National institute for health and clinical excellence
NATIONAL INSTITUTE FOR HEALTH AND
Hip fracture: the management of hip fracture in adults
The Department of Health has asked NICE: ”to prepare a clinical guideline on
the management of fractured neck of femur”.
Clinical need for the guideline
About 70–75,000 hip fractures (proximal femoral fractures) occur
annually in the UK. Hip fracture is the commonest reason for
admission to an orthopaedic ward, and is usually a ‘fragility’
fracture caused by a fall affecting an older person with
osteoporosis or osteopaenia (a lesser degree of bone reduction
and weakness due to the same process as in osteoporosis). The
average age of a person with hip fracture is 77 years. The annual
cost of medical and social care for all the hip fracture cases in the
UK amounts to about £2 billion. Demographic projections indicate
that the UK annual incidence will rise to 91,500 by 2015 and
101,000 in 2020, with an associated increase in annual expenditure
that could reach £2.2 billion by 2020. The majority of this
expenditure will be accounted for by hospital bed days and a
further substantial contribution will come from health and social
aftercare. About a quarter of patients with hip fracture are admitted
from institutional care. About 10–20% of those admitted from home
Mortality is high – about 10% of people with a hip fracture die within
1 month, and about one third within 12 months. However, fewer
than half of deaths are attributable to the fracture. This reflects the
high prevalence of comorbidity in people with hip fractures; often
the combination of fall and fracture brings to light underlying ill
health. This presents major challenges for anaesthetic, surgical,
The primary and secondary prevention of fragility fractures by
treating osteoporosis and reducing the risk of falls are of key
importance to the current and future epidemiology of hip fracture.
These are, or will be, covered by related NICE guidance (see
The diagnosis and management of hip fracture itself and of any
comorbidity before, during and after surgery, have a profound effect
on outcome, both for individuals and for services.
Patients with hip fracture need immediate referral to hospital (other
than in exceptional circumstances). Their assessment and
management on admission commonly involve a range of
specialties and disciplines, but it is not always clear how and when
this involvement should take place. Prompt surgery is important but
1 The strict definition of a fragility fracture is one caused by a fall from standing height or less. For the purposes of this guidance, the definition will be slightly more flexible to encompass all hip fractures judged to have an osteoporotic or osteopaenic basis
is sometimes delayed for administrative or clinical reasons. It is
essential that mobilisation and rehabilitation after surgery are
undertaken according to individual need, but this does not always
In spite of a significant body of evidence, hip fracture management
and the resulting length of hospital stay vary markedly among
Existing UK guidance from other sources includes:
• Scottish Intercollegiate Guidelines Network (2002) Prevention
and management of hip fracture in older people. Available from
• British Orthopaedic Association (2007) The care of patients with
• Department of Health (2001) National service framework for
This clinical guideline will provide guidance on the emergency,
preoperative, operative and postoperative management of hip
fracture, including rehabilitation, in adults. It will not cover those
aspects of hip fracture addressed by related NICE guidance, but
At all stages of hip fracture management, and especially during
rehabilitation, the importance of optimal communication with, and
support for, patients themselves and those who provide or will
provide care – including unpaid care family members or others –
will be a fundamental tenet of guidance development.
2 Elaborates on relevant (but not specific) standards of contextual importance (intermediate care, general hospital care and falls).
The guideline development process is described in detail on the NICE website
(see section 6, ‘Further information’).
This scope defines what the guideline will (and will not) examine, and what the
guideline developers will consider. The scope is based on the referral from the
The areas that will be addressed by the guideline are described in the
Groups that will be covered
Adults aged 18 years and older presenting to the health service
with a clinical diagnosis (firm or provisional) of fragility fracture of
People with the following types of hip fracture:
• intracapsular (undisplaced and displaced) • extracapsular (trochanteric and subtrochanteric).
