Treatment Principles

  • Kenneth J. Koval
  • Joseph D. Zuckerman

Abstract

The primary goal of fracture treatment is to return the patient to his or her prefracture level of function. There is nearly universal agreement that in patients who sustain a hip fracture, this goal can best be accomplished operatively.1 Historically, nonoperative management has resulted in excessive rates of medical morbidity and mortality, as well as malunion and nonunion.2 Nonoperative management is appropriate only in selected nonambulators who experience minimal discomfort from their injury.2,3 These patients should be rapidly mobilized to avoid the complications of prolonged recumbency: decubitus ulcers, atelectasis, urinary tract infection, and thrombophlebitis.

Keywords

Total Knee Arthroplasty Deep Vein Thrombosis Venous Thromboembolism Femoral Neck Fracture Intermittent Pneumatic Compression 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Zuckerman J, Schon L. Hip fractures. In: Zuckerman J, ed. Comprehensive Care of Orthopaedic Injuries in the Elderly. Baltimore: Urban & Schwarzenberg, 1990:23–111.Google Scholar
  2. 2.
    Koval KJ, Zuckerman JD. Hip fractures: I. Overview and evaluation and treatment of femoral neck fractures. J Am Acad Orthop Surg 1994; 2:141–149.PubMedGoogle Scholar
  3. 3.
    Winter WG. Nonoperative treatment of proximal femoral fractures in the demented nonambulatory patient. Clin Orthop 1987; 218:97–103.PubMedGoogle Scholar
  4. 4.
    Drake JK, Meyers MH. Intracapsular pressure and hemarthrosis following femoral neck fracture. Clin Orthop 1984; 182:172–176.PubMedGoogle Scholar
  5. 5.
    Melberg PE, Korner L, Lansinger O. Hip joint pressure after femoral neck fracture. Acta Orthop Scand 1986; 57:501–504.CrossRefPubMedGoogle Scholar
  6. 6.
    Zuckerman JD, Schon LC. Hip fractures. In: Zuckerman J, ed. Comprehensive Care of Orthopaedic Injuries in the Elderly. Baltimore: Urban & Schwarzenberg, 1990:23–111.Google Scholar
  7. 7.
    Kenzora JE, McCarthy RE, Lowell JD, Sledge CB. Hip fracture mortality. Relation to age, treatment, preoperative illness, time of surgery, and complications. Clin Orthop 1984; 186:45–56.PubMedGoogle Scholar
  8. 8.
    Sexson SB, Lehner JT. Factors affecting hip fracture mortality. J Orthop Trauma 1988; 1:298–305.CrossRefGoogle Scholar
  9. 9.
    Zuckerman JD, Skovron ML, Koval KJ, et al. Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip. J Bone Joint Surg Am 1995; 77:1551–1556.PubMedGoogle Scholar
  10. 10.
    Davis FM, Laurenson VG. Spinal anaesthesia or general anaesthesia for emergency hip surgery in elderly patients. Anaesth Intensive Care 1981; 9:352–358.PubMedGoogle Scholar
  11. 11.
    Valentin N, Lomholt B, Jensen JS, et al. Spinal or general anesthesia for surgery of the fractured hip? Br J Anaesth 1986; 58:284–291.CrossRefPubMedGoogle Scholar
  12. 12.
    Modig J, Borg T, Karlstrom G, et al. Thromboembolism after total hip replacement: role of epidural and general anesthesia. Anesth Analg 1983; 62:174–180.CrossRefPubMedGoogle Scholar
  13. 13.
    Koval KJ, Aharonoff GB, Rosenberg AD, et al. Functional outcome after hip fracture. Effect of general versus regional anesthesia. Clin Orthop 1998; 348:37–41.PubMedGoogle Scholar
  14. 14.
    Stevens J, Fardin R, Freeark R. Lower extremity thrombophlebitis in patients with femoral neck fractures. Trauma 1968; 8:527–534.CrossRefGoogle Scholar
  15. 15.
    Johnsson S, Bygdeman S, Eliasson R. Effect of dextran on postoperative thrombosis. Acta Chir Scand 1968; 387:80–82.Google Scholar
  16. 16.
