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Orthogeriatric Care in Patients with Fractures of the Proximal Femur

Heyburn, Gary*; Beringer, Timothy*; Elliott, James*; Marsh, David

Section Editor(s): Strauss, Elton MD

Clinical Orthopaedics and Related Research: August 2004 - Volume 425 - Issue - p 35-43
doi: 10.1097/01.blo.0000131492.01669.51
SECTION I: SYMPOSIUM: Geriatrics in Orthopaedics
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How are we to cope with the complex problems that now surround elderly patients with fractures? What are these problems and what systems should be in place to address them? No matter how successful we may be in treatment of osteoporosis and prevention of falls, it is inevitable that a massive worldwide increase in incidence of fragility fractures will occur in the next 50 years. It is crucial that we upgrade our systems to cope with this, if severe disruption of health services is to be avoided. This review considers the topics of falls, osteoporosis, and impact modification. We review the major medical issues that should be addressed in delivering hospital care that is efficient and of high quality. Various models for organizing the necessary liaison between fracture staff and medical or geriatric staff are examined and the current literature regarding orthogeriatric care is reviewed. We propose that the model of continuous orthogeriatric care, as practiced in Belfast, may be the way forward in addressing the complex problems associated with elderly patients with fractures. A system of ongoing audit of treatment outcomes and the journey of care for elderly patients with fractures of the proximal femur is necessary as a monitoring tool in developing the optimal system for orthogeriatric liaison.

From the *Royal Victoria Hospital and the †Queen’s University of Belfast, Musgrave Park Hospital, Belfast, Northern Ireland.

Correspondence to: Gary Heyburn, MB, MRCPI, Fracture Unit, Royal Victoria Hospital, Belfast BT12 6BA, Northern, Ireland. E-mail: garyheyburn@supanet.com.

Guest Editor

This review will focus on the complex medical issues that surround the inpatient hospital care of elderly patients with fractures and that created the need for an orthogeriatric service. Increasing numbers of evidence-based guidelines and reviews are available to help in the treatment of our orthogeriatric patients.3,4,6,30,31,37,41 It is unclear from the literature which format of orthogeriatric care is optimal in treating our patients, but we propose that the model of continuous orthogeriatric care practiced in Belfast has numerous advantages that make it superior to the other models discussed.

In 1997 in Northern Ireland, there were 1623 hip fractures with a projected increase to 2800 by 2016.5 It is estimated that worldwide there were 1.66 million hip fractures in 1990 and this number is expected to increase to 6.26 million by the year 2050.22 Within the next 40 years, the greatest proportional increase will occur in people older than 90 years with a doubling in numbers.25 Many of these elderly patients will sustain a fracture during their lives. The current annual cost to the National Health Service in the United Kingdom of osteoporosis and fracture care is estimated at £1.7 billion ($2.8 billion; €2.4 billion).47

The combination of an increasingly elderly population and high prevalence of osteoporosis currently and in the future will have major health economic repercussions. The main hospital specialties that will have to address and manage this situation are trauma and orthopaedic surgery and geriatric medicine in conjunction with multidisciplinary services in primary care. An understanding of the causes of falls and their prevention, the contributing role of osteoporosis treatment and prevention, in addition to improved surgical care and rehabilitation, will be essential skills to meet this challenge.

This review therefore concentrates on the etiology of fractures, addressing the issues of falls, bone fragility, and impact modification. Important medical interventions in the acute treatment of elderly patients with fractures are detailed and explored. The systems of orthogeriatric care, currently in use, are discussed together with a review of the literature regarding orthogeriatric care. The model of continuous orthogeriatric care practiced in Belfast is described, and the importance of ongoing audit is highlighted.

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Falls

Falls are a common health problem particularly among older people. Approximately ⅓ of people 65 years and older living at home sustain one or more falls each year.33 Older people who fall once are at a higher risk of falling again.45 An estimated 8% of people 70 years and older seek care each year in Accident and Emergency Departments after falls.40 Of these, 30–40% are admitted to the hospital with a primary diagnosis of fall.39 Approximately one in 100 falls may result in hip fracture. Therefore, prevention of falls is a clear priority for improvement in healthcare of the older person.

