Suspected Hip Fracture in Older Adult
Age ≥55 with hip pain after fall or trauma
All Pathways
Orthopedic SurgeryManagement
Hip Fracture Management in Older Adults (AAOS 2021/NICE)
Hip Fracture Management in Older Adults (AAOS 2021/NICE): Suspected Hip Fracture in Older Adult → Initial Assessment → Fracture visible on X-ray? → MRI ...
Pathway Overview
19 steps
Algorithm Steps
19 total
01Start 02Action Initial Assessment
History, exam, and imaging
- Pain in groin, lateral hip, or referred to knee
- Inability to weight bear
- Shortened, externally rotated leg
- AP and lateral hip X-rays
- Check for other injuries (wrist, spine)
03Decision Fracture visible on X-ray?
Initial radiograph interpretation
04Action MRI for Occult Fracture
AAOS: Moderate evidence supports MRI
- MRI is imaging of choice if X-ray negative
- Obtain within 24 hours
- CT if MRI unavailable or contraindicated
- Do not delay if high clinical suspicion
05Decision Classify Hip Fracture Type
Intracapsular vs Extracapsular
- Intracapsular: Femoral neck fractures
- Extracapsular: Intertrochanteric, Subtrochanteric
- Assess displacement and stability
06Action Preoperative Optimization
Prepare for surgery within 24-48h
- AAOS: Surgery within 24-48h improves outcomes
- Assess cardiac, pulmonary status
- Manage anticoagulation (bridging if needed)
- Correct electrolytes, anemia (transfuse if Hgb <8)
- NPO status, IV fluids
- Pain control (femoral nerve block if available)
- VTE prophylaxis
07Warning ⚠️ High Mortality Risk
Hip fracture carries significant mortality
- 30-day mortality ~10%
- 1-year mortality ~30%
- Delay >48h associated with worse outcomes
- Optimize medically but do not delay unnecessarily
08Decision Femoral Neck Fracture: Displaced?
Garden III/IV vs Garden I/II
09Action Non-displaced Femoral Neck (Garden I/II)
Internal fixation preferred
- Cannulated screws (typically 3)
- Sliding hip screw (SHS) acceptable
- Lower risk of AVN than displaced
- Close follow-up for displacement
10Action Postoperative Care
Multidisciplinary hip fracture program
- Mobilize day 1 post-op (NICE)
- Weight bearing as tolerated (most cases)
- DVT prophylaxis 28-35 days
- Delirium prevention
- Nutritional support
- Osteoporosis assessment and treatment
- Falls prevention program
11Outcome Recovery & Rehabilitation
Return to baseline function is goal
12Decision Displaced Femoral Neck: Patient Factors
Age, activity, cognition, life expectancy
13Action Total Hip Replacement (THR)
NICE: Offer THR for displaced FNF if appropriate
- Independently mobile pre-fracture
- Cognitively intact
- Medically fit for larger procedure
- Better functional outcomes than HA
- Use cemented femoral stem (AAOS moderate evidence)
14Action Tranexamic Acid (TXA)
AAOS: Moderate evidence to reduce blood loss
- 1-2g IV before incision
- Reduces transfusion requirements
- Low VTE risk in appropriate patients
- Consider topical in wound
- Path rejoins step 10Shared downstream outcome
15Action Hemiarthroplasty (HA)
For displaced FNF when THR not suitable
- Cognitive impairment
- Limited mobility pre-fracture
- Shorter life expectancy
- Use cemented stem (AAOS moderate evidence)
- Unipolar or bipolar head
- Path rejoins step 14Shared downstream outcome
16Decision Intertrochanteric Fracture: Stable?
AO/OTA classification, lateral wall integrity
17Action Stable Intertrochanteric (A1)
NICE: Extramedullary implant preferred
- Sliding Hip Screw (SHS/DHS)
- Simple 2-part fracture pattern
- Intact lateral wall
- Lower implant cost, similar outcomes
- Path rejoins step 14Shared downstream outcome
18Action Unstable Intertrochanteric (A2/A3)
AAOS: Cephalomedullary device recommended
- Intramedullary nail (IMN) preferred
- Reverse oblique, subtrochanteric extension
- Lateral wall incompetence
- Short vs long nail based on pattern
- Path rejoins step 14Shared downstream outcome
19Action Subtrochanteric Fracture
Below lesser trochanter
- Cephalomedullary nail (long)
- Consider ORIF with fixed-angle device
- High stress region - malunion/nonunion risk
- Often associated with bisphosphonate use
- Path rejoins step 14Shared downstream outcome
- Path rejoins step 05Shared downstream outcome
Guideline Source
AAOS CPG: Management of Hip Fractures in Older Adults + NICE CG124
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Applies to adults ≥55 years (AAOS), ≥65 for some NICE recommendations
- Does not cover pathologic fractures from malignancy
- Implant selection may vary by surgeon preference and availability
- Anticoagulation management complex - individualized approach needed
Applicable Regions
USEU
UK: NICE CG124 guides practice - Best Practice Tariff applies
US: AAOS 2021 primary reference
Version 1Next review: 2027-01-11
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Related Resources
Frequently Asked Questions
What is the Hip Fracture Management in Older Adults (AAOS 2021/NICE)?
The Hip Fracture Management in Older Adults (AAOS 2021/NICE) is a management clinical algorithm for Orthopedic Surgery. It provides a structured decision tree to guide clinical decision-making, based on AAOS CPG: Management of Hip Fractures in Older Adults + NICE CG124.
What guideline is the Hip Fracture Management in Older Adults (AAOS 2021/NICE) based on?
This algorithm is based on AAOS CPG: Management of Hip Fractures in Older Adults + NICE CG124 (DOI: 10.5435/JAAOS-D-21-00302).
What are the limitations of the Hip Fracture Management in Older Adults (AAOS 2021/NICE)?
Known limitations include: Applies to adults ≥55 years (AAOS), ≥65 for some NICE recommendations; Does not cover pathologic fractures from malignancy; Implant selection may vary by surgeon preference and availability; Anticoagulation management complex - individualized approach needed. Individual patient factors may require deviation from these recommendations.
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