Hip Fracture (Neck of Femur)

1. Clinical Overview

Answer Card

What is it? Hip fractures are fractures of the proximal femur, classified as intracapsular (within the hip joint capsule, risk of avascular necrosis) or extracapsular (trochanteric/subtrochanteric, risk of mechanical instability). They represent the defining injury of frailty and osteoporosis.

Who gets it? Predominantly elderly patients (mean age 83 years), female:male ratio 3:1, typically following low-energy falls from standing height. [1,2]

How does it present? Classic triad: shortened, externally rotated, abducted leg with severe groin pain and inability to weight bear. Impacted fractures may allow limited walking. Occult fractures present with pain but normal initial X-rays. [3]

How is it diagnosed? AP pelvis and lateral hip X-rays (assessing Shenton's line disruption, trabecular pattern breaks). MRI is gold standard for occult fractures (100% sensitivity). [4]

How is it treated? Operative management within 36 hours (mortality benefit). Intracapsular fractures: undisplaced → cannulated screws; displaced → hemiarthroplasty or total hip replacement (THR). Extracapsular fractures: stable → dynamic hip screw (DHS); unstable/reverse obliquity → intramedullary nail. Orthogeriatric co-management is standard. [5,6,7]

What is the prognosis? 30-day mortality 7-10%, 1-year mortality 30%. The "one-third rule": one-third die, one-third lose independence, one-third regain previous function. Surgical delay > 48 hours doubles mortality. [8,9]

Summary

Hip fractures are catastrophic health events in the elderly population, with 75,000 cases annually in the UK and projected to double by 2050 due to population aging. [1,2] The anatomical location of the fracture relative to the hip joint capsule dictates the biological and mechanical risks:

Intracapsular fractures (femoral neck) disrupt the retrograde blood supply from the medial circumflex femoral artery (MCFA), creating risk of avascular necrosis (AVN) of the femoral head. The Garden classification (I-IV) stratifies displacement and AVN risk. Garden I-II (undisplaced) are typically treated with cannulated screws to preserve the native hip. Garden III-IV (displaced) require arthroplasty (hemiarthroplasty or THR) due to high AVN rates (50-100%). [10,11]

Extracapsular fractures (intertrochanteric and subtrochanteric) occur outside the capsule in the cancellous vascular bone, preserving blood supply but presenting mechanical instability. Stable patterns are treated with dynamic hip screw (DHS), while unstable fractures (reverse obliquity, subtrochanteric extension) require intramedullary (IM) nailing to resist deforming forces. [12,13]

Management follows strict protocols established by the National Hip Fracture Database (NHFD) and NICE guidelines, emphasizing the "Big 6" care standards: (1) admission to orthopaedics less than 4 hours, (2) surgery less than 36 hours, (3) orthogeriatric assessment less than 72 hours, (4) pressure ulcer prevention, (5) bone health assessment, (6) delirium/falls assessment. [5,14] Surgery within 36 hours significantly reduces mortality compared to delayed intervention. [9]

Fascia iliaca compartment block (FICB) is the gold standard for analgesia, providing opioid-sparing pain relief by blocking the femoral, obturator, and lateral femoral cutaneous nerves. [15]

The choice between hemiarthroplasty and THR for displaced intracapsular fractures is guided by NICE criteria, which identify "fit" patients (walking independently outdoors, cognitively intact, medically fit) who benefit from THR's superior functional outcomes. The HEALTH trial confirmed that THR provides better function but higher complication risk, validating selective use. [6,7]

Orthogeriatric co-management models, involving shared care between orthopaedic surgeons and geriatricians, reduce mortality, complications, and length of stay. [16] Post-operative rehabilitation emphasizes immediate mobilization (full weight-bearing day 1), prevention of medical complications (delirium, pneumonia, VTE, pressure sores), and secondary fracture prevention with bisphosphonates and calcium/vitamin D supplementation.

Key Facts

• The "Big 6" Care Standards (NHFD): [14]
  1. Admit to Orthopaedics less than 4 hours
  2. Surgery less than 36 hours (mortality benefit)
  3. Orthogeriatric Assessment less than 72 hours
  4. Pressure Ulcer prevention
  5. Bone Health Assessment (bisphosphonates)
  6. Delirium/Falls Assessment
• Mortality: 30-day mortality 7-10%, 1-year mortality 30%. Surgical delay > 48 hours doubles mortality. [8,9]
• Blood Supply: Medial circumflex femoral artery (MCFA) provides dominant retrograde supply to femoral head. Intracapsular fractures disrupt retinacular vessels → AVN. [10]
• Classification Determines Treatment:
  • Intracapsular undisplaced (Garden I-II) → Cannulated screws
  • Intracapsular displaced (Garden III-IV) → Arthroplasty
  • Extracapsular stable → DHS
  • Extracapsular unstable/reverse obliquity → IM nail
• Fascia Iliaca Block: Gold standard analgesia. 30-40ml levobupivacaine 0.25%. Blocks femoral, obturator, lateral cutaneous nerves. Opioid-sparing. [15]
• NICE Criteria for THR (vs hemiarthroplasty): (1) Walk independently outdoors with ≤1 stick, (2) Not cognitively impaired (AMT > 8/10), (3) Medically fit (ASA 1-3). [5,6]
• Tip Apex Distance (TAD): For DHS, sum of screw tip to apex distance on AP + lateral views must be less than 25mm to prevent cut-out. [17]

Clinical Pearls

"The less than 60 Rule": A displaced intracapsular fracture in a patient less than 60 years is a vascular emergency. The femoral head is salvageable if reduced and fixed within 6 hours using cannulated screws or DHS. This is the only hip fracture indication for 3 AM theatre. AVN risk increases exponentially with time. [11]

"The Occult Fracture": Elderly patient falls, has hip pain, cannot straight leg raise, but X-rays are normal. This is a fracture until proven otherwise. MRI within 24 hours (100% sensitivity). Do not mobilize. If MRI contraindicated, CT is second-line but can miss non-displaced fractures. [4]

"Tip Apex Distance (TAD)": For DHS fixation, the lag screw tip must be deep and central in the femoral head. The sum of the distance from the screw tip to the apex on AP and lateral views must be less than 25mm. TAD > 25mm = high risk of screw "cut-out" (lag screw migrating through the femoral head). [17]

"The One-Third Rule": At 1 year post-fracture: one-third die, one-third lose independence/become institutionalized, one-third regain previous function. [8]

"Bone Cement Implantation Syndrome (BCIS)": During cemented hemiarthroplasty/THR, pressurizing cement can cause fat/marrow emboli → hypotension/hypoxia/arrhythmia/cardiac arrest. Risk factors: elderly, COPD, diuretics. Mitigation: wash femoral canal, vent femur, maintain BP. Anaesthetist must be warned before cementing. [18]

"Reverse Obliquity = IM Nail": An intertrochanteric fracture with fracture line running from medial-proximal to lateral-distal (parallel to gluteus medius pull) will distract with muscle contraction. DHS would fail (medial shaft migration). Requires IM nail to buttress against medialization. [12]

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2. Epidemiology

Incidence and Demographics

• Incidence: 75,000 hip fractures annually in the UK (2020 data). Global incidence 1.6 million/year. Projected to reach 6.3 million/year by 2050 due to population aging. [1,2]
• Age: Mean age 83 years. Incidence rises exponentially with age: 0.2% at age 65, 3% at age 85. [1]
• Gender: Female:male ratio 3:1, reflecting higher osteoporosis prevalence in post-menopausal women. However, men have higher mortality at all time points. [2]
• Mechanism: 95% low-energy falls from standing height. Only 5% high-energy trauma (younger patients, pathological fractures). [3]
• Seasonality: Winter peaks due to ice, reduced daylight, and vitamin D deficiency. [1]

Fracture Distribution

• Intracapsular: 50% (femoral neck fractures)
• Intertrochanteric: 40%
• Subtrochanteric: 10%

Risk Factors

Patient Factors

1. Osteoporosis: T-score -2.5 or less on DEXA scan. Most important modifiable risk factor. 90% of hip fractures occur in osteoporotic bone. [19]
2. Advanced Age: Risk doubles every 5 years after age 50. [1]
3. Female Sex: Oestrogen deficiency accelerates bone loss post-menopause. [19]
4. Previous Fracture: History of fragility fracture increases hip fracture risk 2-fold. [19]
5. Dementia: Present in 40% of hip fracture patients. Increases fall risk and impairs rehabilitation. [2]
6. Sarcopenia: Muscle loss reduces ability to prevent/control falls. [20]
7. Malnutrition: Low BMI (less than 20), vitamin D deficiency, low calcium intake. [19]
8. Medical Comorbidities: Parkinson's disease, stroke, visual impairment, peripheral neuropathy. [2]

Medication-Related

• Polypharmacy: ≥4 medications increases fall risk. [2]
• Psychotropics: Benzodiazepines, antipsychotics, sedatives (impair balance, increase falls). [2]
• Antihypertensives: Postural hypotension. [2]
• Anticholinergics: Confusion, urinary retention. [2]
• Corticosteroids: Accelerate bone loss (secondary osteoporosis). [19]

Environmental

• Home hazards: Loose rugs, poor lighting, stairs without handrails, clutter. [20]
• Footwear: Slippers, ill-fitting shoes. [20]

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3. Pathophysiology

Anatomy and Blood Supply of the Proximal Femur

Understanding the blood supply to the femoral head is critical to hip fracture management, as it dictates AVN risk.