Evidence of successful prevention of falls has been reported from a structured bidisciplinary assessment of elderly people living in the community, who were treated in an Accident and Emergency Department after a fall. These patients were offered a combination of medical examination in a day hospital and a home visit by an occupational therapist.8 The risk of falling was reduced significantly in the intervention group with an odds ratio of 0.39. Fall prevention now is a recognized priority for improvement of healthcare for the older person and clearly has been defined in the recently published National Service Framework for Older People30 and in guidelines for the prevention of falls in older persons.3

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Fragility of Bone

In addition to fractures of the proximal femur, other fractures including Colles’ fractures, vertebral fractures, humeral neck fractures, and pelvic fractures commonly occur as a consequence of osteoporosis, resulting in a cumulative one in three lifetime risk of an adult woman having an osteoporotic fracture. The prevalence in males also is substantial with a one in 12 lifetime risk.37

Bone fragility and the risk of fracture increase as people age, particularly after women pass through menopause. Genetic and environmental factors play a part in the development of osteoporosis.42 Although genetic influences contribute significantly to bone mineral density (BMD), environmental factors including alcohol, smoking, and nutrition also play a part. Adequate exercise and calcium intake, smoking cessation and restricted alcohol consumption all have been recommended for prevention of osteoporosis.37 Risk factors identifying subjects at higher risk of osteoporosis include estrogen deficiency, corticosteroid therapy, maternal family history of fracture of the proximal femur, low body mass index, other medical causes associated with osteoporosis (anorexia nervosa, malabsorption, primary hyperparathyroidism, posttransplantation, chronic renal failure, hyperthyroidism, immobilization, Cushing’s syndrome), radiographic evidence of osteopenia and of vertebral deformity, previous fragility fracture particularly of the hips, spine, or wrist, and loss of height and thoracic kyphosis after radiographic confirmation of vertebral deformity.37 The subjects at higher risk should be offered a diagnostic assessment including BMD and appropriate treatment of osteoporosis. Such treatment may include calcium and vitamin D, hormone replacement therapy, selective estrogen receptor modulators [SERMs], and bisphosphonates.9 There are effective treatments available that should be used in patients presenting with low-energy fractures and vertebral wedging as a consequence of osteoporosis and which will significantly reduce the risk of subsequent osteoporotic fracture.

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Impact Modification

The impact of a fall may be cushioned by the use of hip protectors.26 These are external pads worn over the hip to absorb the impact of a fall. Trials to date on their effectiveness have been plagued by poor rates of participation, poor compliance, and high drop out rates. However, one trial21 showed a rate of hip fracture being 54% lower than in a group of control subjects who did not have hip protectors.

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The Complexity of the Elderly Patient with a Fracture

Patients with fractures of the proximal femur tend to be elderly and frail with associated comorbidities and polypharmacy. A full history and examination are essential.

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Clinical Evaluation

Although falls commonly are described as being simple, this is rarely the case and they often are multifactorial7 and many have a cardiac basis.46 If the fall has been witnessed, the etiology may be easier to ascertain because patients’ recollections of preceding events often are incorrect. Low-energy falls indoors account for most of the injuries. Despite the difficulty in taking an accurate history an attempt should be made to determine the cause of the fall. Postural hypotension often is an etiologic factor in the fall, exacerbated by medication such as diuretics and sedatives. The patient with Parkinson’s disease is at particular risk because of postural instability and L-dopa induced postural hypotension. The patient with diabetes also is prone to falls because of poor vision, hypoglycemic episodes, and peripheral and autonomic neuropathy. A full alcohol history may explain the fall and the presence of osteoporosis.

Not all fractures are attributable to osteoporosis and a fracture of the proximal femur may be the first presentation of metastatic bone disease. Unlike other presentations, the bone actually may fracture with minimal or no associated trauma, and the fall may be the result of the fracture—the fracture may not be the result of the fall. Five cancers that commonly metastasize to bone are those from the bronchus, breast, kidney, thyroid, and prostate. Hematologic malignancies such as multiple myeloma and lymphomas also are relatively common.

Use of medication should be assessed on admission and appropriate changes should be considered. Preoperatively, an elderly patient with a fracture of the proximal femur is unlikely to be able to use an inhaler and therefore should be given a nebulizer for the perioperative period. Nonsteroidal medications best are avoided especially because of their detrimental effect on renal function and bone healing. Patients taking warfarin require careful preparation, and surgery best is deferred until the international normalized ratio is less than 1.5. Whether this should be achieved aggressively with the use of vitamin K or fresh-frozen plasma currently is uncertain because there is an absence of research regarding this issue.

