Neck-of-femur fracture and urgent geriatric co-management

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Hip fracture is an acute geriatric syndrome rather than an isolated radiograph. Establish mechanism, pre-fracture mobility, cognition, residence, frailty, medicines, anticoagulants, comorbidity and goals from the patient and collateral sources. Examine both hips, pelvis, spine and the entire limb, including skin and distal neurology. Seek the medical cause of the fall after immediate injuries are treated, using ECG, glucose, infection assessment and postural testing when safe.

Imaging begins with AP pelvis and lateral hip views. Impacted intracapsular and occult insufficiency fractures can be missed. NICE recommends MRI when a hip fracture remains suspected despite adequate negative radiographs; use CT if MRI is not available within twenty-four hours or is contraindicated. Persistent inability to mobilise after a negative CT still merits senior review and often MRI rather than discharge with a soft-tissue label.

Analgesia is preventive medicine. Assess pain at presentation, within thirty minutes of initial treatment, hourly until settled and regularly thereafter. NICE recommends paracetamol every six hours before and after surgery, with additional opioids if required and a nerve block by trained staff when paracetamol and opioids do not provide sufficient pre-operative relief. Nerve block supplements rather than replaces timely surgery and careful opioid monitoring.

Surgery occurs on the day of or day after admission. Anaemia, anticoagulation, volume depletion, electrolytes, uncontrolled diabetes, uncontrolled heart failure, correctable arrhythmia or ischaemia and acute chest infection are treated immediately. A vague request for medical optimisation is not a reason to postpone. Geriatric and anaesthetic review should distinguish a reversible time-critical problem from chronic disease that will not improve through another day in bed.

Procedure follows fracture and person. Displaced intracapsular fractures receive replacement arthroplasty. Consider total hip replacement rather than hemiarthroplasty when the person walked independently outdoors with no more than a stick, has no medical contraindication and is expected to perform independent daily activities beyond two years. Use cemented implants for arthroplasty. Trochanteric and subtrochanteric fractures require the recommended extramedullary or intramedullary fixation strategy for their pattern.

Peri-operative care prevents predictable harms. Avoid prolonged fasting, maintain hydration and warmth, reconcile medicines, provide antibiotic prophylaxis through the operative protocol and use VTE prevention under NICE NG89. For fragility fractures of pelvis, hip or proximal femur, offer pharmacological prophylaxis for one month when thrombosis risk exceeds bleeding risk. Remove urinary catheters early, support orientation, hearing, vision, sleep and bowel function and avoid unnecessary sedatives.

Recovery starts immediately. Choose fixation that permits unrestricted weight bearing, and mobilise with physiotherapy by the day after surgery unless contraindicated. Begin a rehabilitation prescription, nutrition support and discharge planning from admission. A fracture-liaison pathway evaluates osteoporosis and treatment adherence, while falls assessment addresses vision, balance, footwear, environment and hypotensive or psychotropic medicines. Report final pathology when a pathological fracture is suspected.

Key points

Suspect hip fracture with groin pain, shortening, external rotation or inability to bear weight after a fall; impacted fractures may show little deformity and allow painful movement.
Obtain AP pelvis and a true lateral hip radiograph promptly; if suspicion persists despite adequate negative films, offer MRI, or CT if MRI is unavailable within 24 hours or contraindicated.
Assess pain immediately and within 30 minutes of analgesia, then regularly; NICE uses paracetamol every 6 hours, adding opioids and considering a trained nerve block when relief is inadequate.
Admit under a hip-fracture programme with orthopaedic, orthogeriatric, anaesthetic, nursing, therapy and fracture-liaison input from presentation.
Operate on the day of or day after admission, correcting anaemia, anticoagulation, volume depletion, electrolyte imbalance, uncontrolled diabetes, heart failure, arrhythmia, ischaemia or chest infection immediately so they do not create avoidable delay.
Offer replacement arthroplasty for displaced intracapsular fracture; select total rather than hemiarthroplasty for appropriate independently mobile, medically suitable people expected to remain independent beyond 2 years.
Aim for surgery that permits full weight bearing without restriction immediately afterwards and start physiotherapy assessment and mobilisation by the day after surgery when not contraindicated.
Provide delirium prevention, nutrition, pressure care, one month of indicated VTE prophylaxis, medication review, falls assessment and osteoporosis treatment or referral before discharge.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Fragility fall

Most fractures follow a standing-height fall in an older person with osteoporosis, sarcopenia, impaired balance, sensory loss or medicines that increase falling.

High-energy trauma

Younger adults usually require greater force and may have associated pelvic, acetabular, femoral-shaft or visceral injury that changes imaging and fixation strategy.

Pathological fracture

Antecedent night pain, malignancy, atypical location or minimal trauma without osteoporosis raises concern for metastatic, haematological or primary bone disease.