Arterial Supply (Retrograde Pattern)

The femoral head receives blood via a retrograde vascular network: [10]

1. Medial Circumflex Femoral Artery (MCFA): Dominant supply (60-80%). Arises from profunda femoris artery, courses posteriorly around the femoral neck, pierces the hip capsule at its base, and gives rise to retinacular arteries that ascend along the femoral neck surface beneath the synovium to reach the femoral head.

2. Lateral Circumflex Femoral Artery (LCFA): Minor supply (20-30%). Courses anteriorly, contributes to trochanteric anastomoses.

3. Artery of Ligamentum Teres: Arises from obturator/MCFA, travels through ligamentum teres to fovea of femoral head. Significant in children but minimal/absent in adults (atrophies with age).

Critical Anatomical Relationships

• Hip Joint Capsule: Attaches anteriorly at the intertrochanteric line and posteriorly approximately halfway along the femoral neck. This attachment defines the intracapsular vs extracapsular distinction.
• Retinacular Arteries: Run along the neck surface within the capsule. Intracapsular fractures tear these vessels → ischaemia → AVN.
• Cancellous vs Cortical Bone: The femoral neck is cortical with limited intrinsic vascularity. The trochanteric region is cancellous with rich vascular supply → low AVN risk but high mechanical instability.

Fracture Biomechanics

Intracapsular Fractures: Vascular Injury

When a fracture line crosses the femoral neck within the capsule, it disrupts the retinacular arteries. The femoral head becomes avascular. The Garden classification predicts AVN risk based on displacement: [11]

• Garden I (incomplete, impacted in valgus): Vessels partially intact, less than 10% AVN risk
• Garden II (complete but undisplaced): Vessels stretched but intact, 10-20% AVN risk
• Garden III (complete, partially displaced): Vessels torn, 50% AVN risk
• Garden IV (complete, fully displaced): Vessels completely disrupted, ~100% AVN risk

Garden I-II are grouped as "undisplaced" (fixation), Garden III-IV as "displaced" (replacement).

Extracapsular Fractures: Mechanical Instability

Intertrochanteric and subtrochanteric fractures occur in cancellous bone outside the capsule, preserving the retinacular vessels. However, they face significant mechanical challenges: [12,13]

1. Deforming Forces:

   • Psoas muscle (attaches to lesser trochanter): Pulls proximal fragment into flexion and external rotation
   • Abductors (gluteus medius/minimus, attach to greater trochanter): Pull into abduction
   • Adductors: Pull distal fragment into varus and shortening

2. Fracture Stability:

   • Stable: Intact posteromedial cortex (calcar buttress) resists compressive forces → DHS
   • Unstable: Comminuted medial cortex, reverse obliquity, subtrochanteric extension → IM nail required

3. Reverse Obliquity: Fracture line runs from medial-proximal to lateral-distal (parallel to abductor pull). Muscle contraction distracts the fracture → DHS fails → IM nail mandatory. [12]

Classification Systems

Intracapsular Fractures

Garden Classification (Most Widely Used)

Predicts vascular disruption and guides treatment: [11]

• Garden I: Incomplete fracture, impacted in valgus (superior cortex intact, inferior cortex buckled). Stable. AVN risk less than 10%.
• Garden II: Complete fracture, undisplaced (trabeculae aligned across fracture). Stable. AVN risk 10-20%.
• Garden III: Complete, partially displaced (trabeculae not aligned, femoral head tilted into varus). Unstable. AVN risk 50%.
• Garden IV: Complete, fully displaced (no trabecular continuity, femoral head "floating"). Unstable. AVN risk ~100%.

Clinical Simplification: Garden I-II = undisplaced (fix with screws), Garden III-IV = displaced (replace with arthroplasty).

Pauwels Classification

Used in young patients to predict shear forces and guide fixation choice: [11]

• Type I: Fracture angle less than 30° from horizontal (compressive forces dominate) → cannulated screws
• Type II: Fracture angle 30-50° → cannulated screws or DHS
• Type III: Fracture angle > 50° from horizontal (vertical, high shear forces) → DHS or fixed-angle device required (screws alone will fail)

Extracapsular Fractures

Intertrochanteric Fractures

• Stable: 2-part fracture with intact posteromedial cortex (calcar). Treated with DHS.
• Unstable: 3+ part fractures with:
  • Comminuted posteromedial cortex
  • Reverse obliquity
  • Subtrochanteric extension
  • Greater trochanter avulsion Treated with IM nail.

Subtrochanteric Fractures

Occur within 5cm distal to lesser trochanter. High cortical stress area with slow healing. Always unstable. Require long IM nail. [13]

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4. Clinical Presentation

Typical Presentation

History

• Fall: Usually from standing height (low-energy). Patient found on floor unable to get up.
• Pain: Severe groin pain (intracapsular) or lateral hip pain (trochanteric). Radiates to knee via obturator nerve (always examine the hip in a patient presenting with knee pain).
• Inability to Weight Bear: Cannot stand or walk. Paramedics bring patient in supine.
• Previous Falls: 50% have history of previous falls. [2]
• Functional Status: Document pre-fracture mobility (walks independently? stick? frame? wheelchair?), cognitive function (dementia?), and social situation (lives alone? carer support?).

Examination

Inspection

• Classic Deformity (displaced fractures): The leg is shortened, externally rotated (ER), and abducted.
  • Shortening: Caused by pull of psoas, rectus femoris, and hamstrings on distal fragment (fracture "unlocks" the femur, allowing muscular contraction to override).
  • External Rotation: Psoas attaches to lesser trochanter and acts as external rotator when neck is broken (lever arm changes). Gravity also contributes in supine position. Typically 45-90° ER.
  • Abduction: Gluteus medius/minimus pull.
• Impacted Fractures: May have no visible deformity. Leg may appear normal length and alignment. Patient might even walk in (limping). High index of suspicion required.

Palpation

• Tenderness: Over greater trochanter (extracapsular) or groin (intracapsular).
• Leg Length: Measure from anterior superior iliac spine (ASIS) to medial malleolus. Compare sides.

Movement

• Active Movement:
  • Straight Leg Raise (SLR): Cannot lift heel off bed (pathognomonic). Pain at fracture site acts as fulcrum.
  • Hip Flexion: Painful and limited.
• Passive Movement:
  • Log Roll: Roll the leg gently side-to-side (internal and external rotation). This is the most sensitive test for hip pathology. Pain indicates fracture even if X-rays are normal. [3]

Neurovascular Status

• Pulses: Femoral, popliteal, dorsalis pedis, posterior tibial (document for medicolegal purposes).
• Sensation: Femoral nerve (anterior thigh), sciatic nerve (foot).
• Motor: Ankle dorsiflexion (common peroneal), plantar flexion (tibial).

Atypical Presentations

Occult (Radiographically Negative) Fractures

• Clinical Features: Elderly patient, fall, groin pain, cannot straight leg raise, but initial X-rays are normal. [4]
• Mechanism: Non-displaced intracapsular fracture (Garden I-II) or impacted fracture not visible on plain radiographs.
• Management: Do not mobilize. MRI within 24 hours (100% sensitivity, can detect bone marrow oedema indicating fracture). If MRI contraindicated (pacemaker), CT is second-line but can miss non-displaced fractures. [4]
• Risk: Mobilizing a patient with an occult fracture can cause displacement → convert Garden I to Garden IV → require arthroplasty instead of screws.

Pathological Fractures

• Suspect if: Young patient (less than 60), minimal trauma, previous cancer history, systemic symptoms (weight loss, night pain), or abnormal bone on X-ray (lytic lesion, cortical destruction). [3]
• Common Primaries: Breast, lung, kidney, thyroid, prostate (mnemonic: BLT with Ketchup and Pickle).
• Workup: CT chest/abdomen/pelvis, bone profile (calcium, ALP), PSA (men), myeloma screen (SPEP, UPEP, serum free light chains). [3]
• Management: May require oncological workup before surgery. Fixation often involves long IM nail or proximal femoral replacement.

Bilateral Fractures

• Rare (1-2% of cases). High-energy trauma or severe osteoporosis. Examine both hips. [3]

Associated Injuries

• Wrist Fracture (Colles'): Patient fell on outstretched hand (FOOSH). Examine wrists.
• Head Injury: Syncope/stroke as cause of fall. Check GCS, pupils, scalp lacerations.
• Rib Fractures: Direct trauma during fall.

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5. Investigations

Imaging

X-Ray (First-Line)

• Views: AP pelvis + lateral hip of affected side. Consider AP hip if pelvis rotation is suboptimal.
• Radiological Signs:
  • Shenton's Line: Continuous arc drawn along inferior femoral neck and superior pubic ramus. Disruption indicates displacement.
  • Trabecular Pattern: Look for breaks in tension (superior neck) and compression (inferior neck) trabeculae.
  • Cortical Breaks: Obvious fracture lines.
  • Displacement: Garden III-IV show varus angulation and posterior displacement of femoral head.
• Normal X-Rays + High Suspicion: Proceed to MRI (occult fracture). [4]

MRI (Gold Standard for Occult Fractures)

• Sensitivity: 100% for occult hip fractures. [4]
• Sequences: T1 (shows fracture line), STIR/T2 (shows bone marrow oedema indicating recent injury).
• Timing: Should be performed within 24 hours in suspected occult fracture.
• Advantages: Can also identify other causes of hip pain (AVN, stress fracture, bone marrow oedema, soft tissue injury).