A full social history with information on activities of daily living, type of dwelling, and other family members at home, and the use of outside support agencies helps to give a more complete picture of the patient. Previous level of mobility should be ascertained and the use of walking aids should be documented. Abbreviated mini-mental scores can help in the process of deciding whether a patient is able to give informed consent and for monitoring perioperative confusion, which is endemic among elderly patients with fractures.

Special attention should be given during the full clinical examination to recording the patient’s mental state, hydration, cardiac rhythm, and cardiorespiratory status. The possibilities of subdural hematomas should be kept in mind, and the abdomen should be examined carefully to ensure early detection of a pseudo-obstruction.

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Investigations

When a fracture of the proximal femur is diagnosed by standard radiographs, a radiograph of the chest should be obtained at the same time. This ensures the patient is not subjected to additional unnecessary and possibly painful investigations.

A full blood picture, blood group and hold, and urea and electrolytes are mandatory. The fracture results in blood loss and the patient may need transfusion perioperatively. The platelet count should be scrutinized because a low value is a contraindication to spinal anesthesia, the most common type of anesthesia used in lower limb fracture fixation in the elderly.

An electrocardiogram will help to detect arrhythmias and recent infarcts that may have precipitated a fall. Systolic murmurs in the elderly are common35 but create a special problem in the elderly patient with a fracture. Aortic stenosis, which can present as syncope, is a contraindication to spinal anesthesia, and is overrepresented in elderly patients with hip fractures. The difficulty arises in clinically distinguishing benign murmurs from more dangerous murmurs. Therefore, echocardiograms are being used increasingly to help evaluate murmurs and to assess cardiovascular function in the preoperative period. It was reported that echocardiography should be done in the investigation of all cardiac murmurs even if the patient is asymptomatic.44 The increasing use of echocardiograms in the treatment of elderly patients with hip fractures will have major resource implications especially if surgery is deferred until this important investigation is done.

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Analgesia

Analgesia is extremely important in the treatment of fractures of the proximal femur. Poorly controlled pain will delay early mobilization and therefore predispose the patient to the complications of prolonged bed rest and perioperative delirium.20 Repeated studies show that patients with dementia or those who have cognitive impairment receive less analgesia than those who do not have cognitive impairment.10,14,18 This generally is because nursing and medical staff rely on self reporting of pain and rarely consider behavioral (moaning, sighing, guarded posture) or physiologic (tachycardia, high blood pressure) indicators of the presence of pain.

New anesthetic techniques have added to the tools available in the perioperative period. Intrathecal opioid analgesia involves injection of a small amount of opioid analgesia into the cerebrospinal fluid through the subarachnoid space. This can give prolonged pain relief lasting between 12 and 24 hours, but care is required in the management of breakthrough pain. Local nerve blocks also can be used separately or in combination with other anesthetic techniques.

Patient-controlled analgesia involves the intravenous injection of a small bolus of morphine controlled by the patient, helping to more accurately titrate the analgesia required to obtain optimum pain relief. This type of analgesia best is avoided in the patient who is confused.

Many units now have a dedicated pain team led by a consultant anesthetist to aid in the treatment of difficult cases, and to assist in education of the multidisciplinary team.

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Thromboprophylaxis

Elderly patients with fractures of the proximal femur who are bedridden are at high risk for having thromboembolic events. There are several types of thromboprophylactic measures available that can be used alone or in combination. These include low molecular weight heparin, intermittent pneumatic leg compression, oral anticoagulants, dextran, aspirin, and thromboembolic stockings. The optimal regime is unknown because of the relatively small number of trials that have been done13 but the Pulmonary Embolism Prevention Trial suggested a role for low-dose aspirin.34

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Hydration, Nutrition, and Pressure Sore Prevention

Hydration, nutrition, and pressure sore prevention are interlinked closely. Most patients require intravenous fluid supplementation to maintain fluid balance and satisfactory renal function particularly where it is necessary to cancel surgery at short notice resulting in long periods of fasting.

