Hip fracture

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

suitable for surgery

1st line – primary survey

Plus – initial assessment and supportive therapies

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Plus –

initial assessment and supportive therapies

Treatment recommended for ALL patients in selected patient group

If the patient is older and/or frail, involve the multidisciplinary team and ideally treat the patient on an orthogeriatric ward to reduce the risk of complications, such as delirium, as per the National Institute for Health and Care Excellence (NICE), the British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST), and the National Hip Fracture Database guidelines.[45][47][82]

Obtain an orthopaedic opinion urgently.
Surgery should be performed on a planned trauma list on the day of, or the day after, admission.[45][47]

Treat any acute concurrent medical illness, such as sepsis, as this may affect the patient’s suitability for surgery.

Assess fluid status and resuscitate with intravenous fluids as appropriate.[46]

Patients usually need fluid resuscitation and maintenance fluids preoperatively.
- Blood loss, pain, confusion, and fasting for theatre (the operating room) all contribute to a reduced oral intake throughout admission.[46]
Older patients with frailty may not exhibit the usual signs of dehydration, such as tachycardia or hypotension.[46]

Ensure thorough clerking including comorbidities, medication, and functional status to guide management plan.

Assess the patient’s nutritional status within the first 24 hours of admission.[46] Prescribe dietary supplements for those who are malnourished or at risk.
- Malnourishment and dehydration are common.[46]
- Avoid repeated cycles of fasting prior to surgery.[46]
Ensure there is assessment by a senior orthogeriatrician as soon as possible and within 72 hours.[46][47]
- This should include:
  - Documentation of pre-existing frailty
  - Assessment for delirium and dementia
  - Assessment and treatment of existing medical conditions
  - Comprehensive falls assessment
  - An assessment of bone health
  - Estimation of discharge date in line with the multidisciplinary team.
Manage the patient in a frailty pathway that includes Comprehensive Geriatric Assessment (to determine the medical, psychological, and functional capability of an older patient with frailty) starting within 72 hours of injury.[79]
Consider essential medications that should be continued, and consider reversal of anticoagulation. Consider withholding medications that may cause perioperative hypotension or acute kidney injury.
Continue to monitor for other injuries associated with any trauma requiring urgent treatment.

Cognitive impairment is associated with a high risk of falls.

Use a standardised and validated measure to check for cognitive impairment.[42][51][52]

Assess for signs of delirium – hip fracture is a major risk factor.

Use the 4AT assessment for delirium.[52] In critical care or in the recovery room after surgery, use the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) or Intensive Care Delirium Screening Checklist (ICDSC) instead of the 4AT.[52]

Review the pressure area assessment and protect any vulnerable skin areas to prevent incipient pressure ulcers.

The pressure area assessment should be completed by nursing staff on admission.
Patients with hip fractures are at high risk of developing pressure sores.[46]

Provide the patient and carer with verbal and printed information about diagnosis, choice of anaesthesia, and surgical procedures.

Involve an orthogeriatrician or perioperative physician in optimising the patient for surgery and agreeing appropriate ceilings of care with the patient, relatives, and team.
Liaise with the anaesthetist and high-dependency unit/intensive care unit where necessary.
Arrange a falls assessment (if not already arranged as part of the orthogeriatric assessment) as the patient is likely to be at risk of further falls during admission.[47]
- All patients with hip fractures must have a falls risk assessment on admission as part of the nursing assessment and a care plan to modify risk factors put in place (e.g,. sensors on the bed).[46]
The patient should be assessed by a physiotherapist on the day of or the day after surgery.[46][47][79]
Liaise with occupational therapy to understand the patient’s functional status and care needs and impact on discharge planning.
- An occupational therapist assessment should occur early after admission to understand the patient’s functional baseline, care need provision, and expectations about discharge.[46]

Plus – analgesia

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Plus –

analgesia

Treatment recommended for ALL patients in selected patient group

Treat the patient's pain immediately and reassess pain relief after 30 minutes.[45]

Use a pain assessment score.
Use your hospital’s analgesic prescribing protocol, or National Institute for Health and Care Excellence recommendations:[45]
- Give paracetamol preoperatively if not contraindicated
- Add an opioid if paracetamol alone is not sufficient. Older people may need reduced doses of opioids. Start on the lowest possible dose and titrate up as necessary. Give orally if possible.
Do not use non-steroidal anti-inflammatory drugs due to their adverse effects, such as upper gastrointestinal bleeding, nephrotoxicity, and fluid retention. Older people are more susceptible to these effects.
Continue to assess pain hourly until the patient is settled on the ward, and then regularly thereafter.
Ensure there is sufficient analgesia for any investigations.

