Guidance

Recommendations

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Some aspects of hip fracture management are already covered by NICE guidance and are therefore outside the scope of this guideline. To ensure comprehensive management and continuity, the following NICE guidance should be referred to when developing a complete programme of care for each patient:

1.1 Imaging options in occult hip fracture

1.1.1

Offer MRI if hip fracture is suspected despite negative X‑rays of the hip of an adequate standard. If MRI is not available within 24 hours or is contraindicated, consider CT. [2011, amended 2014]

1.2 Timing of surgery

1.2.1

Perform surgery on the day of, or the day after, admission. [2011]

1.2.2

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. [2011]

1.3 Analgesia

1.3.1

Assess the person'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. [2011]

1.3.2

Offer immediate analgesia to people presenting at hospital with suspected hip fracture, including people with cognitive impairment. [2011]

1.3.3

Ensure analgesia is sufficient to allow movements necessary for investigations (as indicated by the ability to tolerate passive external rotation of the leg), and for nursing care and rehabilitation. [2011]

1.3.4

Offer paracetamol every 6 hours preoperatively unless contraindicated. [2011]

1.3.5

Offer additional opioids if paracetamol alone does not provide sufficient preoperative pain relief. [2011]

1.3.6

Consider adding nerve blocks if paracetamol and opioids do not provide sufficient preoperative pain relief, or to limit opioid dosage. Nerve blocks should be administered by trained personnel. Do not use nerve blocks as a substitute for early surgery. [2011]

1.3.7

Offer paracetamol every 6 hours postoperatively unless contraindicated. [2011]

1.3.8

Offer additional opioids if paracetamol alone does not provide sufficient postoperative pain relief. [2011]

1.3.9

Non-steroidal anti-inflammatory drugs (NSAIDs) are not recommended. [2011]

1.4 Anaesthesia

1.4.1

Offer people a choice of spinal or general anaesthesia after discussing the risks and benefits. [2011]

1.4.2

Consider intraoperative nerve blocks for all people undergoing surgery. [2011]

1.5 Planning the theatre team

1.5.1

Schedule hip fracture surgery on a planned trauma list. [2011]

1.5.2

Consultants or senior staff should supervise trainee and junior members of the anaesthesia, surgical and theatre teams when they carry out hip fracture procedures. [2011]

1.6 Surgical procedures

1.6.1

Operate on people with the aim to allow them to fully weight bear (without restriction) in the immediate postoperative period. [2011]

1.6.2

Offer replacement arthroplasty (total hip replacement or hemiarthroplasty) to people with a displaced intracapsular hip fracture. [2017]

1.6.3

Consider total hip replacement rather than hemiarthroplasty for people with a displaced intracapsular hip fracture who:

  • were able to walk independently out of doors with no more than the use of a stick and

  • do not have a condition or comorbidity that makes the procedure unsuitable for them and

  • are expected to be able to carry out activities of daily living independently beyond 2 years. [2023]

For a short explanation of why the committee made the 2023 recommendation and how it might affect practice, see the rationale and impact section on total hip replacement versus hemiarthroplasty.

Full details of the evidence and the committee's discussion are in evidence review B: total hip replacement versus hemiarthroplasty.

1.6.5

Hospitals should aim to use a single type of cemented femoral component for hemiarthroplasties as standard treatment for displaced intracapsular hip fracture management. [2023]

1.6.6

If equivalent cemented femoral component designs are available, organisations should take into account overall costs, including training needs, and how familiar the team is with the component. [2023]

1.6.7

Record long-term data on hemiarthroplasties, including patient-reported outcomes and adverse events, for submission to a national registry. [2023]

For a short explanation of why the committee made the 2023 recommendations and how they might affect practice, see the rationale and impact section on femoral component design used for hemiarthroplasties.

Full details of the evidence and the committee's discussion are in evidence review A: femoral component design used for hemiarthroplasties.

1.6.8

Consider an anterolateral approach in favour of a posterior approach when inserting a hemiarthroplasty. [2011]

1.6.9

Use extramedullary implants such as a sliding hip screw in preference to an intramedullary nail in people with trochanteric fractures above and including the lesser trochanter (except reverse oblique). [2011, amended 2023]

1.6.10

Use an intramedullary nail to treat people with a subtrochanteric fracture. [2011]

1.7 Mobilisation strategies

1.7.1

Offer people a physiotherapy assessment and, unless medically or surgically contraindicated, mobilisation on the day after surgery. [2011]

1.7.2

Offer people mobilisation at least once a day and ensure regular physiotherapy review. [2011]

1.8 Multidisciplinary management

1.8.1

From admission, offer people 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 health, primary care and social services

  • clinical and service governance responsibility for all stages of the pathway of care and rehabilitation, including those delivered in the community. [2011]

1.8.2

If a hip fracture complicates or precipitates a terminal illness, the multidisciplinary team should still consider the role of surgery as part of a palliative care approach that:

  • minimises pain and other symptoms and

  • establishes the person's own priorities for rehabilitation and

  • considers the person's wishes about their end-of-life care. [2011]

1.8.3

Healthcare professionals should deliver care that minimises the person's risk of delirium and maximises their independence, by:

  • actively looking for cognitive impairment when people first present with hip fracture

  • reassessing people to identify delirium that may arise during their admission

  • offering individualised care in line with NICE's guideline on delirium. [2011]

1.8.4

Consider early supported discharge as part of the Hip Fracture Programme, provided the Hip Fracture Programme multidisciplinary team remains involved, and the person:

  • 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 person, carer and family. [2011]

1.8.5

Only consider intermediate care (continued rehabilitation in a community hospital or residential care unit) if all of 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. [2011]

1.8.6

People admitted from care or nursing homes should not be excluded from rehabilitation programmes in the community or hospital, or as part of an early supported discharge programme. [2011]

1.9 Patient and carer information

1.9.1

Offer patients (or, as appropriate, their carer and/or family) verbal and printed information about treatment and care including:

  • diagnosis

  • choice of anaesthesia

  • choice of analgesia and other medications

  • surgical procedures

  • possible complications

  • postoperative care

  • rehabilitation programme

  • long-term outcomes

  • healthcare professionals involved. [2011]