Management of Hip Fractures in the Elderly

Recommendations

1.     Imaging

1.1.  In adults with clinical suspicion of hip fracture but adequate quality negative standard X-rays (anteroposterior pelvis and lateral hip), cross-sectional imaging should be performed. Specifically:

1.1.1.     Magnetic resonance imaging (MRI) is the preferred modality due to higher diagnostic sensitivity and specificity for occult hip fractures. (Strong recommendation)

1.1.2.     Computed tomography (CT) should be considered when MRI is unavailable within 24 hours, contraindicated, or impractical. (Conditional Recommendation)

1.1.3.     If CT is used first and is negative despite ongoing clinical suspicion, MRI should subsequently be obtained to rule out occult fracture (unless contraindicated). (Strong Recommendation).

2.     Preoperative traction

2.1.  We advise against the routine use of preoperative traction for patients with a hip fracture. (Conditional recommendation)

3.     Timing of surgery

3.1.  Perform hip fracture surgery on the day of, or the day after admission to hospital (within 48 hours); taking into consideration the patient optimization for surgery. (Conditional recommendation)

4.     Antithrombotic Management

4.1.  On admission, confirm the antithrombotic agent(s), last dose time, renal function and indication (VTE prophylaxis vs therapeutic anticoagulation) before committing to neuraxial or deep regional techniques. (Strong recommendation)

4.2.  If surgery is delayed beyond the day of admission, consider pharmacological VTE prophylaxis if VTE risk outweighs bleeding risk. Ensure the last dose is at least 12 hours before surgery for low dose LMWH and at least 24 hours for high dose LMWH and fondaparinux. (Strong recommendation)

4.3.  Treat deep (non-compressible) nerve blocks like lumbar plexus or paravertebral blocks, the same way as neuraxial blocks in respect to VTE prophylaxis drugs interruption timing. For superficial (compressible) single-shot blocks like femoral nerve or fascia iliaca plane blocks, apply a site-based bleeding risk assessment and proceed when the expected benefit outweighs bleeding risk. (Strong recommendation)

4.4.  Use Annex 2: Minimum interruption intervals (summary table) for a consolidated table. Key principles:

4.4.1.     Dose intensity and renal function matter for LMWH and DOACs; insertion and removal of neuraxial catheters are both timing events (Strong recommendation)

4.4.2.     It is advised to check platelet count if LMWH has been used for more than 4 days due to heparin-induced thrombocytopenia risk. (Conditional recommendation).

4.5.  When neuraxial or deep catheters are used, coordinate LMWH dosing with both catheter placement and removal.

4.5.1.     Stop low-dose LMWH at least 12 hours before placement or removal of the catheter, and for 24 hours before placement or removal in case of high dose LMWH. (Strong recommendation)

4.5.2.     In all cases; (low and high dose LMWH); start first LMWH dose at least 12 hours after placement and at least 4 hours after removal. (Strong recommendation)

4.6.  Provide post-operative VTE prophylaxis according to individual risk assessment; extended prophylaxis (e.g., 28–35 days) is commonly used after hip fracture surgery. (Conditional recommendation)

5.     Perioperative Analgesia

5.1.  Assess pain score immediately on presentation (at rest and on movement) and reassess within 30 minutes after any analgesic intervention; then hourly until pain is controlled, and thereafter with routine observations. (Strong recommendation)

5.2.  Offer regular paracetamol/acetaminophen every 6 hours pre- and post-operatively unless contraindicated; use intravenous dosing when oral administration is unreliable. (Strong Recommendation)

5.3.  Use opioids as rescue therapy with small, titrated doses (prefer immediate-release oral or carefully titrated IV boluses) when paracetamol alone is insufficient. Avoid initiating prolonged-release opioids in the acute perioperative phase. (Strong recommendation)

5.4.  Offer an early peripheral nerve block [e.g., fascia iliaca, femoral, or Pericapsular Nerve Group (PENG)] block when trained staff and ultrasound are available, to improve pain control and reduce systemic opioid requirements. Do not delay surgery for block placement. (Conditional recommendation)

5.5.  When opioids are used, prescribe antiemetic and bowel regimen, monitor sedation score, respiratory rate, and oxygen saturation, and screen for delirium daily. Encourage early mobilization and physiotherapy when clinically appropriate. (Strong recommendation)

