How should I approach the management of fractures in patients with comorbidities or those on anticoagulant therapy?

When managing fractures in patients with comorbidities or those on anticoagulant therapy, a comprehensive and individualised approach is crucial to ensure timely and effective care.

• For patients with hip fractures, it is essential to identify and treat correctable comorbidities immediately to prevent delays in surgery NICE CG124. These include, but are not limited to, anaemia, volume depletion, electrolyte imbalance, uncontrolled diabetes, uncontrolled heart failure, correctable cardiac arrhythmia or ischaemia, acute chest infection, and exacerbation of chronic chest conditions NICE CG124.
• Documentation of comorbidities should be considered from the patient's first presentation NICE NG38.
• Recognise that current disease-oriented guidelines may not fully account for the interactions between multiple conditions, and an individualised management plan should be developed and agreed upon with the patient NICE CKS. This plan should outline goals, future care, medication adjustments, prioritisation of appointments, and anticipation of health changes NICE CKS.
• For patients at risk of fragility fractures, such as those with osteoporosis, assess for vitamin D deficiency and inadequate calcium intake, and identify risk factors for falls NICE CKS. Oral bisphosphonates may be offered, especially if there is a prior fragility fracture or other risk factors, with specialist referral considered if oral bisphosphonates are not tolerated or are contraindicated NICE CKS.

• Anticoagulation is a correctable comorbidity that should be addressed immediately to avoid delaying surgery, particularly for hip fractures NICE CG124.
• The perioperative management of proximal femoral fractures in the elderly, especially concerning antiplatelet and anticoagulant therapy, is a significant area of clinical focus Merloz 2018Malliou et al. 2023Šteňo et al. 2024.
• Patients on anticoagulant therapy should be informed about potential adverse effects, drug interactions, and the importance of carrying an 'anticoagulant alert card' NICE CKS.

• Provide patients with both verbal and written information about their management plan, including expected outcomes, activities to aid recovery, home care options, and rehabilitation details NICE NG38.
• Ensure all healthcare professionals have access to previously given information to maintain consistency NICE NG38.