Primary options

paracetamol: oral: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; intravenous (<51 kg body weight): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; intravenous (≥51 kg body weight): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)

Secondary options

-- AND / OR --

codeine phosphate: 30-60 mg orally/intramuscularly every 4 hours when required, maximum 240 mg/day

morphine sulfate: 5-10 mg orally (immediate-release)/subcutaneously/intravenously/intramuscularly every 4 hours initially, adjust dose according to response

Consider – nerve block

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Consider –

nerve block

Additional treatment recommended for SOME patients in selected patient group

Consider arranging a nerve block (i.e., femoral nerve block or fascia iliaca compartment block) by a trained practitioner.[45][54]

Nerve blocks are effective in relieving pain, and can reduce the need for opioids.[59][83] This is important in older patients who are often more sensitive to the adverse effects of opioids, such as constipation, delirium, and nausea.[54]

The procedures should be carried out only by someone with prior training. They may be performed with ultrasound guidance.
The block may be repeated by the anaesthetic team, to provide initial postoperative pain relief (i.e., for the first postoperative night).[59]
Nerve blocks may reduce the time to first mobilisation after the surgical procedure (but the evidence for this is less clear).[83]

Complications of a fascia iliaca compartment block are rare but include:[84]

Local anaesthetic toxicity
- The risk of this is highest in the first 15 to 30 minutes so the patient must be closely monitored at this stage
- Signs include perioral numbness, tinnitus, dizziness, arrhythmia, and seizures
Intravascular injection
Temporary or permanent nerve damage
Infection
Block failure
Injury secondary to numbness/weakness of limb
Allergy.

Plus – presurgical assessment

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Plus –

presurgical assessment

Treatment recommended for ALL patients in selected patient group

Encourage intake of oral fluids up to 2 hours prior to surgery. This prevents dehydration and improves the patient’s comfort.[46] Avoid repeatedly fasting patients in preparation for surgery.[46]

The orthopaedic surgeon will consent the patient, mark the limb, and confirm the likely timing of surgery so the nil-by-mouth policy can be initiated.

Prior to surgery, identify and treat any correctable comorbidities so that surgery is not delayed.[45] These may include:

Anaemia
- Consider the cause of anaemia and whether it is acute or chronic. If the fracture is unexplained, consider a diagnosis of myeloma and offer a full blood count and blood tests for calcium and plasma viscosity or erythrocyte sedimentation rate.[49]
- Follow local protocols for when a preoperative blood transfusion is necessary.
- Ensure appropriate investigations including haematinics are sent prior to transfusion.
- Consider early discussion with a haematologist if macrocytic anaemia is present.
- A haemoglobin concentration <80 g/L (<8 g/dL) may be a reason to delay surgery.[59]
Uncontrolled diabetes
- Review local guidelines for management.
- Monitor blood sugars perioperatively.

Anticoagulation
- Attend to a reversible coagulopathy so that it does not cause an unnecessary delay to surgery.[59]
- Consider the indication for the oral anticoagulant and, if high risk, whether bridging anticoagulation (using a short-acting parenteral anticoagulant while the oral anticoagulant is temporarily stopped) is required.
- Consider the timing of the last dose, the half-life of the drug, and whether it will require active reversal for surgery and anaesthetic (also need to know when surgery is planned).
Volume depletion
Electrolyte imbalance
- A plasma sodium concentration <120 or >150 mmol/L (<120 or >150 mEq/L) needs correcting. Consider cause and follow local guidelines
- A plasma potassium concentration <2.8 or >6 mmol/L (<2.8 or >6 mEq/L) needs correcting. Consider cause and follow local guidelines.

Arrhythmia
- Perform an ECG preoperatively to enable cardiac assessment.

Assess for common medical conditions such as decompensated heart failure, poorly controlled atrial fibrillation, or exacerbation of chronic obstructive airways disease.

Manage as per local guidelines.
Consider urgent medical review if patient is unstable.

Provide patients and carers with verbal and written information about anaesthetic and surgical choices and the likelihood of functional recovery.