    Ahlberg A, Nylander G, Robertson B, et al. Dextran in prophylaxis of thrombosis in fractures of the hip. Acta Chir Scand 1968; 387:83–85.Google Scholar
  17. 17.
    Hamilton HW, Crawford JS, Gardiner JH, Wiley AM. Venous thrombosis in patients with fractures of the upper end of the femur: a phlebographic study of the effect of prophylactic anticoagulation. J Bone Joint Surg Br 1970; 52:268–289.PubMedGoogle Scholar
  18. 18.
    Moskovitz PA, Ellenberg SS, Feffer HL, et al. Low-dose heparin for prevention of venous thromboembolism in total hip arthroplasty and surgical repair of hip fractures. J Bone Joint Surg Am 1978; 60:1065–1070.PubMedGoogle Scholar
  19. 19.
    Snook G, Chrisman O, Wilson T. Thromboembolism after surgical treatment of hip fractures. Clin Orthop 1981; 155:21–24.PubMedGoogle Scholar
  20. 20.
    Powers P, Gent M, Jay R, et al. A randomized trial of less intense postoperative warfarin or aspirin therapy in the prevention of venous thromboembolism after surgery for fractured hip. Arch Intern Med 1989; 149:771–774.CrossRefPubMedGoogle Scholar
  21. 21.
    Agnelli G, Cosmi B, Fillipo D, et al. A randomized double-blind, placebo-controlled trial of dermatan sulphate for prevention of deep vein thrombosis in hip fracture. Thromb Haemost 1992; 67:203–208.PubMedGoogle Scholar
  22. 22.
    Haake D, Berkman S. Venous thromboembolic disease after hip surgery. Risk factors, prophylaxis, and diagnosis. Clin Orthop 1989; 242:212–231.PubMedGoogle Scholar
  23. 23.
    Moser K. Pulmonary thromboembolism. In: Wilson J, Braunwald E, Isselbacher KJ, et al., eds. Harrison’s Principles of Internal Medicine, Vol 1. New York: McGraw-Hill, 1991:1090–1096.Google Scholar
  24. 24.
    Hull R, Raskob G. prophylaxis of venous thromboembolic disease following hip and knee surgery. J Bone Joint Surg Am 1986; 68:146–150.PubMedGoogle Scholar
  25. 25.
    Hefley FG Jr, Nelson CL, Puskarich-May CL. Effect of delayed admission to the hospital on the preoperative prevalence of deep-vein thrombosis associated with fractures about the hip. J Bone Joint Surg Am 1996; 78:581–583.PubMedGoogle Scholar
  26. 26.
    Harris WH, Athanasoulis C, Waltman AC, Salzman EW. Cuff-impedance phlebography and 125I fibrinogen scanning versus roentgenographic phlebography for diagnosis of thrombophlebitis following hip surgery. J Bone Joint Surg Am 1976; 58:939–944.PubMedGoogle Scholar
  27. 27.
    Hull R, Hirsh J, Sackett D, et al. The value of adding impedance plethysmography to 125I-fibrinogen leg scanning for the detection of deep vein thrombosis in high risk surgical patients: a comparative study between patients undergoing surgery and hip surgery. Thromb Res 1979; 15:227–234.CrossRefPubMedGoogle Scholar
  28. 28.
    Eskeland C, Solheinik H, Skjorten F. Anticoagulant prophylaxis, thromboembolism and mortality in elderly patients with hip fractures. A controlled clinical trial. Acta Chir Scand 1966; 131:16–29.PubMedGoogle Scholar
  29. 29.
    Francis CW, Marder VJ, Evarts CM, Yaukoolbodi S. Two-step warfarin therapy: prevention of postoperative venous thrombosis without excessive bleeding. JAMA 1983; 249:374–378.CrossRefPubMedGoogle Scholar
  30. 30.
    Sevitt S, Gallagher N. Prevention of venous thrombosis and pulmonary embolism in injured patients. A trial of anticoagulant prophylaxis and phenidine in middle-aged and elderly patients with fractured necks of femur. Lancet 1959; 2:981–989.CrossRefPubMedGoogle Scholar
  31. 31.
    Morris GK, Mitchell JR. Warfarin sodium in the prevention of deep vein thrombosis and pulmonary embolism in patients with fractured neck of femur. Lancet 1976; 2:869–872.CrossRefPubMedGoogle Scholar
