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Hip fracture

Key sources
The following summarized guidelines for the evaluation and management of hip fracture are prepared by our editorial team based on guidelines from the Eastern Association for the Surgery of Trauma (EAST/AOTA 2023), the American College of Physicians (ACP 2023), the Surgical Infection Society Europe (SIS-E/GAIS/WSES/WSIS/AAST 2023), the American Academy of Family Physicians (AAFP 2022), the American Academy of Orthopaedic Surgeons (AAOS 2022), the World Falls Guidelines (WFG 2022), the American College of Obstetricians and Gynecologists (ACOG 2022; 2021), the Academy of Orthopaedic Physical Therapy (AOPT 2021), the American College of Endocrinology (ACE/AACE 2020), the Endocrine Society (ES 2020), the American College of Radiology (ACR 2019), the Danish Health Authority (DHA 2018), the U.S. Preventive Services Task Force (USPSTF 2018), the British Medical Journal (BMJ 2017), the Eastern Association for the Surgery of Trauma (EAST 2016), and the Osteoporosis Canada (OC 2010).
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Guidelines

1.Diagnostic investigations

Diagnostic imaging: as per AAFP 2022 guidelines, obtain cross-table lateral hip and anteroposterior pelvis radiography as initial evaluation for suspected hip fracture.
B
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  • Functional tests

2.Medical management

Management of pain
As per EAST 2023 guidelines:
Consider administering NSAIDs (such as ketorolac) for pain management in adult patients with a traumatic fracture.
C
Insufficient evidence to recommend the preferential use of either selective NSAIDs (COX-2 inhibitors) or nonselective NSAIDs.
I

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  • Management of osteoporosis (indications)

  • Management of osteoporosis (regimens)

  • Management of osteoporosis (duration)

3.Inpatient care

Prevention of inpatient complications: provide multicomponent nonpharmacological intervention programs delivered by an interprofessional team (including physicians, nurses, and possibly other healthcare professionals) for the entire hospitalization to prevent delirium in at-risk older adult patients undergoing hip surgery.
B
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4.Therapeutic procedures

Low-intensity pulsed ultrasound: do not use low-intensity pulsed ultrasound in adult and pediatric patients with a fracture.
D

5.Perioperative care

Preoperative analgesia: administer multimodal analgesia incorporating preoperative nerve block for pain after hip fracture.
A

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  • Preoperative traction

  • Perioperative antibiotics

  • Perioperative thromboprophylaxis

  • Perioperative blood transfusion

6.Surgical interventions

Surgical management, timing, AAFP: perform surgery for a hip fracture within 24-48 hours of injury unless a delay is needed to stabilize comorbidities, recognizing that early operative management improves pain control, decreases the length of hospitalization, and reduces complications.
B

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  • Surgical management (anesthesia)

  • Surgical management (approach)

  • Surgical management (technical considerations)

7.Preventative measures

Prevention of falls, general principles
Incorporate the individual's values and preferences in the care plan developed to prevent falls and related injuries.
A
Include both the individual's and their caregivers' perspectives when creating fall prevention care plans for older adults with cognitive impairment.
B
Advise on how to maintain safe mobility and optimize physical functioning in older patients at low risk of falls, taking into consideration the individual's circumstances, priorities, preferences, and resources. Reinforce health promotion/prevention messaging relevant to falls and fracture risks, including physical activity, lifestyle habits, and nutrition, including vitamin D intake.
E

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  • Prevention of falls (environmental modifications)

  • Prevention of falls (exercise interventions)

  • Prevention of falls (multifactorial interventions)

  • Prevention of falls (vestibular rehabilitation)

  • Prevention of falls (vitamin D/calcium supplementation)

  • Prevention of falls (medication review)

  • Hip protectors

8.Follow-up and surveillance

Serial clinical assessment: assess and document hip extensor and abductor muscle strength in post-acute clinical settings.
B
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  • Discharge from hospital

  • Postoperative rehabilitation