral lower limb injury - polytrauma - traumatic spine injury

With regard to hip fracture surgery, patients going back to their home environment should be considered for extended thromboprophylaxis for 35 days post fracture.

Care needs to be used when dealing with spinal patients because of the risk of spinal haematoma. Elective spinal patients should have their thromboembolic risk assessed as per other admissions. In general graduated elastic compression stockings should be used preoperatively and enoxaparin commenced 24 hours posoperatively unless otherwise stated.

Acute spinal cord injury patients have one of the highest incidences of DVT among hospitalised groups. Enoxaparin at the 40mg dose should be commenced when primary haemostasis is evident (after 24 hours). 30

Graduated elastic compression stockings can be used initially until this time frame has elapsed. If there is going to be a prolonged preoperative delay enoxaparin can be used after 24 hours but should be omitted the night before surgery. Put simply in spinal patients, enoxaparin should be commenced 24 hours after injury, stopped the night before surgery and recommenced 24 hours after surgery This protocol will be discussed at each induction of the new house officers and they will be given their own personal copy of the instructions. USEFUL REFERENCES 1.The Prevention of Venous Thromboembolism in Hospitalised Patients. House of Commons Health Committee. Second Report of Session 2004-05. Feb 2005. www.parliament.uk/parliamentary_committees/health_committee.cfm 2. Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery. NICE Guidance: http://guidance.nice.org.uk/CG46 APPENDICES Appendix 1 : Example of risk Categorisation Appendix 2 : Risk factors for venous thromboembolism Appendix 3 : Contraindications and cautions for aspirin and heparins in prophylaxis of venous thromboembolism Appendix 4 : Contraindications and cautions for use of graduated elastic compression stockings Appendix 5 : Management of the patient admitted on warfarin

31

Appendix 1

Example of Risk Categorisation1

Low risk Minor surgery (<30 min2) + no risk factors other than age Major surgery (> 30 min), age <40 yrs + no other risk factors Minor trauma or medical illness

Moderate risk Major general, urological, gynaecological, cardiothoracic, vascular or neurological surgery + age >40 yrs or other risk factor Major medical illness or malignancy Major trauma or burn Minor surgery, trauma or illness in patients with previous DVT, PE or thrombophilia

High risk Fracture or major orthopaedic surgery of pelvis, hip or lower limb Major pelvic or abdominal surgery for cancer Major surgery, trauma or illness in patient with previous DVT, PE or thrombophilia Major lower limb amputation

1. The Prevention of Venous Thromboembolism in Hospitalised Patients .House of Commons Health Committee. Page 16 2. i.e. surgery lasting less than 30 minutes.

32

Appendix 2 Table 1: Risk factors for venous thromboembolism 1

Age

Exponential increase in risk with age. In the general population: < 40 years - annual risk 1/10,000 60-69 years - annual risk 1/1,000 > 80 years - annual risk 1/100 May reflect immobility and coagulation activation 3 x risk if obese (body mass index >= 30 kg/m2) May reflect immobility and coagulation activation

Obesity

Varicose veins 1.5 x risk after major general / orthopaedic surgery But low risk after varicose vein surgery Previous VTE Recurrence rate 5% / year, increased by surgery

Thrombophilias Low coagulation inhibitors (antithrombin, protein C or S) Activated protein C resistance (e.g. factor V Leiden) High coagulation factors (I, II, VIII, IX, XI) Antiphospholipid syndrome High homocysteine Other thrombotic states Malignancy 7 x risk in the general population Heart failure Recent myocardial infarction / stroke Severe infection Inflammatory bowel disease, nephrotic syndrome Polycythaemia, paraproteinaemia Bechets disease, paroxysmal nocturnal haemoglobinuria Oral combined contraceptives, HRT, raloxifene, tamoxifen 3 x risk High-dose progestogens 6 x risk 10 x risk

Hormone therapy

Pregnancy, puerperium Immobility

Bedrest > 3 days, plaster cast, paralysis, 10 x risk; increases with duration

Prolonged

33

travel Hospitalisation Acute trauma, acute illness, surgery 10 x risk CAUTION SUncorre 2 x general vs spinal / epidural cted bleeding disorders , e.g. Anaesthe sia

haemo phil ias

oral anti coa gul ant s

platele t cou nt <70 x10 9 /L Bleeding or potentially bleeding lesions

oesop hag eal vari ces

active pep

34

tic ulc er

recent (3 mo nth s) GI or intr acr ani al ble ed

intracr ani al ane ury sm or ang iom a Allergy Heparin associate d thrombocy topenia or thrombosi s (heparin)

Asthma (aspirin) 1.Scottish Intercollegiate Guidelines Network .Guideline 62 Prophylaxis of Venous Thromboembolism. October 2002.

1.Scottish Intercollegiate Guidelines Network .Guideline 62 Prophylaxis of Venous Thromboembolism. October 2002.

35

*This table has been slightly modified from that in the SIGN Guidelines

36

Appendix 4

Table 2: Contraindications and cautions for use of GECS 1

CONTRAINDICATIONS Massive leg oedema Pulmonary oedema (e.g. heart failure) Severe peripheral arterial disease Severe peripheral neuropathy Major leg deformity Dermatitis

CAUTIONS Select correct size Apply carefully, aligning toe hole under toe Check fitting daily for change in leg circumference Do not fold down Remove daily for no more than 30 minutes

1.Scottish Intercollegiate Guidelines Network .Guideline 62 Prophylaxis of Venous Thromboembolism. October 2002.