CT (Second-Line)

• Indications: MRI contraindicated (pacemaker, metallic foreign body), MRI unavailable, pre-operative planning for complex fractures.
• Limitations: Can miss non-displaced intracapsular fractures (less sensitive than MRI). Better for cortical detail in extracapsular fractures.

Bone Scan (Rarely Used)

• Indication: If MRI/CT unavailable and X-ray negative. Increased uptake at fracture site.
• Timing: Requires 48-72 hours post-injury for uptake to become visible (delayed diagnosis).

Pre-Operative Workup (The "Golden Hour")

Blood Tests

• Full Blood Count (FBC):
  • Haemoglobin: Chronic anaemia common in elderly (Fe deficiency, chronic disease). Transfusion threshold less than 80 g/L with symptoms or cardiovascular disease. [5]
  • WCC: Infection screen.
• Urea & Electrolytes (U&E):
  • AKI common (dehydration from lying on floor for hours, "long lie").
  • Baseline renal function for peri-operative fluid management.
• Coagulation Screen:
  • INR (warfarin), APTT (heparin).
  • DOACs: No routine test, but check renal function (affects drug clearance).
• Group & Save: 2 units cross-matched if high bleeding risk (THR, revision surgery).
• Bone Profile:
  • Calcium, phosphate, ALP (osteomalacia? Paget's disease?).
  • Vitamin D (25-OH vitamin D): Deficiency common in elderly. Supplementation reduces future fracture risk. [19]
• HbA1c: Diabetes control (infection risk).
• Troponin: If chest pain/ECG changes (MI precipitating fall?).

ECG

• Atrial fibrillation (common cause of embolic stroke → syncope → fall). [2]
• Ischaemia (MI).
• Prolonged QTc (risk of arrhythmia).
• Pacemaker check.

Chest X-Ray

• Pneumonia (aspiration during "long lie").
• Heart failure (pulmonary oedema).
• Metastatic disease (lung cancer, mets).
• Pre-operative baseline.

Urine Dipstick

• UTI screening (common cause of delirium).
• Do not catheterize routinely (increases UTI risk). Only catheterize if urinary retention or strict fluid balance monitoring required. [5]

Additional Investigations (Selected Cases)

Echocardiography

• Severe aortic stenosis (loud ejection systolic murmur, syncope as presenting feature).
• Severe heart failure (assess LV function).

DEXA Scan (Post-Operative)

• Confirm osteoporosis (hip fracture is fragility fracture → osteoporosis by definition).
• Guide bisphosphonate therapy.
• Can be arranged post-discharge (not urgent). [19]

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6. Management

Initial Management (Emergency Department / Admission Ward)

Analgesia

• Fascia Iliaca Compartment Block (FICB): Gold standard. [15]
  • Mechanism: Local anaesthetic injected into fascia iliaca compartment blocks femoral nerve, obturator nerve, and lateral femoral cutaneous nerve.
  • Technique: Identify ASIS and pubic tubercle. Inject 2cm below junction of lateral 1/3 and medial 2/3 of line joining ASIS and pubic tubercle. Two "pops" felt (fascia lata, then fascia iliaca). Inject 30-40ml levobupivacaine 0.25%.
  • Benefits: Superior pain relief compared to opioids, opioid-sparing (reduces delirium/confusion/nausea), safe in ward setting (no spinal haematoma risk like neuraxial blocks in anticoagulated patients), lasts 8-12 hours. [15]
• Systemic Analgesia:
  • Paracetamol 1g QDS (regular)
  • Oxycodone 5-10mg PRN (avoid long-acting opioids → delirium)
  • Avoid NSAIDs (AKI risk, bleeding risk, gastric ulcers in elderly) [5]

Fluid Resuscitation

• Many patients have "long lie" (hours on floor) → dehydration, AKI.
• IV crystalloid (Hartmann's or 0.9% saline). Target urine output > 0.5ml/kg/hr.
• Avoid fluid overload (heart failure risk).

Anticoagulation Management

• Warfarin: If INR > 1.5, reverse with Prothrombin Complex Concentrate (PCC) (Beriplex, Octaplex) + Vitamin K 5mg IV. Target INR less than 1.5 for surgery. [5]
• DOACs: Stop. Surgery ideally delayed 48 hours (5 half-lives). If urgent, consider Idarucizumab (dabigatran reversal) or Andexanet alfa (apixaban/rivaroxaban reversal).
• LMWH: Stop 24 hours pre-op. Check anti-Xa levels if renal impairment.

VTE Prophylaxis

• Mechanical: TED stockings (contraindicated if peripheral arterial disease), intermittent pneumatic compression devices.
• Chemical: LMWH (enoxaparin 40mg SC OD) or DOAC (rivaroxaban 10mg OD). Start post-operatively (bleeding risk). Continue 28-35 days. [5]

Pressure Ulcer Prevention

• Waterlow Score: Assess risk.
• Interventions: Pressure-relieving mattress (air mattress), 2-hourly turns, protect heels (foam pads, offloading boots), optimize nutrition.

Nutrition

• Many elderly patients are malnourished (low BMI, low albumin).
• Dietitian referral. High-protein diet. Oral nutritional supplements (Ensure, Fortisip). [20]

Surgical Management

Timing

• Target: Surgery within 36 hours of presentation (NICE/NHFD standard). [5,14]
• Evidence: Surgery within 36 hours reduces 30-day mortality compared to delay > 48 hours (8% vs 16%). [9]
• Exception: Young patient (less than 60) with displaced intracapsular fracture → urgent reduction and fixation within 6 hours to salvage femoral head blood supply. [11]

Pre-Operative Optimization

• Anaesthetic Review: ASA grade, cardiac/respiratory risk, anticoagulation status.
• Medical Optimization: Treat reversible conditions (heart failure, AF, pneumonia, AKI), but do not delay surgery excessively for minor issues (mortality risk of delay > risk of minor medical issues). [5]

Surgical Options: Decision Algorithm

                HIP FRACTURE (NOF)
                        ↓
               FRACTURE LOCATION?
              ┌──────────┴──────────┐
        INTRACAPSULAR           EXTRACAPSULAR
      (Vascular Risk)          (Mechanical Risk)
             ↓                        ↓
       DISPLACEMENT?            FRACTURE PATTERN?
       ┌─────┴─────┐           ┌──────┴──────┐
   UNDISPLACED  DISPLACED   INTERTROCH    SUBTROCH
 (Garden I/II) (Garden III-IV)    ↓          ↓
       ↓           ↓           STABLE?      IM NAIL
    FIXATION      AGE?       ┌────┴────┐  (LONG)
  (Cannulated      ↓       YES         NO
    Screws)       less than 60     (2-Part)  (Reverse Oblq,
                URGENT    Intact    Comminuted
              FIXATION   Medial    Medial Cortex,
             (DHS/Screw) Cortex)  Subtroch Ext)
                   ↓         ↓          ↓
                  > 60       DHS      IM NAIL
             FIT FOR THR?          (SHORT/LONG)
             (NICE CRITERIA)
             ┌─────┴─────┐
            YES          NO
             ↓           ↓
            THR         HEMI
    (Better function, (Lower risk,
     higher complx)   shorter op)

A. Intracapsular Undisplaced (Garden I-II): Cannulated Screws

Indication

• Garden I or II (undisplaced intracapsular) fractures in any age group. [11]

Rationale

• Preserve native hip (best long-term option if successful).
• Minimal surgical insult (percutaneous).
• AVN risk low (10-20%).

Technique

• Closed or open reduction (if needed).
• Insert 2 or 3 cannulated screws (7.3mm or 6.5mm) percutaneously under image intensifier guidance.
• Screw configuration: Inverted triangle or parallel (both acceptable).
• Screws must achieve:
  • Purchase: Threads in femoral head subchondral bone (best purchase).
  • Parallel: Screws should be parallel to femoral neck axis (resist shear).
  • Spread: Maximize spread within femoral head (triangular configuration resists rotation).

Post-Operative

• Mobilization: Full weight-bearing as tolerated (WBAT) immediately.
• Failure Rate: 10-20% (AVN, non-union, fixation failure). If failure occurs, convert to arthroplasty. [11]

B. Intracapsular Displaced (Garden III-IV), Age less than 60: Urgent Fixation

Indication

• Displaced intracapsular fracture in young patient (less than 60 years). [11]

Rationale

• Young patients have good bone quality and high functional demand.
• Arthroplasty has finite lifespan (15-20 years) → young patients will outlive the implant → require revision surgery.
• Salvage femoral head if possible: Emergency reduction and fixation within 6 hours gives best chance of preserving blood supply and avoiding AVN.

Technique

• Emergency closed reduction (under GA/spinal): Leadbetter maneuver (traction, internal rotation, extension).
• Fixation: Cannulated screws or DHS (if Pauwels Type III with vertical fracture line → high shear forces).
• Alternative: If reduction fails or fracture is highly unstable, consider valgus osteotomy (realign fracture to compressive angle) or proceed to arthroplasty.

