Initial management
Provide adequate analgesia.
A fascia iliaca or femoral nerve block can markedly reduce opioid requirements in older patients.
Correct reversible physiological problems promptly rather than delaying surgery unnecessarily.
For geriatric hip fracture, operate on the day of admission or the following day where possible.
Young or physiologically young patient
Preserve the femoral head whenever feasible.
A displaced femoral neck fracture requires urgent anatomical reduction and stable internal fixation.
Reduction goals are:
- Restore normal neck shaft angle
- Correct rotational displacement
- Avoid varus
- Restore posterior cortical alignment
Poor reduction cannot be compensated for by excellent hardware.
If acceptable reduction cannot be obtained closed, perform open reduction rather than accepting malalignment.
Garden I or II, low angle fracture
Multiple parallel cannulated screws can provide adequate fixation.
Basicervical or Pauwels III fracture
A sliding hip screw, femoral neck system or another fixed angle construct generally provides greater resistance to vertical shear than isolated parallel screws. A supplementary antirotation screw may be used with selected constructs.
Severe posterior comminution increases instability.
Protected weight bearing is usually required after fixation in younger patients until sufficient healing occurs.
Older patient with nondisplaced fracture
Garden I and II fractures are commonly treated with internal fixation using cannulated screws or another low morbidity fixation system.
Very elderly patients with substantial posterior tilt, poor bone quality or a high likelihood of fixation failure require individual consideration because arthroplasty may sometimes provide a more reliable outcome.
Older patient with displaced fracture
Garden III or IV fracture should usually undergo arthroplasty rather than internal fixation.
Use hemiarthroplasty for patients with lower functional demand, significant frailty or limited independent life expectancy.
Consider total hip arthroplasty when the patient:
- Previously walked independently outdoors with no more than a stick
- Is medically suitable for the larger operation
- Is expected to remain independently functional for more than approximately 2 years.
Use a cemented femoral stem for hip fracture arthroplasty in most older adults unless a specific contraindication exists.
Postoperative care
Aim for immediate or early weight bearing as tolerated after stable arthroplasty or appropriate geriatric fixation.
Mobilise beginning the day after surgery where possible.
For fragility fractures of the hip or proximal femur, provide pharmacological venous thromboembolism prophylaxis for approximately 1 month when bleeding risk permits. LMWH can begin approximately 6 to 12 hours after surgery.
Investigate and treat osteoporosis because the fracture is frequently a sentinel fragility event.