37

Appendix 5 MANAGEMENT OF THE PATIENT ADMITTED ON WARFARIN Many patients are now being admitted on warfarin. This anticoagulant can be prescribed for a variety of reasons, the commonest being to treat thromboembolic events (such as deep venous thrombosis or pulmonary emboli ) of to reduce the risk of stroke in patients with atrial fibrillation. The effect of warfarin can be monitored by the INR. In a normal person not on anticoagulants, this should equal 1. Patients on warfarin should have an INR between 2 and 4, depending on the indication. The higher the INR the more anticoagulated the patient is. Obviously a patient cannot go to theatre if they are fully anticoagulated ( as they would bleed excessively). PREOPERATIVE MANAGEMENT

The aim is to reduce the INR to 1.5 or less

1. Stop the warfarin 2. Check the INR daily 3. When the INR is less than 2 give enoxaparin subcutaneously to provide anticoagulation 4. When the INR is 1.5 or less the patient can go to theatre. POSTOPERATIVE MANAGEMENT

The aim is to fully anticoagulate the patient as quickly and safely as possible
1. Recommence the warfarin the night of theatre if there is no contraindication (ie severe haemorrhage) 2. Daily INR 3. Give enoxaparin and warfarin together until the INR is greater than 2 for 48 hours and then stop the enoxaparin

38

INSERT ANTIBIOTIC GUIDELINE

39

Transfusion thresholds: For otherwise healthy patients less that 65 years of age a transfusion trigger of 7g/dl is appropriate. For otherwise healthy patients over 65 years of age a transfusion trigger of 8g/dl is appropriate. For otherwise healthy patients with additional risk factors of cardiac and cerebrovascular insufficiency, a higher trigger of 9g/dl is permitted. Red cells should not be routinely administered above these thresholds. Consideration can be given to administering red cell transfusions below these thresholds but this does not mean transfusion should always be administered. A higher threshold of 10g/dl is reserved for patients who are symptomatic of anaemia which is documented and specified, for patients who are actively bleeding significantly and finally for patients who have a marrow injury, often due to effects of chemotherapy, radiation therapy or primary marrow disorder. All of these patients are less able to compensate and adapt to their anaemia and additive red cell transfusions are of clinical benefit.

40

Acute Orthogeriatric Care in the Perioperative period

Where in a hospital are elderly frail patients with an average age of 80years, several comordities , on multiple medications admitted as emergencies and almost invariably operated on? The answer is the local fracture unit where the numbers of older people with hip fractures is now being recognised as a major problem.

In Belfast almost half the fracture admissions are over the age of 65y. The commonest inpatient fracture in the older person is a hip fracture (SEE GRAPH) and almost one third of the trauma theatre cases involve hip fracture surgery.

ankle fem ur spine hum erus w rist hip pubic ram i olecranon tibia

10

20

30

40

50

60

70

80

Graph showing cause of inpatient fracture admission over a one month period: 70% suffered a hip fracture, 9% had more than one fracture on admission
The patients who fall and fracture can be extremely complex to manage. Falls in the older person are a common event, with 1 in 10 resulting in fracture. 1 Only 1 % of falls in people over 65 y of age result in a hip fracture.2 A fall that results in hip fracture can be defined as a serious fall and Tinetti has identified 4 risk factors for such an event. 3

41

FACTORS INDEPENDENTLY ASSOCIATED WITH SERIOUS INJURY Cognitive impairment Presence of at least two chronic conditions Balance and gait impairment Low body mass index Table 1 Factors independently associated with serious injury* The fall is rarely a simple event and the aetiology is normally multifactorial including intrinsic factors (such as poor vision 4) and extrinsic factors (poor lighting, obstacles such as electric cables). Seeking corroboration on the details of the fall from a witness is always worthwhile as certain conditions can cause amnesia for the event. 5 The risk factors for a hip fracture are a combination of those for osteoporosis and those for falls. 6 (SEE TABLE 2) RISK FACTORS FOR HIP FRACTURE Female Excess consumption of alcohol and caffeine Physical inactivity Low body weight Tall stature Previous hip fracture Certain psychotropic medications Residence in an institution Visual impairment* dementia

The other aetiological factor resulting in fracture is bone quality. Considering why the bone breaks is important as treatments may be available to try and help prevent further fracture. Osteoporosis is the major reason why bone fractures after a low trauma fall. However metastatic bone disease should be considered in the differential diagnosis as should haematological malignancies such as multiple myeloma and metabolic bone disease such as osteomalacia..