Discuss and document ceilings of care. Involve the patient and any family members or carers in these discussions, as appropriate.

Consider any advanced directives, lasting powers of attorney, and safeguarding issues.[79]

Practical tip

It is essential to have a multidisciplinary approach to presurgical assessment. Decisions regarding risks and benefits to delaying surgery are best made with senior nursing, orthopaedic, anaesthetic, and orthogeriatric involvement. Involve patients and their families in discussions and decisions.

Consider – thromboprophylaxis

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Consider –

thromboprophylaxis

Additional treatment recommended for SOME patients in selected patient group

Assess the patient’s bleeding and venous thromboembolism risk prior to surgery.[76][79]

The National Institute for Health and Care Excellence recommends the Department of Health venous thromboembolism risk assessment tool.[76] Department of Health VTE risk assessment tool Opens in new window
Reassess the risk of bleeding and venous thromboembolism at the point of consultant review or if the patient’s clinical condition changes.
Arrange a group and save and crossmatch.
Factors that may indicate a higher risk of bleeding include:[87]
- Trochanteric fracture
- Initial haemoglobin level <120 g/L (<12 g/dL)
- Age older than 75 years.
For patients on an anticoagulant, send a coagulation screen and follow local guidelines to correct any coagulopathy. Follow your hospital protocol for patients taking a direct oral anticoagulant (DOAC) or discuss with a haematologist.
Venous thromboembolism prophylaxis with either a low molecular weight heparin (LMWH) such as enoxaparin or fondaparinux may be needed for people who are immobile and whose risk of venous thromboembolism outweighs their risk of bleeding.[76]
Consider preoperative venous thromboembolism prophylaxis for people with fragility fractures of the pelvis, hip, or proximal femur if surgery is delayed beyond the day after admission.[76]
- Give the last dose no less than 12 hours before surgery for LMWH, or 24 hours before surgery for fondaparinux.
If pharmacological prophylaxis is contraindicated, consider intermittent pneumatic compression for people with fragility fractures of the pelvis, hip, or proximal femur at the time of admission. Continue until mobility is restored to the patient’s baseline level.[76]
Compression stockings may cause severe discomfort and worsen skin conditions.

Primary options

enoxaparin: 40 mg subcutaneously every 24 hours; last dose to be given no less than 12 hours before surgery

fondaparinux: 2.5 mg subcutaneously every 24 hours; last dose to be given no less than 24 hours before surgery

Plus – prophylactic antibiotic

Consider – tranexamic acid

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Consider –

tranexamic acid

Additional treatment recommended for SOME patients in selected patient group

Consider tranexamic acid.

There is evidence to support the use of tranexamic acid to reduce blood loss and blood transfusion in patients with hip fracture.[88][89][90]
Multidisciplinary teams should agree local policies on the use of tranexamic acid in this setting.[91]

Primary options

tranexamic acid: consult specialist for guidance on dose

intracapsular hip fracture: undisplaced

Plus – internal fixation or replacement arthroplasty

Back

Plus –

internal fixation or replacement arthroplasty

Treatment recommended for ALL patients in selected patient group

Offer internal fixation with a dynamic hip screw or three cannulated hip screws.[59] One Cochrane review found that there may be little or no difference between screws and fixed angle plates in functional status, quality of life, 1-year mortality, or unplanned reoperations.[100]

If the fracture is undisplaced but not suitable for fixation, offer replacement arthroplasty (total hip replacement or hemiarthroplasty).[45][59]

Offer total hip replacement rather than hemiarthroplasty to patients who:[45]
- Were able to walk independently out of doors with no more than the use of a stick, AND
- Do not have a condition or comorbidity that makes the procedure unsuitable for them, AND
- Are expected to be able to carry out activities of daily living independently beyond 2 years.
For patients with valgus impacted fractures, also consider non-operative management on a case-by-case basis.

Evidence: Choice of procedure

Choice of procedure depends on the location of the fracture and whether it is displaced.

