Fractured Neck of Femur

Fracture of the neck of the femur in the elderly is a common and complex anesthetic problem. In 1990, it was estimated that 1.7 million patients worldwide suffered a neck of femur fracture,^[90] and the numbers are increasing rapidly with the aging population. The average patient is 80 years old, and most are women with multiple medical problems. In-hospital morbidity is at least 3%, and at 1 year, 20% have died.^[91] Dementia, American Society of Anesthesiologists (ASA) category, and age influence mortality.

Regional anesthesia (spinal or epidural) has been demonstrated to reduce the perioperative risk of death, pulmonary complications, and deep venous thrombosis (DVT) by 30% to 50%.^[92] The most common causes of death are myocardial infarction and pulmonary embolism,^{[93] [94]} but postoperative complications include pneumonia, confusion, heart failure, bleeding, and sacral decubiti. Optimal anesthesia appears to focus on appropriate fluid management,^[95] adequate pain control without excessive narcotics, early ambulation, and the use of regional anesthesia. The use of femoral or fascia-iliacus blocks on arrival in the hospital and lumbar plexus blocks for postoperative pain provides excellent pain relief while limiting narcotic administration. Epidural analgesia is an excellent adjunct. Hemodynamic monitoring facilitates fluid management, especially in patients with impaired cardiac function, and appears to improve outcome.^[96] Outcome appears to be improved if patients are managed in a high-dependency unit for 24 to 48 hours.^[97]