Guidelines produced by the Royal College of Physicians and the Scottish Intercollegiate Guidelines Network stress the importance of early surgery for older people with hip fracture.2,7 .Both guidelines recommend surgery within 24 hours if the medical condition of the patient permits it. The SIGN Guidelines state that delayed surgery increases mortality and morbidity and has adverse effects on rehabilitation. However there is a limited evidence base for these claims. An audit commission report in Feb 2000 stated that half of patients wait more than 24 hours for their operation and, 18 % wait more than 48 hours. 8 A recent study in

42

2004 suggests that a similar percentage of patients still have to wait more than 48 hours for their surgery.9Prompt surgery provides pain relief by stabilising the fracture and helps avoid the problems of prolonged bedrest such as chest and urine infections, pressure sores and thromboembolism Humanitarian concerns would also suggest that early surgery is appropriate. However patients who are medically unfit should not be rushed to theatre because an arbitrary time frame has elapsed. Delays to theatre are usually multifactorial but can involve deficiencies in the systems of delivering orthogeriatric care 10

A working group of the department of health commissioned a literature review on the effect of admission to operation time on outcome .This review involved a Medline search covering the years 1986-1996. No reviews were identified addressing this issue. The studies reviewed tended to be retrospective and were not of rigorous design. Not unexpectedly no randomized controlled trials were found. The conclusion of this review was that there is insufficient evidence to support the use of time from admission to operation as a process indicator of quality of care for fractured neck of femur
11

The modern day complexity of the older person with a hip fracture has been recognised by national guidelines which suggest systems of orthogeriatric care should be developed. 12,13,14 The National Services Framework for Older People states that at least one general ward in the acute hospital should be developed as a centre of excellence for orthogeriatric practice The British Geriatric Societys Framework Document on Orthogeriatric Services states that in the acute fracture ward the presence of specialised medical staff in the acute orthopaedic ward is of great benefit .The National Confidential Enquiry into Patient Outcome and Death report Extremes of Age states that a team of senior surgeons, anaesthetists and physicians needs to be closely involved in the care of elderly patients who have poor physical status and high operative risk.

The British Orthopaedic Association has added to the debate with their publication on the care of fragility fracture patients.15 Immediate involvement of orthogeriatricians from admission to discharge has been advocated as the way forward with the expected benefits

43

listed in table 3.16 (TABLE 3) The question is no longer whether orthogeriatric care is appropriate but rather which model is best suited to deliver it.

BENEFITS OF ACUTE ORTHOGERIATRIC CARE Superior medical care Optimal Scheduling of Fracture Surgery Better communication with patients and their relatives Better communication within the multidisciplinary team Initiation of research, education and audit Reduction in adverse events Earlier initiation of rehabilitation and more effective use of discharge resources

CASES There is a paucity of good quality data concerning the population we are managing. Sometimes a common sense approach has to be adopted in the absence of an evidence base on which to make our decisions.The perioperative management of the older patient with a fracture can be extremely difficult. Studies tend not to focus on this age group and very frail patients with conditions like dementia are often excluded from trials. The following fictional cases highlight current problems in the management of older patients with hip fracture

CASE 1

An 89 year old lady with a history of ischaemic heart disease is admitted after a low trauma fall. In her history she describes an episode of chest pain lasting 30 minutes just prior to her collapse. On admission her ECG shows ST changes in the anterior chest leads but no ST elevation .24 hours after her chest pain she remains pain free but her troponin T comes back at 0.1 (normal range < 0.03)

How should we proceed?

44

This lady presents with the acute coronary syndrome. If she had been admitted purely with this history and no fracture she would be considered for treatment with aspirin, clopidogrel, low molecular heparin, an ace inhibitor, a statin and a beta blocker 17.

This case illustrates the difficulties presented by new drugs such as clopidogrel and new blood tests such as troponins.

In recent years there have been developments in the use of biochemical markers to help diagnose cardiac events. Creatine kinase and its isoenzyme CK-MB have been used for many years in this role. CK MB rises wthin 3-4 hours of myocardial injury and then falls back to normal ranges within 24-36 hours. This assay is therefore useful in detecting infarction and reinfarction but has a major disadvantage in the field of acute orthogeriatrics. Skeletal muscle contains CK MB and therefore acute musculoskeletal injuries such as in our case above can produce results which are very difficult to interpret.

The development of troponin assays has enabled the clinician to more reliably diagnose acute coronary events sustained at the same time as muscle injury.

The cardiac troponin are regulatory proteins contained in cardiac muscle. Two subunits of this complex, troponin I and troponin T are highly sensitive and specific markers of myocardial injury. Both can be used as a tool for risk stratification in patients presenting with acute coronary syndromes18,19. Troponin I can be measured by various assays while Troponin T is assessed by a single assay allowing results which can be compared between different centres20. Troponins are more sensitive and specific for detecting myocardial injury than CK MB and therefore are especially useful in cases of musculoskeletal injury. However the troponins may stay raised for 4-10 days. This may be useful in detecting individuals who have had ischaemic episodes some days before their presentation. However it can create diagnostic difficulties in cases of reinfarction. Cardiac troponins can take 3-12 hours to become elevated so attention must be paid to the time at which the sample is taken. Other conditions can cause rises in troponins such as renal impairment, pulmonary emboli, sepsis

45

and stroke. Even in the absence of acute coronary syndromes and myocardial infarction troponin rises in these situations have been associated with poor clinical outcome.