A Cochrane review comparing the relative effects (benefits and harms) of any type of internal fixation versus any type of arthroplasty for intracapsular hip fractures in adults looked at the results of 19 trials.[101]
- Length of surgery, operative blood loss, need for blood transfusion, and risk of deep wound infection were significantly less for internal fixation compared with arthroplasty.
- Fixation had a significantly higher re-operation rate compared with arthroplasty (40% versus 11%; risk ratio 3.22, 95% CI 2.31 to 4.47, 19 trials).
- No definite differences for hospital stay, mortality, or regain of pre-injury residential state were found.
The National Institute for Health and Care Excellence (NICE) recommends:[45]
- Replacement arthroplasty (total or hemiarthroplasty) to patients with a displaced intracapsular hip fracture
- A sliding hip screw in preference to an intramedullary nail in patients with trochanteric fractures above and including the lesser trochanter
- An intramedullary nail to treat a subtrochanteric fracture.

Perform surgery on the day of, or the day after, admission to avoid increased risk of mortality.[45][46][47]

Early surgery:
- Allows earlier mobilisation and functional recovery
- Is associated with less pain and reduced length of hospital stay.[95]

Evidence: Timing of surgery

Perform surgery on the day of, or the day after, admission to avoid increased risk of mortality and complications.

Delayed fixation of a hip fracture is associated with increased 1-year mortality, increased complications, and increased hospital stay.[46] Therefore, older patients with frailty and multiple comorbidities must be rapidly assessed and optimised for surgery without causing any delay.

NICE states that early and appropriate surgery is the most effective form of pain relief, expediting rehabilitation and reducing complications.
- Postponement of surgery carries an increased risk of complications, as well as prolongation of pain, and the need for repeated preoperative fasting.[45]
- A delay of 24 to 36 hours allows these factors to be balanced with appropriate assessment and allows patients to be operated on in a planned trauma list.
A systematic review and meta-analysis looked at 16 prospective or retrospective observational studies (involving 257,367 patients) of surgical timing and mortality in hip fracture.[96]
- It found that operative delay beyond 48 hours after admission may increase the odds of 30-day all-cause mortality by 41% and of 1-year all-cause mortality by 32%.
Another study on whether the timing of surgery in such patients could influence the short-term clinical outcome looked at 36-hour and 48-hour time limits.[97]
- Patients who had the operation more than 36 and 48 hours after admission were less likely to return to independent living within 4 months (odds ratio 0.44 and 0.33, respectively), whereas there was no significant difference with use of the 24-hour cut-off limit.
- The incidence of pressure ulcers in the groups that had the operation later was increased at all three cut-off limits (a delay of more than 24 hours, more than 36 hours, and more than 48 hours) (odds ratio 2.19, 3.42, and 4.34, respectively).
- The length of hospitalisation was also increased in the groups that had the later operation (median of 14 compared with 18 days, 15 compared with 19 days, and 15 compared with 21 days, respectively) (P <0.001 for all comparisons).

The risks and benefits of spinal or general anaesthesia should be discussed with the patient preoperatively.[45]

The estimated blood loss associated with different surgical procedures will vary. Transfusion to prevent unacceptable postoperative anaemia may be necessary.

The patient should be able to fully bear weight on the affected limb in the immediate postoperative period.[45]

Check operation note for any restrictions.

Operative management results in a reduced length of hospital stay and improved rehabilitation compared with conservative methods (bed rest and traction), which are no longer recommended.[98]

intracapsular hip fracture: displaced

Plus – replacement arthroplasty

Back

Plus –

replacement arthroplasty

Treatment recommended for ALL patients in selected patient group

Offer replacement arthroplasty (total hip replacement or hemiarthroplasty).[45][59]

Offer total hip replacement rather than hemiarthroplasty to patients who:[45]
- Were able to walk independently out of doors with no more than the use of a stick, AND
- Do not have a condition or comorbidity that makes the procedure unsuitable for them, AND
- Are expected to be able to carry out activities of daily living independently beyond 2 years.
A minority of patients may have displaced intracapsular fractures that will be fixed or reduced and fixed rather than treated with arthroplasty: for example, young patients, and some valgus impacted fractures.

Perform surgery on the day of, or the day after, admission to avoid increased risk of mortality.[45][46][47]

Early surgery:
- Allows earlier mobilisation and functional recovery
- Is associated with less pain and reduced length of hospital stay.[51]

Evidence: Timing of surgery

Perform surgery on the day of, or the day after, admission to avoid increased risk of mortality and complications.