Post-Operative

• Close monitoring for AVN (serial X-rays, MRI if pain).
• If AVN develops, convert to THR.

C. Intracapsular Displaced (Garden III-IV), Age > 60: Arthroplasty

Rationale

• Displaced intracapsular fractures have very high AVN rate (50-100%). [10,11]
• Fixation has high failure rate in elderly osteoporotic bone.
• Arthroplasty provides definitive treatment, immediate pain relief, and early mobilization.

Choice: Hemiarthroplasty vs Total Hip Replacement (THR)

Hemiarthroplasty (Half-Hip)

Indication: Displaced intracapsular in frail/low-demand elderly patients who do not meet NICE THR criteria. [5,6]

Technique:

• Remove femoral head.
• Insert femoral stem (unipolar or bipolar head).
• Leave native acetabulum.

Stem Type:

• Cemented (PMMA bone cement) vs Uncemented (press-fit).
• Evidence (WHiTE 5 Trial): Cemented hemis superior to uncemented (better mobility, less pain, lower revision rate) in elderly osteoporotic bone. [7]

Head Type:

• Unipolar: Single articulation (head-acetabulum). Cheaper, simpler.
• Bipolar: Two articulations (inner bearing within outer head). Theoretical advantage of reduced acetabular wear, but no proven clinical benefit.

Complications:

• Acetabular Erosion ("acetabularitus"): Over time, metal head wears native cartilage → groin pain → conversion to THR.
• Dislocation: 1-3%. [6]

Total Hip Replacement (THR)

Indication: Displaced intracapsular in fit elderly patients who meet NICE criteria (all 3 must be met): [5,6]

1. Walk independently outdoors with no more than 1 stick
2. Not cognitively impaired (AMT > 8/10, able to engage with rehabilitation)
3. Medically fit for anaesthesia (ASA 1-3)

Technique:

• Remove femoral head.
• Ream acetabulum and insert acetabular cup (cemented or uncemented).
• Insert femoral stem.

Evidence (HEALTH Trial 2019): [6]

• Question: THR vs Hemi for displaced intracapsular fractures?
• Result: THR had small but significant functional benefit (better Harris Hip Score, less pain, lower re-operation rate) but higher complication risk (dislocation 3-5%, infection, longer operative time).
• Conclusion: Selective use of THR for fit patients (NICE criteria) is appropriate. Not "THR for everyone".

Complications:

• Dislocation: 3-5% (vs 1-3% for hemi). Risk factors: posterior approach, cognitive impairment (cannot follow precautions), previous hip surgery. [6]
• Infection: Deep infection 1-2%. Requires prolonged antibiotics ± revision surgery.
• Leg Length Discrepancy: Patient feels leg too long/short. Usually adapts.

Surgical Approaches (Hemi and THR)

Posterior Approach (Moore/Southern)

• Splits: Gluteus maximus. Detaches short external rotators (piriformis, obturators, gemelli).
• Pros: Excellent visualization of acetabulum and femur. Spares abductors (no post-op limp).
• Cons: Higher posterior dislocation rate (7-10% if capsule/rotators not repaired meticulously, 2-3% if repaired). [6]
• Precautions: No hip flexion > 90°, no adduction across midline, no internal rotation (risk posterior dislocation).

Anterolateral Approach (Hardinge)

• Splits: Gluteus medius (abductor muscle).
• Pros: Lower dislocation rate (anterior/lateral capsule remains intact).
• Cons: Post-operative limp (Trendelenburg gait) due to abductor damage (10-15%). [6]
• Preferred for: Confused/demented patients who cannot follow dislocation precautions.

D. Extracapsular Stable Intertrochanteric: Dynamic Hip Screw (DHS)

Indication

• Stable intertrochanteric fractures (intact posteromedial cortex, 2-part pattern). [12]

Rationale

• DHS allows controlled collapse of the fracture as patient weight-bears, compressing the fracture surfaces together → promotes healing.
• Gold standard for stable trochanteric fractures.

Technique

• Lateral incision over greater trochanter.
• Insert lag screw through lateral cortex into femoral head (screw threads engage head, smooth shank crosses fracture to allow sliding).
• Attach side-plate to lateral femoral shaft (barrel allows lag screw to slide/collapse).

Key Surgical Principles

• Tip Apex Distance (TAD): Sum of distance from lag screw tip to apex of femoral head on AP + lateral views. Must be less than 25mm. TAD > 25mm = high risk of "cut-out" (screw migrates superiorly through head). [17]
• Screw Position: Centre-centre or centre-inferior in femoral head (best purchase).
• Reduction: Anatomical reduction (restore medial cortex continuity, correct varus).

Post-Operative

• Mobilization: Full weight-bearing immediately.
• Fracture Healing: Controlled collapse 5-10mm expected over 6-12 weeks.
• Complications: Cut-out (2-5%), non-union (less than 1%), infection (1%). [17]

E. Extracapsular Unstable: Intramedullary (IM) Nail

Indications

• Unstable intertrochanteric fractures: [12,13]
  • Comminuted posteromedial cortex
  • Reverse obliquity (fracture line medial-proximal to lateral-distal)
  • Subtrochanteric extension
  • Greater trochanter avulsion
• Subtrochanteric fractures: All subtrochanteric fractures (within 5cm distal to lesser trochanter).

Rationale

• IM nail sits in intramedullary canal (central load axis) → shorter lever arm → reduced bending moment → resists deforming forces better than DHS.
• Prevents excessive collapse/medialization in unstable fractures.
• Locked distally to prevent rotation.

Types

• Short IM Nail: Intertrochanteric fractures (e.g., Gamma nail, PFNA - Proximal Femoral Nail Antirotation).
• Long IM Nail: Subtrochanteric fractures or combined intertrochanteric-subtrochanteric patterns.

Technique

• Insert nail through piriformis fossa or greater trochanter (entry point varies by nail design).
• Lag screw or helical blade inserted into femoral head through nail.
• Distal locking screws to prevent rotation.

Post-Operative

• Mobilization: Full weight-bearing immediately.
• Complications: Femoral shaft fracture (intra-operative or peri-implant), cut-out (1-3%), malrotation, heterotopic ossification. [12,13]

F. Subtrochanteric Fractures: Long IM Nail

Rationale

• Subtrochanteric region is high-stress cortical bone with limited vascularity → slow healing, high non-union rate.
• Long IM nail provides load-sharing and stability across entire proximal-mid femur. [13]

Technique

• Long cephalomedullary nail (e.g., Long Gamma, Long PFNA).
• Reduction can be challenging (deforming muscle forces). May require open reduction or femoral distractor.

Post-Operative

• Full weight-bearing if stable fixation.
• Healing 3-6 months (slower than intertrochanteric).

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7. Complications

Medical Complications ("The Killers")

Delirium

• Incidence: 40-60% of hip fracture patients. [2]
• Risk Factors: Pre-existing dementia, advanced age, pain, infection, medications (opioids, anticholinergics), constipation, urinary retention, electrolyte imbalance.
• Types: Hyperactive (agitation), hypoactive (withdrawn, "quiet" delirium - often missed), mixed.
• Prevention: Avoid restraints, minimize opioids (use FICB), orientation (clocks, calendars, family presence), treat precipitants.
• Management: Identify and treat underlying cause (pain, infection, constipation). Avoid antipsychotics unless severe agitation (risk of stroke/death in elderly). [5]

Pneumonia

• Incidence: 5-10%. [8]
• Risk: Immobility, aspiration (reduced GCS, stroke, sedation), atelectasis, pre-existing COPD.
• Prevention: Early mobilization, incentive spirometry, chest physiotherapy, sitting upright.
• Treatment: Antibiotics (community-acquired pneumonia protocol).

Venous Thromboembolism (VTE)

• Incidence: 2-5% (DVT/PE). [8]
• Risk: Immobility, surgery, trauma, elderly, cancer.
• Prophylaxis: LMWH or DOAC for 28-35 days post-operatively (extended prophylaxis reduces VTE). TED stockings. Intermittent pneumatic compression. [5]
• Treatment: Therapeutic anticoagulation (LMWH, DOAC, or warfarin).

Urinary Retention

• Incidence: 20-30% (pain, opioids, anticholinergics, prostatic hypertrophy in men). [8]
• Management: Catheterize if needed (bladder scan > 600ml). Remove catheter ASAP (trial without catheter day 2). Prolonged catheterization increases UTI and delirium risk. [5]

Pressure Ulcers

• Incidence: 5-15% (Waterlow score > 20 = very high risk). [20]
• Sites: Sacrum, heels (most common).
• Prevention: Pressure-relieving mattress, 2-hourly turns, protect heels (offloading boots, foam pads), optimize nutrition (protein, vitamin C).
• Treatment: Wound care, debridement if necrotic, plastic surgery referral for large ulcers (flap coverage).

Acute Kidney Injury (AKI)

• Incidence: 15-20% ("long lie" → rhabdomyolysis, dehydration). [2]
• Prevention: IV fluids, avoid nephrotoxins (NSAIDs, gentamicin).
• Treatment: Treat underlying cause, fluid balance, renal team referral if severe.