In the case under discussion the patient has had chest pain, ECG changes and a troponin rise. The acute coronary syndrome consists of unstable angina, non STelevation myocardial infarct (NSTEMI) and ST elevation myocardial infarct(STEMI). The difference between unstable angina and NSTEMI is the presence of a biochemical marker for myocardial necrosis The diagnosis in this case, as there is a troponin rise, is therefore a non ST elevation myocardial infarct

In the absence of evidence to the contrary I would defer surgery arbitrarily for 1 week. This is a personal policy with which our local orthopaedic surgeons, anaesthetists and geriatricans tend to agree with. During this period the patient is treated with aspirin, clexane, a beta blocker and statin. The perioperative period is probably not the best time to commence an ACE inhibitor . I advocate 3 days of treatment with clopidogrel and then discontinue it 4 days before the planned date of surgery. An echocardiogram also assists in the evaluation of the patienr and excludes severe valvular heart disease. During the week long period of observation I would take the opportunity to discuss and explain management to the patient and any relatives highlighting the dangers of the perioperative period. Key areas in the management of this patient that should not be neglected include, adequate hydration, analgesia, thromboprophylaxis, nutrition and pressure sore prevention.The anaesthetist would be informed in advance of the case appearing on his list and it would be suggested that the procedure should be led by senior experienced doctors both surgically and anaesthetically . Use of high dependency settings including the coronary care unit, may be considered.

Clopidogrel belongs to the thienopyridine class of drugs and is a potent antiplatelet agent increasingly being used in the management of vascular disease. 21,22Patients undergoing elective surgery are currently advised to discontinue this medication 7 days before their surgery.23 A major concern is the increased risk of haemorrhage and spinal haematoma in those undergoing regional anaesthesia with spinal or epidural techniques .Hip fracture surgery

46

is a emergency procedure and not an elective one. It is unlikely that an elderly patient who presents on this medication could tolerate a 7 day delay to surgery without significant morbidity. The available literature does not help us at present in suggesting the timing of surgery in the uncomplicated case of a patient with stable cardiovascular disease, a hip fracture and who is currently on clopidogrel. . In the setting of cardiac surgery where many patients may be on potent antiplatelet medications, platelet transfusion may be considered to try and reduce excess bleeding in the perioperative period. 24

CASE 2

A 90 year old lady with a history of dementia and multiple falls presents with a fractured neck of femur. Clinical examination reveals the presence of a systolic murmur over the aortic area of auscultation.

How should we proceed?

Basal systolic murmurs have been estimated to occur in 50% of the elderly 25 and many of these murmurs are detected by inexperienced surgical house officers. All the clinical signs of severe aortic stenosis are unreliable.26 (TABLE 4)

loud ejection systolic murmur soft or absent second heart sound slow rising carotid pulse systemic hypotension with a reduced pulse pressure Table 4: the signs of severe aortic stenosis

However it has been demonstrated that non cardiologists can use a bedside clinical prediction rule to detect significant aortic stenosis.27This rule states that if a murmur is heard radiating to

47

the right clavicle and there are 3-4 associated findings (reduced second heart sound,reduced carotid volume, slow carotid upstroke and a murmur loudest in the second right intercostal space), then there is a high chance that significant aortic stenosis is present.(SEE TABLE 5) the presence of a murmur radiating to the right clavicle and 3 or more of the following reduced second heart sound reduced carotid volume slow carotid upstroke a murmur loudest in the second right intercostal space Table 5 : Diagnosis of significant aortic stenosis for the non specialist

A recent echocardiographic study of an older population showed that aortic sclerosis is more common than aortic stenosis but on follow up is also associated with a marked increase in the risk of death from cardiovascular causes.28 The presence of a systolic murmur may therefore be a possible indicator for increased operative risk even if aortic stenosis is not the diagnosis. Aortic stenosis is also common and may occur in 5% of those over 75 years of age 29. Syncope is one of the cardinal symptoms of aortic stenosis and many of the patients presenting to the fracture service have had an unwitnessed fall and are subsequently found to have a systolic murmur.

Spinal anaesthesia is being used with increasing frequency in hip fracture surgery despite any definite evidence of a superiority over general anaesthesia. 30 Aortic stenosis is a thought to be a contra-indication to spinal anaesthesia but it is unclear from the literature whether it is an absolute or relative contra-indication. A recent review article on the use of neuraxial blockade in non cardiac surgery in patients with aortic stenosis confirms the paucity of an evidence base in this area 31, which consists mainly of case reports32. In our unit where at least one case of significant aortic stenosis is detected on a weekly basis, the anaesthetists tend to avoid spinal anaesthesia.

The National Confidential Enquiry into Peri-operative Deaths 2001 report highlighted the dangers of aortic stenosis in the perioperative period. 33 It stated that an asymptomatic cardiac

48

murmur may indicate significant cardiac disease and should be investigated preoperatively by echocardiography. If such recommendations are followed then the resource implications for the local echocardiography units will be huge and already delays to theatre are being reported in the literature as patients await echocardiograms 34.

The definition of what constitutes significant aortic stenosis is unclear from the available literature. In his review article Carabello defined mild-to moderate aortic stenosis as a transvavular gradient in the range of 10 to 30mmHg and a valve area of more than 1 cm 2
35

In

our unit bedside echocardiography is used and the transvalvular gradient is reported rather than the valve area.

Aortic Stenosis has long been identified as a potential risk factor for cardiac complications in non cardiac surgical procedures36. However there is a paucity of published research material on carrying out non cardiac surgical procedures on patients identified with aortic stenosis. In the studies available the numbers are small and the type of surgery varied 37,38,39.

