Updated US guideline highlights importance of early surgery and interdisciplinary care to improve outcomes in older people with hip fractures
The American Academy of Orthopaedic Surgeons has issued an update to its 2014 guideline on the management of hip fractures in older patients. Updated information for patients aged 65 and over includes:
Strong evidence supports surgery for hip fractures within 24-48 hours of admission. Recent data from high volume centers has shown better outcomes if surgery is within 24 hours, although the guideline makes a recommendation of 24-48 hours to recognise variations in resources at different centers.
Interdisciplinary care programs are recommended for the care of hip fracture patients, based on strong evidence that they can decrease mortality and complications and improve outcomes.
In an upgraded recommendation, venous thromboembolism (VTE) prophylaxis is now strongly recommended based on significant established risk factors in these patients including age, major surgery and potential delays to surgery.
Arthroplasty is strongly recommended over fixation for unstable (displaced) femoral neck fractures based on updated evidence from randomized trials that report consistently better outcomes (reoperation rate, pain scores, functional status, and/or complication rate) for arthroplasty.
A new strong recommendation for tranexamic acid in all patients with hip fracture to reduce blood loss and blood transfusion.
Multimodal analgesia incorporating preoperative nerve block is recommended to treat pain after hip fracture.
Hip fractures occur predominantly in older people. The risk increases significantly with age.
Associated most commonly with low-energy injury (e.g., fall from standing height) and osteoporosis or osteopenia.
Treatment is most commonly surgical. The choice of implant depends on the fracture pattern and the surgeon's preference.
A hip fracture is generally considered to be any fracture of the femur distal to the femoral head and proximal to a level a few centimeters below the lesser trochanter.
History and exam
Key diagnostic factors
- inability to bear weight
- pain in affected leg/hip
- pain with hip movement
Other diagnostic factors
- shortened and externally rotated leg
- age over 65 years
- low body mass index
- female sex
- high-energy trauma
1st investigations to order
- plain x-rays
Investigations to consider
- MRI pelvis
- CT pelvis
- technetium bone scan
intracapsular (femoral neck) fracture
extracapsular (intertrochanteric) fracture
Herman Johal, MD, MPH, FRCSC
Orthopaedic Trauma Surgeon
Department of Surgery
HJ declares that he has no competing interests.
Dr Herman Johal would like to gratefully acknowledge Dr Bradley A. Petrisor and Dr Mohit Bhandari, the previous contributors to this topic.
BAP and MB declare that they have no competing interests.
Marc F. Swiontkowski, MD
Department of Orthopedic Surgery
University of Minnesota
MFS is Editor-in-Chief of the Journal of Bone and Joint Surgery.
Rudolf Poolman, MD, PhD
Consultant Orthopaedic Surgeon
Onze Lieve Vrouwe Gasthuis
Teaching Hospital with The University of Amsterdam
Department of Orthopaedic Surgery
RP has been reimbursed by LINK for organizing education and research consultancy.
David Hackam, MD, PhD
Assistant Professor of Surgery
Children's Hospital of Pittsburgh
DH declares that he has no competing interests.
- Acetabular fracture
- Pubic rami fracture
- Femoral shaft or subtrochanteric femur fracture
- Management of hip fractures in older adults
- ACR appropriateness criteria: acute hip pain - suspected fracture
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