Introduction
Sub- capital fracture of the femoral neck is a common injury among the ageing population and is regarded as “unsolvable fractures”. This is a growing health concern in every country as the healthcare expenditure is very high. The surgical options, especially for elderly population, highly depend on the patient’s profile, their preference and the experience of the surgeon . Mrs. Pollard, 75- year- old, sustained a left sub- capital fractured neck of femur. Due to her age and her other complications such as hypertension and Type- 2 diabetes, a total hip replacement might be a better surgical option as it will help her attaining an independent lifestyle and less complications or re-operation . This article will discuss the viable options for treating Mrs. Pollard along with the post- operative challenges, management of the chosen surgical method and post- surgery interventions and the discharge procedures will be discussed.
Surgical options
A number of surgical and non- surgical options are available however, the decision of opting for one treatment option is based on a number of factors . Although a number of non- surgical options are now available, however, they are limited to physically inactive i.e., terminally ill or bed- ridden patients. Surgical interventions such as unipolar and bipolar hemiarthroplasty (HA), ORIF/ CRIF, total hip arthroplasty (THA), and cannulated screw fixation are considered as the gold standard treatment. The general surgical considerations are controversial as it needs to be done within 4 days of the injury and is based on the displacement degree, patient’s age, and fixation of the femoral neck .
The ORIF allows stronger fixation and requires higher load for failure. It is mostly recommended for younger people (age range of 20- 50 years). On the other hand, the hemiarthroplasty technique is a reconstruction option that is performed either as unipolar or bipolar, which is a short- duration procedure and allows faster mobilization as compared to total hip replacement . However, the posterior approach of this technique increases the risks of dislocation while the antero- lateral approach results in elevated abductor weakness, increased stress on the acetabulum bone and has increased risk of re-operation. Contrastingly, THA is considered using the antero- lateral approach and larger heads are selectively used to set the fractured femoral head. THA results in improved hip functional score and low re-surgery rates. Research has proved that THA can yield better clinical short-term and long- term outcomes .
In comparison to total or partial hip arthroplasty, the ORIF has been reported to have high re- operation rate (34% to 43%) as a result of fixation failure, avascular necrosis and reunion . As compared to the young individuals, total arthroplasty is recommended for old patients as the complication rate is lower among them and the patient’s life- span during that point is lower than the arthroplasty and related functional demands. Therefore, THA appears to be a preferable surgical option .
Potential post-operative complications and intervention
Nursing Intervention for Surgical site infection (SSI)
Infections can occur either on the wound or deep inside the prosthesis. The incident rate of surgical site infection ranges in between 0.68 % - 1.6 % and 0.67 %- 2.4 %. SSI’s can be prevented by maintaining safe and hygienic contact with the patients. SSIs can significantly increase the mortality, morbidity, healthcare costs and duration of hospital stay of the patients. Therefore, the nursing interventions will include wound area cleaning with chlorhexidine alcohol or with providine – iodine scrub .
The nurse will use sterile techniques to change the incision dressing. The patient and family will also be educated by her about the care process, sterile techniques, signs and symptoms of SSI and are advised to report to the nurse or physician in case of discomfort, redness, rashes or other signs. Since the pins present in the soft tissue area pose a threat of infections, she will carefully perform the cleaning around the pin site care daily or weekly post 48- 72 hours of the placement by using 2mg/ml of chlorhexidine solution . In case of excessive incisional bleeding or drainage, the nurse will contact the physicians and will collect the drainage fluid for culturing and checking the presence of micro- organisms.
Monitoring the surgical site infection
Nursing Intervention for Deep Vein thrombosis (DVT)
One out of 100 patients dies as a result of DVT. Development DVT in patient post- surgery increases the mortality and morbidity in patients . In most cases, thrombosis occurs in the deep veins and is one of the major causes of increasing mortality and morbidity in patients. In order to prevent DVT in patient post- surgery, nurses administer prophylaxis in patients. In 50% of patients, DVT has no specific clinical symptoms, thus it is essential to perform tests such as fibrinogen-uptake test, Doppler ultrasonography, impedance plethysmography, venography, and duplex ultrasound post- surgical intervention continuously in order to prevent the DVT .