The National Institute for Health and Care Excellence states that early and appropriate surgery is the most effective form of pain relief, expediting rehabilitation and reducing complications.
- Postponement of surgery carries an increased risk of complications, as well as prolongation of pain, and the need for repeated preoperative fasting.[45]
- A delay of 24 to 36 hours allows these factors to be balanced with appropriate assessment and allows patients to be operated on in a planned trauma list.
A systematic review and meta-analysis looked at 16 prospective or retrospective observational studies (involving 257,367 patients) of surgical timing and mortality in hip fracture.[96]
- It found that operative delay beyond 48 hours after admission may increase the odds of 30-day all-cause mortality by 41% and of 1-year all-cause mortality by 32%.
Another study on whether the timing of surgery in such patients could influence the short-term clinical outcome looked at 36-hour and 48-hour time limits.[97]
- Patients who had the operation more than 36 and 48 hours after admission were less likely to return to independent living within 4 months (odds ratio 0.44 and 0.33, respectively), whereas there was no significant difference with use of the 24-hour cut-off limit.
- The incidence of pressure ulcers in the groups that had the operation later was increased at all 3 cut-off limits (a delay of more than 24 hours, more than 36 hours, and more than 48 hours) (odds ratio 2.19, 3.42, and 4.34, respectively).
- The length of hospitalisation was also increased in the groups that had the later operation (median 14 compared with 18 days, 15 compared with 19 days, and 15 compared with 21 days, respectively) (P <0.001 for all comparisons).

The risks and benefits of spinal or general anaesthesia should be discussed with the patient preoperatively.[45]

The estimated blood loss associated with different surgical procedures will vary. Transfusion to prevent unacceptable postoperative anaemia may be necessary.

The patient should be able to fully bear weight on the affected limb in the immediate postoperative period.[45]

Check operation note for any restrictions.

Operative management results in a reduced length of hospital stay and improved rehabilitation compared with conservative methods (bed rest and traction), which are no longer recommended.[98]

extracapsular hip fracture

Plus – internal fixation

Back

Plus –

internal fixation

Treatment recommended for ALL patients in selected patient group

Offer fixation with a dynamic hip screw or intramedullary nail.

For patients with an extracapsular hip fracture:[45][59]

Use a dynamic hip screw for fixation of stable intertrochanteric hip fractures
Use an intramedullary nail to treat patients with a subtrochanteric fracture.

Perform surgery on the day of, or the day after, admission to avoid increased risk of mortality.[45][46][47]

Early surgery:
- Allows earlier mobilisation and functional recovery
- Is associated with less pain and reduced length of hospital stay.[95]

Evidence: Timing of surgery

Perform surgery on the day of, or the day after, admission to avoid increased risk of mortality and complications.

The National Institute for Health and Care Excellence states that early and appropriate surgery is the most effective form of pain relief, expediting rehabilitation and reducing complications.
- Postponement of surgery carries an increased risk of complications, as well as prolongation of pain, and the need for repeated preoperative fasting.[45]
- A delay of 24 to 36 hours allows these factors to be balanced with appropriate assessment and allows patients to be operated on in a planned trauma list.
A systematic review and meta-analysis looked at 16 prospective or retrospective observational studies (involving 257,367 patients) of surgical timing and mortality in hip fracture.[96]
- It found that operative delay beyond 48 hours after admission may increase the odds of 30-day all-cause mortality by 41% and of 1-year all-cause mortality by 32%.
Another study on whether the timing of surgery in such patients could influence the short-term clinical outcome looked at 36-hour and 48-hour time limits.[97]
- Patients who had the operation more than 36 and 48 hours after admission were less likely to return to independent living within 4 months (odds ratio 0.44 and 0.33, respectively), whereas there was no significant difference with use of the 24-hour cut-off limit.
- The incidence of pressure ulcers in the groups that had the operation later was increased at all 3 cut-off limits (a delay of more than 24 hours, more than 36 hours, and more than 48 hours) (odds ratio 2.19, 3.42, and 4.34, respectively).
- The length of hospitalisation was also increased in the groups that had the later operation (median of 14 compared with 18 days, 15 compared with 19 days, and 15 compared with 21 days, respectively) (P <0.001 for all comparisons).

The risks and benefits of spinal or general anaesthesia should be discussed with the patient preoperatively.[45]

The estimated blood loss associated with different surgical procedures will vary. Transfusion to prevent unacceptable postoperative anaemia may be necessary.

