Quick reference guide Hip fracture The management of hip fracture in adults
Developed by the National Clinical Guideline Centre
Hip fracture About this booklet This is a quick reference guide that summarises the recommendations NICE has made to the NHS in ‘Hip fracture: the management of hip fracture in adults‘ (NICE clinical guideline 124). Who should read this booklet? This quick reference guide is for healthcare professionals and other staff who care for people with hip fracture. Who wrote the guideline? The guideline was developed by the National Clinical Guideline Centre, which is based at the Royal College of Physicians. The Guideline Centre worked with a group of healthcare professionals, patients and carers, and technical staff, who reviewed the evidence and drafted the recommendations. The recommendations were finalised after public consultation. For more information on how NICE clinical guidelines are developed, go to www.nice.org.uk Where can I get more information about the guideline? The NICE website has the recommendations in full, reviews of the evidence they are based on, a summary of the guideline for patients and carers, and tools to support implementation (see inside back cover for more details). National Institute for Health and Clinical Excellence
National Institute for Health and Clinical
Excellence, 2011. All rights reserved. This material
may be freely reproduced for educational and
not-for-profit purposes. No reproduction by orfor commercial organisations, or for commercial
purposes, is allowed without the express written
NICE clinical guidelines are recommendations about the treatment and care of people with specificdiseases and conditions in the NHS in England and Wales. This guidance represents the view of NICE, which was arrived at after careful consideration of theevidence available. Healthcare professionals are expected to take it fully into account whenexercising their clinical judgement. However, the guidance does not override the individualresponsibility of healthcare professionals to make decisions appropriate to the circumstances of theindividual patient, in consultation with the patient and/or guardian or carer, and informed by thesummary of product characteristics of any drugs they are considering. Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance,in their local context, in light of their duties to avoid unlawful discrimination and to have regard topromoting equality of opportunity. Nothing in this guidance should be interpreted in a way thatwould be inconsistent with compliance with those duties. Hip fracture Contents Introduction Key priorities for implementation When the patient presents at hospital Analgesia Multidisciplinary rehabilitation Further information Patient-centred care Treatment and care should take into account patients’ individual needs and preferences. Good communication is essential, supported by evidence-based information, to allow patients to reach informed decisions about their care. Follow advice on seeking consent from the Department of Health or Welsh Assembly Government if needed. If the patient agrees, families and carers should have the opportunity to be involved in decisions about treatment and care. NICE clinical guideline 124 Quick reference guide Hip fracture Introduction ● Hip fracture is a major public health issue due to an ever increasing ageing population. About
70,000 to 75,000 hip fractures occur each year and the annual cost (including medical and socialcare) for all UK hip fracture cases is about £2 billion.
● About 10% of people with a hip fracture die within 1 month and about one-third within 12 months.
Most of the deaths are due to associated conditions and not to the fracture itself, reflecting the highprevalence of comorbidity.
● Because the occurrence of fall and fracture often signals underlying ill health, a comprehensive
multidisciplinary approach is required from presentation to subsequent follow-up, including thetransition from hospital to community.
This guideline covers the management of hip fracture from admission to secondary care through tofinal return to the community and discharge from specific follow-up. Some aspects of hip fracture management are already covered by NICE guidance and are thereforeoutside the scope of the guideline. In order to ensure comprehensive management and continuity, thefollowing NICE guidance should be referred to when developing a complete programme of care for eachpatient: osteoporotic fragility fracture prevention (NICE technology appraisals guidance 204, 161 and160), falls (NICE clinical guideline 21), pressure ulcers (NICE clinical guideline 29), nutrition support (NICEclinical guideline 32), dementia (NICE clinical guideline 42), surgical site infection (NICE clinical guideline74), venous thromboembolism (NICE clinical guideline 92) and delirium (NICE clinical guideline 103). Key to terms Hip fractures (or proximal femoral fractures) Fractures occurring between the edge of the femoral head and 5 cm below the lesser trochanter. The regions where hip fractures occur Intracapsular fractures Fractures between the
edge of the femoral head and insertion of the
capsule of the hip joint. Also known as femoral neck fractures. Extracapsular fractures Fractures between the
insertion of the capsule of the hip joint and aline 5 cm below the lesser trochanter. Trochanteric fractures A subgroup of the
extracapsular group that includes inter- orpertrochanteric and reverse oblique fractures. Subtrochanteric fractures A subgroup of the extracapsular group where the fracture occurs below the lesser trochanter.
4 NICE clinical guideline 124 Quick reference guide Hip fracture Key priorities for implementation Timing of surgery ● Perform surgery on the day of, or the day after, admission.
