Aftercare

Abstract

There are numerous considerations required for care following both operative and non-operative treatment of fragility fractures of the pelvis. Comorbidities have a significant effect on clinical outcome and should be carefully managed to keep them in a state of equilibrium. Geriatric frailty is a condition characterized by weakness, weight loss, diminished physical function and a variety of other reductions in function. A geriatrician or hospitalist familiar with care of frail older adults will be very helpful in the management of these patients. Several acute medical conditions may develop in the early aftercare treatment for pelvic fracture patients. Problems include bleeding from the fracture site, immobility, resulting in pressure sores, hypoxia, venous thromboembolic events, and aspiration pneumonia. Delirium is common and frequently develops acutely in the hospital, but can be avoided in many cases. A careful assessment of the patient’s medication list upon admission by the medical physician is needed. Pelvic fragility fracture patients commonly have many chronic medical conditions. Chronic cardiac disease and chronic obstructive pulmonary disease are especially challenging. Pain relief is very important and helps to prevent delirium and other adverse events. Management of pain should be multimodal. It is standard practice to provide thromboembolic prophylaxis. Goals of operative management include pain control, early mobilization, fracture union and personal independence. Prevention of infection and wound complications is paramount. After surgery, patients are permitted short transfers, sitting in a chair or wheelchair, and limited weight bearing until signs of healing are noted on follow-up radiographs. After 6 weeks’ time, weight bearing is progressed to patient’s pain tolerance. In the rehabilitation phase, it is important to perform a baseline assessment with a work-up for osteoporosis. Vitamin D levels are found to be deficient very often and vitamin D repletion should be started. Secondary causes of osteoporosis may be identified and should be treated. Another part of secondary fracture management is a falls assessment. The majority of patients with a fragility fracture of the pelvis is unable to return to their pre-injury living situation after hospital discharge. The system of care makes a difference. Post-acute aspects of care involve excellent communication, sharing of health information, and alignment of care incentives and goals. Many older adults with a pelvic fracture will fail to regain their pre-injury functional status, resulting in a more dependent living situation. Mortality rates at 1 year in the range of 16–30% have been reported.