Hip fracture perioperative pathway — Rapid

Synopsis

Deliver rapid, humane and coordinated care from suspected fracture through surgery and recovery, balancing analgesia, anticoagulation, delirium, comorbidity, nutrition, mobility, bone health and the person's pre-fracture goals.

First-line suspected hip-fracture care is analgesia, safe positioning, pressure care, radiographs and admission to a coordinated orthopaedic–orthogeriatric pathway.
MRI is the reference test when hip fracture remains suspected after adequate negative radiographs; use CT if MRI is contraindicated or unavailable within 24 hours.
Offer immediate regular paracetamol unless contraindicated, add opioids when needed and use nerve block to limit opioid dose; NICE advises against NSAIDs in hip-fracture care.
Surgery should occur on the day of or day after admission, with correctable anaemia, anticoagulation, volume depletion, electrolytes, diabetes, heart failure, arrhythmia and chest infection addressed without avoidable delay.
Use replacement arthroplasty for displaced intracapsular fracture and consider total hip replacement using pre-fracture mobility, comorbidity and expected independent function criteria.
Use cemented implants for arthroplasty and fixation selected to fracture pattern and current guidance.
Provide venous-thromboembolism prophylaxis using current NICE risk, bleeding and renal criteria and the selected anaesthetic and operative timing.
Screen for delirium and provide orientation, sensory aids, hydration, nutrition, pain, sleep, bowel and bladder care rather than relying on sedation.
Mobilise on the day after surgery unless medically or surgically contraindicated and offer mobilisation at least daily with regular physiotherapy review.
Before transition, address osteoporosis treatment, multifactorial falls prevention, cognition, mood, continence, wound, medication, carers and realistic rehabilitation goals.

Key red flags

Haemodynamic instability, major blood loss, hypoxia or another life-threatening injury requires immediate resuscitation while the fracture pathway continues.

New neurovascular deficit, open fracture or threatened skin requires urgent orthopaedic intervention.

A normal radiograph with persistent inability to weight bear or pain on rotation requires occult-fracture imaging rather than forced mobilisation.

Head strike, anticoagulation, vomiting, amnesia or focal neurology requires parallel head-injury assessment.

Sepsis, uncontrolled heart failure, unstable arrhythmia, severe electrolyte disturbance or diabetic emergency requires immediate correction and senior perioperative planning.

Delirium, uncontrolled pain, urinary retention or prolonged fasting can rapidly worsen physiology and must not be treated as an inevitable part of age.

Classic hip fracture

Groin pain, inability to weight bear and a shortened externally rotated limb after a fall is highly concerning.

Occult hip fracture

Persistent pain on hip movement or weight bearing despite normal radiographs requires cross-sectional imaging.

Delirium presentation

Inattention, fluctuating alertness or acute functional loss may be the dominant perioperative complication.

Investigation priorities

Hip radiographsFirst stepFirst line

Confirm and classify suspected fracture first line.

Management branches

First-line admission sequenceRelieve pain and reach surgery quickly

Hip fracture is suspected or confirmed.

Give analgesia, protect pressure areas, obtain radiographs and use MRI or CT promptly for occult fracture.
Admit to coordinated hip-fracture care and document baseline, comorbidity, cognition, medicines and goals.
Optimise correctable problems in parallel and operate on the day of or day after admission where possible.

Key medicines

ParacetamolA common adult regimen is 1 g orally or intravenously every six hours, maximum 4 g in 24 hours; use a lower maximum or longer interval for body weight under 50 kg, malnutrition, liver risk or other product-specific factors.Count all combination products, review liver and nutrition risk and reassess pain rather than leaving an automatic high dose in a frail low-weight patient.

Immediate-release opioidUse a small titrated oral or intravenous dose according to local protocol and prior exposure; reduce and lengthen dosing in frailty or renal impairment and reassess after each dose.Monitor respiratory rate, sedation, delirium, nausea, constipation and renal accumulation; prescribe bowel care and avoid a fixed one-size regimen.

Open full textbook →Answer 2 questions