● Identify and treat correctable comorbidities immediately so that surgery is not delayed by:
– anaemia– anticoagulation– volume depletion– electrolyte imbalance– uncontrolled diabetes– uncontrolled heart failure– correctable cardiac arrhythmia or ischaemia– acute chest infection– exacerbation of chronic chest conditions. Planning the theatre team ● Schedule hip fracture surgery on a planned trauma list. Surgical procedures ● Perform replacement arthroplasty (hemiarthroplasty or total hip replacement) in patients with a
● Offer total hip replacements to patients with a displaced intracapsular fracture who:
– were able to walk independently out of doors with no more than the use of a stick and – are not cognitively impaired and – are medically fit for anaesthesia and the operation.
● Use extramedullary implants such as a sliding hip screw in preference to an intramedullary nail in
patients with trochanteric fractures above and including the lesser trochanter (AO classificationtypes A1 and A2). Mobilisation strategies ● Offer patients a physiotherapy assessment and, unless medically or surgically contraindicated,
mobilisation on the day after surgery.
● Offer patients mobilisation at least once a day and ensure regular physiotherapy review. NICE clinical guideline 124 Quick reference guide Hip fracture Key priorities for implementation continued Multidisciplinary management ● From admission, offer patients a formal, acute orthogeriatric or orthopaedic ward-based Hip
Fracture Programme that includes all of the following:– orthogeriatric assessment– rapid optimisation of fitness for surgery– early identification of individual goals for multidisciplinary rehabilitation to recover mobility and
independence, and to facilitate return to pre-fracture residence and long-term wellbeing
– continued, coordinated, orthogeriatric and multidisciplinary review– liaison or integration with related services, particularly mental health, falls prevention, bone
– clinical and service governance responsibility for all stages of the pathway of care and
rehabilitation, including those delivered in the community.
● Consider early supported discharge as part of the Hip Fracture Programme, provided the Hip
Fracture Programme multidisciplinary team remains involved and the patient: – is medically stable and – has the mental ability to participate in continued rehabilitation and – is able to transfer and mobilise short distances and – has not yet achieved their full rehabilitation potential, as discussed with the patient,
6 NICE clinical guideline 124 Quick reference guide Hip fracture When the patient presents at hospital ● Assess the patient’s pain.
● Offer immediate analgesia to patients with suspected hip fracture, including people with cognitive
● Offer magnetic resonance imaging (MRI) if hip fracture is suspected despite negative anteroposterior
pelvis and lateral hip X-rays. If MRI is not available within 24 hours or is contraindicated, considercomputed tomography (CT).
● Offer all patients a formal, acute, orthogeriatric or orthopaedic ward-based Hip Fracture Programme. Hip Fracture Programme This includes all of the following:
● rapid optimisation of fitness for surgery
● early identification of individual goals for multidisciplinary rehabilitation to recover mobility and
independence, and to facilitate return to pre-fracture residence and long-term wellbeing
● continued, coordinated, orthogeriatric and multidisciplinary review
● liaison or integration with related services
● clinical and service governance responsibility for all stages of the pathway of care and
● Actively look for cognitive impairment and keep reassessing patients to identify delirium.
Offer individualised care in line with ‘Delirium’ (NICE clinical guideline 103).
● If a hip fracture complicates or precipitates a terminal illness, consider the role of surgery as part
of a palliative care approach that: – minimises pain and other symptoms and – establishes patients’ own priorities for rehabilitation and – considers patients’ wishes about their end-of-life care. Patient support and information ● Offer patients (or, as appropriate, their carer and/or family) verbal and printed information about
treatment and care including:– diagnosis
– choice of analgesia and other medications – long-term outcomes– surgical procedures
– healthcare professionals involved. NICE clinical guideline 124 Quick reference guide Hip fracture Analgesia ● Assess the patient’s pain:
– immediately upon presentation at hospital and – within 30 minutes of administering initial analgesia and – hourly until settled on the ward and – regularly as part of routine nursing observations throughout admission.
● Ensure analgesia is sufficient to allow movements necessary for investigations and for nursing care
● Non-steroidal anti-inflammatory drugs (NSAIDs) are not recommended.