The patient should be able to fully bear weight on the affected limb in the immediate postoperative period.[45]

Check operation note for any restrictions.

Operative management results in a reduced length of hospital stay and improved rehabilitation compared with conservative methods (bed rest and traction), which are no longer recommended.[98]

pathological hip fracture

Plus – specialist consultation and consider surgery

not currently suitable for surgery: not receiving end-of-life care

1st line – primary survey

Plus – initial assessment and supportive therapies

Back

Plus –

initial assessment and supportive therapies

Treatment recommended for ALL patients in selected patient group

Assess fluid status and resuscitate with intravenous fluids as appropriate.[46]

Blood loss, pain, and confusion, all contribute to a reduced oral intake throughout admission.[46]
Older patients with frailty may not exhibit the usual signs of dehydration, such as tachycardia or hypotension.[46]

Ensure thorough clerking including comorbidities, medication, and functional status to guide management plan.

Assess the patient’s nutritional status within the first 24 hours of admission.[46] Prescribe dietary supplements for those who are malnourished or at risk.
- Malnourishment and dehydration are common.[46]
Ensure there is assessment by a senior orthogeriatrician as soon as possible and within 72 hours.[46][47]
- This should include:
  - Documentation of pre-existing frailty
  - Assessment for delirium and dementia
  - Assessment and treatment of existing medical conditions
  - Comprehensive falls assessment
  - An assessment of bone health.

Manage the patient in a frailty pathway that includes Comprehensive Geriatric Assessment (to determine the medical, psychological, and functional capability of an older patient with frailty) starting within 72 hours of injury.[79]

Continue to monitor for other injuries associated with any trauma requiring urgent treatment.

Cognitive impairment is associated with a high risk of falls.

Use a standardised and validated measure to check for cognitive impairment.[42][52][51]

Assess for signs of delirium – hip fracture is a major risk factor.

Use the 4AT assessment for delirium.[52] In critical care or in the recovery room after surgery, use the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) or Intensive Care Delirium Screening Checklist (ICDSC) instead of the 4AT.[52]

Review the pressure area assessment and protect any vulnerable skin areas to prevent incipient pressure ulcers.

The pressure area assessment should be completed by nursing staff on admission.
Patients with hip fractures are at high risk of developing pressure sores.[46]

Arrange a falls assessment (if not already arranged as part of the orthogeriatric assessment) as the patient is likely to be at risk of further falls during admission.[47]

All patients with hip fractures must have a falls risk assessment on admission as part of the nursing assessment and a care plan to modify risk factors put in place (e.g,. sensors on the bed).[46]

Plus – analgesia

Back

Plus –

analgesia

Treatment recommended for ALL patients in selected patient group

Treat the patient's pain immediately and reassess pain relief after 30 minutes.[45]

Use a pain assessment score.
Use your hospital’s analgesic prescribing protocol, or National Institute for Health and Care Excellence recommendations:[45]
- Give paracetamol if not contraindicated
- Add an opioid if paracetamol alone is not sufficient. Older people may need reduced doses of opioids. Start on the lowest possible dose and titrate up as necessary. Give orally if possible
Do not use non-steroidal anti-inflammatory drugs due to their adverse effects, such as upper gastrointestinal bleeding, nephrotoxicity, and fluid retention. Older people are more susceptible to these effects.
Continue to assess pain hourly until the patient is settled on the ward, and then regularly thereafter.
Ensure there is sufficient analgesia for any investigations.

Primary options

Secondary options

-- AND / OR --

codeine phosphate: 30-60 mg orally/intramuscularly every 4 hours when required, maximum 240 mg/day

morphine sulfate: 5-10 mg orally (immediate-release)/subcutaneously/intravenously/intramuscularly every 4 hours initially, adjust dose according to response

Consider – nerve block

Back

Consider –

nerve block

Additional treatment recommended for SOME patients in selected patient group

Consider arranging a nerve block (i.e., femoral nerve block or fascia iliaca compartment block) by a trained practitioner.[45]

Nerve blocks are effective in relieving pain, and can reduce the need for opioids.[59][83] This is important in older patients who are often more sensitive to the adverse effects of opioids, such as constipation, delirium, and nausea.[54]

The procedures should be carried out only by someone with prior training. They may be performed with ultrasound guidance.

