Hip fracture: management

Clinical guideline
Published: 22 June 2011
Last updated: 6 January 2023

www.nice.org.uk/guidance/cg124

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Hip fracture: management (CG124)

Your responsibility
The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals
and practitioners are expected to take this guideline fully into account, alongside the
individual needs, preferences and values of their patients or the people using their service.
It is not mandatory to apply the recommendations, and the guideline does not override the
responsibility to make decisions appropriate to the circumstances of the individual, in
consultation with them and their families and carers or guardian.

All problems (adverse events) related to a medicine or medical device used for treatment
or in a procedure should be reported to the Medicines and Healthcare products Regulatory
Agency using the Yellow Card Scheme.

Local commissioners and providers of healthcare have a responsibility to enable the

guideline to be applied when individual professionals and people using services wish to
use it. They should do so in the context of local and national priorities for funding and
developing services, and in light of their duties to have due regard to the need to eliminate
unlawful discrimination, to advance equality of opportunity and to reduce health
inequalities. Nothing in this guideline should be interpreted in a way that would be
inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally

sustainable health and care system and should assess and reduce the environmental
impact of implementing NICE recommendations wherever possible.

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Contents
Overview ................................................................................................................................... 4

Who is it for? ....................................................................................................................................... 4

Recommendations .................................................................................................................... 5

1.1 Imaging options in occult hip fracture ......................................................................................... 5

1.2 Timing of surgery ......................................................................................................................... 5

1.3 Analgesia ....................................................................................................................................... 6

1.4 Anaesthesia .................................................................................................................................. 7

1.5 Planning the theatre team ........................................................................................................... 7

1.6 Surgical procedures ..................................................................................................................... 7

1.7 Mobilisation strategies ................................................................................................................. 9

1.8 Multidisciplinary management .................................................................................................... 9

1.9 Patient and carer information ...................................................................................................... 11

Recommendations for research .............................................................................................. 13

1 Imaging options in occult hip fracture ........................................................................................... 13

2 Anaesthesia ..................................................................................................................................... 14

3 Undisplaced intracapsular hip fractures ....................................................................................... 14

4 Intensive rehabilitation therapies after hip fracture .................................................................... 15

5 Early supported discharge in care home patients ....................................................................... 15

6 Long-term effectiveness of total hip replacement ...................................................................... 16

7 Femoral component design ............................................................................................................ 17

Rationale and impact................................................................................................................ 18

Total hip replacement versus hemiarthroplasty .............................................................................. 18

Femoral component design used for hemiarthroplasties............................................................... 20

Context ...................................................................................................................................... 22

Finding more information and committee details .................................................................. 24

Update information .................................................................................................................. 25

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This guideline is the basis of QS16.

Overview
This guideline covers managing hip fracture in adults. It aims to improve care from the time
people aged 18 and over are admitted to hospital through to when they return to the
community. Recommendations emphasise the importance of early surgery and
coordinating care through a multidisciplinary Hip Fracture Programme to help people
recover faster and regain their mobility.

NICE has also produced a guideline on osteoporosis: assessing the risk of fragility fracture.

Who is it for?
• Healthcare professionals

• Commissioners and providers

• Adults with hip fracture and their families and carers.

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Recommendations
People have the right to be involved in discussions and make informed decisions
about their care, as described in NICE's information on making decisions about your
care.

Making decisions using NICE guidelines explains how we use words to show the
strength (or certainty) of our recommendations, and has information about
prescribing medicines (including off-label use), professional guidelines, standards
and laws (including on consent and mental capacity), and safeguarding.

Some aspects of hip fracture management are already covered by NICE guidance and are
therefore outside the scope of this guideline. To ensure comprehensive management and
continuity, the following NICE guidance should be referred to when developing a complete
programme of care for each patient:

• NICE technology appraisal guidance on preventing osteoporotic fragility fractures in

postmenopausal women (alendronate, denosumab, etidronate, risedronate, raloxifene,
strontium ranelate and teriparatide).

