38 | Delayed surgical management in proximal femoral fractures: implications in a frail older patient

Introduction. Proximal femoral fractures in older adults are associated with high morbidity and mortality. Current evidence strongly supports surgical treatment within 48 hours from the fall, to help reducing complications and improving survival; however, delays frequently occur in frail patients with multiple comorbidities. Case Presentation. We report the case of an 89-year-old woman with dementia, hypertensive heart disease and moderate aortic stenosis, who sustained an unwitnessed fall while at home. On Emergency Department admission, she presented with respiratory failure due to acute decompensated heart failure, requiring antibiotic therapy, intravenous diuretics, and oxygen support. Initial brain computed tomography scan was negative for acute findings. Due to bed unavailability, she was admitted to the Orthogeriatric ward two days later. Cardiology evaluation showed worsening aortic stenosis. Given the high perioperative risk, intensive care monitoring was recommended, delaying surgery until day 6 post-injury. Surgery was completed without immediate complications. On postoperative day one, early mobilization revealed left upper limb weakness. Brain CT initially showed a right parietal hygroma; a follow-up CT scan at 48 hours revealed a Ponto mesencephalic hemorrhage, leading to withdrawal of antithrombotic prophylaxis. The subsequent CT scan documented progressive resolution of both the brain hemorrhage and the parietal hygroma, so it was possible to reintroduce prophylaxis. Afterwards, the patient continued rehabilitation and is currently awaiting transfer to a hospital-based rehabilitation unit. Conclusions. Surgical delay in frail older patients with femur fractures may increase the risk of severe, preventable complications, even when clinically justified. Early surgery remains the standard of care to improve outcomes and preventing morbidity and even mortality.