Hip fracture: management – NICE guideline

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This National Institute for Health and Care Excellence (NICE) guideline covers managing hip fracture in adults. It aims to improve care from the time people aged 18 and over are admitted to hospital through to when they return to the community.

Key recommendations

Recommendations emphasise the importance of early surgery and coordinating care through a multidisciplinary hip fracture programme to help people recover faster and regain their mobility.

Timing of surgery

  • Perform surgery on the day of, or the day after, admission.
  • Identify and treat correctable comorbidities immediately so that surgery is not delayed by:
    • anaemia
    • anticoagulation
    • volume depletion
    • electrolyte imbalance
    • uncontrolled diabetes
    • uncontrolled heart failure
    • correctable cardiac arrhythmia or ischaemia
    • acute chest infection
    • exacerbation of chronic chest conditions.

Planning the theatre team

  • Schedule hip fracture surgery on a planned trauma list.

Surgical procedures

  • Perform replacement arthroplasty (hemiarthroplasty or total hip replacement) in patients with a displaced intracapsular fracture.
  • Offer total hip replacements to patients with a displaced intracapsular fracture who:
    • were able to walk independently out of doors with no more than the use of a stick and
    • are not cognitively impaired and
    • are medically fit for anaesthesia and the procedure.
  • Use extramedullary implants such as a sliding hip screw in preference to an intramedullary nail in patients with trochanteric fractures above and including the lesser trochanter (AO classification types A1 and A2).

Mobilisation strategies

  • Offer patients a physiotherapy assessment and, unless medically or surgically contraindicated, mobilisation on the day after surgery.
  • Offer patients mobilisation at least once a day and ensure regular physiotherapy review.

Multidisciplinary management

  • From admission, offer patients a formal, acute orthogeriatric or orthopaedic ward-based hip fracture programme that includes all of the following:
    • orthogeriatric assessment
    • rapid optimisation of fitness for surgery
    • early identification of individual goals for multidisciplinary rehabilitation to recover mobility and independence, and to facilitate return to pre-fracture residence and long-term wellbeing
    • continued, coordinated, orthogeriatric and multidisciplinary review
    • liaison or integration with related services, particularly mental health, falls prevention, bone health, primary care and social services
    • clinical and service governance responsibility for all stages of the pathway of care and rehabilitation, including those delivered in the community.
  • Consider early supported discharge as part of the hip fracture programme, provided the hip fracture programme multidisciplinary team remains involved, and the patient:
    • is medically stable and
    • has the mental ability to participate in continued rehabilitation and
    • is able to transfer and mobilise short distances and
    • has not yet achieved their full rehabilitation potential, as discussed with the patient, carer and family.

Hip fracture is a major public health issue due to an ever increasing ageing population. About 70,000 to 75,000 hip fractures occur each year and the annual cost (including medical and social care) for all UK hip fracture cases is about £2 billion. About 10% of people with a hip fracture die within 1 month and about one-third within 12 months. Most of the deaths are due to associated conditions and not to the fracture itself, reflecting the high prevalence of comorbidity. Because the occurrence of fall and fracture often signals underlying ill health, a comprehensive multidisciplinary approach is required from presentation to subsequent follow-up, including the transition from hospital to community.

Although hip fracture is predominantly a phenomenon of later life (the National Hip Fracture Database reports the average age of a person with hip fracture as 84 years for men and 83 for women), it may occur at any age in people with osteoporosis or osteopenia, and this guidance is applicable to adults across the age spectrum. Management of hip fracture has improved through the research and reporting of key skills, especially by collaborative teams specialising in the care of older people (using the general designation 'orthogeriatrics'). These skills are applicable in hip fracture irrespective of age, and the guidance includes recommendations that cover the needs of younger patients by drawing on such skills in an organised manner.

You can read the guideline on NICE's website.