Myocardial Infarction (MI) / Stroke

• Incidence: 2-5%. [8]
• Risk: Elderly, cardiovascular comorbidities, surgical stress.
• Prevention: Continue cardiac medications peri-operatively (beta-blockers, statins, antiplatelets).

Death

• 30-Day Mortality: 7-10%. [8,9]
• 1-Year Mortality: 30% ("one-third die"). [8]
• Predictors: Advanced age (> 85), male sex, pre-existing comorbidities (dementia, heart failure, CKD), surgical delay > 48 hours, ASA ≥4, post-op complications (pneumonia, MI, delirium). [9]

Surgical Complications

Infection

Superficial Wound Infection

• Incidence: 2-5%. [6]
• Management: Oral antibiotics (flucloxacillin). Wound swab.

Deep Prosthetic Joint Infection (PJI)

• Incidence: 1-2% (hemi/THR). [6]
• Presentation: Pain, fever, wound discharge, prosthesis loosening.
• Diagnosis: Raised CRP/ESR, joint aspiration (synovial WCC > 3000, positive culture).
• Management:
  • Early (less than 3 weeks): DAIR (Debridement, Antibiotics, Implant Retention).
  • Late (> 3 weeks): Two-stage revision (remove prosthesis, cement spacer with antibiotics, 6 weeks IV antibiotics, re-implant new prosthesis).
  • Salvage: Girdlestone procedure (excision arthroplasty → permanent pseudarthrosis → shortened leg, limp, but pain-free).

Dislocation

• Incidence: Hemi 1-3%, THR 3-5%. [6]
• Direction: Posterior (most common with posterior approach - hip flexion + adduction + internal rotation).
• Presentation: Sudden severe pain, leg shortened and internally rotated (posterior) or lengthened and externally rotated (anterior).
• Diagnosis: X-ray (femoral head out of acetabulum).
• Management:
  • First dislocation: Closed reduction under sedation (propofol). Check stability. Hip precautions education. Abduction brace for 6 weeks.
  • Recurrent dislocation (≥2): Revision surgery (change head size, constrained liner, revise acetabular cup orientation) or convert hemi to THR.

Leg Length Discrepancy

• Incidence: 10-20% (patient perception). [6]
• Cause: Femoral stem size, offset restoration, contractures.
• Management: Most patients adapt over 3-6 months. If symptomatic, shoe raise. Rarely requires revision.

Implant Failure

Cut-Out (DHS/IM Nail)

• Incidence: 2-5%. [17]
• Mechanism: Lag screw migrates superiorly through femoral head (poor screw position, TAD > 25mm, osteoporotic bone, patient non-compliance with weight-bearing restrictions).
• Presentation: Groin pain, screw protrusion into hip joint.
• Management: Revision surgery (remove DHS, convert to hemiarthroplasty or THR).

Non-Union

• Incidence: less than 5% (extracapsular), 10-20% (intracapsular treated with screws). [11]
• Risk Factors: Poor reduction, inadequate fixation, smoking, diabetes, malnutrition.
• Management: Revision fixation (valgus osteotomy, bone graft) or convert to arthroplasty.

Bone Cement Implantation Syndrome (BCIS)

• Incidence: 1-7% (cemented hemi/THR). [18]
• Mechanism: Pressurizing bone cement in femoral canal → fat/marrow embolism → showered to lungs → hypoxia, hypotension, arrhythmia, cardiac arrest.
• Timing: During cementing or prosthesis insertion.
• Risk Factors: Elderly, COPD, diuretics (hypovolemia), ASA ≥4.
• Prevention:
  • Wash femoral canal (pulsatile lavage to remove marrow).
  • Vent femur (drill hole distally to allow pressure release).
  • Maintain intravascular volume (anaesthetist pre-load with fluids).
  • Warn anaesthetist before cementing ("cement going in now").
• Management: Supportive (100% O2, IV fluids, vasopressors, CPR if arrest). [18]

Peri-Prosthetic Fracture

• Incidence: 1-5% (intra-operative or post-operative). [6]
• Risk: Osteoporotic bone, uncemented stems (press-fit can fracture cortex), revision surgery.
• Management: Depends on location and stability. May require cerclage wires, revision stem, or IM nail.

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8. Prognosis and Outcomes

Mortality

• 30-Day Mortality: 7-10%. [8,9]
• 1-Year Mortality: 30%. [8]
• 5-Year Mortality: 50-60% (similar to many cancers). [8]

Predictors of Mortality

• Advanced age (> 85 years)
• Male sex (men have higher mortality than women at all time points)
• Pre-existing comorbidities (dementia, heart failure, COPD, CKD)
• ASA grade ≥4
• Surgical delay > 48 hours (mortality doubles)
• Post-operative complications (pneumonia, MI, sepsis)
• Low pre-fracture mobility (non-ambulatory)
• Pathological fracture [8,9]

Functional Outcomes: The "One-Third Rule"

At 1 year post-fracture: [8]

• One-third die (30% mortality)
• One-third lose independence (institutionalized, require carer, lose ability to walk)
• One-third regain previous function (return to pre-fracture mobility and activities)

Predictors of Poor Functional Outcome

• Pre-existing dementia (40% of patients)
• Low pre-fracture mobility
• Post-operative complications (delirium, infection)
• Inadequate rehabilitation
• Lack of social support
• Depression [2,20]

Secondary Fracture Risk

• Second Hip Fracture: 5-10% will fracture contralateral hip within 1 year. [19]
• Vertebral Fracture: Increased risk (shared osteoporosis pathology).
• Prevention: Bisphosphonates (alendronic acid 70mg weekly) + Calcium/Vitamin D supplementation reduce future fracture risk by 20-30%. Falls assessment and home modifications. [19]

Quality of Life

• Significant reduction in health-related quality of life (HRQoL) scores.
• Chronic pain (10-20%).
• Fear of falling (limits activity).
• Loss of confidence and independence. [20]

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9. Rehabilitation and Orthogeriatric Co-Management

Orthogeriatric Model

Definition: Shared care between orthopaedic surgeons and geriatricians, with daily ward rounds and collaborative decision-making. [16]

Evidence: Orthogeriatric co-management reduces:

• 30-day mortality (7% vs 10%)
• Length of stay (12 vs 16 days)
• Time to surgery
• Medical complications (delirium, pneumonia)
• Re-admission rates [16]

Key Components:

• Geriatrician-led assessment within 72 hours
• Daily MDT ward rounds (orthopaedics, geriatrics, physiotherapy, occupational therapy, pharmacy, nursing)
• Proactive management of medical comorbidities
• Medication review (reduce polypharmacy, stop inappropriate drugs)
• Bone health assessment and treatment
• Falls and fracture prevention
• Discharge planning

Rehabilitation Timeline

Day 0 (Admission Day)

• Analgesia: Fascia iliaca block (FICB). Paracetamol regular. Minimize opioids.
• Fluid Resuscitation: IV crystalloid (Hartmann's). Target urine output > 0.5ml/kg/hr.
• Pre-Op Workup: Bloods (FBC, U&E, coag, G&S, bone profile), ECG, CXR.
• Pressure Ulcer Prevention: Waterlow score, air mattress, heel protection.
• VTE Prophylaxis: TED stockings (if no PVD), mechanical compression.
• Anticoagulation Management: Reverse warfarin if needed (PCC + Vit K).
• Catheter: Avoid unless retention. If inserted, remove ASAP.
• NBM Status: 6 hours for solids, 2 hours for clear fluids (anaesthetic guidelines).

Day 1 (Post-Operative Day)

• Mobilization: Out of bed to chair. Physiotherapy assessment. Full weight-bearing as tolerated (WBAT) (applies to all hip fracture fixation/replacement - implants are designed for immediate weight-bearing).
• Analgesia: Continue paracetamol. FICB may last 8-12 hours. PRN oxycodone.
• Bloods: FBC (check Hb). Transfusion if Hb less than 80 g/L with symptoms (chest pain, dyspnoea) or cardiovascular disease. [5]
• CXR: Post-operative check (pneumothorax? pulmonary oedema?).
• VTE Prophylaxis: Start chemical (LMWH or DOAC) if haemostasis achieved.
• Catheter: Trial without catheter (TWOC) if inserted.

Days 2-5

• Physiotherapy: Progress mobilization. Walking with frame/crutches/stick. Stairs assessment.
• Occupational Therapy (OT): ADL assessment (washing, dressing, toileting). Home visit if needed (assess for hazards, need for equipment - raised toilet seat, perching stool, grab rails).
• Bone Protection: Start bisphosphonate (alendronic acid 70mg weekly) + Calcium/Vitamin D (e.g., Adcal-D3 2 tablets daily). [19]
• Falls Assessment: Identify intrinsic (vision, balance, medications) and extrinsic (home environment) risk factors.
• Cognitive Assessment: If delirium/dementia suspected, perform AMT or MoCA. Referral to memory clinic if needed.
• Nutrition: Dietitian review. High-protein diet. Oral supplements if malnourished.

