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Post-operative Nursing

Management:
Hip Fracture Surgery
Eva AU
APN, O&T, QEH
8 J uly, 2007
Epidemiology
Hip fracture is a major health problem as
population ages
HK (1995): 11/1000 in women, 5/1000 in
men >70yrs (Lau et al, 1999)
2003: 40,000 elderly fall, 25% fracture
HK (2031): 24.3% population >65yrs
World wide (2050): 6.3 million hip #
women & 1/3 men sustain a fragility
fracture during their life time (Karlsson et al, 2005)
ORIF VS Hemiarthroplasty
Parker et al 2002 (RCT of 455 patients)
ORIF
Hemi-
arthroplasty
Shorter length of
anaesthesia

Less blood loss


Lower blood transfusion


requirement

Low risk for 2



surgery

ORIF VS THR
Tidermark et al, 2003 (RCT of 102 patients)
ORIF
THR
Lower failure rate

Better hip function


HRQOL

Low revision rate


Arthroplasty as 1

surgery
THR > bipolar hemiarthroplasty > ORIF
#NOF in active, alert, independent elderly
Better function
Minimize 2

surgery e.g. removal, revision
Better HRQOL
(Blomfeldt et al, 2007 RCT of 120 patients)
Post-op
D0

D1-3 RV off, X-ray


Weight bearing as tolerated

D14 off S/S


Immediate Post-op
Hourly homodynamic status
Monitor blood loss and fluid balance
Observe for wound oozing and signs of
infection
Wound care
Lower limb circulation and sensation
Pain management
Alignment
Early post-op
Back
Out of bed
Muscle training
Progressive resistance muscle
training optimize muscle strength &
improve functional capability in
elderly after hip fracture surgery
Knee extension: 72%+/-56%
Leg press: 37%+/-30%
(Host et al, 2007)
Muscle training
Back
END?
Complications
Massive blood loss
Wound infection
Superior gluteal nerve dysfunction
DVT
AROU
Post-op delirium
Dislocation
(Dharmarajan & Prabir, 2006) Fall
DVT
Risk period: 3 month after hip surgery
(Bjornara et al, 2006)
35% - 42% in Caucasian hip #
(Eriksson et al, 2003)
3% in Chinese population with hip #
Not recommended for prophylaxis anti-
coagulation therapy
(Chan et al, 2004)
Management of DVT
Prevention
Prevention
Ankle pump
exercise
Early ambulation
Treatment
Treatment
Bed rest
LMWH
Warfarin
Monitor clotting
Pressure stocking
Back
AROU
Risk factor
Pain
Position
Anesthesia effect
AROU UTI systematic infection
Management of AROU (QEH)
Multi-disciplinary approach between O&T
surgeons, urologist & nurse
Foley intra-op
Remove Foley within 2 days post-op
Early mobilization & weight bearing
Treat constipation, pain & UTI
To KH after PU without Foley
Trial without Catheter
Re-insert + CSU
R/O bowel/ renal disorder
Consult Surgery/Urology
Treat constipation, pain & UTI
Early mobilization & weight bearing
Try off Foley 2 days after re-insert
To KH after PU without Foley
Trial without Catheter
Foley to BSB
Ix & Tx underlying cause by urologist e.g.
BPH
Treat constipation, pain & UTI
CIC/CISC with RU monitoring in KH till
problem solved
FU by urologist for further Ix e.g. CMG
Back
Delirium
41% after hip surgery
(Brauer et al, 2000)
Electrolyte imbalance, metabolic
abnormalities
Infection, hypoxia
Pain, medications
Altered environment, dementia
(Dharmarajan & Prabir, 2006)
Management of Delirium (QEH)
S Stress reduction
M keep Memory
A Ask question
R Recall events
T Time and date orientation and pain
control
SMART
Target patients
Target patients
> 65 years
MMSE > 20
No communication problem
SMART
Orientate nursing intervention
e.g. environment, reason for hospitalization, peri-
operative managements
