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Management of Hip fracture: NICE Guidelines

Management of Hip fracture: NICE Guidelines

Hip fracture refers to a fracture occurring in the area between the edge of the femoral head and 5 centimetres below the lesser trochanter. These fractures are generally divided into two 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.

National Institute for Health and Care Excellence, UK (NICE) has updated the guidelines on Hip fracture: Management in May 2017. Following are its major recommendations

1.1 Imaging options in occult hip fracture

1.1.1 Offer magnetic resonance imaging (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 computed tomography (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 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. [2011]

1.3.2 Offer immediate analgesia to patients 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 patients a choice of spinal or general anaesthesia after discussing the risks and benefits. [2011]

1.4.2 Consider intraoperative nerve blocks for all patients 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 patients 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 patients with a displaced intracapsular hip fracture. [2017]

1.6.3 Offer total hip replacement rather than hemiarthroplasty to patients 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
  • are not cognitively impaired and
  • are medically fit for anaesthesia and the procedure. [2017]

1.6.4 Use a proven femoral stem design rather than Austin Moore or Thompson stems for arthroplasties. Suitable designs include those with an Orthopaedic Data Evaluation Panel rating of 10A, 10B, 10C, 7A, 7B, 5A, 5B, 3A or 3B. [2011]

1.6.5 Use cemented implants in patients undergoing surgery with arthroplasty[1]. [2011]

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

1.6.7 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). [2011]

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

1.7 Mobilisation strategies

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

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

1.8 Multidisciplinary management

1.8.1 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 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 patients’ own priorities for rehabilitation and
  • considers patients’ wishes about their end-of-life care. [2011]

1.8.3 Healthcare professionals should deliver care that minimises the patient’s risk of delirium and maximises their independence, by:

  • actively looking for cognitive impairment when patients first present with hip fracture
  • reassessing patients 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 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, 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 Patients 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]

To read full guidelines click on the following link.

Source: NICE

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