Anaesthesia for fractured neck of femur

Abstract

Fracture of the femoral neck is a common injury in the elderly, and many patients have significant co-morbidities. Effective management requires a multidisciplinary approach involving anaesthetists, medical physicians and orthopaedic surgeons. Although early surgery within 24–48 hours is beneficial, there may be medical conditions that need prior optimization. Both general anaesthesia and regional neuroaxial anaesthesia can be used, although it appears regional anaesthesia is preferred by most anaesthetists as it is associated with reduced early postoperative mortality, less deep vein thrombosis, less fatal pulmonary embolism, and fewer pulmonary complications.

Introduction

Femoral neck fractures are associated with aging and osteoporosis and can occur after relatively trivial trauma in elderly patients. Each year around 75,000 people in the UK suffer from fracture hip.¹ The mean age for men is 84 years and women 83 years.¹ The incidence worldwide was 1.26 million in 1990 and is expected to increase to 4.5 million by 2050.² Femoral neck fracture is associated with a 30-day postoperative mortality between 5 to 10%,³ and 1-year mortality of around 30%.¹ This mortality rate has remained relatively constant over the past 20 years and it continues to be a major cause for mortality, morbidity and loss of functional activity.

Optimal perioperative care emphasizes early optimization and early surgery, effective multimodal analgesia, and use of a multidisciplinary team. The multidisciplinary team should consist of the anaesthetist, orthopaedic surgeon, medical physicians/geriatricians, physiotherapist and nursing staff. Good communication and discussion of patient management between team members is essential. The perioperative management of these patients is challenging as most are elderly with frequent co-morbidities. Current evidence suggests that early surgery is beneficial, but sometimes medical optimization or further investigations are required before surgery can proceed safely. Thus a balance needs to be made between optimization/investigations and avoiding unnecessary surgical delay needs.

There is great variation in anaesthetic technique for hip fracture surgery, mainly because previous studies have not shown clear benefit with any particular technique. In this article we will review the perioperative management of patients with fractured neck of femur with emphasis on preoperative optimization, minimization of surgical delay, potential consequence of surgical delay, and best anaesthetic technique.