Show equipment
Maintain memory ability
e.g. call by name, refer to calander
Provide functional visual or hearing aids
Provide visual and verbal orientation to
date & time
Adequate pain control
SMART
Consequent Assessments
Consequent Assessments
On admission
The day before OT
Post-op D1
Results
Results
experimental group: control group
19.4% : 60%
Back
Dislocation
Anterior VS Posterior approach
Higher rate of dislocation in posterior
capsular approach (Bush & Wilson, 2007)
Treatment: CR +/- OR +/- Revision
Posterior Approach
Anterior Approach
ADL aids
Home Modification
Back
END?
Subsequent Fall
Management of hip # does not end with
surgery
Prevention of fall
Screen for osteoporposis and risk of fall
Prevent and treat osteoporosis
(Dharmarajan & Banik, 2006)
Prevent Subsequent #
Community fall prevention campaign
Fall assessment
Hip Protector
Thank You!
References
Bjornara BT, Gudmundsen TE, Dahl OE; 2006; Frequency and
timing of clinical venous thromboembolism after major joint surgery:
The J ournal of Bone & J oint Surgery (Br), Mar 2006, 88,3; pp 386
391
Blomfeldt R, Tornkvist H, Eriksson K, Soderqvist A, Ponzer S,
Tidermark J ; 2007; A randomized controlled tril comparing bipolar
hemiarthroplasty with total hip replacement for displaced
intracapsular fractures of the femoral neck in elderly patients; The
J ournal of Bone & J oint Surgery (Br), Feb 2007, 89, 2; pp 160 165
Brauer C, Morrison RS, Silberzweig SB; 2000; The cause of delirium
in patients with hip fracture; Arch Intern Med 2000, 160(12), pp
1856 1860
Bush J B, & Wilson MR; 2007; Dislocation after hip hemiarthroplasty:
anterior versus posterior capsular approach; Orthopedics Feb 2007,
Vol 30, No.2; pp 138 - 144
Chan YK, Chiu KY, Cheung SWK, Ho P; 2004; The incidence of
deep vein thrombosis in elderly Chinese suffering hip fracture is low
without prophylaxis: a prospective study using serial duplex
ultrasound; J ournal of Orthopaedic Surgery, 2004, 12(2), pp. 178
183
Dharmarajan TS, Prabir B; 2006; Hip fracture: risk factors,
preoperative assessment , and postoperative management;
Postgraduate Medicine, J un/J ul 2006, 119,1; pp 31 - 38
Eriksson BI, Lassen MR; 2003; Duration of prophylaxis against
venous thromboembolism with fondaparinus after hip fracture
surgery: a multicenter, randomized, placebo-controlled, double-blind
study; Arch Intern Med 2003, 163; pp 1337 1342
Host HH, Sinacore DR, Bohnert KL, Steger-May K, Brown M, Binder
EF; 2007; Training-induced strength and functional adaptations after
hip fracture; Physical Therapy, Mar 2007, 87,3, pp 292 303
Karlsson MK, Gerdhem P, Ahlborg HG; 2005; The prevention of
osteoporotic fractures; The J ournal of Bone & J oint Surgery (Br), Oct
2005, 87, 10; pp.1320 -1327
Lau EMC, Cooper C, Fung H, Lam KK, Tsang KK; 1999; Hip
fracture in Hong Kong over the last decade a comparison with the
UK; J ournal of Public Health Medicine, Vol. 21, No.3, pp.249 -250;
Faculty of Public Health Medicine
Parker MJ , Khan RJ K, Crawford GAP; 2002; Hemiarthroplasty
versus internal fixation for displaced intracapsular hip fractures in
the elderly; The J ournal of Bone & J oint Surgery (Br); Nov 2002,
84,8; pp 1150 -1155
Tidermark J , Ponzer S, Svensson O. Soderqvist A, Tornkvist H;
2003; Internal fixation compared with total hip replacement for
displaced femoral nect fractures in the elderly; The J ournal of Bone
& J oint Surgery (Br); Apr 2003, 85, 3; pp 380 388