Stress and insufficiency injury

Repetitive load or weakened bone can produce an incomplete femoral-neck fracture with progressive groin pain before displacement occurs.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Intracapsular vascular risk
Displacement can disrupt retinacular vessels to the femoral head, increasing nonunion and avascular necrosis and favouring arthroplasty in many older adults.
2
Extracapsular bleeding
Trochanteric and subtrochanteric fractures expose vascular cancellous bone and surrounding muscle, causing pain, swelling and clinically important concealed blood loss.
3
Immobility cascade
Pain and bed rest rapidly reduce ventilation, muscle mass, skin integrity and venous flow while precipitating delirium and loss of independence.
4
Frailty stress response
Surgery, fasting, inflammation and unfamiliar surroundings destabilise cognition, cardiac function, glucose, hydration and continence in a person with limited reserve.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Displaced intracapsular pattern

Shortening, external rotation and inability to straight-leg raise with a subcapital or transcervical line and displacement indicates threatened femoral-head viability.

Impacted occult pattern

Groin pain on axial load or hip rotation with little deformity and negative initial films can represent an undisplaced or insufficiency fracture.

Extracapsular pattern

Trochanteric tenderness, bruising and a fracture through intertrochanteric or subtrochanteric bone often causes substantial hidden blood loss.

Delirium at presentation

Acute inattention, altered arousal or fluctuating cognition may reflect pain, hypoxia, infection or dehydration and requires treatment rather than exclusion from surgery.

Pathological concern

Antecedent pain, lytic lesion, cortical destruction or an atypical low-energy fracture in non-osteoporotic bone needs oncological investigation and operative planning.

Peri-operative instability

Chest pain, decompensated heart failure, sepsis, severe electrolyte disturbance or uncontrolled arrhythmia needs immediate correction with senior anaesthetic ownership.

Red flags requiring action

A shortened externally rotated leg, inability to bear weight or new hip and groin pain after a fall should be treated as fracture even if initial radiographs are non-diagnostic.
Haemodynamic instability, severe anaemia, chest pain, hypoxia, sepsis, anticoagulant-related bleeding or another major injury requires simultaneous resuscitation and senior peri-operative planning rather than routine ward delay.
New confusion, uncontrolled pain, urinary retention, pressure damage, dehydration or prolonged fasting signals preventable harm and should trigger immediate orthogeriatric and anaesthetic action.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
First-line AP pelvis and lateral hip radiographsFirst stepFirst line
Why
Confirm fracture location, displacement and arthritic or pathological features.
Interpretation and limitations
Review intracapsular, trochanteric and subtrochanteric regions and the opposite hip; an adequate negative study does not exclude occult fracture.
02
Preferred MRI for occult fracturePreferred
Why
Confirm a radiographically occult proximal femoral or pelvic insufficiency injury.
Interpretation and limitations
NICE recommends MRI when suspicion persists; MRI also detects sacral, marrow and soft-tissue pathology that can explain immobility.
03
Alternative CT within 24 hours
Why
Identify occult fracture when MRI is unavailable promptly or contraindicated.
Interpretation and limitations
A positive CT guides treatment, but a negative CT with persistent focal pain or inability to mobilise may still need MRI and senior review.
04
Pre-operative blood panel and ECG
Why
Identify correctable anaemia, renal, electrolyte, glucose, coagulation and cardiac issues.
Interpretation and limitations
Interpret tests to enable surgery rather than seeking normal values; obtain group and screen and agent-specific anticoagulant history promptly.
05
Chest testing only when indicated
Why
Investigate acute respiratory or cardiac symptoms that may alter immediate anaesthesia.
Interpretation and limitations
Do not use routine chest radiography or broad testing to delay an otherwise ready patient; target symptoms and examination.
06
Bone and falls assessment
Why
Reduce future fragility fracture after acute treatment.
Interpretation and limitations
Use fracture-liaison assessment, medication review, calcium and vitamin D or DXA when appropriate; a hip fragility fracture itself establishes very high future risk.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Pelvic fragility fracture

Pubic rami and sacral fractures cause groin, buttock or low-back pain and inability to mobilise, sometimes with normal initial pelvic radiographs.

Hip dislocation or acetabular fracture

High-energy deformity, fixed rotation and severe pain suggests joint displacement or acetabular injury requiring urgent trauma imaging and reduction planning.

Soft-tissue hip injury

Contusion, gluteal tear or trochanteric pain syndrome may preserve cautious weight bearing, but cannot be diagnosed until occult fracture is excluded.

Septic or crystal arthritis

Fever, systemic illness, atraumatic severe pain and inflammatory findings raise an urgent joint-aspiration pathway rather than fragility-fracture care.

Lumbar radiculopathy

Back pain with dermatomal symptoms can refer to the hip, although new immobility after trauma still warrants adequate proximal femoral and pelvic imaging.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01AdmissionDiagnose, relieve pain and co-manageFirst stepAn older person has suspected or confirmed hip fracture after a fall.

1Perform ABCDE, assess skin and distal neurology, obtain collateral baseline and give regular paracetamol with titrated additional analgesia.
2Obtain urgent radiographs, then MRI or timely CT for persistent occult-fracture suspicion and avoid testing weight bearing repeatedly.
3Admit through the hip-fracture programme and involve orthogeriatrics and anaesthesia while pressure, hydration, delirium and VTE measures start.
4Identify and treat immediately reversible surgical barriers with an explicit same-day decision rather than an open-ended optimisation request.

