Hip Fracture Management in Older Adults (AAOS 2021/NICE)

Algorithm Steps

1. ▶

   Start

   Suspected Hip Fracture in Older Adult

   Age ≥55 with hip pain after fall or trauma

   1. ●

      Action

      Initial Assessment

      History, exam, and imaging

      • Pain in groin, lateral hip, or referred to knee
      • Inability to weight bear
      • Shortened, externally rotated leg
      • AP and lateral hip X-rays
      • Check for other injuries (wrist, spine)
      1. ◆

         Decision

         Fracture visible on X-ray?

         Initial radiograph interpretation

         1. ●

            Action

            MRI for Occult Fracture

            AAOS: Moderate evidence supports MRI

            • MRI is imaging of choice if X-ray negative
            • Obtain within 24 hours
            • CT if MRI unavailable or contraindicated
            • Do not delay if high clinical suspicion
            1. ◆

               Decision

               Classify Hip Fracture Type

               Intracapsular vs Extracapsular

               • Intracapsular: Femoral neck fractures
               • Extracapsular: Intertrochanteric, Subtrochanteric
               • Assess displacement and stability
               1. ●

                  Action

                  Preoperative Optimization

                  Prepare for surgery within 24-48h

                  • AAOS: Surgery within 24-48h improves outcomes
                  • Assess cardiac, pulmonary status
                  • Manage anticoagulation (bridging if needed)
                  • Correct electrolytes, anemia (transfuse if Hgb <8)
                  • NPO status, IV fluids
                  • Pain control (femoral nerve block if available)
                  • VTE prophylaxis
                  1. ⚠

                     Warning

                     ⚠️ High Mortality Risk

                     Hip fracture carries significant mortality

                     • 30-day mortality ~10%
                     • 1-year mortality ~30%
                     • Delay >48h associated with worse outcomes
                     • Optimize medically but do not delay unnecessarily
               2. ◆

                  Decision

                  Femoral Neck Fracture: Displaced?

                  Garden III/IV vs Garden I/II

                  1. ●

                     Action

                     Non-displaced Femoral Neck (Garden I/II)

                     Internal fixation preferred

                     • Cannulated screws (typically 3)
                     • Sliding hip screw (SHS) acceptable
                     • Lower risk of AVN than displaced
                     • Close follow-up for displacement
                     1. ●

                        Action

                        Postoperative Care

                        Multidisciplinary hip fracture program

                        • Mobilize day 1 post-op (NICE)
                        • Weight bearing as tolerated (most cases)
                        • DVT prophylaxis 28-35 days
                        • Delirium prevention
                        • Nutritional support
                        • Osteoporosis assessment and treatment
                        • Falls prevention program
                        1. ✓

                           Outcome

                           Recovery & Rehabilitation

                           Return to baseline function is goal

                  2. ◆

                     Decision

                     Displaced Femoral Neck: Patient Factors

                     Age, activity, cognition, life expectancy

                     1. ●

                        Action

                        Total Hip Replacement (THR)

                        NICE: Offer THR for displaced FNF if appropriate

                        • Independently mobile pre-fracture
                        • Cognitively intact
                        • Medically fit for larger procedure
                        • Better functional outcomes than HA
                        • Use cemented femoral stem (AAOS moderate evidence)
                        1. ●

                           Action

                           Tranexamic Acid (TXA)

                           AAOS: Moderate evidence to reduce blood loss

                           • 1-2g IV before incision
                           • Reduces transfusion requirements
                           • Low VTE risk in appropriate patients
                           • Consider topical in wound
                     2. ●

                        Action

                        Hemiarthroplasty (HA)

                        For displaced FNF when THR not suitable

                        • Cognitive impairment
                        • Limited mobility pre-fracture
                        • Shorter life expectancy
                        • Use cemented stem (AAOS moderate evidence)
                        • Unipolar or bipolar head
               3. ◆

                  Decision

                  Intertrochanteric Fracture: Stable?

                  AO/OTA classification, lateral wall integrity

                  1. ●

                     Action

                     Stable Intertrochanteric (A1)

                     NICE: Extramedullary implant preferred

                     • Sliding Hip Screw (SHS/DHS)
                     • Simple 2-part fracture pattern
                     • Intact lateral wall
                     • Lower implant cost, similar outcomes
                  2. ●

                     Action

                     Unstable Intertrochanteric (A2/A3)

                     AAOS: Cephalomedullary device recommended

                     • Intramedullary nail (IMN) preferred
                     • Reverse oblique, subtrochanteric extension
                     • Lateral wall incompetence
                     • Short vs long nail based on pattern
               4. ●

                  Action

                  Subtrochanteric Fracture

                  Below lesser trochanter

                  • Cephalomedullary nail (long)
                  • Consider ORIF with fixed-angle device
                  • High stress region - malunion/nonunion risk
                  • Often associated with bisphosphonate use