In Belfast echocardiography is almost becoming a routine preoperative investigation. The major indication for ordering echocardiograms is to investigate the cause of a systolic murmur.(SEE TABLE 6) In one period studied 19.9% of all hip fracture patients underwent echocardiography. Significant aortic stenosis(defined as a gradient of 30mmHg across the aortic valve) was picked up in nearly 1 in 6 (16.9%) of all echocardiograms carried out. 40

Indication Ejection systolic murmur Pansystolic murmur Systolic murmur Pan and ejection systolic murmur Left ventricular function Not available other indications: total

No of patients 144 31 69 5 7 15 36

% 46.9% 10.1% 22.5% 1.6% 2.3% 4.9% 11.7%

Table 6. Indications for Echocardiograms in Hip Fracture Patients

49

In the case under discussion the an echocardiogram is appropriate and if significant aortic stenosis was detected surgery would still proceed but general anaesthesia would be used in preference to spinal anaesthesia. Consideration would be given to the possible use of a high dependency unit. Requesting and interpreting the echocardiogram would probably delay surgery for 48 hours.

Case 3 A 75 year old is admitted with a fractured hip. He has a history of lung carcinoma and metastatic bone disease which is known to involve his spine and ribs. He is competent and requests a do not resuscitate order be entered in his chart. He also states that he wishes surgery to proceed to help his pain and to regain his mobility. He asks that if he has a cardiopulmonary arrest whilst in theatre he still does not want to be resuscitated.

How should we proceed?

It is important to adopt the correct language when discussing resuscitation with many hospitals now using the phrase do not attempt resuscitation(DNAR). It is felt this is superior to the phrase do not resuscitate(DNR) which implies that resuscitation would be successful if attempted.41

The type of case under discussion is not uncommon in the fracture service and may become even commoner with advances in oncological and palliative care. Ethical dilemmas abound in the fracture service where many of the patients come from nursing homes and suffer from dementia. Often these types of patients develop bronchopneumonia and after discussion with their relatives DNAR orders may be applied. Sometimes these patients are scheduled for surgery despite their DNAR status and the DNAR order is suspended by default without discussion or documentation.

50

The question arises therefore what should be done with regard to their DNAR status during surgery? I am unaware of any United Kingdom anaesthetic guidelines which deal with this difficult issue and it is not addressed by the 2001 joint statement on resuscitation produced by the British Medical Association, The Resuscitation Council(UK) and the Royal College of Nursing42.

It must be emphasised that the operating theatre is a totally different environment to the general wards. Survival rates following anaesthetic related cardiorespiratory arrest can be as high as 92% 43This compares with survival rates of on average 14% after in hospital cardiopulmonary arrests.(worse outcomes with metatatic cancer, advanced age, recent stroke, sepsis and a dependent lifestyle)44 Difficulties also arise when one considers cardiopulmonary arrests that may occur during the operation due to physician error. This emotive issue is difficult to resolve but ethically the patient would probably have no distinction in his mind between the outcome of a disease related arrest and that caused by a physician. Feelings of guilt and concerns about possible medicolegal implications may make the team reconsider the DNAR order.

However one of the key principles of medical ethics is patient autonomy. In North America DNAR orders were routinely suspended prior to guidelines issued by the American Society of Anesthesiology in 1993(revised 1998)45These guidelines stated that automatically suspending a DNAR in the operating theatre may not sufficiently address a patients rights or selfdetermination in a responsible and ethical manner. and similar sentiments were expressed by the American College of Surgeons46 and the Canadian AnesthesiologistsSociety Committee on Ethics in 2002 47

In a review of this subject Tungpalan et al suggest a number of guidelines. They agree that the DNAR order should not be automatically suspended but that there should be only one alternative to DNAR in the operating room and that is full resuscitation. 48Another review suggests 3 main categories of resuscitation, full resuscitation, goal directed resuscitation and

51

procedure directed resuscitation.. The goal directed option involves judgement of the anaesthetist and surgeon in dictating how far and what resuscitative measures should be employed taking into account the patients values and goals. The procedure directed option allows the patient some degree of autonomy in being able to select certain resuscitative procedures. One of the potential problems with this approach is that the evidence base for advanced cardiac life support is for the full package and not the individual elements. However it is appreciated that some procedures are essential to providing anaesthetic care(such as airway management and intravenous fluids). Refusal of these procedures would not be consistent with a request for anaesthesia and surgery. 49

In the case under discussion my feeling is that surgery should proceed if an operating team can be found that accepts this patients goals and the burdens he is prepared to accept to achieve these goals. There must be close cooperation between the orthopaedic surgeon, anaesthetist and geriatrician. The DNAR should not automatically be suspended. Discussions should take place concerning what resuscitative measures are acceptable for the patient and the team. For example in the Human Rights Act 1998 the only article which is absolute with no derogations is Article 3(the prohibition of torture and inhuman and degrading treatment). Chest compressions in a gentleman with known metastatic bone disease involving his ribs would quite probably result in rib fractures at the very least. A competent and articulate patient may find the burdens of this intervention unacceptable. A DNAR order in the operating theatre is a highly contentious issue. The resolution of this difficulty is not helped by the lack of UK guidelines addressing the issue.

CASE 4 A 90 year old lady with a history of falls and vascular dementia falls in her nursing home and fractures her hip She has a long history of ischaemic heart disease.. On admission she is found to be in atrial fibrillation with a ventricular response of 120 beats per minute but her blood pressure is maintained. There are bibasal crepitations on auscultation and bilateral ankle oedema. Her oxygen saturations are 90% off oxygen. A diagnosis of heart failure is made. How should we proceed?