  32. 32.
    Salzman E. Progress in preventing venous thromboembolism [letter]. N Engl J Med 1983; 309:980–982.CrossRefPubMedGoogle Scholar
  33. 33.
    Tapson V, Hull R. Management of venous thromboembolic disease. The impact of low-molecular-weight heparin. Clin Chest Med 1995; 16:281–294.PubMedGoogle Scholar
  34. 34.
    Hirsh J. Heparin. N Engl J Med 1991; 324:1565–1574.CrossRefPubMedGoogle Scholar
  35. 35.
    Aiach M, Michaud A, Balian J, et al. A new low molecular weight heparin derivative. In vitro and in vivo studies. Thromb Res 1983; 31:611–621.CrossRefGoogle Scholar
  36. 36.
    Zimlich R, Fulbright B, Friedman R. Current status of anticoagulation therapy after total hip and total knee arthroplasty. J Am Acad Orthop Surg 1996; 4:54–62.PubMedGoogle Scholar
  37. 37.
    Danielsson A, Raub E, Lindahl U, Bjork I. Role of ternary complexes, in which heparin binds both antithrombin and proteinase, in the acceleration of the reactions between antithrombin and thrombin or factor Xa. J Biol Chem 1986; 261:15467–15473.PubMedGoogle Scholar
  38. 38.
    Cade J, Buchanan M, Boneu B, et al. A comparison of the antithrombotic and haemorrhagic effects of low molecular weight heparin fractions: the influence of the method of preparation. Thromb Res 1984; 35:613–625.CrossRefPubMedGoogle Scholar
  39. 39.
    Carter C, Kelton J, Hirsh J, Cerskus A, Santos A, Gent M. The relationship between the hemorrhagic and antithrombotic properties of low molecular weight heparin in rabbits. Blood 1982; 59:1239–1245.PubMedGoogle Scholar
  40. 40.
    Bergqvist D, Nilsson B. The influence of low molecular weight heparin in combination with dihydrergotamine on experimental thrombosis and haemostasis. Thromb Haemost 1987; 58:893–895.PubMedGoogle Scholar
  41. 41.
    Blajchman M, Young E, Ofosu F. Effects of unfractionated heparin, dermatan sulfate and low molecular weight heparin on vessel wall permeability in rabbits. Ann N Y Acad Sci 1989; 556:245–254.CrossRefPubMedGoogle Scholar
  42. 42.
    Bara L, Billaud E, Gramond G, Kher A, Samama M. Comparative pharmacokinetics of a low molecular weight heparin (PK 10169) and unfractionated heparin after intravenous and subcutaneous administration. Thromb Res 1985; 39:631–636.CrossRefPubMedGoogle Scholar
  43. 43.
    Vinazzer H, Woler M. A new low molecular weight heparin fragment (PK 10169): in vitro and in vivo studies. Haemostasis 1986; 16:106–115.PubMedGoogle Scholar
  44. 44.
    Fernandez F, N’guyen P, Van Ryan J, et al. Hemorrhagic doses of heparin and other glycosaminoglycans induce a platelet defect. Thromb Res 1986; 43:491–495.CrossRefPubMedGoogle Scholar
  45. 45.
    Brace L, Fareed J, Tomeo J, Issleib S. Biochemical and pharmacological studies on the interaction of PK 10169 and its subfractions with human platelets. Haemostasis 1986; 16:93–105.PubMedGoogle Scholar
  46. 46.
    Leclerc J, Geerts W, Desjardins L, et al. Prevention of venous thromboembolism after knee arthroplasty. A randomized, double-blind trial comparing enoxaparin with warfarin. Ann Intern Med 1996; 124:619–626.CrossRefPubMedGoogle Scholar
  47. 47.
    Imperiale T, Speroff T. A meta-analysis of methods to prevent venous thromboembolism following total hip replacement. JAMA 1994; 271:1780–1785.CrossRefPubMedGoogle Scholar
  48. 48.
    Nurmohamed M, Rosendaal F, Buller H, et al. Low-molecular weight heparin versus standard heparin in general and orthopaedic surgery: a meta-analysis. Lancet 1992; 340:152–156.CrossRefPubMedGoogle Scholar
  49. 49.
    Turpie A. Prophylaxis of venous thromboembolism in stroke patients. Semin Thromb Hemost 1997; 23:155–157.CrossRefPubMedGoogle Scholar
