Medication Summary
Nearly all patients with a femoral fracture are in significant pain, and parenteral analgesia should always be a consideration. Preoperative prophylactic antibiotics are recommended for the patient undergoing immediate internal fixation, with the usual dose being 1 g of a first-generation cephalosporin.
Prophylactic antibiotics are also indicated for open fractures. In a clean laceration smaller than 1 cm, an IV bolus of 1 g of a first-generation cephalosporin is adequate. An antibiotic that covers gram-negative organisms should be added for a laceration larger than 1 cm. With a laceration that has an extensive soft-tissue injury or appears moderately contaminated, 1.5 mg/kg of gentamicin or tobramycin should also be added. If the laceration appears grossly contaminated, penicillin should be added to cover clostridial infections.
The results from one study of elderly patients (65 y and older) noted that opioid analgesia can be used for postoperative hip surgery pain control without concern for a direct link to postoperative delirium. [13]
Antibiotics
Class Summary
Antibiotic therapy must be comprehensive and cover all likely pathogens in the context of the clinical setting.
Cefazolin (Ancef, Kefzol, Zolicef)
First-generation semisynthetic cephalosporin that arrests bacterial cell wall synthesis, inhibiting bacterial growth. Primarily active against skin flora, including Staphylococcus aureus. Typically used alone for skin and skin-structure coverage. IV and IM dosing regimens are similar.
Tobramycin (Nebcin)
Used in skin, bone, and skin-structure infections caused by S aureus, Pseudomonas aeruginosa, Proteus species, Escherichia coli, Klebsiella species, and Enterobacter species. Indicated in the treatment of staphylococcal infections when penicillin or potentially less toxic drugs are contraindicated and when bacterial susceptibility and clinical judgment justifies its use.
Ampicillin and sulbactam (Unasyn)
Drug combination of beta-lactamase inhibitor with ampicillin. Covers skin, enteric flora, and anaerobes. Not ideal for nosocomial pathogens.
Gentamicin (Gentacidin, Garamycin)
Aminoglycoside antibiotic for gram-negative coverage. Used in combination with both an agent against gram-positive organisms and one that covers anaerobes.
Analgesics
Class Summary
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or who have sustained injuries.
Morphine (Astramorph, Depodur, Duramorph)
DOC for analgesia because of reliable and predictable effects, safety profile, and ease of reversibility with naloxone.
Various IV doses are used; commonly titrated until desired effect obtained.
Ketorolac (Toradol)
Inhibits prostaglandin synthesis by decreasing the activity cyclooxygenase, which results in decreased formation of prostaglandin precursors.
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A subcapital femoral neck fracture. Slight compression of the femoral head onto the femoral neck can be seen. Note the cortical break medially. This fracture could be missed if not closely evaluated.
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A view of the contralateral hip for comparison.
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Intraoperative x-ray film (fluoroscopic view) of placement of the lag screw.
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Addition of a superior derotational screw to maintain alignment and allow compression.
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Internal fixation of the subcapital femoral neck fracture with a screw and short side plate with an additional derotational screw above. Final anteroposterior view.
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Garden I femoral neck fracture. Note the valgus impaction with compression of the superior femoral head-neck junction.
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Lateral view of a Garden I femoral neck fracture. Compression of the head-neck junction inferiorly.
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Anteroposterior view of the pelvis with a displaced femoral neck fracture.
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Lateral view of a displaced femoral neck fracture.
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Displaced femoral neck fracture treated with a conventional, noncemented monopolar hemiarthroplasty.
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Lateral view of a unipolar hemiarthroplasty.
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An example of a calcar replacement hemiarthroplasty. A low femoral neck fracture extending into the calcar femoralis, not amenable to internal fixation or conventional hemiarthroplasty, requiring a calcar replacement prosthesis.
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A lateral x-ray film of a calcar replacement hemiarthroplasty.
