Tranexamic acid for Neck of Femur Fractures in the Emergency Department

Report by: Callum Williams, Zahra Butt - Medical Student
Search checked by: Callum Williams, Zahra Butt - Medical Student
Institution: Emergency Department, Manchester Royal Infirmary In [patients with neck of femur fractures]
Date Submitted:
Date Accepted:
Last Modified: 14 November, 2024

Three Part Question
In [patients with neck of femur fractures] is [administration of tranexamic acid in the emergency department] [associated with a reduction in perioperative blood transfusions, perioperative blood loss, length of hospital stay, and mortality]

Clinical Scenario
An elderly patient presents to the emergency department (ED) with hip pain after a fall from standing. They are unable to weight bear. You notice extensive bruising around their left hip and an X-ray confirms a neck of femur fracture. You wonder if giving tranexamic acid (TXA) in the ED would improve their outcome when they later undergo surgery.

Search Strategy
EMBASE and Ovid MEDLINE(R) (ALL) databases were searched (1974-2024) utilising the Ovid interface
(exp *Tranexamic Acid/ or txa.mp.) and ((hip fracture.mp. or exp *Hip Fractures/ or exp *Femoral Neck Fractures/ or (hip.mp. or exp *Hip/ or (exp *Femur/ or femur.mp.))) and fracture.mp.) No search filters were utilised, including language. A supplementary search of the Cochrane database was conducted using the same search terms: that is, a combination of ‘TXA / tranexamic*’ and ‘femo* / femu* / hip fracture /fractured hip) in the title or abstract. The Google Scholar ‘cited by’ function was then used to find studies that had referenced the papers we identified as relevant in our EMBASE, MEDLINE and Cochrane searches. Reference lists of relevant papers were screened for any studies missed by our search paradigm.

Search Outcome
386 papers were identified by our EMBASE and Medline search, 264 papers after deduplication. 258 were excluded following title and abstract review as they were not relevant to three-part question. One paper was identified by scanning the reference lists. Seven papers underwent full take review, four were not relevant to three-part question and three were retained for analysis. 251 papers were identified by our Cochrane search. 245 were excluded following title and abstract review as they were not relevant to three-part question (n = 242) or were duplicates of the EMBASE and Medline search (n = 3). Six papers underwent full text review, five were excluded as they were trial protocols (n = 1), discontinued (n = 1) or not relevant to the three-part question (n=3) and one paper was retained for analysis. Four papers1–4 were retained for final analysis. Three were randomised controlled trials (RCTs)1,3,4 and one was a cohort study2. The key results of these studies are summarised in Table 1. No statistically significant findings were reported for length of hospital stay or mortality.

Comments
Two of the RCTs included in our review1,3 indicate that for patients with hip fractures, early TXA administration in ED decreases subsequent perioperative blood loss and three studies demonstrated a reduction in blood transfusion1–3. However, one RCT found no difference in estimated blood loss or blood transfusion rates, although a post-hoc power calculation demonstrated the study was significantly underpowered to detect a difference in blood transfusion rates.4 None of the studies found evidence of increased adverse events, such as venous thromboembolism1–4. The results of our review should be interpreted cautiously. The three RCTs1,3,4 restricted their sample to extracapsular hip fractures, limiting the generalisability of results to intracapsular fractures, which make up the majority of hip fractures5. However, extracapsular fractures are associated with greater blood loss6 and may therefore be a more clinically relevant sub-group for a TXA study. The trials in our review variously excluded patients who were taking anticoagulants1,3, multiply injuried1,3,4, or unable to present to hospital within six hours of injury1,3. This may limit the generalisability of their findings to our frailer patients, who commonly take anticoagulants, incur multiple injuries from falls, and present to hospital late – either because they cannot self-mobilise after falling, or struggle to access healthcare services in general. Unfortunately, it is this complex sub-group of patients who are likely to be the most vulnerable to the consequences of blood loss after hip fracture. Finally, it is unclear whether any benefits demonstrated by the studies in our review lead to improved outcomes for patients as none of the RCTs were powered to detect a difference in length of hospital stay, functional outcomes or mortality.1,3,4

Bottom Line
Early TXA administration in the ED for extracapsular femoral neck fractures appears safe and may reduce perioperative blood transfusions. The associated impact on patient-centred outcomes, such as length of hospital stay and mortality, is unclear. Currently, evidence for TXA in the ED for intracapsular hip fractures is insufficient.