Review Question - QID 219171

In the absence of clear risk factors for severe valvular disease, arrhythmias, worsening heart failure, or coronary artery stenosis, an echocardiogram is unlikely to change peri-operative complications or the need for pre-operative cardiac catheterization, leading only to surgical delay given the time needed to obtain and interpret the test.

Intertrochanteric fractures of the femur represent common extracapsular hip fractures seen in elderly patients following ground-level falls. Though this population of patients typically comes with numerous comorbidities, operative intervention is always indicated and should not be delayed for pre-operative tests that will not change the management of the patient's comorbidities prior to planned operative intervention. This is particularly important given that intertrochanteric hip fractures confer an increased risk of mortality of up to 30% at one year, a risk that has been shown to be reduced with early surgery (within 24-48 hours from presentation). Early medical optimization and co-management with medical hospitalists or geriatricians in an interdisciplinary fashion are strongly recommended by the AAOS to prevent unnecessary delays and ensure safe and timely surgical intervention.

Adair et al. published updated clinical practice guidelines (CPGs) in JBJS in 2017 that decreased the unnecessary use of echocardiograms before hip fracture surgery. The authors performed a retrospective review of data on 100 geriatric patients with hip fractures who had undergone preoperative trans-thoracic echocardiogram (TTE). They found that a TTE was ordered in accordance with the published ACC/AHA CPGs for 66% of the patients but found that it revealed disease with the potential to modify anesthesia or medical management in only 14% of the patients. They concluded that in this study population, following the ACC/AHA guidelines could have prevented the performance of TTE in 34% of the patients without missing any disease.

Hoehmann et al. review the use of unnecessary pre-operative cardiology evaluation and TTE in the setting of geriatric hip fractures. The authors reviewed 412 patients at a Level I trauma center and found that 44.4% received a Cardiology consultation and despite only 33.3% of patients meeting the criteria for TTE based on current ACC/AHA clinical practice guidelines, 89.4% of these patients received a TTE. Time to surgery was statistically significantly increased for those receiving TTE. The authors concluded that cardiology consultation and TTE are frequently used against AHA/ACC CPGs, with these measures ultimately being expensive and causing delays in time surgery, which ultimately increase morbidity and mortality for the patient.

Figure A is a low AP pelvis radiograph demonstrating a displaced intertrochanteric femur fracture of the left hip.

Incorrect Answers:
Answer 1: Consulting a hospitalist pre-operatively has not directly been shown to delay surgical care but has been shown to be beneficial in the multi-disciplinary total care of the admitted geriatric fracture patient.
Answer 3: Performing a fascial iliac block in the ER has been shown to be beneficial in terms of peri-operative pain control and has not been linked to increased delay to surgical fixation.
Answers 4-5: Appropriate fluid resuscitation and monitoring of fluid status with Foley catheter placement have not been shown to cause surgical delay.