DIVISION OF HOSPITAL MEDICINE PERIOPERATIVE MEDICINE

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1 DIVISION OF HOSPITAL MEDICINE PERIOPERATIVE MEDICINE Hip Fracture Management: Role of Internists SESSION OUTLINE INTRODUCTION Hip fractures are a major cause of hospitalization, morbidity and mortality, particularly in our increasing elderly population. Because many hip fracture patients have multiple chronic, and potentially acute, medical problems internists play a critical role in their care. The goal of his module is to provide internal medicine residents with the foundations and best practices to participate in the care of patients with hip fractures in collaboration with orthopedic surgeons and other members of the healthcare team. GOALS 1. Perform an appropriate preoperative medical evaluation for patients undergoing hip fracture repair. 2. Describe the optimal timing for surgical repair of a hip fracture to improve patient outcomes. 3. Describe common perioperative medical complications associated with hip fractures and apply risk reduction strategies. The specific pertinent learning objectives (from the curricular map) along with teaching and assessment methods are included in TABLE SESSION CONTENT Brief summary description of what is covered in this session. Case based discussion covering 1. Goals of the healthcare team caring for patients with hip fractures 2. Morbidity and mortality associated with hip fractures 3. Optimal timing for surgical repair of a hip fracture to improve patient outcomes. 4. Common perioperative medical complications associated with hip fractures and risk reduction strategies. 5. Secondary prevention in patients who have had a hip fracture 1

2 AGENDA & METHODS Independent Reading Case Discussion with Faculty FACILITIES & EQUIPMENT None HAND OUTS Hung, WW, et al. Hip fracture management tailoring care for the older patient. JAMA 2012;307: COURSE EVALUATION 1. Before and after questionnaires about the perceived needs and abilities with regard to teaching. To evaluate the usefulness/acceptability of the session, whether participants achieved the workshop objectives, and identify areas were participants felt more work was needed. 2. Online evaluation forms 3. Teaching evaluation by students, peers, chief residents using valid and reliable rating scales. REFERENCES Cohn, Steven L, et. Perioperative Medicine. Chapter 12 Orthopedic Surgery. Springer 2011 Falk-Yitter Y, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. CHEST 2012; 141(2)(Suppl):e278S e325s Hung, WW, et al. Hip fracture management tailoring care for the older patient. JAMA 2012;307: McLaughlin MA, et al. Preoperative status and risk of complications in patients with hip fracture. J Gen Int Med 2006;21:

3 Case 1 You are paged by the orthopedic surgery resident with a request to evaluate a patient in the emergency department who has a right hip fracture. The patient is an 84 year old woman with diabetes mellitus, hypertension and congestive heart failure. She tripped on a rug in her kitchen while making breakfast. There is OR time available later today and they will take her to surgery today if you believe she is medically optimized. Case Discussion Questions: What are (or should be) common goals of healthcare team members who care for patients with hip fractures? List responsibilities specifically of internists who participate in the inpatient care of hip fracture patients. List the anatomic site(s) of fracture encompassing the term hip fracture. Label the images at the end of the case discussion. List the most common surgical approaches to hip fracture management. Cite why a general understanding by internists is important. You review the patient s chart. She has never been to this medical center before. You proceed to the emergency department. The patient is very sleepy after receiving a dose of hydromorphone shortly before your evaluation. She falls asleep not long after being awoken. The patient s daughter is at the bedside and provides you with the following information: The patient has diabetes mellitus and is on glipizide and metformin. The patient monitors her blood sugars periodically and states that they are good. She a long history of high blood pressure for which she takes metoprolol and lisinopril. She was hospitalized 1 year ago for heart failure. She has had no problems since and has not been on a water pill for the past several months. She lives alone and does her own cooking and light cleaning. She uses a cane when she walks outside of her home. She seems to be a little forgetful but her family feels very comfortable with her living alone since they visit often. Her daughter has not heard the patient complain of shortness of breath or chest pain. She does not smoke or drink. She takes the medications mentioned above and an occasional acetaminophen for knee and hand arthritis. She has no known drug allergies. 3

4 Physical exam: BP 138/72, pulse 64, respiratory rate 12, afebrile, oxygen saturation on RA 95%. You perform a complete physical examination. There are no findings which concern you. LABS: Na 135 K 3.9 Cl 109 CO2 25 BUN 25 Cr 2.1 Glucose 201 WBC 13,600 Hgb 11.5 Plt 136,000 PT/aPTT normal EKG - tracing at end of case The patient s daughter becomes tearful and asks What does this fracture mean for mom? Will she be able to live at home by herself again? Cite general epidemiologic and prognostic data for patients who sustain a hip fracture. You begin your consult note. While in the midst of writing it, the orthopedic resident pages you and asks if they can take her to the OR shortly. If not, then the surgeon will not be available until the day after tomorrow. Given the data, how would you respond? Patients with hip fracture should undergo surgical repair within 48 hours --- Myth or Truth? Give examples of major preoperative medical abnormalities. List the most common perioperative complications associated with hip fracture How common are delirium and venous thromboembolism? Describe risk reduction strategies for both. 4

5 Describe an approach to secondary prevention in patients who have had a hip fracture. Case 2 A 74-year old man with severe aortic stenosis for whom surgical and percutaneous replacement have been deemed too high risk, systolic heart failure, metastatic pancreatic cancer, and stage II sacral decubitus ulcer sustains a hip fracture when he slips out of his wheelchair. He has been bedbound for the past 2 months. Case Discussion Question: How would you approach this patient s preoperative risk assessment and therapy? 5

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6 Label each image with the type of fracture depicted. 6

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Images have been removed from the PowerPoint slides in this handout due to copyright restrictions. Arterial Blood Gas Interpretation Routine Assessment Inspection Palpation Auscultation Labs Na 135-145 K 3.5-5.3 Chloride 95-105 CO2 22-31 BUN 10-26 Creat.5-1.2 Glu 80-120 Arterial Blood Gases WBC 5-10K