Management of Proximal Femoral Fractures 2011 - aagbi

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Anaesthesia 2011Griffiths et al. | Guidelines: proximal hip fracturesdoctors’ decision to administer treatment that is deemed to be bothnecessary and in the patient’s best interests; doctors should be prepared tojustify their decisions to treat ⁄ deny ⁄ withdraw treatment to the courts ifnecessary. Decisions must not be biased by reference to the patient’s age.Doctors must consult relatives about treatment decisions, and should seekto ascertain whether the patient had previously written an advanceddirective, or appointed a Lasting Power of Attorney. The Courts may beconsulted if there is uncertainty about a patient’s management or if thereis dispute between clinical staff and relatives.Rationing of healthcareImplicit in the anti-discriminatory tenor of both the MCA and the HumanRights Act 1998 is the requirement to provide equal access to, andadministration of, medical treatment (for example, high dependency unit(HDU) care) to all patients, regardless of age and infirmity. This is at oddswith common law, which appears to support the rationing of serviceswithin the NHS, and the issue remains unresolved in law. Doctors are notobliged to deliver treatment that they consider to be futile or not in thepatient’s best interests.Do not attempt resuscitation (DNAR) decisionsA joint statement from the British Medical Association, the ResuscitationCouncil (UK) and the Royal College of Nursing provides the frameworkunder which DNAR decisions are made and ratified [27].Do not attempt resuscitation decisions are increasingly prevalentamong the patient population with hip fracture, and may proscribecardiopulmonary resuscitation in the event of arrest. Although DNARdecisions are presumed not to apply during surgery and anaesthesia,resuscitation may not be in the patient’s best interests, or even desired bythe patient. The AAGBI has recognised these potential difficulties, andissued guidance [28].Discussions about DNAR should precede surgery, and anaesthetistsmust take steps to make themselves aware of the outcome of thesediscussions.Intra-operative managementSurgical considerationsA number of hip fracture classification systems exist. Generally, 50% offractures are intracapsular, the remainder extracapsular (Fig. 2).14 Anaesthesia ª 2011 The Association of Anaesthetists of Great Britain and Ireland
Griffiths et al. | Guidelines: proximal hip fractures Anaesthesia 2011Intracapsular fracturesIntracapsular fractures include subcapital, transcervical and basicervicalfractures, and may be displaced or undisplaced. Blood loss from anintracapsular fracture at the time of injury is minimal because of the poorvascular supply at the fracture site and tamponade effected by the capsule.Occasionally, undisplaced fractures may be treated conservatively, butthere is a 30–50% risk of subsequent displacement. Current preference isfor all undisplaced intracapsular fracture to be treated by internal fixationwith multiple screws or a sliding hip screw.Untreated, disruption to the capsular blood supply of the head of thefemur by a displaced intracapsular fracture can lead to avascular necrosisof the bone, resulting in a painful hip of limited function. Therefore,surgical treatment involves hemiarthroplasty; even then, intracapsularfracture is associated with longer-term arthritis, and increasingly, total hiparthroplasty is preferred for younger patients.Compared to uncemented arthroplasty, cemented arthroplastyimproves hip function and is associated with lower residual painpostoperatively.Figure 2 Common sites of proximal femoral fractures. Arrows show theinsertion of the joint capsule.Anaesthesia ª 2011 The Association of Anaesthetists of Great Britain and Ireland 15
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Management of Proximal Femoral Fractures 2011 - aagbi

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