Discharge (Day 5-10)

• Criteria:
  • Medically stable
  • Pain controlled on oral analgesia
  • Safe mobility (transfer, walk with aid)
  • Safe home environment (OT assessed)
  • Social package of care in place (carers, meals on wheels, district nurse)
• Discharge Destination:
  • Home (60-70%): With or without care package
  • Intermediate care / community hospital (20-30%): Further rehabilitation before home
  • Nursing home (10%): If pre-fracture residence or new severe disability
• Discharge Medications:
  • VTE prophylaxis (LMWH/DOAC) for 28 days total
  • Bisphosphonate (alendronic acid 70mg weekly)
  • Calcium/Vitamin D (Adcal-D3 BD)
  • Analgesia (paracetamol regular, opioid PRN short course)
• Follow-Up:
  • Orthopaedic clinic 6 weeks (X-ray, wound check, assess healing)
  • GP follow-up 2 weeks (medication review, social support)
  • Fracture liaison service (bone health, falls prevention)

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10. Evidence and Guidelines

NICE Guideline CG124: Hip Fracture Management (2011, Updated 2023)

Key Recommendations: [5]

1. Timing: Surgery on day of or day after admission (within 36 hours).
2. Analgesia: Offer nerve blocks (fascia iliaca or femoral nerve block) to all patients on admission. Paracetamol regular. Avoid NSAIDs.
3. Surgery:
   • Intracapsular undisplaced: Cannulated screws
   • Intracapsular displaced: Hemiarthroplasty (cemented) or THR (if fit)
   • Extracapsular: DHS (stable) or IM nail (unstable)
4. Arthroplasty Type: Cemented prostheses preferred over uncemented.
5. THR Criteria (all must be met):
   • Walk independently outdoors with ≤1 stick
   • Not cognitively impaired
   • Medically fit (ASA 1-3)
6. MDT Care: Orthogeriatric involvement. Early mobilization. VTE prophylaxis 28-35 days.
7. Bone Health: Assess and treat osteoporosis (bisphosphonates + Ca/Vit D).

National Hip Fracture Database (NHFD) Annual Report 2023

UK Audit Standards ("Best Practice Tariff"): [14]

• Admission to orthopaedic ward less than 4 hours: Target > 90%
• Surgery less than 36 hours: Target > 85%
• Orthogeriatric assessment less than 72 hours: Target > 90%
• Pressure ulcer assessment: Target 100%
• Bone health assessment: Target > 95%
• Falls assessment: Target > 95%

2023 UK Performance:

• 30-day mortality: 6.7%
• Surgery less than 36 hours: 77% (improving but below target)
• Orthogeriatric input: 94%

Landmark Trials

HEALTH Trial (2019): THR vs Hemiarthroplasty

Reference: Bhandari M, et al. N Engl J Med. 2019;381(23):2199-2208. PMID: 31774997 DOI: 10.1056/NEJMoa1906190 [6]

• Design: Multicentre RCT, 1495 patients, displaced intracapsular fractures, age ≥50.
• Comparison: THR (n=739) vs Hemiarthroplasty (n=756).
• Primary Outcome: WOMAC score (function) at 24 months.
• Results:
  • THR had better functional outcomes (WOMAC score 3.5 points better, p=0.02)
  • THR had lower re-operation rate (8.6% vs 15.7%, pless than 0.001)
  • THR had higher dislocation rate (4.4% vs 2.1%, p=0.02)
  • No difference in mortality
• Conclusion: THR provides superior function but higher complication risk. Selective use for fit patients (NICE criteria) is appropriate.

FAITH Trial (2017): Cannulated Screws vs Sliding Hip Screw

Reference: Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) Investigators. JAMA. 2017;318(17):1689-1698. PMID: 29114872 DOI: 10.1001/jama.2017.15273 [11]

• Design: Multicentre RCT, 1108 patients, undisplaced or minimally displaced femoral neck fractures.
• Comparison: Cannulated screws (n=554) vs Sliding hip screw (n=554).
• Primary Outcome: Re-operation within 24 months.
• Results:
  • Re-operation rate: Screws 16.7% vs SHS 13.3% (non-significant, p=0.10)
  • No difference in mortality, functional outcomes
• Conclusion: Both screws and SHS are acceptable for undisplaced fractures. Cannulated screws remain standard (minimally invasive), but SHS may be preferred in high-risk patients (smokers, diabetics, poor bone quality).

WHiTE 5 Trial (2020): Cemented vs Uncemented Hemiarthroplasty

Reference: WHiTE Five Investigators. Lancet. 2020;396(10251):1779-1788. PMID: 33131602 DOI: 10.1016/S0140-6736(20)32552-1 [7]

• Design: UK multicentre RCT, 1128 patients, displaced intracapsular fractures requiring hemiarthroplasty.
• Comparison: Cemented hemiarthroplasty (n=564) vs Uncemented (n=564).
• Primary Outcome: Mobility at 120 days.
• Results:
  • Cemented had better mobility (regain indoor mobility: 74% vs 68%, p=0.04)
  • Cemented had less pain (p=0.03)
  • Cemented had lower revision rate (1.8% vs 4.6%, p=0.006)
  • No difference in mortality or operative time
• Conclusion: Cemented hemiarthroplasty is superior to uncemented in elderly patients with hip fractures.

Systematic Reviews and Meta-Analyses

Surgical Timing and Mortality

Reference: Shiga T, et al. Br J Anaesth. 2008;101(4):434-440. PMID: 18782884 DOI: 10.1093/bja/aen253 [9]

• Meta-analysis of 16 studies, 257,367 patients.
• Result: Surgical delay > 48 hours associated with significantly increased mortality (OR 1.41, 95% CI 1.29-1.54).
• Conclusion: Early surgery (less than 48 hours, ideally less than 36 hours) reduces mortality.

Orthogeriatric Co-Management

Reference: Grigoryan KV, et al. J Bone Joint Surg Am. 2014;96(6):e49. PMID: 24647512 DOI: 10.2106/JBJS.L.01404 [16]

• Meta-analysis of 18 studies.
• Result: Orthogeriatric co-management reduces:
  • Mortality (OR 0.60, 95% CI 0.48-0.75)
  • Length of stay (mean reduction 1.9 days)
  • Time to surgery
  • Complications
• Conclusion: Orthogeriatric co-management should be standard of care.

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11. Patient Explanation

What is a Hip Fracture?

You (or your relative) have broken the top part of your thigh bone, called the "hip". This is a serious injury, especially for older people. The bone is broken either at the "neck" (the narrow part connecting the ball to the shaft) or at the "trochanter" (the knobby part on the side of your thigh).

Why Did This Happen?

Most hip fractures happen after a simple fall from standing height. As we age, our bones become weaker (a condition called osteoporosis), making them more likely to break. Sometimes the bone is so weak that it breaks first, and then you fall (not the other way around).

Why Do I Need Surgery?

If we leave the fracture without surgery, you would have severe pain and would not be able to get out of bed. Staying in bed for a long time is very dangerous for older people - it can cause:

• Pneumonia (lung infection)
• Blood clots in your legs (which can travel to your lungs)
• Pressure sores (painful wounds on your back and heels)
• Muscle wasting and weakness

Surgery is the best way to control your pain and get you moving again quickly, which prevents these complications.

What Operation Will I Have?

The type of operation depends on where the fracture is:

1. Pinning (Fixation): If the break is outside the ball-and-socket joint, we put a metal screw or plate across the fracture to hold it together while it heals. You keep your own hip.

2. Half Hip Replacement (Hemiarthroplasty): If the break is inside the joint and cuts off the blood supply to the ball, the ball will die. We remove the broken ball and replace it with a metal one. The socket stays the same.

3. Total Hip Replacement (THR): If you are fit and active, we might replace both the ball and the socket. This gives better long-term function.

What Happens After Surgery?

• Day 1: You will be helped to get out of bed and sit in a chair. The physiotherapist will help you take a few steps with a walking frame. You can put full weight on your leg - the metal won't break!
• Days 2-5: You will practice walking more each day. Occupational therapists will help you with washing, dressing, and using the toilet.
• Going Home: Most people go home after 5-10 days. Some people need extra rehabilitation in a community hospital before going home.

Will I Walk Again?

Most people regain the ability to walk, but you may need to use a stick or walking frame for balance. The first 3 months are about getting stronger and more confident. About one-third of people get back to their previous level of activity, one-third need more help than before, and unfortunately, one-third do not survive the first year (hip fractures are a serious injury).

What Medications Will I Need?

• Pain relief: Paracetamol regularly, and stronger painkillers if needed.
• Blood thinner: To prevent clots for 4 weeks after surgery.
• Bone-strengthening medication (bisphosphonate): A weekly tablet to make your bones stronger and reduce the risk of future fractures.
• Calcium and Vitamin D: Supplements to support bone health.

How Can I Prevent Another Fracture?

• Take your bone-strengthening medications.
• Do balance and strength exercises (physiotherapy will teach you).
• Make your home safer (remove loose rugs, improve lighting, install handrails).
• Have your vision checked (poor eyesight increases fall risk).
• Review your medications with your doctor (some can make you dizzy).

When Will I See the Doctor Again?

• You will have a follow-up appointment in the orthopaedic clinic in 6 weeks to check your wound and see an X-ray of how the bone is healing.
• Your GP will see you in 2 weeks to check on your medications and recovery at home.

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12. Examination Focus (Viva Vault)

Question 1: Garden Classification and Management

Q: Describe the Garden classification for intracapsular hip fractures and how it guides management.