Those with comorbidity strongly predictive of outcome, and those
without such comorbidity. The influence (if any) of advanced age or
gender on clinical decision-making, management and outcome will
Groups that will not be covered
People with fractures caused by specific pathologies other than
osteoporosis or osteopaenia (because these would require more
Secondary care settings where preoperative, operative, and
postoperative acute and subacute care are undertaken.
Primary, secondary and social care settings, as well as an
individual’s own home, where rehabilitation is undertaken.
Key clinical issues that will be covered
Using alternative radiological imaging to confirm or exclude a
suspected hip fracture in patients with a normal X-ray.
Involving a physician or orthogeriatrician in the care of patients
Optimal preoperative and postoperative analgesia (pain relief),
Regional (spinal – also known as ‘epidural’) versus general
anaesthesia in patients undergoing surgery for hip fracture.
Does surgeon experience reduce the incidence of mortality, the
need for repeat surgery, and poor outcome in terms of mobility?
• internal fixation versus arthroplasty (hip replacement surgery) • total hip replacement versus hemiarthroplasty (replacing the
Choice of surgical implants - Sliding hip screw versus
intramedullary nail for trochanteric extracapsular fracture.
3 These terms explain where the bone has fractured, which can be either near or within the hip joint.
Choice of surgical implants - Sliding hip screw versus
intramedullary nail for subtrochanteric extracapsular fracture.
Cemented versus non-cemented arthroplasty implants.
Hospital-based multidisciplinary rehabilitation for patients who have
Early transfer to community-based multidisciplinary rehabilitation
for patients who have undergone hip fracture surgery.
Clinical issues that will not be covered
The following will not be directly covered in this guideline, but related NICE
guidance will be referred to if appropriate:
Primary and secondary prevention of fragility fracture.
Prevention and management of pressure sores.
Prevention and management of infection at the surgical site.
Selection of prostheses for hip replacement.
Complementary and alternative therapies.
Length of time before community resettlement/discharge.
Place of residence (compared with baseline) 12 months after
Short-, medium- and long-term functional status.
Short-, medium- and long-term quality of life.
Developers will take into account both clinical and cost effectiveness when
making recommendations involving a choice between alternative
interventions. A review of the economic evidence will be conducted and
analyses will be carried out as appropriate. The preferred unit of effectiveness
is the quality-adjusted life year (QALY), and the costs considered will usually
be only from an NHS and personal social services (PSS) perspective. Further
detail on the methods can be found in 'The guidelines manual' (see ‘Further
The development of the guideline recommendations will begin in June 2010.
Related NICE guidance
• Surgical site infection. NICE clinical guideline 74 (2008). Available from
• Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and
teriparatide for the secondary prevention of osteoporotic fragility fractures
in postmenopausal women. NICE technology appraisal guidance 161
• Alendronate, etidronate, risedronate, raloxifene and strontium ranelate for
the primary prevention of osteoporotic fragility fractures in postmenopausal
women. NICE technology appraisal guidance 160 (2008). Available from
• Venous thromboembolism. NICE clinical guideline 46 (2007). Available
• Nutrition support in adults. NICE clinical guideline 32 (2006).
• The management of pressure ulcers in primary and secondary care. NICE
clinical guideline 29 (2005). Available from
• Falls. NICE clinical guideline 21 (2004). Available from
• Preoperative tests. NICE clinical guideline 3 (2003). Available from
• The selection of prostheses for primary total hip replacement. NICE
technology appraisal guidance 2 (2000). Available from
Guidance under development
NICE is currently developing the following related guidance (details available
• Osteoporosis. NICE clinical guideline. Publication date to be confirmed. • Venous thromboembolism –prevention. NICE clinical guideline. Publication
• Delirium: diagnosis, prevention and management of delirium. Publication
Information on the guideline development process is provided in:
• ‘How NICE clinical guidelines are developed: an overview for stakeholders,
These are available from the NICE website
(www.nice.org.uk/guidelinesmanual). Information on the progress of the
guideline will also be available from the NICE website (www.nice.org.uk).
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