Following the physician’s instructions and recommended guidelines, the nurse will administer DVT prophylactic medications. To prevent thrombosis, she will position the patients’ legs by elevating the leg above the heart every 20- minute several times and will recommend bed rest until pain relief and no position that can compromise blood flow (Moyet, 2009). She will also teach some exercises to the patient, which she will help him doing at least for 1- 2 hours a day when awake and will encourage early ambulation. Patients and family will be educated by her about the signs and symptoms (pink- tinged sputum, anxiety, shortness of breath, chest pain, cough, wheezing, etc.) of DVT and will be requested to report immediately. Following the anti- coagulant care plan, she will make the patient use gradient elastic stockings, which will be removed and re-applied every 8 hours . Furthermore, if the physician prescribes then she will administer anti- coagulants.
Monitoring the post- operative DVT
Based on the DVT guidelines, she will monitor signs of edema enlargement in the unilateral extremity, swelling, clod foot, thigh pain, dull or sharp pain and tenderness in the calf with dorsi- flexion foot are monitored. She will also assess other parameters: low grade fever, tachycardia, tachypnea, temperature, heart sound thrombophlebitis, respiratory functioning, increased turgor in skin, and superficial venous collateral distention. Based on the international normalized ratio (INR), the prothrombin time (PT), she will also assess the platelets and activated thromboplastin time (aPTT) . The skin color, pain, leg heaviness, fatigue, spider veins, and ulceration will be also monitored by her and will report to the physician immediately if the skin appears pale or cyanotic, cold or presence of swelling, which occurs due to venous blockage or obstruction in arterial blood flow. She will also assess the fluid therapy in order to decrease the chances of hypercoagulability .
Nursing Intervention for Dislocation
It is important to maintain the component of the femoral head in the acetabular cup. As nursing intervention to prevent hip prosthesis dislocation, the nurse will first educate the patient about leg positioning in abduction . She will position the hip in abduction by using abduction splint, where two to three pillows will be kept in between the legs. During shifting, she will ensure that the hip is in abduction to prevent dislocation. The nurses’ will ensure that the patient’s hip is not flexed greater than 90 degrees. For using the fracture bedpan, she will teach the patient to flex using the uninjured hip and then use a trapeze to raise the pelvis on the pan. She will ask to keep the hip in extension and with her support pivot the unaffected leg to prevent flexion, abduction, rotation or excessive weight bearing .
She will use raised toilet seats, orthopedic chairs, and semi- circling wheelchairs to minimize the hip joint flexion and in the sitting posture, she will ensure that the hips are raised at higher levels than that the knees and the legs are never raised . To prevent leg rotation, she will use cradle boot to support the patient’s heel off the bed . She will also advise the patient not to sleep sideways on the affected area or bending on waist or crossing or legs. In case of dislocation, she will immediately inform the surgeons so that the hips are immediately reduced and stabilized to prevent nerve or circulatory damage .
Monitoring of dislocation
Dislocation can result in severe pain, swelling or immobilization, thus she will frequently check for these signs and will also assess the presence of acute groin pain near the operated hip or discomfort. Symptoms of neurovascular dysfunction, paraesthesias, pain upon movement, low body temperature, reduced pulse rate and pallor will be also monitored by her. The nurse will also monitor other signs such as leg shortening or abnormal internal or external rotation or inability or restriction to move the leg or popping sensation in the hip and in its presence will immediately report the surgeon. Patients’ position in correct alignment, enough exercise is done to attain control over the extremity and whether the sitting posture is accurate will be also assessed .
Conclusion
Higher mortality and morbidity rate has been observed in elderly patients. This is because total hip replacement is associated with major clinical challenges and has many post- operative complications. Therefore, extra care needs to be taken to optimize patient care. In this case study, Mrs. Pollard was an elderly woman with no support i.e., even if she had her daughter who stayed 10 mins away from her, she had to manage her life on her own. Therefore, it was important to decide the best treatment for her to enable maximum restoration of her leg. Total hip replacement has been recommended by surgeons and researchers to be more effective in elderly population with little or no complications. Thus, total hip replacement might be a better surgical option in her case. The post- surgery nursing intervention as described above can effectively minimize the risks of post- operation complications. Thus, it is important to follow the guidelines recommended by experts.