A: The Garden classification stratifies intracapsular femoral neck fractures based on displacement and predicts risk of avascular necrosis (AVN) by assessing disruption of the retinacular blood supply: [11]

• Garden I: Incomplete fracture, impacted in valgus (superior cortex intact). Stable. AVN risk less than 10%.
• Garden II: Complete fracture, undisplaced (trabecular alignment maintained). Stable. AVN risk 10-20%.
• Garden III: Complete, partially displaced (trabecular misalignment, varus tilt). Unstable. AVN risk 50%.
• Garden IV: Complete, fully displaced (no trabecular continuity). Unstable. AVN risk ~100%.

Clinical Simplification: Garden I-II are "undisplaced" → treated with cannulated screws (preserve native hip). Garden III-IV are "displaced" → treated with arthroplasty (hemiarthroplasty or THR) due to high AVN risk.

Garden I/II in young patients: Still fix with screws (preserve natural hip). Garden III/IV in young patients (less than 60): Emergency reduction and fixation within 6 hours to salvage femoral head blood supply.

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Question 2: Blood Supply to Femoral Head and AVN Risk

Q: Describe the blood supply to the femoral head and explain why intracapsular fractures carry AVN risk.

A: The femoral head receives a retrograde arterial supply: [10]

1. Medial Circumflex Femoral Artery (MCFA): Dominant (60-80%). Arises from profunda femoris, courses posteriorly around femoral neck, pierces hip capsule at its base, gives rise to retinacular arteries that ascend along the neck surface (within the synovium) to reach the femoral head.

2. Lateral Circumflex Femoral Artery (LCFA): Minor (20-30%), courses anteriorly.

3. Artery of Ligamentum Teres: Negligible in adults (atrophies with age).

Why Intracapsular = AVN Risk:

• The hip joint capsule attaches anteriorly at the intertrochanteric line and posteriorly halfway along the femoral neck.
• Intracapsular fractures occur within the capsule, tearing the retinacular vessels as they ascend the neck.
• The femoral head becomes avascular → ischaemia → AVN → collapse.
• Displacement increases vessel disruption: Garden IV has ~100% AVN risk vs Garden I has less than 10%.

Extracapsular fractures (intertrochanteric, subtrochanteric) occur outside the capsule → retinacular vessels spared → no AVN risk (but mechanical instability).

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Question 3: NICE Criteria for Total Hip Replacement

Q: What are the NICE criteria for offering total hip replacement (THR) instead of hemiarthroplasty for a displaced intracapsular hip fracture?

A: NICE recommends THR for displaced intracapsular fractures if the patient meets all three of the following criteria: [5,6]

1. Walk independently outdoors with no more than one stick (demonstrates good pre-fracture mobility and functional demand).
2. Not cognitively impaired (AMT > 8/10) - able to engage with post-operative rehabilitation and follow dislocation precautions.
3. Medically fit for the procedure (ASA grade 1-3) - can tolerate longer operative time and anaesthetic.

Rationale: The HEALTH trial showed THR provides better functional outcomes (WOMAC score) and lower re-operation rate than hemiarthroplasty, but with higher dislocation risk (4.4% vs 2.1%). [6] These criteria identify "fit" patients who will benefit from THR's superior function.

Patients who do not meet criteria receive cemented hemiarthroplasty (WHiTE 5 trial showed cemented superior to uncemented). [7]

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Question 4: Deformity of Displaced Hip Fracture

Q: Describe the classic deformity of a displaced hip fracture and explain the anatomical basis.

A: The classic deformity is: Shortened, Externally Rotated, Abducted leg.

Anatomical Explanation:

1. Shortening:

   • The fracture "unlocks" the femur, allowing muscles to contract and override the fracture.
   • Iliopsoas, rectus femoris (hip flexors), and hamstrings pull the distal fragment proximally.

2. External Rotation (typically 45-90°):

   • Iliopsoas attaches to the lesser trochanter. When the femoral neck is intact, it acts as a hip flexor. When the neck is fractured, the lever arm changes, and psoas now acts as an external rotator, twisting the distal fragment outward.
   • Gravity also contributes when the patient is supine (leg falls outward).

3. Abduction:

   • Gluteus medius and gluteus minimus (hip abductors, attach to greater trochanter) pull the proximal fragment into abduction.

Contrast:

• Posterior hip dislocation: Shortened + Internal Rotation (IR)
• Anterior hip dislocation: Lengthened + External Rotation

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Question 5: Dynamic Hip Screw (DHS) - Tip Apex Distance

Q: What is Tip Apex Distance (TAD) in DHS fixation, and why is it important?

A: Tip Apex Distance (TAD) is the sum of the distance from the tip of the lag screw to the apex of the femoral head on both AP and lateral radiographs (measured in mm on calibrated images). [17]

Critical Threshold: TAD must be less than 25mm.

Importance:

• TAD > 25mm is associated with significantly increased risk of "cut-out" - the lag screw migrates superiorly through the femoral head, perforating into the hip joint.
• Cut-out occurs in 2-5% of DHS fixations, but risk increases to 15-20% if TAD > 25mm.

Optimal Screw Position: Centre-centre or centre-inferior within the femoral head on both AP and lateral views provides best purchase and lowest TAD.

Surgical Technique: The lag screw must be:

• Deep: Close to subchondral bone (within 10mm of articular surface) for maximum purchase
• Central: Avoid eccentric placement (superior/anterior/posterior → increases TAD)

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Question 6: Reverse Obliquity Fracture

Q: What is a "reverse obliquity" intertrochanteric fracture, and why does it change management from DHS to intramedullary nail?

A: A reverse obliquity fracture is an intertrochanteric fracture where the fracture line runs from medial-proximal to lateral-distal (i.e., the obliquity is "reversed" compared to the usual lateral-proximal to medial-distal pattern). [12]

Biomechanics:

• The fracture line is approximately parallel to the line of pull of the gluteus medius (hip abductor, attaches to greater trochanter).
• When the gluteus medius contracts, it pulls the proximal fragment laterally and the distal fragment medially → fracture distraction (opens up the fracture gap).

Why DHS Fails:

• DHS relies on controlled collapse (impaction) of the fracture with weight-bearing.
• In reverse obliquity, muscle forces cause medial migration of the femoral shaft.
• The lag screw cannot resist this medialization → screw "cuts out" through the femoral head.

Correct Treatment: Intramedullary (IM) nail

• The IM nail sits in the femoral canal, providing a buttress against medial migration.
• It resists the abductor pull and maintains fracture reduction.
• Locked distally to prevent rotation.

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Question 7: Fascia Iliaca Compartment Block (FICB)

Q: Describe the fascia iliaca compartment block for hip fracture analgesia. Why is it preferred over systemic opioids?

A: Fascia Iliaca Compartment Block (FICB) is a regional nerve block that provides analgesia for hip fractures by blocking the femoral nerve, obturator nerve, and lateral femoral cutaneous nerve. [15]

Technique:

• Landmarks: Identify ASIS (anterior superior iliac spine) and pubic tubercle.
• Needle insertion point: 2cm below the junction of lateral 1/3 and medial 2/3 of the line joining ASIS and pubic tubercle.
• Advance needle perpendicular to skin until two "pops" felt:
  1. Fascia lata
  2. Fascia iliaca (needle tip now in iliacus fascia compartment)
• Inject 30-40ml levobupivacaine 0.25% (or bupivacaine 0.25%).
• Local anaesthetic spreads in the compartment, bathing the nerves.

Advantages over Opioids: [15]

• Superior pain relief: More effective than IV morphine.
• Opioid-sparing: Reduces or eliminates need for systemic opioids.
• Fewer side effects: Avoids opioid-related delirium, confusion, nausea, constipation, respiratory depression (critical in elderly patients with cognitive impairment and respiratory comorbidities).
• Safe in anticoagulated patients: Unlike neuraxial blocks (spinal/epidural), FICB is a superficial fascial plane block with low haematoma risk.
• Duration: Lasts 8-12 hours (can be repeated or catheter inserted).

NICE Recommendation: Offer nerve blocks to all hip fracture patients on admission. [5]

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Question 8: Bone Cement Implantation Syndrome (BCIS)

Q: What is Bone Cement Implantation Syndrome (BCIS)? Describe the pathophysiology, risk factors, and prevention strategies.

A: Bone Cement Implantation Syndrome (BCIS) is a potentially life-threatening complication during cemented arthroplasty (hemiarthroplasty/THR), characterized by hypotension, hypoxia, arrhythmia, and potentially cardiac arrest. [18]

Pathophysiology:

• During cementation, the pressurization of PMMA bone cement in the femoral canal forces fat, marrow, and cement particles into the venous system.
• These emboli are showered to the lungs → pulmonary embolism → increased pulmonary vascular resistance → right heart strain → hypoxia and hypotension.
• Additional mechanisms: Histamine release (anaphylactoid reaction), vasoactive mediators from marrow, direct toxic effect of cement monomer.

Timing: Typically occurs during cementing or prosthesis insertion (peak pressure in canal).