Complications of a fascia iliaca compartment block are rare but include:[84]

Local anaesthetic toxicity
- The risk of this is highest in the first 15 to 30 minutes so the patient must be closely monitored at this stage
- Signs include perioral numbness, tinnitus, dizziness, arrhythmia, and seizures
Intravascular injection
Temporary or permanent nerve damage
Infection
Block failure
Injury secondary to numbness/weakness of limb
Allergy.

Plus – bed rest/non-weight bearing

Plus – continue to monitor and regularly reassess suitability for surgery

not currently suitable for surgery: receiving end of life care

1st line – end-of-life care pathway

ONGOING

post-surgery

1st line – analgesia

Back

1st line –

analgesia

Continue to evaluate pain and give regular analgesia.[70] Postoperative analgesia requirements will vary considerably.[59]

Use your hospital’s prescribing protocol, or National Institute for Health and Care Excellence recommendations:[45]

Give paracetamol postoperatively unless contraindicated.
Add an opioid if paracetamol alone is not sufficient. Older patients may need reduced doses of opioids. Start on the lowest possible dose and titrate up as necessary. Give orally if possible.
Do not use non-steroidal anti-inflammatory drugs due to their adverse effects, such as upper gastrointestinal bleeding, nephrotoxicity, and fluid retention. Older people are more susceptible to these effects.

Assess pain hourly until the patient is settled on a ward.[45]

Primary options

Secondary options

-- AND / OR --

codeine phosphate: 30-60 mg orally/intramuscularly every 4 hours when required, maximum 240 mg/day

morphine sulfate: 5-10 mg orally (immediate-release)/subcutaneously/intravenously/intramuscularly every 4 hours initially, adjust dose according to response

Consider – nerve block

Back

Consider –

nerve block

Additional treatment recommended for SOME patients in selected patient group

A nerve block (i.e., femoral nerve block or fascia iliaca compartment block) may be repeated by the anaesthetic team, to provide initial postoperative pain relief (i.e., for the first postoperative night),[59] particularly when paracetamol and an opioid do not provide sufficient relief, or to limit the dose of the opioid.[45]

The procedures should be carried out only by someone with prior training. They may be performed with ultrasound guidance.
Nerve blocks may reduce the time to first mobilisation after the surgical procedure (but the evidence for this is less clear).[83]

Nerve blocks are effective in relieving pain, and can reduce the need for opioids.[59][83] This is important in older patients who are often more sensitive to the adverse effects of opioids, such as constipation, delirium, and nausea.[54]

Complications of a fascia iliaca compartment block are rare but include:[84]

Local anaesthetic toxicity
- The risk of this is highest in the first 15 to 30 minutes so the patient must be closely monitored at this stage
- Signs include perioral numbness, tinnitus, dizziness, arrhythmia, and seizures
Intravascular injection
Temporary or permanent nerve damage
Infection
Block failure
Injury secondary to numbness/weakness of limb
Allergy.

Consider – thromboprophylaxis

Back

Consider –

thromboprophylaxis

Additional treatment recommended for SOME patients in selected patient group

Venous thromboembolism prophylaxis with either a low molecular weight heparin (LMWH) such as enoxaparin or fondaparinux may be needed for people who are immobile and whose risk of venous thromboembolism outweighs their risk of bleeding.[76]

Offer venous thromboembolism prophylaxis for 1 month after surgery to people with fragility fractures (i.e., a fracture sustained from a fall from a standing height) of the pelvis, hip, or proximal femur if the risk of venous thromboembolism outweighs the risk of bleeding.[76]
Consider stopping prophylaxis if lower limb immobilisation continues beyond 42 days.[76]
If pharmacological prophylaxis is contraindicated, consider intermittent pneumatic compression for people with fragility fractures of the pelvis, hip, or proximal femur at the time of admission. Continue until mobility is restored to the patient’s baseline level.[76]
Compression stockings may cause severe discomfort and worsen skin conditions.

Primary options

enoxaparin: 40 mg subcutaneously every 24 hours; start treatment 6-12 hours after surgery

fondaparinux: 2.5 mg subcutaneously every 24 hours; start treatment 6 hours after surgery providing there is a low risk of bleeding

Plus – rehabilitation

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Plus –

rehabilitation

Treatment recommended for ALL patients in selected patient group

Every patient should have a physiotherapy assessment as soon as possible.

