Hf qrg v5_rt.pdf

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 www.nice.org.uk
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 www.nice.org.uk/guidance/CG124
primary prevention of osteoporotic fragilityfractures in postmenopausal women ● The NICE guideline – all the recommendations.
● A quick reference guide (this document) – www.nice.org.uk/guidance/TA160
● Denosumab for the prevention of osteoporotic ● ‘Understanding NICE guidance’ – a summary technology appraisal guidance 204 (2010).
Available from ● The full guideline – all the recommendations, www.nice.org.uk/guidance/TA204
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 www.nice.org.uk/guidance/CG103
● 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 www.nice.org.uk/guidance/IPG363
● Surgical site infection. NICE clinical www.nice.org.uk/guidance/CG124).
guideline 74 (2008). Available from
www.nice.org.uk/guidance/CG74
Related NICE guidance
www.nice.org.uk/guidance/CG42
see www.nice.org.uk
● Nutrition support in adults. NICE clinical ● Alendronate, etidronate, risedronate, www.nice.org.uk/guidance/CG32
raloxifene, strontium ranelate and teriparatide ● Pressure ulcers. NICE clinical guideline 29 for the secondary prevention of osteoporotic fragility fractures in postmenopausal women www.nice.org.uk/guidance/CG29
(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 www.nice.org.uk/guidance/CG3
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 www.nice.org.uk/guidance/CG124
guidance 2 (2000). Available from
www.nice.org.uk/guidance/TA2
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