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Hip Fracture: A Complex Illness Among Complex Patients

William W. Hung, MD; and R. Sean Morrison, MD
[+] Article, Author, and Disclosure Information

From James J. Peters Veterans Affairs Medical Center, Bronx, NY 10468, and Mount Sinai School of Medicine, New York, NY 10029.

Grant Support: By a New York Academy of Medicine Hoar Fellowship (Dr. Hung) and by grant R01AG030141 and Mid-Career Investigator Award in Patient-Oriented Research AGK24AG022345 from the National Institute on Aging (Dr. Morrison).

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-1559.

Requests for Single Reprints: William W. Hung, MD, Mount Sinai School of Medicine, 1 Gustave L. Levy Place, Box 1070, New York, NY 10029.

Current Author Addresses: Drs. Hung and Morrison: Mount Sinai School of Medicine, 1 Gustave L. Levy Place, Box 1070, New York, NY 10029.

Ann Intern Med. 2011;155(4):267-268. doi:10.7326/0003-4819-155-4-201108160-00012
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In this issue, Vidáan and colleagues present data showing that in-hospital mortality and complications were not significantly associated with surgical delay of less than 120 hours after adjustment for the presence of acute medical conditions that caused the delay. The editorialists caution that this study should not be viewed as license not to take medically stable patients to surgery as soon as possible and discuss the challenges in providing care for patients with hip fracture that is multidisciplinary, patient-centered, and outcomes-driven and operates seamlessly across care settings.


hip fractures

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Hip Fracture: A Complex Illness Among Complex Patients
Posted on August 30, 2011
Northern California Arthritis Center
Conflict of Interest: None Declared

To the Editor: In their editorial on hip fractures, Hung and Morrison (1) state that high quality care requires optimization of five core elements. The majority of hip fractures are secondary to osteoporosis. I was, therefore, surprised to see that there is no mention in the editorial of screening and treating osteoporosis as part of the treatment plan.

Rajiv Dixit, MD Northern California Arthritis Center

Reference: 1. Hung W W, and Morrison R S. Hip fracture: a complex illness among complex patients. Ann Intern Med. 2011;155:267-268

Conflict of Interest:

None declared

Pain Management for Deliberately Unrepaired Hip Fracture
Posted on September 11, 2011
Joanne Lynn
Altarum Institute
Conflict of Interest: None Declared

The two reports and the editorial on management of hip fractuire in the August 16 edition of Annals skip over the situation in which the hip fracture will not be surgically repaired. I have had only a couple such patients, who made this decision and were more than a few days from death. Both were competent to make their own choices. Despite encouragement to reconsider, these very elderly patients firmly decided not to undergo surgery and to die in their beds.

In caring for these patients, I could not convince anesthesiologists to consider regional approaches that might mitigate the need to use substantial narcotic analgesia, and that might make it much easier to maintain hygiene and intact skin. PIER does mention the need to provide "adequate" doses of narcotic analgesia in persons who will not have operative repair, thus at least noticing the problem. However, regional anesthesia could be continuous (e.g., epidural) and could allow for a much more comfortable course. We should undertake to test this approach and to report on the results so that patients who choose this course, and their physicians, have the benefit of prior experience.

Conflict of Interest:

None declared

Author's response
Posted on September 27, 2011
William W. Hung
Mount Sinai School of Medicine
Conflict of Interest: None Declared

Although the vast majority of hip fracture patients are treated operatively, approximately 6% do not receive surgery (1). There are a paucity of data to guide treatment decisions in this population and well designed prospective studies are needed. In the absence of such data, extrapolation from studies that have used regional techniques (e.g, femoral nerve blocks) prior to and following operative repair suggest that these techniques are viable and effective options for reducing systemic opioid requirements and improving the management of hip fracture pain (2). A more definitive study on its efficacy is currently underway. Nevertheless, pain control in patients undergoing nonoperative care may require a combination of regional block and a systemic analgesic program.

Dr. Dixit makes an excellent point that osteoporosis care is an important aspect of post hip fracture care. Treatment with bisphosphonates, namely zoledronic acid, a mainstay of osteoporosis treatment, initiated within 90 days after fracture, may reduce clinical fractures and mortality at a median follow up of 1.9 years (3), although the mechanism of the mortality benefit appear to be mostly related to reduction in cardiovascular events and pneumonia rather than in subsequent fracture prevention (4). The role of osteoporosis screening and treatment in the immediate peri-operative period is less clear and as such was not addressed in our editorial.


1. Neuman MD, Fleisher LA, Even-Shoshan O, Mi L, Silber JH. Nonoperative care for hip fracture in the elderly: the influence of race, income, and comorbidities. Med Care. 2010;48(4):314-20.

2. Abou-Setta AM, Beaupre LA, Rashiq S, Dryden DM, Hamm MP, Sadowski CA, et al. Comparative effectiveness of pain management interventions for hip fracture: a systematic review. Ann Intern Med. 2011;155(4):234-45.

3. Lyles KW, Colon-Emeric CS, Magaziner JS, Adachi JD, Pieper CF, Mautalen C, et al. Zoledronic acid and clinical fractures and mortality after hip fracture. N Engl J Med. 2007;357(18):1799-809.

4. Colon-Emeric C, Kuchibhatla M, Pieper C, Hawkes W, Fredman L, Magaziner J, et al. The contribution of hip fracture to risk of subsequent fractures: data from two longitudinal studies. Osteoporos Int. 2003;14(11):879-83.

Conflict of Interest:

Dr. Hung is a recipient of New York Academy of Medicine, Hoar Fellowship, and supported by the John A. Hartford Foundation as a Center of Excellence Scholar.

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