Malnutrition is common in elderly patients and patients with musculoskeletal disorders28 and is associated with increased morbidity and mortality leading to longer hospital stays, higher infection rates, and increased costs.48 However, it is unclear whether nutritional supplementation, either orally or by nasogastric tube feeding, improves outcomes.4

Pressure sore prevention should be considered at the earliest opportunity.41 Lying on a hard surface, such as a hospital trolley, for as few as 30 minutes can result in the development of a pressure sore. Special pressure-relieving mattresses, heel pads, and regular movement should be used immediately. Early mobilization in the postoperative period also will aid in pressure sore prophylaxis.

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Perioperative Care

The majority of patients are operated on because conservative treatment involves prolonged bed rest and considerable complications.

The aims of surgery are to control pain and to aid early mobilization. Ideally surgery should occur within 24 hours of injury if the patient is medically fit and should be done by experienced surgeons and anesthetists.41 Spinal anesthesia usually is used because it is associated with less thromboembolic complications and reduced perioperative mortality.31

Common additional perioperative complications include urinary tract infection, pressure sores, chest infection, thromboembolism, sepsis, and pseudo-obstruction.

Antibiotics are given at the time of surgery to reduce wound, urine, and chest infections.

Postoperative care should focus on the priorities of early mobilization (commencing on Day 1 postoperatively) and the prevention of medical complications. Daily assessments of cardiorespiratory status, fluid balance, analgesia, thromboprophylaxis, pressure sore prevention, and nutrition are essential.

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Secondary Prevention

Although clinical risk factors identify only approximately ⅓ of postmenopausal women at increased risk of osteoporotic fracture, the occurrence of one fracture commonly predicts a second fracture.11 The United Kingdom Royal College of Physicians and the Bone and Tooth Society, jointly, recently published guidelines to help in the identification and treatment of patients at risk for nonvertebral osteoporotic fractures, especially those with a previous fracture.37 A major culture change is needed in fracture services to ensure that every patient presenting with a fragility fracture is assessed for osteoporosis and referred for treatment as appropriate.

Furthermore, secondary prevention should not only address osteoporosis. The risk of additional falls should be assessed, in terms of the patient’s medical condition and of their environment. Treatment of remedial medical conditions, and consideration of preventive environmental measures, are common sense, but the system to deliver them reliably has yet to be instituted in many fracture services worldwide.

Because of the high proportion of fragility fractures that are not the patient’s first fracture, the potential payoff of systematic secondary prevention is considerable and must form an important part of the battle to survive the epidemic that confronts us.

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Rehabilitation

After surgery, various options are available for additional care of the patient. Some patients may be suitable for early discharge to their homes with appropriate support services,32 and others may be discharged to a nursing home.

Selected patients may benefit from a period in a rehabilitation unit with early involvement of a multidisciplinary team including medical staff, nursing staff, occupational therapists, physiotherapists, social workers, patients, and their families.

Patients with a good level of mobility and lack of mental impairment before fracture tend to benefit most from rehabilitation schemes.2 The period in rehabilitation obviously depends on the individual but can be in excess of 30 days.

Specialized units have been shown to improve outcomes in patients with strokes, but more studies are required to assess the effectiveness of coordinated multidisciplinary inpatient rehabilitation for elderly patients with fractures of the proximal femur.15,36

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Systems of Orthogeriatric Care

It is important that early surgery and mobilization is afforded by the organization of services for patients with hip fractures. The National Service Framework for Older People30 states that “at least one general ward in an acute hospital should be developed as a center of excellence for orthogeriatric practice.” It does not, however, recommend a particular type of orthogeriatric collaboration, but advocates that this should be agreed at a local level. What are the different models of orthogeriatric care currently in use?

In the traditional model, the elderly patient with a fracture is admitted to a trauma ward, and his or her care and subsequent rehabilitation mainly is managed by the orthopaedic surgeon and his or her team. Any medical queries are dealt with by a consultative service.

The second model is a variation on the traditional model with regular input from the geriatricians. This could take the format of a twice-weekly multidisciplinary ward round involving geriatricians and orthopaedic surgeons or other similar liaisons.

The third model involves preoperative treatment by the orthopaedic team with early postoperative transfer to a geriatric rehabilitation unit. This may involve additional combined orthopaedic and geriatric ward rounds in the rehabilitation unit.

The final model involves combined orthogeriatric care. The patient with a fracture is admitted to a specialized orthogeriatric ward under the care of geriatricians and orthopaedic surgeons. The patient is assessed by the geriatric team preoperatively and postoperatively. Rehabilitation may occur in this setting or in a step-down rehabilitation unit.

