Managing Hip Fractures during COVID19

Professor Opinder Sahota, Professor of Ortho-Geriatric Medicine and Consultant Physician, Nottingham University Hospitals highlights important areas of the recently published clinical guide for the perioperative care of people with fragility fractures during the coronavirus pandemic.

Neck of femur fractures are usually a mainstay of admissions to orthogeriatric services. A recent review of this with recommendations around surgery, in light of the current COVID-19 pandemic, has recently been released by NHS England.

The main points of this guidance are summarised below.

• Hip fracture surgery is likely to be one of the most common major operations undertaken during the coronavirus pandemic and is used as the example in these guidelines, but the principles should be applied as appropriate to other injuries in older people;
• Most hip fractures occur in the home and the social isolation policy will not prevent these. A significant reduction in the incidence of hip fracture is not anticipated;
• Late presentation may be more common;
• Most people with coronavirus will survive, even those with frailty. Risks after a fragility fracture are increased but surgery is humane, facilitates nursing care and will reduce overall impact on health & social care services;
• Rehabilitation services may be limited but early discharge should be supported if possible.

Atypical coronavirus presentations are increasingly recognised in the older patient, however confirmation of COVID-19 status via swab should not delay decisions about management. The aim should still be for prompt (<24 hours) consultant delivered surgical and anaesthetic care where possible, which may in turn help reduce length of hospital stay. As with other frail and older patients, it is important that ceilings of treatment should be discussed and documented pre-operatively.

Confirmed or suspected coronavirus infection is not a reason to delay or cancel surgery, though adaptions must be considered. The Association of Anaesthetists 2011 guidance on reasons for postponement and optimisation for hip fracture surgery should be followed as usual. This guideline details the preferred mode of anaesthesia (regional or spinal anaesthesia if possible) aiming to improve theatre throughput, and in the current climate, to reduce the risks of aerosol generation. This may mean that lower SpO2 levels are accepted, if this enables general anaesthesia to be avoided safely. Specific guidance on PPE for the awake patient are also detailed.

Almost all fragility fracture surgery requires an element of bone drilling and aerosol generation, and therefore PPE guidelines for staff should follow Public Health England guidance for aerosol generating procedures.

Further details of the new guideline are available here.