52

As anyone dealing with elderly fracture patients on a regular basis is aware , this is not an uncommon presentation. Symptoms and signs can be difficult to elicit in such a patient and cooperation with the examination process may be minimal. This patient could have a number of potential diagnoses such as a degree of atelectasis, lower respiratory tract infection or she may be in heart failure either as a cause or a consequence of her atrial fibrillation.In all three of these cases the atrial fibrillation may be exacerbated by pain and anxiety. The chest X rayis often technically difficult to obtain and even more difficult to interpret. Normally such X rays are taken in the AP supine position making comment on the pulmonary vascularity of limited value.

Atrial fibrillation is common in the elderly occuring in 10 % of the population over the age of 70 years.50 Common precipitants include valvular and ischaemic heart disease but in an acute fracture setting pulmonary embolism, infection and toxins such as alcohol should be remembered. It is a recognised risk factor for stroke and patients with established atrial fibrillation are often treated with aspirin or warfarin to reduce this risk. In the setting of acute orthogeriatric care this can create problems with timing of surgery whilst coagulation problems are sorted out. There has been much debate over the last number of years on the importance of rate or rhythm control but it appears that there is no outcome advantage of one over the other51,52.Drugs commonly used to control rate acutely in atrial fibrillation include cardioselective beta blockers, calcium antagonists ,digoxin and amiodarone (SEE TABLE 7). Amiodarone is a useful agent for rate control and can be used inpatients with heart failure. Interestingly although amiodarone is effective at both rhythm and rate control in atrial fibrillation, there is a limited evidence base to support its use in rate control 53,54. Digoxin is no longer regarded as a first line treatment for acute atrial fibrillation except in patients with heart failure or left ventricular dysfunction.54.Non-dihydropyridine calcium antagonists(such as verapamil and diltiazem) are effective at rate control but should be avoided in patients with heart failure. In the absence of acute left ventricular failure or severe asthma with wheeze betablockers are probably the agents of choice especially in cases were there is high adrenergic tone such as the perioperative period.54However in acute orthogeriatrics cardiovascular and respiratory morbidity is high and beta blockers must be used with care.

53

DRUG diltiazem esmolol metoprolol propranolol verapamil digoxin amiodarone Table 7 :Intravenous pharmacological heart rate control in atrial fibrillation

In this lady the diagnosis is heart failure and this would be treated in the normal way with oxygen and diuretics. Digoxin or amiodarone would be more appropriate for rate control in this setting although a low dose beta blocker(such as bisoprolol) could be added as the heart failure is brought under control. ). Electrical cardioversion to try to obtain sinus rhythm would only be undertaken in an emergency situation such as when the blood pressure drops. Only when the heart failure has been successfully treated and the ventricular response has been reduced to less than 100 beats per minute the patient would be presented for surgery. Careful attention to analgesic and fluid management in the perioperative period is important. Consideration may be given to ordering an echocardiogram to assess left ventricular function and to exclude valvular heart disease such as mitral stenosis. Post operatively, although at risk of stroke this lady would not be a suitable candidate for anticoagulation with warfarin (multiple falls) but her risk could be reduced with the use of aspirin.

Conclusion The cases discussed demonstrate the complexity and ethical dilemas involved in managing the older patient with fractures. Our difficulties are not helped by the lack of quality research in this area and the fact that studies tend not to involve the frail elderly population who fall and fracture. Systems of acute orthogeriatric care need to be developed that focus on preoperative as well as postoperative care. Such systems will need to be critically evaluated and

54

appropriately resourced Only with close co-operation between geriatricians, anaesthetists and orthopaedic surgeons can the ultimate goal of improved outcomes for the older patient with a fracture be achieved.

INFORMING THE CORONER

The majority of patients admitted to the fracture ward have received their injuries as the direct result of trauma. If a patient subsequently dies his case will need to be referred to the coroner. It is often forgotten that an elderly patient with a fractured neck of femur who dies during their admission will also fall into this category. If a trauma patient dies the following protocol should be followed: 1. Document in the medical notes the fact of death i.e. no neurological function no cardiovascular function no respiratory function and then the time of death. 2. Immediately contact the next of kin and inform them as humanely as possible- if the death is unexpected it may be best to ask them to come urgently to the ward. 3. Contact the Coroner and discuss the case with him- the telephone number is available at the switchboard. All the Coroner requires is a brief history and a likely cause of death , if known. He may request a Coroner's post mortem-this is his legal right and may not be overruled by the relatives. Alternatively he may request that the doctor fills in a death certificate(with the likely causes of death) but does not sign it. A covering letter explaining the clinical history should then be written and together with the unsigned death certificate, sent to the Coroner's Office. A post mortem is then not required. If a Coroner's Post Mortem is requested a chain of events is initiated that usually involves the Police, pathologists and mortuary technicians.This is routine and is normally to clarify the cause of death. It does not imply any medical malpractice and is not to be feared! If no post mortem is required the patient is then transported to the mortuary and will eventually be removed to the relevant undertakers ( selected by the relatives ) 4. Inform the Consultant involved as soon as possible. 5. Inform the patient's General Practitioner.

