Synopsis
Recognise hip fracture promptly, relieve pain and prevent delirium, correct reversible barriers without avoidable delay, and deliver surgery, geriatric co-management, early weight bearing and secondary fracture prevention.
- 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.
Key red flags
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.
Investigation priorities
Confirm fracture location, displacement and arthritic or pathological features.
Confirm a radiographically occult proximal femoral or pelvic insufficiency injury.
Management branches
An older person has suspected or confirmed hip fracture after a fall.
- Perform ABCDE, assess skin and distal neurology, obtain collateral baseline and give regular paracetamol with titrated additional analgesia.
- Obtain urgent radiographs, then MRI or timely CT for persistent occult-fracture suspicion and avoid testing weight bearing repeatedly.
- Admit through the hip-fracture programme and involve orthogeriatrics and anaesthesia while pressure, hydration, delirium and VTE measures start.
- Identify and treat immediately reversible surgical barriers with an explicit same-day decision rather than an open-ended optimisation request.