Other innovative schemes such as supported home discharges or the use of step-down nursing home beds with appropriate services could be used in tandem with any of the aforementioned models of care. Whatever model is used will depend on local resources and the actual size of the orthogeriatric service needs.

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Review of the Current Literature Regarding Orthogeriatric Care

Evidence for the benefits of multidisciplinary inpatient rehabilitation for elderly patients with fractures of the proximal femur6 are not as clear cut as for stroke units because of a relative paucity of high quality trials and the heterogenous nature of current orthogeriatric care.

Some models of combined orthogeriatric care where the patients were routinely medically reviewed including preoperatively now will be described.

The Sheba model1 of treating patients with hip fractures involved in setting up a dedicated orthogeriatric ward in Sheba Hospital in Israel in June 1999. The entire care of the patient preoperatively and postoperatively and the rehabilitation were managed in one setting. The patient was cared for throughout his or her stay by the geriatric rehabilitation team and seen daily by the orthopaedic surgeons until wound healing. Rates of major complications and mortality were reported as being extremely low. The cost effectiveness of the system was not evaluated, and a comparative study with traditional orthopaedic care is being done.

A prospective study of combined orthogeriatric care in the treatment of patients with hip fractures was done from 1992–1996.24 It compared outcome before and after appointment of a consultant orthogeriatrician. Before the appointment of the orthogeriatrician, patients were under the sole care of the orthopaedic surgeons with a consultation service available from the geriatricians as required. After appointment, an orthogeriatric ward was created and patients were treated jointly by the two specialties. There was daily input from the geriatric team during the working week. The chosen outcomes of mortality, length of stay, and discharge destination showed no significant differences when the two periods were compared. The current authors wondered whether there were more suitable performance indicators to measure the impact of orthogeriatric care.

Another study19 compared traditional orthopaedic care with continuous geriatric care in orthopaedic wards. The patients were seen daily by the geriatricians, and consultation with the surgeons occurred twice a week. The period before appointment of the geriatrician (1985–1988) was compared with that after the appointment of the geriatrician (1989–1990). The conclusion was that continuous orthogeriatric care was associated with increased operation rate, decreased mortality, and shortened length of stay.

A study by Elliott et al compared traditional orthopaedic care involving a referral system with the geriatrician and a new system involving a geriatrician seeing all patients older than 65 years on a twice weekly basis.12 The conclusion was that this system saved bed days, reduced costs, and produced an improved outcome.

An orthogeriatric liaison service has been described as an alternative to orthogeriatric units.16 In the system, there was a weekly fixed-time multidisciplinary ward round involving surgeons and geriatricians and a consultative service. This was thought to improve the quality of care without extra costs and abolished the need for transfer of patients to the geriatric ward for rehabilitation. Morale and communication were improved in the multidisciplinary team. It also was thought that the scheme offered excellent training opportunities in orthogeriatric medicine.

The role of orthogeriatric rehabilitation focusing on the postoperative period now will be discussed.

A study done in an inner city health district29 looked at the effect of opening an orthogeriatric unit in 1981. In this system, the orthopaedic surgeons postoperatively selected patients to go to a rehabilitation unit run by the geriatricians. A multidisciplinary meeting involving the geriatrician and the orthopaedic surgeon then was held once a week. Using Hospital Activity Analysis data for 1980–1985, this approach saved bed days in the orthopaedic unit. It was suggested that in the future intervention from the day of admission to the fracture unit would maximize efficiency.

A randomized-controlled trial done in 198823 studied the effectiveness of geriatric rehabilitative care after hip fractures in elderly women. The control subjects received traditional care in the orthopaedic ward until discharge whereas the intervention group were transferred postoperatively, when fit, to a rehabilitation unit run by the geriatricians. Orthopaedic advice in this unit was by consultation only. Outcome measures of physical independence, residence after discharge, and length of stay were examined. Significantly better results were obtained for the first two variables and median length of stay was shorter in the intervention group.

These patients were reviewed at 1 year36 when benefits in independence and mortality were shown in the intervention group. No differences were observed between the groups in life satisfaction or strain on caregivers.

A prospective randomized study15 done between 1984 and 1986 compared postoperative rehabilitation in orthopaedic wards with rehabilitation in an orthogeriatric ward. The orthogeriatric ward was under the overall care of the orthopaedic surgeons but a combined multidisciplinary ward round including the geriatricians was held once a week. The control group remained under the care of the orthopaedic surgeons with a geriatric consultation service as required, and there was no multidisciplinary ward round. No statistical differences were detected between the groups with the outcome indicators used, namely mortality, length of stay, and placement. More medical complications were detected and treated in the intervention group.