5.6.  Avoid routine NSAIDs/COX-2 inhibitors in frail older hip fracture patients. Consider them only when a senior clinician documents a favourable risk-benefit assessment and there are no contraindications (renal dysfunction, high bleeding risk, active GI disease, interacting anticoagulants). (Conditional recommendation)

5.7.  Routine use of epidural analgesia for hip fracture surgery is discouraged. If used, restrict to selected cases under acute pain service or senior anaesthesia oversight, with explicit anticoagulant coordination and haemodynamic monitoring. (Conditional recommendation)

5.8.  Use a layered multimodal regimen for all hip fracture patients unless contraindicated: regular paracetamol (acetaminophen) as baseline therapy, early peripheral nerve block (single-shot fascia iliaca or femoral nerve block where available), and opioids for rescue analgesia using small, titrated immediate-release doses. Reserve short-course NSAID/COX-2 inhibitor only in carefully selected low-risk patients (Strong recommendation)

6.     Anaesthetic management

6.1.  Proceed to surgery as soon as feasible once immediately reversible problems are addressed (e.g., hypoxia, hypovolaemia, severe electrolyte derangements, uncontrolled pain). (Strong Recommendation)

6.2.  Either neuraxial (spinal) or general anaesthesia is acceptable. Choose the technique that can be delivered safely and promptly given antithrombotic timing, physiological reserve, airway risk, expected surgical duration, and local expertise. (Conditional recommendation)

6.3.  Aim to maintain any change in systolic blood pressure/mean arterial pressure within approximately 20% of the patient’s baseline, avoid hypoxia and hypercarbia, maintain normothermia, and use a proactive vasopressor strategy with judicious fluids. (Strong recommendation)

6.4.  For cemented arthroplasty, identify high-risk patients and apply BCIS (Bone Cement Implantation Syndrome) precautions: a team 'cement pause', maintain blood pressure close to baseline, optimize oxygenation, and have vasopressors immediately available. (Strong Recommendation)

6.5.  Implement multimodal analgesia, delirium prevention measures (adequate pain control, oxygenation, hydration, sleep-wake support), and early mobilization. Coordinate VTE prophylaxis timing with any neuraxial or deep catheter use. (Strong recommendation)

7.     Planning the theatre team

7.1.  Schedule hip fracture surgery on a planned trauma list

7.2.  Consultants or senior staff must supervise trainees and junior members of the anaesthesia, surgical, and theatre teams when they carry out hip fracture procedures (Good practice statement).

8.     Surgical Procedures

8.1.  Stable femoral neck fractures

8.1.1.     In patients with stable femoral neck fractures (impacted/non-displaced, Garden’s I and II, Annex 6: Garden Classification of Femoral Neck Fracture), internal fixation or arthroplasty may be considered, after assessment of the patient and imaging of the hip joint. (Conditional recommendation)

8.2.  Unstable femoral neck fractures

8.2.1.     Arthroplasty vs Fixation

8.2.1.1.          For displaced (Garden III/IV) fractures neck femur in ambulatory or functionally independent elderly patient, HA or THA is strongly recommended over internal fixation. (Strong Recommendation)

8.2.2.     Unipolar/bipolar hemiarthroplasty

8.2.2.1.          Use a femoral stem design other than Austin Moore or Thompson stems for arthroplasties. Unipolar (Austin Moore or Thompson) prosthesis should be used in strictly limited conditions, e. g. Unavailable bipolar prosthesis. (Good practice statement)

8.2.3.     Total Arthroplasty vs Hemi Arthroplasty

8.2.3.1.          For fit, active elderly patients (≥60 years) with displaced femoral neck fractures, Total Hip Arthroplasty (THA) is suggested rather than Hemiarthroplasty (HA) to improve function and reduce revision risk. (Conditional recommendation)

8.2.3.2.          For frail, medically complex, or cognitively impaired patients with limited mobility, Hemiarthroplasty (HA) may be preferred due to shorter operative time and reduced perioperative risk. (Conditional recommendation)

8.2.3.3.          Decisions should incorporate individual patient comorbidities, cognition, pre-fracture mobility, surgical risk, and patient preference. (Strong recommendation)

8.2.4.     Cemented femoral stems

8.2.4.1.          Cemented stem implants are preferred in patients undergoing surgery with arthroplasty. (Conditional recommendation)