Mobilise the patient on the day of or the day after surgery.[45][46][47]

Aim to have the patient standing, using equipment where necessary.
Patients who cannot stand should be hoisted out to a chair.

Occupational therapy assessment is needed by the end of day 3 postoperatively.[46]

Consider dietician review in patients who are malnourished or at risk of malnourishment.

Assess the patient’s bone health to prevent future fractures. The patient is now considered at higher risk of another fracture and risk factors should be reduced if possible.[46]

A previous fracture will approximately double the risk of a subsequent fracture with the greatest risk occurring in the first year following the incident fracture.[46]
A meta-analysis of previous fracture and subsequent fracture risk showed that previous fracture history was associated with a significantly increased risk of any fracture compared with individuals without a prior fracture (RR = 1.86; 95% CI = 1.75 to 1.98). The risk ratio was similar for the outcome of osteoporotic fracture and for hip fracture. There was no significant difference in risk ratio between men and women.[102]

Review the wound.

Check for signs of infection.
Liaise with nursing staff.

Review bladder and bowels.

Prescribe to prevent constipation as needed.
Remove urinary catheters.

Practical tip

In patients with a high risk of urinary retention (history of prostate disease or spinal stenosis) it may be more successful to remove the catheter once the patient can stand.

Give verbal and written information on the signs and symptoms of deep vein thrombosis and pulmonary embolism, how patients can reduce their risk, and how to seek help if these are suspected.

Test for delirium within the week after surgery.[47]

Delirium is the most common complication of all forms of surgery and anaesthesia in older people.[47] Use the 4AT assessment for delirium.[52]

With senior colleagues and your multidisciplinary team, consider end-of-life care when necessary.

Plus – falls risk assessment

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Plus –

falls risk assessment

Treatment recommended for ALL patients in selected patient group

Identify patients with frailty as ‘at risk of falls’ using tools such as the electronic frailty index (eFI) and ensure appropriate follow-up is given.[51]

Perform a multifactorial falls risk assessment prior to discharge. This includes:[42]
- Identification of falls history
- Assessment of gait, balance and mobility, and muscle weakness
- Assessment of osteoporosis risk
- Assessment of the older person's perceived functional ability and fear relating to falling
- Assessment of visual impairment
- Assessment of cognitive impairment and neurological examination
- Assessment of urinary incontinence
- Assessment of home hazards
- Cardiovascular examination
- Medication review.
Address future falls risk and offer an individualised intervention aimed at promoting independence and improving physical and psychological function.
These assessments and interventions are likely to be offered by the multidisciplinary teams (orthogeriatrician, nurses, physiotherapists, occupational therapists).
- Offer physiotherapy and multidisciplinary rehabilitation programmes to restore patients to pre-fracture functioning with the aim of returning them to where they lived pre-fracture.[103][104]
- Offer access to interventions and services that reduce falls and fracture risk factors such as:[51]
  - Strength and balance training. A meta-analysis of 40 randomised controlled trials (n=4059) showed that interventions targeting improvement in mobility after hip fracture may cause clinically meaningful improvement in mobility and walking speed in hospital and post‐hospital settings, compared with conventional care. Interventions that include gait and balance training and functional tasks are particularly effective.[105]
  - Smoking cessation.
  - Reducing alcohol intake.

Plus – treatment of underlying cause

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Hip fracture

Treatment algorithm

suitable for surgery

primary survey

initial assessment and supportive therapies

analgesia

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

nerve block

presurgical assessment

Practical tip

thromboprophylaxis

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

prophylactic antibiotic

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

tranexamic acid

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

intracapsular hip fracture: undisplaced

internal fixation or replacement arthroplasty

Evidence: Choice of procedure

Evidence: Timing of surgery

intracapsular hip fracture: displaced

replacement arthroplasty

Evidence: Timing of surgery

extracapsular hip fracture

internal fixation

Evidence: Timing of surgery

pathological hip fracture

specialist consultation and consider surgery

not currently suitable for surgery: not receiving end-of-life care

primary survey

initial assessment and supportive therapies

analgesia

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

nerve block

bed rest/non-weight bearing

continue to monitor and regularly reassess suitability for surgery

not currently suitable for surgery: receiving end of life care

end-of-life care pathway

post-surgery

analgesia

Primary options

Secondary options

nerve block

thromboprophylaxis

Primary options

rehabilitation

Practical tip

falls risk assessment

treatment of underlying cause