The Elderly Patient with a Displaced Femoral Neck Fracture and Cardiac Comorbidity
An 82-year-old man falls at home and cannot bear weight. He has a history of heart failure with an ejection fraction of 30%, atrial fibrillation on apixaban (last dose 36 hours ago), and mild cognitive impairment. He lives alone and ambulates with a walker indoors. Examination shows a shortened, externally rotated right leg; he is in severe pain. Radiographs show a displaced transcervical femoral neck fracture (Garden III-IV). Labs: creatinine 1.6 mg/dL, hemoglobin 10.2 g/dL, platelets 110,000. The family asks whether he will walk again.
1. How do you choose between internal fixation, hemiarthroplasty, and total hip arthroplasty, and how does his anticoagulation affect timing?
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In a displaced femoral neck fracture in a patient over 70 with limited but existing ambulation, internal fixation has a high reoperation rate and is generally reserved for nondisplaced or young patients; hemiarthroplasty is the workhorse. Total hip arthroplasty is reasonable if he were a higher-demand, cognitively intact patient with good bone stock; his cognitive impairment and walker use make hemiarthroplasty the pragmatic choice, reducing dislocation risk and operative time. Anticoagulation: apixaban with a 36-hour last dose puts him at elevated bleeding risk for neuraxial anesthesia and surgery. Check renal function (creatinine 1.6 affects clearance), consider reversal with andexanet alfa or prothrombin complex concentrate if urgent, or delay 12-24 hours if stable and pain-controlled. Timing should balance early mobilization (mortality benefit) against bleeding risk; involve anesthesia and cardiology. Platelets 110,000 and Hb 10.2 are acceptable for surgery with blood availability.
2. What preoperative medical optimization would you insist on, and what perioperative risks do you explicitly discuss with the family?
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Optimization: assess volume status and heart failure (avoid fluid overload), check electrolytes and renal function, correct anemia if symptomatic, ensure rate-controlled atrial fibrillation, and obtain cardiology input given EF 30%. Review apixaban timing and plan reversal if needed. Risks to discuss: perioperative mortality (roughly 5-10% at 30 days in this population), myocardial infarction and heart failure exacerbation, pneumonia, delirium (especially with cognitive impairment), pressure injury, VTE, prosthetic dislocation, periprosthetic fracture, and the possibility of not returning to prior ambulation. Set realistic goals: pain control, early mobilization, and return to walker-assisted ambulation rather than independent walking. Document the discussion of code status and goals of care.
3. Postoperatively he becomes confused on day 2. Outline your differential and management priorities.
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Delirium in an elderly postoperative patient is multifactorial: pain, opioid side effects, urinary retention, constipation, hypoxia, infection (urinary, pneumonia, wound), electrolyte disturbance, dehydration, myocardial ischemia, and medication effects (anticholinergics, benzodiazepines). Management priorities: (1) ABCs, oxygen, glucose and electrolytes; (2) review medications and stop deliriogenic agents; (3) assess for urinary retention and constipation; (4) screen for infection with urinalysis, chest imaging, and wound inspection; (5) ECG and troponin if cardiac symptoms; (6) nonpharmacologic measures - orientation, sleep hygiene, early mobilization, family presence, glasses/hearing aids; (7) reserve antipsychotics for severe agitation with danger to self/others, at low dose and short duration. Avoid restraints. Reassess the hip for dislocation or fracture complication if pain is new.