A study done by the East Dorset Health Authority17 compared traditional orthopaedic care with “relatively little involvement of the geriatricians” with rehabilitation in an orthogeriatric unit run by the geriatricians. There were no formal combined rounds with the orthopaedic surgeons but an on-site consultative service did exist. In the second group, there was a significant reduction in inpatient stay but no significant difference at 6 months in the other outcome indicators used (mortality, pain, mobility, change in dependency, or social status).

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The Belfast Model of Continuous Orthogeriatric Care for Elderly Fracture Patients

From February 1997, the Royal Group of Hospitals (Belfast, Northern Ireland) has used a full-time medical staff grade physician to provide daily medical care and advice in the perioperative treatment of elderly patients with fractures. After the amalgamation with another local fracture unit in November 1999, this service now has 95 dedicated fracture beds in four wards. Approximately 4000 inpatients are treated each year with ½ the patients being older than 65 years. Approximately 1000 hip fracture operations are done per year corresponding to ⅓ of all patients treated in the trauma theaters.

The physician is fully integrated into the fracture service providing daytime medical coverage with weekends and out of hours coverage being provided by the on-call medical teams.

Three consultant geriatrician-led ward rounds occur per week when any additional medical support and advice are offered, and patients suitable for rehabilitation are identified and assessed.

Medical input begins with admission to the fracture service and continues smoothy into the postoperative period.

The advantages of this type of model are:

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Superior Medical Care

There are many opportunities for medical intervention in the perioperative treatment of elderly patients with fractures. The orthogeriatrician is well placed for early identification and treatment of complications and liaises with other medical specialties as required.

Complex ethical issues can arise in elderly patients with dementia regarding consent and nutrition difficulties. Such issues are resolved more easily with an on-site orthogeriatrician to give advice and leadership to the multidisciplinary team.

Delirium is common in elderly patients with hip fracture, and daily intervention by a geriatrician27 has been shown to reduce this distressing symptom in such patients. In 1999, the National Confidential Enquiry into Perioperative Deaths published a report.43 It stated that “A team of senior surgeons, anaesthetists and physicians needs to be closely involved in the care of elderly patients who have poor physical status and high operative risk.” This description is applicable to many elderly patients with fractures of the proximal femur.

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Optimal Scheduling of Fracture Surgery

A daily orthogeriatric presence enables anesthetists to be contacted well in advance of operations on patients who are frail to help coordinate the required preoperative investigations and to optimize the patient medically. Patients who are at high risk can be identified in advance, enabling appropriate scheduling of patients for treatment by senior anesthetic and surgical staff.

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Better Communication with Patients and Their Relatives

This process is enhanced greatly by a daily orthogeriatric presence. Often because of the emergency nature of fracture surgery, surgeons may not be available readily at ward level to discuss cases with patients and their relatives. This can generate anxiety, distress, and complaints. Delays of surgery often are attributable to acute medical deterioration, and the orthogeriatrician may be more easily accessible to discuss these problems. A fracture of the proximal femur can be a catastrophe for an elderly patient, and its consequences can be greatly feared.

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Better Communication within the Multidisciplinary Team

Appropriate treatment of elderly patients with fractures relies on excellent communication among the various members of the multidisciplinary team. Successful perioperative care, rehabilitation, and discharge require close cooperation involving patients and their relatives, nursing staff, physiotherapists, occupational therapists, social workers and discharge coordinators. A readily available orthogeriatrician only can enhance this process.

The presence of the orthogeriatrician may enable the entire rehabilitive process to take place in the initial fracture ward.

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Initiation of Research, Education, and Audit

The orthogeriatrician is in a position to initiate and take part in innovative research and audit activities with the emphasis being on medical issues rather than the traditional surgical issues. Expertise in geriatric medicine is conveyed to the various members of the multidisciplinary team by education initiatives fostering a culture where all the patients’ problems are considered not just their surgical treatment. Supervision and education of the surgical preregistration house officers is enhanced.