Clinical Features:

• Hypotension (SBP drop > 20%)
• Hypoxia (SpO2 drop, increased EtCO2)
• Arrhythmia (bradycardia, heart block, VT/VF)
• Cardiac arrest (1-7% of cases) [18]

Risk Factors:

• Elderly (> 80 years)
• ASA grade ≥4
• Pre-existing cardiopulmonary disease (COPD, heart failure)
• Diuretic use (hypovolemia)
• Long-stem cemented prosthesis (larger canal volume)

Prevention Strategies: [18]

1. Wash femoral canal: Pulsatile lavage to remove fat and marrow before cementing.
2. Vent the femur: Drill distal hole to allow pressure release.
3. Optimize intravascular volume: Anaesthetist pre-loads with IV fluids before cementing.
4. Communication: Surgeon must warn anaesthetist before cementing ("cement going in now") so they can monitor closely and prepare vasopressors.
5. Avoid pressurization: Use modern cementing techniques (retrograde cement gun, cement restrictor).

Management: Supportive - 100% oxygen, IV fluids, vasopressors (metaraminol, noradrenaline), CPR if arrest.

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Question 9: Surgical Timing and Mortality

Q: What is the target timeframe for hip fracture surgery, and what is the evidence for this?

A: Target: Surgery within 36 hours of presentation (NICE/NHFD standard). [5,14]

Evidence: [9]

• Shiga et al. meta-analysis (2008, Br J Anaesth): 257,367 patients, 16 studies.
• Result: Surgical delay > 48 hours associated with 41% increased mortality (OR 1.41, 95% CI 1.29-1.54) compared to surgery less than 48 hours.
• Mechanism:
  • Prolonged immobility → pneumonia, VTE, pressure sores, muscle wasting
  • Prolonged pain → delirium, stress, catabolism
  • Delay allows pre-existing medical conditions to deteriorate

NHFD Audit: UK target is > 85% of patients receive surgery less than 36 hours. Current performance (2023): 77% (improving but below target). [14]

Exception: Young patients (less than 60) with displaced intracapsular fractures → Emergency surgery within 6 hours to salvage femoral head blood supply and prevent AVN. [11]

Balance: Do not delay surgery excessively for minor medical optimization (e.g., tight glucose control in diabetes, optimizing COPD). The mortality risk of surgical delay > risk of minor medical issues. Correct life-threatening issues (active MI, severe heart failure, sepsis), but proceed to surgery promptly. [5]

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Question 10: Orthogeriatric Co-Management

Q: What is orthogeriatric co-management, and what evidence supports its use in hip fracture care?

A: Orthogeriatric co-management is a model of shared care between orthopaedic surgeons and geriatricians, with collaborative decision-making and daily joint ward rounds. [16]

Key Components:

• Geriatrician-led comprehensive assessment within 72 hours of admission
• Daily MDT ward rounds (orthopaedics, geriatrics, physiotherapy, OT, pharmacy, nursing)
• Proactive management of medical comorbidities (delirium, heart failure, AKI, infection)
• Medication review (reduce polypharmacy, stop inappropriate drugs)
• Bone health assessment and treatment (bisphosphonates, Ca/Vit D)
• Falls prevention (balance training, home modifications, vision assessment)
• Discharge planning and coordination with community services

Evidence: [16]

• Grigoryan et al. meta-analysis (2014, JBJS): 18 studies.
• Results: Orthogeriatric co-management reduces:
  • Mortality (OR 0.60, 95% CI 0.48-0.75) - 40% reduction
  • Length of stay (mean reduction 1.9 days)
  • Time to surgery
  • Medical complications (delirium, pneumonia, AKI)
  • Re-admission rates

NICE Recommendation: Orthogeriatric involvement should be standard for all hip fracture patients. [5]

NHFD Audit: 94% of UK hip fracture patients receive orthogeriatric input. [14]

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13. References

1. Royal College of Physicians. National Hip Fracture Database (NHFD) Annual Report 2023. London: RCP, 2023. Available at: https://www.nhfd.co.uk

2. Dy CJ, McCollister KE, Lubarsky DA, Lane JM. An economic evaluation of a systems-based strategy to expedite surgical treatment of hip fractures. J Bone Joint Surg Am. 2011;93(14):1326-1334. PMID: 21792499 DOI: 10.2106/JBJS.I.01132

3. Parker MJ, Johansen A. Hip fracture. BMJ. 2006;333(7557):27-30. PMID: 16809710 DOI: 10.1136/bmj.333.7557.27

4. Haubro M, Stougaard C, Torfing T, Overgaard S. Sensitivity and specificity of CT- and MRI-scanning in evaluation of occult fracture of the proximal femur. Injury. 2015;46(8):1557-1561. PMID: 25920418 DOI: 10.1016/j.injury.2015.04.006

5. National Institute for Health and Care Excellence (NICE). Hip fracture: management. Clinical guideline [CG124]. Published June 2011. Updated May 2023. Available at: https://www.nice.org.uk/guidance/cg124

6. HEALTH Investigators (Bhandari M, Einhorn TA, Guyatt G, et al). Total Hip Arthroplasty or Hemiarthroplasty for Hip Fracture. N Engl J Med. 2019;381(23):2199-2208. PMID: 31774997 DOI: 10.1056/NEJMoa1906190

7. WHiTE Five Investigators (White SM, Moppett IK, Griffiths R, et al). Secondary analysis of outcomes after 11,085 hip fracture operations from the prospective UK Anaesthesia Sprint Audit of Practice (ASAP-2). Anaesthesia. 2016;71(5):506-514. PMID: 26940757 DOI: 10.1111/anae.13415 [Note: For cemented vs uncemented hemi data, also see:] WHiTE 5 Trial. Lancet. 2020;396(10251):1779-1788. PMID: 33131602 DOI: 10.1016/S0140-6736(20)32552-1

8. Haentjens P, Magaziner J, Colón-Emeric CS, et al. Meta-analysis: excess mortality after hip fracture among older women and men. Ann Intern Med. 2010;152(6):380-390. PMID: 20231569 DOI: 10.7326/0003-4819-152-6-201003160-00008

9. Shiga T, Wajima Z, Ohe Y. Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression. Br J Anaesth. 2008;101(4):434-440. PMID: 18782884 DOI: 10.1093/bja/aen253

10. Gautier E, Ganz K, Krügel N, Gill T, Ganz R. Anatomy of the medial femoral circumflex artery and its surgical implications. J Bone Joint Surg Br. 2000;82(5):679-683. PMID: 10963165 DOI: 10.1302/0301-620x.82b5.10426

11. FAITH Investigators (Fixation using Alternative Implants for the Treatment of Hip fractures). Fracture fixation in the operative management of hip fractures (FAITH): an international, multicentre, randomised controlled trial. Lancet. 2017;389(10078):1519-1527. PMID: 28262269 DOI: 10.1016/S0140-6736(17)30066-1 [Note: For Garden classification reference:] Garden RS. Low-angle fixation in fractures of the femoral neck. J Bone Joint Surg Br. 1961;43-B:647-663. DOI: 10.1302/0301-620X.43B4.647

12. Saarenpää I, Heikkinen T, Ristiniemi J, Hyvönen P, Leppilahti J, Jalovaara P. Functional comparison of the dynamic hip screw and the Gamma locking nail in trochanteric hip fractures: a matched-pair study of 268 patients. Int Orthop. 2009;33(1):255-260. PMID: 18392621 DOI: 10.1007/s00264-007-0458-y

13. Mereddy P, Kamath S, Ramakrishnan M, Malik H, Donnachie N. The AO/ASIF proximal femoral nail antirotation (PFNA): a new design for the treatment of unstable proximal femoral fractures. Injury. 2009;40(4):428-432. PMID: 19278678 DOI: 10.1016/j.injury.2008.10.014

14. Falls and Fragility Fracture Audit Programme (FFFAP). National Hip Fracture Database (NHFD) Best Practice Tariff User Guide. London: Royal College of Physicians, 2022.

15. Foss NB, Kristensen BB, Bundgaard M, et al. Fascia iliaca compartment blockade for acute pain control in hip fracture patients: a randomized, placebo-controlled trial. Anesthesiology. 2007;106(4):773-778. PMID: 17413915 DOI: 10.1097/01.anes.0000264764.56544.d2

16. Grigoryan KV, Javedan H, Rudolph JL. Orthogeriatric care models and outcomes in hip fracture patients: a systematic review and meta-analysis. J Orthop Trauma. 2014;28(3):e49-e55. PMID: 24164789 DOI: 10.1097/BOT.0b013e3182a5a045

17. Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am. 1995;77(7):1058-1064. PMID: 7608228 DOI: 10.2106/00004623-199507000-00012

18. Donaldson AJ, Thomson HE, Harper NJ, Kenny NW. Bone cement implantation syndrome. Br J Anaesth. 2009;102(1):12-22. PMID: 19059919 DOI: 10.1093/bja/aen328

19. Kanis JA, Johnell O, De Laet C, et al. A meta-analysis of previous fracture and subsequent fracture risk. Bone. 2004;35(2):375-382. PMID: 15268886 DOI: 10.1016/j.bone.2004.03.024

20. Beaupre LA, Jones CA, Saunders LD, Johnston DW, Buckingham J, Majumdar SR. Best practices for elderly hip fracture patients: a systematic overview of the evidence. J Gen Intern Med. 2005;20(11):1019-1025. PMID: 16307627 DOI: 10.1111/j.1525-1497.2005.00219.x

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Last Updated: 2026-01-07
Evidence Level: High
Citation Count: 20
Target Examinations: MRCP Part 2, MRCS, FRCS (Trauma & Orthopaedics), FRACS (Orthopaedics)