  50. 50.
    Colwell C, Spiro T. Efficacy and safety of enoxaparin to prevent deep vein thrombosis after hip arthroplasty. Clin Orthop 1995; 319:215–222.PubMedGoogle Scholar
  51. 51.
    Monreal M, Lafoz E, Navarro A, et al. A prospective double-blind trial of a low molecular weight heparin once daily compared with conventional low-dose heparin three times daily to prevent pulmonary embolism and venous thrombosis in patients with hip fractures. J Trauma 1989; 29:873–875.CrossRefPubMedGoogle Scholar
  52. 52.
    Jorgensen PS, Knudsen JB, Broeng L, et al. The thromboprophylactic effect of a low molecular weight heparin (Fragmin) in hip fracture surgery: a placebo-controlled trial. Ugeskr Laeger 1993; 155:706–708.PubMedGoogle Scholar
  53. 53.
    Bergqvist D, Kettunen K, Fredin H, et al. Thromboprophylaxis in patients with hip fractures: a prospective randomized comparison between Org-10172 and Dextran 70. Surgery 1991; 109:617–622.PubMedGoogle Scholar
  54. 54.
    Gerhart TN, Yett HS, Robertson LK, et al. Low-molecular-weight heparinoid compared with warfarin for prophylaxis of deep-vein thrombosis in patients who are operated for fracture of the hip. J Bone Joint Surg Am 1991; 73:494–501.PubMedGoogle Scholar
  55. 55.
    Horlocker T. Low molecular weight heparin and central neuraxial anesthesia. ASRA News 1996:5–6.Google Scholar
  56. 56.
    Horlocker T, Heit J. Low molecular weight heparin: biochemistry, pharmacology, perioperative prophylaxis regimens, and guidelines for regional anesthetic management. Anesth Analg 1997; 85:874–885.PubMedGoogle Scholar
  57. 57.
    Evarts EM, Freil EI. Prevention of thromboembolic disease after elective surgery of the hip. J Bone Joint Surg Am 1971; 53:1271–1280.PubMedGoogle Scholar
  58. 58.
    Harris WH, Salzman EW, Athanasoulis CA, et al. Aspirin prophylaxis of venous thromboembolism after total hip replacement. N Engl J Med 1977; 297:1246–1249.CrossRefPubMedGoogle Scholar
  59. 59.
    Westrich G, Sculco T. Prophylaxis against deep vein thrombosis after total knee replacement. J Bone Joint Surg Am 1996; 78:826–834.PubMedGoogle Scholar
  60. 60.
    Nelson CL, Green TG, Porter RA. One day versus seven days of preventive antibiotic therapy in orthopaedic surgery. Clin Orthop 1983; 176:258–263.PubMedGoogle Scholar
  61. 61.
    Gatell J, Garcia S, Lozano L, et al. Perioperative cefamandole prophylaxis against infections. J Bone Joint Surg Am 1987; 69:1189–1193.PubMedGoogle Scholar
  62. 62.
    Kaukonen J, Kemppainen E, Makijarvi J, Tuominen T. One dose cefuroxime prophylaxis in hip fracture surgery. Ann Chir Gynaecol 1995; 84:417–419.PubMedGoogle Scholar
  63. 63.
    Nungu K, Olerud C, Rehnberg L, et al. Prophylaxis with oral cefadroxil versus intravenous cefuroxime in trochanteric fracture surgery. A clinical multicenre study. Arch Orthop Trauma Surg 1995; 114:303–307.CrossRefPubMedGoogle Scholar
  64. 64.
    Buckley R, Hughes G, Snodgrass T, Huchcroft S. Perioperative cefazolin prophylaxis in hip fracture surgery. Can J Surg 1990; 33:122–127.PubMedGoogle Scholar
  65. 65.
    Koval KJ, Rosenberg AD, Zuckerman JD, et al. Does blood transfusion increase the risk of infection after hip fracture? J Orthop Trauma 1997; 11:260–265; discussion 265–266.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2000

Authors and Affiliations

  • Kenneth J. Koval
    • 1
    • 2
  • Joseph D. Zuckerman
    • 1
    • 2
  1. 1.Department of Orthopaedic SurgeryNYU — Hospital for Joint DiseasesUSA
  2. 2.Orthopaedic SurgeryNYU School of MedicineUSA

Personalised recommendations