References
AAOS. (2011, October). Managing Pain With Medications After Orthopaedic Surgery. Retrieved from Ortho Info: http://orthoinfo.aaos.org/topic.cfm?topic=A00650
Berry, S. S. (2009). Survival of aged nursing home residents with hip fracture. J Gerontol A Biol Sci Med Sci, 771- 777. doi: 10.1093/gerona/glp019
Blomberg, J. (2016). Femoral Neck Fractures. Retrieved from Ortho Bulletien: http://www.orthobullets.com/trauma/1037/femoral-neck-fractures
Bonner, L. &. (2014). Deep vein thrombosis: diagnosis and treatment. Nursing Standard, , 28(21), 51-58. doi:10.7748/ns2014.01.28.21.51.e8222.
Carpintero, P. C. (2014). Complications of hip fractures: A review. World J Orthop, 402- 411. doi: 10.5312/wjo.v5.i4.402
Connell, S. B. (2010). Textbook of Medical-surgical Nursing. Lippincott Williams & Wilkins.
Dai Z, L. Y. (2009). Meta-Analysis Comparing Arthroplasty with Internal Fixation for Displaced Femoral Neck Fracture in the Elderly. . J Surg Res. doi: 10.1016/j.jss.2009.03.029.
Dargel, J. O. (2014). Dislocation Following Total Hip Replacement. Dtsch Arztebl Int, 111(51-52): 884–890. doi: 10.3238/arztebl.2014.0884.
Emeric, C. (2012). Postoperative management of hip fractures: interventions associated with improved outcomes. Bonekey Rep, 241- 251. doi: 10.1038/bonekey.2012.241
Eseonu, K. M. (2011). A retrospective study of risk factors for poor outcomes in methicillin-resistant staphylococcus aureus (MRSA) infection in surgical patients. Journal of Orthopaedic Surgery and Research, 223-231. doi: 10.1073/pnas.0510077103.
Greene, L. (2012). Guide to the elimination of orthopedic surgery surgical site infections: an executive summary of the Association for Professionals in Infection Control and Epidemiology elimination guide. Am J Infect Control. , 40(4):384-6.
Kakkar, A. S. (2013). Incidence of Venous Thromboembolism in Orthopedic Surgery. Thromboembolism in Orthopedic Surgery, 143- 153. DOI 10.1007/978-1-4471-4336-9_2,.
Malanga, G. (2016, Jan 19). Femoral Neck Fracture Treatment & Management. Retrieved from Medscape: http://emedicine.medscape.com/article/86659-treatment?pa=Jb8SFRFFjfXxshpFN2cpSXygbX2O1cI%2F1tepc2i59JFZVq8QRPdJNDqerblFBY1u1I27l60b%2BNK0o1lFqFFGl3Ba6qMPn9v9%2B17kWmU%2BiQA%3D
Marya, S. S. (2008). Prosthetic replacement in femoral neck fracture in the elderly: Results and review of the literature. Indian J Orthop, 61- 67. doi: 10.4103/0019-5413.38583
Miyamoto, R. K. (2008). Surgical management of hip fractures: an evidence-based review of the literature. I: femoral neck fractures. . J Am Acad Orthop Surg, 596- 607. doi: 10.1038/orthop.2008.241
Moyet, L. (2009). Nursing care plan & documentation. 5th ed. Lippincott Williams & Wilkins.
NICE guidelines. (2006). Clinical practice guideline for Surgical site infection: prevention and treatment of surgica site infection. Retrieved from NICE. Org: https://www.nice.org.uk/guidance/cg74/documents/surgical-site-infection-consultation-full-guideline2
NSGMED. (2014). Fracture and dislocations-nursing management, nursing assessment, nursing diagnosis, nursing interventions. Nursing Journals and articles.
Ossendorf, C. S. (2010). Treatment of femoral neck fractures in elderly patients over 60 years of age - which is the ideal modality of primary joint replacement? BioMed Central. doi: 10.1038/orthop.2008.241
Robinson, T. E. (2008). Postoperative delirium in the elderly: diagnosis and management. CLin Interv Aging, 351- 355. doi: PMC2546478
Sanghera, N. N. (2011). Fractured neck of femurs (NOF) and post- operative infection rates. Orthopedic proceedings, 151-152.
Scheon, D. (2000). Adult Orthopaedic Nursing. Lippincott Williams & Wilkins.
Smith, M. D. (2016). Clinical Practice Guidelines surgical site infection prevention. Retrieved from Lippincott Nursing Center: http://www.nursingcenter.com/cearticle?an=00006416-201309000-00004