55

Death certificates can be obtained from the Sister's Office on the relevant ward. It isprobably good practice to document a copy of what is written in the death certificate into the medical notes ( possibly for future reference. )

Insert model death certificate and covering letter

56

DELIRIUM CHECK LIST 1. Adequate CNS oxygen delivery: Supplemental oxygen to keep saturation > 90%,preferably >95%. Treatment to raise systolic blood pressure >2/3 baseline or >90mmHg Maintain Hb

2. Fluid/electrolyte balance. Treatment to restore serum sodium, potassium, glucose to normal limits Treat fluid overload or dehydration 3. Treatment of pain. 4. Elimination of unnecessary medications: Discontinue/minimize benzodiazepines, anticholinergics, antihistamines Eliminate drug interactions, adverse effects Eliminate medication redundancies 5. Regulation of bowel/bladder habit 6. Adequate nutritional intake: Dentures used properly, proper positioning of meals, assist as needed 7. Early mobilisation and rehabilitation 8. Prevention, early detection and treatment of major postoperative complications: Myocardial infarction/ischaemia ECG, cardiac enzymes if needed Supraventricular arrhythmias/AF appropriate rate control, electrolyte adjustments, anticoagulation Pneumonia/COAD screening, treatment. Pulmonary embolus appropriate anticoagulation Screening for and treatment of urinary tract infection 9. Appropriate environmental stimuli:

57

Appropriate use of glasses and hearing aids Provision of clock and calendar If available, use of radio, tape recorder, and soft lighting

10. Treatment of agitated delirium Appropriate diagnostic workup/management Calm reassurance, family presence, and/or sitter Only resort to medication if absolutely necessary

ANALGESIA FOR THE OLDER PATIENT WITH A FRACTURE 1. Review the patients analgesic agents on admission and discontinue any that interfere with the following regime. 2. Prescribe regular soluble paracetamol 1g four times a day for baseline pain relief. 3. If rapid onset analgesia is required for patients with severe respiratory or renal compromise in which opiate side effects would be undesirable consideration should be given to the use of intravenous paracetamol 4. Prescribe morphine sulphate sc as a prn regime as follows: Age less than 70 years - morphine sulphate 10mg 4 hourly Age 70-80years - morphine sulphate 7.5mg 6 hourly Age > 80years - morphine sulphate 5mg 6 hourly Special indwelling cannulas are now available to give morphine sc. These have a lifespan of 1 week. This regime should be prescribed pre-operatively for severe pain. Dosage alterations may be required in heavier/lighter patients. 5. If the patient has breakthrough pain on the above regime morphine sulphate can be given intravenously at a dose of 1mg per minute until analgesia is obtained. 6. Tramadol at a dose of 50mg 6 hourly prn may be given orally or im for moderate pain. 7. Post operatively morphine sulphate should be discontinued and oral sevredol prescribed at the 10mg dose 2 hourly prn. 8. In younger patients sevredol can be prescribed at doses of 20mg 2 hourly prn 9. Analgesic assessments must be carried out daily (as per the care pathway for hip fractures) 10. The anti-emetic ondansetron should be prescribed for nausea at the 4mg dose 12 hourly prn. 11. Lactulose 10mls nocte should be prescribed regularly for constipation Movicol can be added after 3 days if there has been no bowel movement.. 12. Do not routinely prescribe compound preparations containing more than 30mg of codeine.

58

13. Do not prescribe NSAIDs (G.I.,renal, cardiorespiratory and bone side effects) cyclimorph (cyclizine is sedating ), tylex or DF118. 14. If patients receive intrathecal diamorphine consult the ward protocol. 15. Any difficult cases may be discussed with the pain team.

59

MANAGEMENT OF DIABETIC PATIENTS DURING ORTHOPAEDIC SURGERY ON ADMISSION a) Obtain details of patients age, duration of diabetes, treatment type and dosage (diet, tablets, insulin). b) Check: blood glucose, urea and electrolytes and urinalysis (glucose, ketones and protein); if ketones present do arterial astrup c) If emergency admission, erect IV fluids: usually a combination of 5% Dextrose and Normal Saline depending on patients needs (add 6 units of Actrapid to each bag of 500mls of 5% Dextrose) d) If blood sugar >20 mmol/l and/or ketonuria seek medical/metabolic advice e) Preprandial glucometer readings as a minimum f) Normal diabetic medication if eating and drinking PREPARATION FOR SURGERY a) b) c) d) e) f) g) Fast patients from 12 midnight 2-hourly glucometer readings from 12 midnight; if GM <6 mmol/l then hourly Add additional insulin to bag of 5% dextrose according to sliding scale Omit usual diabetic tablets/insulin the morning of surgery Fasting plasma glucose at 6.30 am Ideally the patient should be first on the list If blood glucose >20 mmol/l seek medical/metabolic advice

IF blood glucose <2 mmol/l erect 500 mls 5% dextrose running 2 hourly (if fasting give 50% dextrose 10-40 mls IV and recheck in 10-15 minutes) IF blood sugar < 5 mmol/l erect 500mls 5% dextrose @70 mls per hour IF blood sugar 5-10 mmol/l erect 500 mls 5% dextrose +10 units actrapid +10 mmol KCL @70 mls /h IF blood sugar 11-20 mmol/l erect 500 mls 5% dextrose +15 units actrapid +10 mmol KCL @70 mls/h IF blood sugar > 20 seek medical/metabolic advice POSTOPERATIVELY Until the patient is eating and drinking: a) Continue 2-hourly capillary glucose readings b) Continue IV fluids with sliding scale c) Soluble insulin to cover any food eaten eg 4-6 units actrapid depending on: i) Capillary glucose before a meal ii) Meal to be eaten iii) Usual insulin requirement iv) Response to previous dose of insulin When the patient is eating and drinking: a) Restart previous diabetic medication b) Discontinue IV fluids (possible leave venflon in situ a little longer) c) Reduce glucometer readings to pre meals NOTE: a) It is usually possible to return to preoperative insulin requirements within 24-48 hours b) Ill patients require careful monitoring and medical/metabolic advice c) In the eventuality of any difficulty contact the metabolic registrar on call 7/2000

