Frail Older Adult With a Displaced Femoral Neck Fracture on Apixaban
An 86-year-old woman who lives in an assisted-living facility fell while reaching for her walker and has not been able to stand since. She arrives 2 hours later with a shortened, externally rotated right leg. She has hypertension, atrial fibrillation, stage 3b chronic kidney disease (baseline creatinine 1.5 mg/dL), and mild cognitive impairment; she knows her name and the year but not the month. She takes apixaban 5 mg twice daily, and the last dose was 16 hours ago. Her daughter holds her healthcare proxy. Radiographs show a displaced femoral neck fracture with 25 degrees of angulation and no cortical continuity (Garden III). Hemoglobin is 10.9 g/dL, platelets 190,000/µL, and INR is 1.1. She weighs 48 kg. The facility cannot provide 24-hour supervision on return, and her daughter works full time. Before the fall she walked 15 meters with a walker and had never had a fragility fracture workup.
1. How do you reconcile the timing of surgery with her recent apixaban dose? Give your recommendation and the reasoning, including anesthetic considerations.
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Two priorities compete: the mortality benefit of early surgery (within 24-48 hours) versus a recent direct oral anticoagulant.
Apixaban 5 mg twice daily, last dose 16 hours ago, with an eGFR near 40. Neuraxial anesthesia guidelines recommend stopping apixaban for about 72 hours before spinal or epidural placement. Waiting that long would push surgery to roughly 56 hours after admission, an unacceptable delay for a frail 86-year-old with a displaced femoral neck fracture.
Recommendation: proceed within 24 hours under general anesthesia, with a peripheral nerve block for analgesia, after discussing the plan with anesthesia; general anesthesia does not carry the neuraxial hematoma risk. Routine reversal with andexanet alfa or prothrombin complex concentrate is not indicated in a non-bleeding patient and should be reserved for major bleeding. Anti-Xa testing does not reliably guide reversal timing and should be ordered only for a specific question. Do not delay for the INR, which is already normal. Transfuse for symptoms or a hemoglobin below about 8 g/dL. Document the shared decision with the daughter.
2. Write your preoperative analgesia and delirium-prevention plan, naming agents you would avoid and why.
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Analgesia: a fascia iliaca compartment block (single-shot with weight-adjusted local anesthetic, or a continuous catheter) substantially reduces opioid requirements and is associated with less delirium. Add scheduled acetaminophen 650 mg every 6 hours (maximum 3 g/day in this age group) and low-dose IV opioid for breakthrough.
Avoid: NSAIDs such as ketorolac because of stage 3b CKD and bleeding risk; meperidine because normeperidine accumulates; codeine and morphine because active metabolites accumulate in renal impairment (use hydromorphone or fentanyl instead); benzodiazepines and diphenhydramine because they precipitate delirium.
Delirium prevention: screen with the 4AT or CAM on admission and each shift; orient her and involve her daughter; bring glasses and hearing aids; maintain daylight and sleep hygiene; mobilize preoperatively if safe; avoid urinary catheters and restraints; treat constipation and pain; look for urinary retention, dehydration, hypoxia, and medication effects (including precipitated withdrawal from her home medications) before adding any drug. Antipsychotics are not for prophylaxis.
3. Which implant do you anticipate, what discharge disposition is appropriate, and what secondary prevention do you initiate?
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Implant: this is a displaced femoral neck fracture in a low-demand, cognitively impaired 86-year-old with limited pre-fracture mobility. A cemented hemiarthroplasty is appropriate; cementing reduces periprosthetic fracture and postoperative pain compared with an uncemented stem, and total hip arthroplasty is generally reserved for independent patients with intact cognition and higher function. Internal fixation is not appropriate for a displaced femoral neck fracture in this age group.
Disposition: she cannot return to a facility without 24-hour supervision, and going home with a working daughter is not realistic. Discharge to a skilled nursing facility for rehabilitation with physical and occupational therapy, and complete a home safety evaluation before she returns to assisted living.
Secondary prevention: this is a fragility fracture with no prior workup. Order DXA, check vitamin D, ensure adequate calcium and vitamin D intake, and start an antiresorptive or anabolic agent with attention to renal function (bisphosphonate or denosumab; avoid zoledronic acid if creatinine clearance is below 35 mL/min). Address falls: review sedatives and antihypertensives, vision, footwear, home hazards, and walking aid. Refer to a fracture liaison service and confirm the daughter understands that treatment lowers the risk of the next fracture.