02SurgeryOperate by the next dayFracture is confirmed and immediate reversible problems are being corrected.

1Schedule surgery on the day of or day after admission and communicate any true contraindication, treatment and reassessment deadline.
2Use arthroplasty for displaced intracapsular fracture, selecting total or hemiarthroplasty from mobility, fitness and likely independent function.
3Use pattern-appropriate fixation for extracapsular injury and aim for immediate unrestricted postoperative weight bearing.
4Deliver operative antibiotic, blood conservation, pressure and thrombosis measures through the current local protocols.

03RecoveryMobilise and prevent the next fractureSurgery is complete and physiology permits rehabilitation.

1Assess for mobilisation and physiotherapy by the day after surgery, treating pain, hypotension, delirium and equipment barriers promptly.
2Provide one month of pharmacological VTE prophylaxis when indicated and continue mechanical prevention until mobility improves.
3Begin fracture-liaison osteoporosis care, falls and medicine review, nutrition and a patient-centred rehabilitation prescription.
4Communicate weight-bearing status, wound care, cognitive baseline, anticoagulant plan and emergency return signs to the receiving setting.

Key medicines and prescribing safety2 treatments · regimens, roles and cautions

Provides scheduled baseline analgesia, reducing opioid exposure and supporting breathing, cognition, positioning and early mobilisation.

Paracetamol

Give 1 g orally or intravenously every 6 hours before and after surgery, maximum 4 g in 24 hours; reduce the maximum in adults under 50 kg or with frailty, malnutrition, chronic alcohol excess or hepatic risk.

Count combination products, adjust for low weight and liver risk and do not use intravenous administration when the oral route is reliable without a clinical reason.

Reduces postoperative venous thromboembolism during the prolonged high-risk period created by fragility fracture, surgery and immobility.

Enoxaparin for postoperative hip-fracture prophylaxis

When the local NG89 pathway selects enoxaparin and haemostasis is secure, give 40 mg subcutaneously once daily starting 6–12 hours after surgery and continue pharmacological prophylaxis for one month; use the product and renal-adjustment protocol.

Assess active bleeding, platelets, renal function, body weight and neuraxial timing; severe renal impairment requires dose adjustment and suspected heparin-induced thrombocytopenia requires immediate cessation and specialist advice.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Delirium

Pain, infection, hypoxia, dehydration, constipation, urinary retention, sleep disruption and deliriogenic medicines cause acute cognitive change and worse recovery.

Venous thromboembolism

Fracture, age, surgery and immobility create high thrombosis risk requiring mechanical and pharmacological prevention balanced against bleeding.

Pressure and chest complications

Prolonged immobility causes pressure injury, atelectasis, secretion retention and pneumonia, supporting surgery and mobilisation without avoidable delay.

Nonunion or avascular necrosis

Retained displaced intracapsular fractures may fail to unite or lose femoral-head blood supply, causing pain and later salvage surgery.

Loss of independence

Deconditioning, fear of falling and incomplete rehabilitation can lead to new care needs, institutionalisation and increased mortality despite a technically successful operation.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Reassess pain within thirty minutes of initial analgesia and regularly, documenting sedation, nausea, constipation and respiratory effects of opioids.
Screen daily for delirium and address oxygenation, infection, hydration, bowel, bladder, pain, sensory aids, sleep and unnecessary medicines.
Track admission-to-theatre time and document every delay with a reversible cause, responsible clinician and reassessment point.
After surgery monitor wound, haemoglobin, renal function, mobilisation, pressure areas, VTE symptoms and anticoagulant timing.
Ensure fracture-liaison, falls, osteoporosis, nutrition and rehabilitation plans are active before transfer, with follow-up ownership.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

Negative films do not end suspicion

Persistent inability to mobilise and focal groin pain after a fall needs MRI or appropriate CT, not a forced walking trial.

Optimisation has a clock

Treat correctable illness immediately; another bed-bound day can harm more than stable chronic comorbidity affects anaesthesia.

Delirium is often multifactorial

Pain, retention, constipation, dehydration and unfamiliar surroundings may be corrected while surgery proceeds rather than sequentially delaying it.

Operation enables rehabilitation

Procedure choice should permit immediate full weight bearing because many frail patients cannot comply with partial-weight-bearing instructions.

The next fracture starts today

Falls and bone-health treatment during admission is part of hip-fracture care rather than an optional outpatient add-on.

11Common pitfallsFrequent interpretation and management errors.

01
Discharging persistent groin pain and immobility after negative radiographs without occult-fracture imaging.
02
Using repeated fasting and vague medical optimisation to delay surgery beyond the day after admission.
03
Treating nerve block as a replacement for regular analgesia, monitoring or timely operation.
04
Leaving weight-bearing instructions unclear and thereby preventing early mobilisation.
05
Using sedatives or urinary catheters routinely and worsening delirium and infection risk.
06
Repairing the fracture but omitting osteoporosis, falls, nutrition and rehabilitation planning.