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Reduction in Adverse Events

A medical presence on the ward is likely to reduce the incidence of adverse events. This may be by simple measures such as reviewing admission medications or by the development of protocols for treating patients at high risk such as patients with diabetes or those taking warfarin. Clerk-ins by the junior staff are monitored continually leading to higher standards of documentation.

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Earlier Initiation of Rehabilitation and More Effective Use of Discharge Resources

An orthogeriatrician based on the fracture ward ideally is placed to identify patients suitable for rehabilitation38 and step-down schemes. This ensures their smooth passage through the perioperative period into the rehabilitation phase. Issues such as fall prevention and additional treatment and investigation of osteoporosis can be addressed at an early stage.

The treatment of these patients can be daunting for an experienced practitioner let alone a newly qualified house officer. It would be expected that an orthogeriatrician seeing the patients on a daily basis, providing continuity of care, would be superior to a consultative service were different doctors of different grades may see the patient on different days. Early interventions for medical complications are likely to prevent acute deterioration leading to surgical delays or even death.

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Audit

Because hip fracture is the most common condition treated by units treating musculoskeletal injuries, their standard of care is used as an index of the quality of treatment and enables comparison with other units. The journey of care has many stages, and inadequacy in any of them can have a detrimental effect on outcome. Efficient and appropriate treatment, medical and surgical, reduces delays and complications thereby freeing up resources for the treatment of patients with other injuries.

Effective audit of outcome and the process of care are complex and expensive, requiring personnel to be used for these purposes. In Belfast, data are collected by two research nurses and analyzed in the Fracture Outcomes Research Unit at the Royal Victoria Hospital, Belfast. The audit is supervised by consultants in the Departments of Trauma and Orthopaedic Surgery and Geriatrics. It has been extended to include all patients treated in Northern Ireland and covers approximately 1800 patients per annum. We have been aided by the example of the Scottish Hip Fracture Audit and the impressive Guideline produced by the Scottish Intercollegiate Guidelines Network.41

The Belfast audit is prospective and harvests details regarding demography, before injury status (walking ability, domicile, previous hip or wrist fracture, previous cerebrovascular accident, drugs taken on admission), type of fracture, nature of treatment, complications, time taken to reach each stage in the journey of care and outcome (walking ability, Barthel score, domicile, and mortality) at 4, 6, and 12 months.

This audit has been helpful in identifying and solving problems, stimulating the interest of many individuals within the multidisciplinary team, facilitating discussions regarding the provision of resources, and monitoring equity in the provision of care to different sections of our catchment population.

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DISCUSSION

This review has highlighted the complex nature of the problems associated with the treatment of elderly patients with fractures. Osteoporosis and the high incidence of falls in the elderly largely are responsible for this deluge of fractures. Regarding falls, the current literature focuses on fall prevention rather than fracture prevention. More research needs to be done looking at this important area identifying risk factors that result in patients falling and having fractures.

Many patients present to outpatient fracture clinics with fragility fractures. These patients should be followed up by a DEXA scan appropriate lifestyle advice, and pharmacologic treatment, if required. This is not widely practiced. Already many fracture units have recognized this deficit in their management of outpatient fracture services and are developing new systems to cope with the issue of fracture prevention. The argument has been advanced that orthopaedic surgeons are having a hard enough job coping with fracture management without adding to the burden by focusing on fracture prevention. Imaginative solutions to this problem such as the use of nurse practitioners may be the way forward.

In the clinical treatment of elderly patients with hip fractures controversies exist over the ideal type of thromboprophylaxis. However, the goal of early mobilization to avoid the complications of prolonged bedrest is uncontroversial.

The review of the current literature regarding orthogeriatric care cannot yet tell us which is the optimal system for delivering such care and which outcomes are improved consistently. The expected benefits of the model of continuous orthogeriatric care practiced in Belfast have been described. The disadvantages of such a system include cost, difficulties in the recruitment of medical staff, and possible loss of skills of the orthopaedic staff.

The argument is not whether there should be orthogeriatric care but rather what is the best model for delivering it and at what point should it be initiated. The evidence for the various models described is neither strong nor plentiful and it is difficult to produce good evidence for the superiority of one model over another. The benefits of having an orthogeriatrician team fully integrated into the fracture service and working there full-time are obvious but, again, the exact composition of this team is open to debate. The goals of future developments in orthogeriatric care should be to reduce mortality and morbidity, improve functional outcome, prevent subsequent fractures, and make efficient use of resources.

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References

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