AAOS Appropriate Use Criteria: Treatment of Hip Fractures in the Elderly

The American Academy of Orthopaedic Surgeons (AAOS) approved the Appropriate Use Criteria (AUC) document Treatment of Hip Fractures in the Elderly in an effort to assist the clinician in the evaluation and management of these injuries. Here, we present two clinical scenarios and postoperative rehabilitation treatment options to demonstrate how these AUC can be incorporated into clinical decision making. Case 1 History A 71-year-old woman presented to the hospital after slipping and falling from a ground-level height while gardening in her back yard. Prior to falling, she was a high-functioning person with high activity demands. After her fall, the patient experienced pain in her left hip and could not bear weight in her left lower extremity. Patient Assessment and Treatment The patient was transported to the emergency department, and an unstable, displaced reverse obliquity intertrochanteric fracture of the left hip was diagnosed on plain radiographs (Figure 1). Asymptomatic hip osteoarthritis was noted radiographically. Shortening of the left lower extremity and external rotation were diagnosed based on physical examination, along with tenderness to palpation of the left hip. The patient also experienced tenderness of the left hip on the log rolling maneuver. She had a history of asymptomatic mitral valve prolapse, with normal ejection fraction on echocardiography.Figure 1: AP pelvic (A) and lateral (B) radiographs demonstrating a reverse obliquity fracture of the left proximal femur of a 71-year-old woman.The patient was seen and assessed by the internal medicine team for surgical fitness. She was felt to be a satisfactory surgical candidate and in optimal condition. On the day after admission, the patient underwent treatment with a long cephalomedullary nail (Figure 2).Figure 2: Same patient as in Figure 1. Intraoperative AP (A) and lateral (B) fluoroscopic images of the proximal left femur and intraoperative AP (C) and lateral (D) fluoroscopic images of the distal left femur demonstrating satisfactory reduction and fixation with the use of a long cephalomedullary nail.Rehabilitation After surgery, the patient underwent physical and occupational therapy. Weight bearing as tolerated was begun on postoperative day 1. On postoperative day 5, the patient was discharged home with home health care. Discussion This case best reflects Scenario 26 of the AAOS AUC document Treatment of Hip Fractures in the Elderly1 (Table 1).Table 1: Treatment of Hip Fractures in the Elderly: Scenario 26Case 2 History A 72-year-old man presented to the hospital after he missed a step at home, experiencing a ground-level fall onto his left hip that resulted in immediate pain and inability to ambulate. Prior to injury, he was an independent ambulator with moderate to low functional capacity and lived at home. Patient Assessment and Treatment The patient was transferred from another hospital after a 4-day delay at that first hospital. The patient had previously undergone aortic valve replacement to manage aortic stenosis. He also had a history of cardiac arrest, cardiomyopathy, deep vein thrombosis with pulmonary embolism (managed with warfarin), and cephalomedullary nailing of his right hip to manage a hip fracture. The patient was evaluated by the internal medicine team for preoperative risk assessment. He was also assessed by a cardiologist. Surgical treatment was undertaken <24 hours after hospital admission. The patient was taking warfarin at the time of surgery; because of his anticoagulation status, general anesthesia was administered. He was treated surgically with the use of a short cephalomedullary nail in his left hip to achieve fixation of the stable intertrochanteric hip fracture (Figures 3 and 4).Figure 3: Preoperative AP (A) and lateral (B) radiographs of the pelvis demonstrating a stable intertrochanteric fracture of the left hip in a 72-year-old man.Figure 4: Same patient as in Figure 3. Postoperative AP pelvic radiograph (A), as well as AP (B) and lateral (C) radiographs of the left hip, demonstrating fixation of the stable intertrochanteric fracture of the left hip with the use of a short cephalomedullary nail.Rehabilitation Postoperatively, the patient was allowed to bear weight as tolerated. He was discharged to a skilled nursing facility for rehabilitation on postoperative day 3. Discussion This case best reflects Scenario 16 of the AAOS AUC document Treatment of Hip Fractures in the Elderly.1 As seen in Table 2, the use of a short cephalomedullary nail is an acceptable option, although the voting panel felt that a sliding hip screw might have been a more appropriate choice for this patient.Table 2: Treatment of Hip Fractures in the Elderly: Scenario 16

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