AN INDEPTH ANALYSIS OF WHY DECISION OF CONSERVATIVE MANAGEMENT OF HIP FRACTURES WAS MADE IN 50 PATIENTS: A STUDY DONE IN UNITED KINGDOM

Abstract

Introduction: Hip fractures guidelines suggest that ‘all patients with fracture neck of femur should be operated upon as soon as possible (within 24hrs). Despite this different studies suggest that still 11% of hip fractures are treated conservatively (varies 3–37%).

Aim: Our main aim was to find out whether there is a place for non-operative treatment as a definitive primary option in patients with significant medical comorbidity. We also wanted to audit best practice for conservative treatment in medically compromised patients and in those patients whose hip fractures are not suitable for surgical repair.

Methods: We did this audit in 2007 collating information on 1010 hip fracture patients across 14 NHS hospitals in England. 50 out of 1010 (4.95%) patients were treated conservatively. We reviewed the records of these 50 patients (range 66–99, mean age 78 years) and looked at patient demographics, radiographic features, mobility, accommodation, cognition, and ASA class were recorded.

Results: There were 17 males and 33 females patients managed conservatively in our study. Before injury, 37 (74%) were living at home and 13 (26%) were institutionalised. During hospitalisation, 4 became bedridden and 30 died (mainly due to medical comorbidities). Among these 50 patients, eight were deemed physically unfit for surgery by anaesthetists and two by medical consultants. The decision of conservative treatment was made by orthopaedic consultants in ten cases and by multidisciplinary team in four cases. Five patients refused surgery and five patients were palliative due to terminal illnesses. Patients who did not proceed to surgery (either treated conservatively by choice or presented at admission with complications) had significantly higher mortality rates (overall mortality rate 60 %) suggesting that they were physiologically much worse group of patients.

Discussion: As the average life span of our population increases, some hip fractures are now treated non-operatively because of the possibility of severe or fatal complications due to surgery. Often, refusal of surgery by the patient or the patients’ family obligates the need for non-operative treatment. It is acceptable to postpone the surgery if the patients are medically unfit for these reasons (eg. acute cardiac event, patient dying, severe aortic stenosis, multi-organ failure). It is not considered appropriate if surgery is cancelled due to pyrexia, chest infection, borderline Hb or awaiting ECHO for murmur. Administrative or logistic reasons (eg. no HDU bed) needs to be looked at higher levels as well.