60

MANAGEMENT OF METASTATIC BONE DISEASE FROM UNKNOWN PRIMARY

1. Full history and examination with particular focus on the following common causes of metastatic bone disease; bronchus, breast, prostate, kidney and thyroid. Heamatological malignancies are also relatively common such as multiple myeloma and lymphoma.

2. Baseline investigations should include: full blood picture urea and electrolytes liver function tests bone profile ESR plasma protein electrophoresis urinary Bence Jones prostatic specific antigen chest X ray urine dipstick. 3. Further investigations that may have a role in the work up are:
MAMMOGRAM ULTRASOUND OF ABDOMEN FAECAL OCCULT BLOODS TUMOUR MARKERS CA125 ,CEA ,CA19-9 CT OF ABDOMEN/PELVIS/CHEST 4. CT GUIDED BIOPSY OF THE LESION AT AN EARLY STAGE MAY LIMIT THE NUMBER OF UNNECESSARY INVESTIGATIONS CARRIED OUT

61

Medical management of men and women aged over 45 years who have or are at risk of osteoporosis
Major risk factors [other than previous fragility fracture] include the following: 1. Untreated hypogonadism [premature menopause, 2 amenorrhoea, 1 hypogonadism in women; 1 or 2 hypogonadism in men] 2. Glucocorticoids [7.5 mg per day prednisolone for 6 months or more] 3. Disease associated with increased prevalence of osteoporosis [eg gastrointestinal disease, chronic liver disease, hyperparathyroidism, hyperthyroidism] 4. Radiological osteopenia Other risk factors in national and international guidelines include family history, low body weight, cigarette smoking, height loss, or low bone mass as assessed by other techniques. Lifestyle advice

Adequate nutrition especially with calcium and vitamin D Regular weight bearing exercise Avoidance of tobacco use and alcohol abuse

Previous fragility fracture Defined as a fracture from standing height or less and includes prevalent vertebral deformity. A previous fragility fracture is a strong independent risk for further fracture and may be regarded as an indication for treatment without the need for BMD measurement when the clinical history is unequivocal. Investigations

FBC, ESR Bone and liver function tests [Ca, P, alk phos, albumin, AST/gGT] Serum creatinine Serum TSH

If indicated

Lateral thoracic and lumbar spine X-rays Serum paraproteins and urine Bence Jones protein Isotope bone scan Serum FSH if hormonal status unclear [women] Serum testosterone, LH and SHBG [men]

62

THE RENAL DIALYSIS PATIENT

Patients requiring renal dialysis are often admitted to the fracture service. The following points should be considered in their management: 1. When a patient requiring dialysis is admitted the renal registrar in the City Hospital should be contacted with the patients details ( indication for dialysis, when, where and how often it occurs and the date of the last dialysis) 2. What is the fluid restriction? 3. Fill out the dialysis form 4. Reduce standard dose of enoxaparin to 20mg at night 5. Reduce standard analgesia dose (such as morphine sulphate 5mg 6 hourly) or use intravenous paracetamol

BEWARE OPIATE TOXICITY

63

TRANSFERRING AN OLDER PATIENT WITH A FRACTURE

When transferring an older patient with a fracture patient the following sub categories are considered: Medical Issues: Is the patient fit for transfer? The following parameters can be helpful in reaching this conclusion: 1. Patient comfort. 2. Oxygen saturations greater than 90 %. 3. Absence of a tachycardia. 4. Satisfactory blood pressure (systolic greater than 90 mmHg) 5. Satisfactory haemoglobin 6. Optimised urea + electrolytes. 7. Absence of a significant pyrexia. Nursing Issues: Is the senior nurse on the ward content that the patient should be transferred ? Issues which will be considered will include wound management, Surgical Issues: Is acute Fracture management complete ? Can further treatment be facilitated in receiving unit ?

Multidisciplinary team issues ( physiotherapist, social worker, occupational therapist ): Are staff in the multidisciplinary team content with transfer ? Patient and family issues: Are they content about the proposed transfer? The consideration of these issues will determine the appropriateness of transfer, but it is also crucial that we all liaise closely with receiving units, in order that full and adequate information is provided on patients leaving the Fracture Unit.

64

BEWARE
All systolic BPs to be above at least 90mmHG All oxygen saturations to be above 90% Prevent the DTs with chlordiazepoxide Use enoxaparin as thromboprophylaxis Remember tazocin is a penicillin Erect drips on fasting patients Ensure that all investigations are readily available in the immediate preoperative period Check blood results on a daily basis but especially at weekends

Severe liver impairment, alcoholism Severe kidney impairment Major trauma or surgery to brain, eye or spinal cord

65

Spinal or epidural block

Appendix 3 Table 1 : Contraindications and cautions for aspirin and heparins in prophylaxis of VTE 1*

CONTRAINDICATIONS

66