Patient presents with suspected hip fracture
Assess the patient’s pain: on presentation
analgesia or to limit opioid dosage.
trained personnel. Do not substitute nerve
8 NICE clinical guideline 124 Quick reference guide Hip fracture Timing of surgery ● Perform surgery on the day of, or the day after,
● Identify and treat correctable comorbidities
Planning surgery ● Schedule surgery on a planned trauma list ● Consultants or senior staff should supervise trainee
and junior staff during hip fracture surgery
Anaesthesia ● Offer patients a choice of spinal or general
anaesthesia after discussing the risks and benefits
Surgical procedures ● Operate on patients with the aim to allow them to fully weight bear
(without restriction) in the immediate postoperative period
● Perform replacement arthroplasty in patients with a displaced
● Offer total hip replacements to patients with a displaced intracapsular
fracture who: – were able to walk independently and – are not cognitively impaired and – are medically fit for anaesthesia and the procedure
● Use a proven femoral stem design rather than Austin Moore or
● Use cemented implants in patients undergoing surgery with arthroplasty● Consider an anterolateral approach in favour of a posterior approach
● Use extramedullary implants such as a sliding hip screw in preference to
an intramedullary nail in patients with trochanteric fractures above and
including the lesser trochanter (AO classification types A1 and A2)
● Use an intramedullary nail to treat patients with a subtrochanteric fracture
NICE clinical guideline 124 Quick reference guide Hip fracture Multidisciplinary rehabilitation Mobilisation strategies ● Offer a physiotherapy assessment and, unless medically or surgically contraindicated, mobilisation on
● Offer mobilisation at least once a day and ensure regular physiotherapy review. Early supported discharge ● Consider early supported discharge as part of the Hip Fracture Programme, provided the
multidisciplinary team remains involved and the patient: – is medically stable and – has the mental ability to participate and – is able to transfer and mobilise short distances and – has not yet achieved their full rehabilitation potential. Intermediate care ● Only consider intermediate care (continued rehabilitation in a community hospital or residential care
unit) if all the following criteria are met: – intermediate care is included in the Hip Fracture Programme and – the Hip Fracture Programme team retains the clinical lead, including patient selection, agreement
of length of stay and ongoing objectives for intermediate care and
– the Hip Fracture Programme team retains the managerial lead, ensuring that intermediate care is
not resourced as a substitute for an effective acute hospital Programme. Patients admitted from care or nursing homes ● Patients admitted from care or nursing homes should not be excluded from a rehabilitation
programme in the community or hospital, or as part of an early supported discharge programme.
10 NICE clinical guideline 124 Quick reference guide Hip fracture Further information Ordering information
● Alendronate, etidronate, risedronate,
You can download the following documents from
raloxifene and strontium ranelate for the
primary prevention of osteoporotic fragilityfractures in postmenopausal women
● The NICE guideline – all the recommendations.
● A quick reference guide (this document) –
● Denosumab for the prevention of osteoporotic
● ‘Understanding NICE guidance’ – a summary
technology appraisal guidance 204 (2010). Available from
● The full guideline – all the recommendations,
reviews of the evidence they were based on.
● Delirium. NICE clinical guideline 103 (2010).
For printed copies of the quick reference guide or
‘Understanding NICE guidance’, phone NICE
● Venous thromboembolism – reducing the risk.
NICE clinical guideline 92 (2010). Available from www.nice.org.uk/guidance/CG92
● Minimally invasive hip replacement. NICE
● N2572 (‘Understanding NICE guidance’). Implementation tools
NICE has developed tools to help organisations
● Surgical site infection. NICE clinical
guideline 74 (2008). Available from www.nice.org.uk/guidance/CG74 Related NICE guidance www.nice.org.uk/guidance/CG42
● Nutrition support in adults. NICE clinical
● Alendronate, etidronate, risedronate,
raloxifene, strontium ranelate and teriparatide
● Pressure ulcers. NICE clinical guideline 29
for the secondary prevention of osteoporotic
fragility fractures in postmenopausal women
(amended). NICE technology appraisalguidance 161 (2011). Available from
● Falls. NICE clinical guideline 21 (2004). www.nice.org.uk/guidance/TA161
Available from www.nice.org.uk/guidance/CG21 NICE clinical guideline 124 Quick reference guide Hip fracture
● Preoperative tests. NICE clinical guideline 3
● Osteoporosis: risk assessment of people
with osteoporosis. NICE clinical guideline.
● Guidance on the use of metal on metal hip
resurfacing arthroplasty. NICE technologyappraisal guidance 44 (2002). Available from
Updating the guideline www.nice.org.uk/guidance/TA44
This guideline will be updated as needed,and information about the progress of
● The selection of prostheses for primary total
hip replacement. NICE technology appraisal
guidance 2 (2000). Available from www.nice.org.uk/guidance/TA2 National Institute for Health and Clinical Excellence MidCity Place 71 High Holborn London WC1V 6NA www.nice.org.uk
* Alles was Mann wissen muss - Neue Website informiert über günstige „Viagra®-Kopien“, Generika und Erektionsstörungen * produkt- & firmenneutral, arztgeprüft, wissenschaftlich-medizinisch, faktenorientiert Hofheim, 25. April 2013 – Am 23. Juni verliert das weltweit erfolg- reichste Potenzmittel Viagra® seinen Patentschutz - und erstmals we