8.2.5.     Surgical approach

8.2.5.1.          In patients undergoing treatment of femoral neck fractures with hip arthroplasty, evidence does not show a favoured surgical approach. Select approach based on surgeon’s experience and preference. (Good practice statement)

8.3.  Intertrochanteric fractures

8.3.1.     In patients with stable intertrochanteric fractures, use of either a sliding hip screw or a cephalomedullary device is recommended. Use a dynamic hip screw (DHS) in preference to an intramedullary nail in patients with stable intertrochanteric fractures (Strong recommendation)

8.3.2.     In patients with unstable intertrochanteric fractures, the use of cephalomedullary device is recommended. (Strong recommendation)

8.3.3.     In patients with subtrochanteric or reverse obliquity fractures a cephalomedullary device is recommended. (Strong recommendation)

9.     Blood transfusion

9.1.  A blood transfusion threshold of no higher than 8g/dl is suggested in asymptomatic postoperative hip fracture patients. (Conditional recommendation)

10.  Tranexamic acid

10.1.                 Tranexamic acid should be administered to reduce blood loss and blood transfusion in patients with hip fractures. (Strong recommendation)

11.  Interdisciplinary/Multidisciplinary care programs

11.1.                 On admission, offer patients a formal, acute orthogeriatric or orthopaedic ward-based fracture program that includes the following steps (Conditional recommendation):

11.1.1.  Comprehensive orthogeriatric assessment to evaluate both current and baseline level of functioning

11.1.2.  Rapid optimization to make patient fit for surgery

11.1.3.  Identify individual goals for multidisciplinary rehabilitation to recover mobility and independence, and to achieve return to pre-fracture residence when possible

11.1.4.  Offer longitudinal, coordinated, orthogeriatric and multidisciplinary review

11.1.5.  Provide liaison or integration with related services, particularly mental health (delirium prevention), falls prevention, bone health, primary care and social services

11.1.6.  Clinical and service governance responsibility for all stages of the pathway of care and rehabilitation, including those provided in the community.

12.  Postoperative rehabilitation

12.1.                 In patients undergoing surgical stabilization of hip fractures, early mobilization, including functional movement within 24–48 hours postoperatively is recommended, provided the patient is medically and mobilization is consistent with the surgeon’s postoperative instructions (Strong recommendation)

12.2.                 Following hip fracture surgery, weight-bearing should be initiated as early as clinically feasible, with full weight-bearing as tolerated recommended after stable fixation, unless contraindicated by surgical or patient-specific factors (Conditional recommendation)

12.3.                 Rehabilitation after hip fracture surgery should follow a structured, phased pathway, spanning the acute inpatient phase, home or inpatient rehabilitation services, and outpatient rehabilitation, aligned with the patient’s recovery stage and care setting (Conditional recommendation)

12.4.                 Fall prevention strategies should begin with identification and management of underlying fall risk factors, including muscle weakness, balance deficits, cognitive impairment, medication-related side effects, orthostatic hypotension, visual impairment, and environmental hazards. These strategies should be systematically integrated into all phases of postoperative rehabilitation following hip fracture surgery (Conditional recommendation).

12.5.                 Standardized functional and mobility outcome measures, such as the Timed Up and Go Test (TUG test), should be used regularly to guide rehabilitation progression and monitor recovery after hip fracture surgery. (Conditional recommendation)

12.6.                 Discharge planning should begin early during hospitalization and be individualized based on medical stability, functional recovery, cognitive status, family support, and access to rehabilitation services. In the Egyptian healthcare setting, most patients require a short inpatient stay followed by home-based or facility-based rehabilitation. Early discharge within 24–48 hours may be considered for selected, medically stable patients with adequate family support and rehabilitation access. Same-day or next-day discharge should be limited to exceptional cases. (Conditional recommendation)

12.7.                 Following hip fracture surgery, appropriate assistive devices should be prescribed and regularly reassessed to support safe ambulation. A walker is recommended in the early postoperative phase, with progression to a cane held in the contralateral hand to the operated limb as balance, strength, and weight-bearing tolerance improve. (Good practice statement)

13.  Patient and carer information

13.1.                 It is crucial to offer the patients (or when appropriate, their carers) information about their medical diagnosis and its implications and treatment options and management plan either verbally or in printed form (Good practice statement)