Hip fracture: management

Context

Hip fracture refers to a fracture occurring in the area between the edge of the femoral head and 5 cm below the lesser trochanter (see figure 1 in the full guideline). These fractures are generally divided into 2 main groups. Those above the insertion of the capsule of the hip joint are termed intracapsular, subcapital or femoral neck fractures. Those below the insertion are extracapsular. The extracapsular group is split further into trochanteric (inter- or pertrochanteric and reverse oblique) and subtrochanteric.

Hip fracture is a major public health issue due to an ever-increasing ageing population. About 65,000 hip fractures occur each year and the annual cost (not including the considerable cost of social care) for all UK hip fracture cases is about £1 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 high prevalence 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 the transition from hospital to community.

This guideline covers the management of hip fracture from admission to secondary care through to final return to the community and discharge from specific follow‑up. It assumes that anyone clinically suspected of having a hip fracture will normally be referred for immediate hospital assessment. It excludes (other than by cross‑reference) aspects covered by parallel NICE guidance, most notably primary and secondary prevention of fragility fractures, but recognises the importance of effective linkage to these closely related elements of comprehensive care. Although hip fracture is predominantly a phenomenon of later life (the National Hip Fracture Database reports the average age of a person with hip fracture as 84 years for men and 83 for women), it may occur at any age in people with osteoporosis or osteopenia, and this guidance is applicable to adults across the age spectrum. Management of hip fracture has improved through the research and reporting of key skills, especially by collaborative teams specialising in the care of older people (using the general designation 'orthogeriatrics'). These skills are applicable in hip fracture irrespective of age, and the guidance includes recommendations that cover the needs of younger people by drawing on such skills in an organised manner.

Although not a structured service delivery evaluation, the Guideline Development Group was required to extend its remit to cover essential implications for service organisation within the NHS where these are fundamental to hip fracture management, and this has been done.

The NICE surveillance review identified new studies that were consistent with the current recommendations. However, because of a low level of compliance (around 30% nationally) with the recommendation to offer total hip replacement to people with displaced intracapsular hip fractures, we have updated this part of the guideline. The 2017 update also covers interventions for undisplaced intracapsular hip fractures, which were not covered in the original guideline.

The guideline will assume that prescribers will use a drug's summary of product characteristics to inform decisions made with individual patients.