• NICE guidelines on falls in older people, pressure ulcers, nutrition support for adults,
dementia, surgical site infections, venous thromboembolism in over 16s, delirium and
osteoporosis: assessing the risk of fragility fracture.

1.1 Imaging options in occult hip fracture

1.1.1 Offer 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 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

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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 person'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 people 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]

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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 people a choice of spinal or general anaesthesia after discussing
the risks and benefits. [2011]

1.4.2 Consider intraoperative nerve blocks for all people 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 people with the aim to allow them to fully weight bear
(without restriction) in the immediate postoperative period. [2011]

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1.6.2 Offer replacement arthroplasty (total hip replacement or

hemiarthroplasty) to people with a displaced intracapsular hip fracture.
[2017]

1.6.3 Consider total hip replacement rather than hemiarthroplasty for people
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

• do not have a condition or comorbidity that makes the procedure unsuitable for
them and

• are expected to be able to carry out activities of daily living independently

beyond 2 years. [2023]

For a short explanation of why the committee made the 2023 recommendation and
how it might affect practice, see the rationale and impact section on total hip
replacement versus hemiarthroplasty.

Full details of the evidence and the committee's discussion are in evidence review B:
total hip replacement versus hemiarthroplasty.

1.6.4 Use cemented implants in people undergoing surgery with arthroplasty.

[2011]

The Association of Anaesthetists of Great Britain and Ireland, British

Orthopaedic Association and British Geriatric Society have produced a
safety guideline on reducing the risk from cemented hemiarthroplasty for
hip fracture. The guideline is not NICE accredited.

1.6.5 Hospitals should aim to use a single type of cemented femoral

component for hemiarthroplasties as standard treatment for displaced
intracapsular hip fracture management. [2023]

1.6.6 If equivalent cemented femoral component designs are available,

organisations should take into account overall costs, including training
needs, and how familiar the team is with the component. [2023]

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1.6.7 Record long-term data on hemiarthroplasties, including patient-reported

outcomes and adverse events, for submission to a national registry.
[2023]

For a short explanation of why the committee made the 2023 recommendations and
how they might affect practice, see the rationale and impact section on femoral
component design used for hemiarthroplasties.

Full details of the evidence and the committee's discussion are in evidence review A:
femoral component design used for hemiarthroplasties.

1.6.8 Consider an anterolateral approach in favour of a posterior approach

when inserting a hemiarthroplasty. [2011]

1.6.9 Use extramedullary implants such as a sliding hip screw in preference to

an intramedullary nail in people with trochanteric fractures above and
including the lesser trochanter (except reverse oblique). [2011, amended
2023]

1.6.10 Use an intramedullary nail to treat people with a subtrochanteric fracture.

[2011]

1.7 Mobilisation strategies

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

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

1.8 Multidisciplinary management

1.8.1 From admission, offer people a formal, acute, orthogeriatric or
orthopaedic ward-based Hip Fracture Programme that includes all of the
following:

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• 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 the person's own priorities for rehabilitation and

• considers the person's wishes about their end-of-life care. [2011]

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

• actively looking for cognitive impairment when people first present with hip
fracture

• reassessing people 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 person:

• is medically stable and

• has the mental ability to participate in continued rehabilitation and

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• is able to transfer and mobilise short distances and

• has not yet achieved their full rehabilitation potential, as discussed with the
person, 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 People 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

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• healthcare professionals involved. [2011]

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Recommendations for research

The 2011, 2017 and 2023 guideline committees have made the following recommendations
for research.

The 2011 committee's full set of recommendations for research are detailed in the full
guideline.

As part of the 2017 update, the standing committee removed the recommendation for
research on displaced intracapsular hip fractures and made an additional recommendation
for research on undisplaced intracapsular hip fractures. Full details are available in section
3.5 of the full guideline addendum.

1 Imaging options in occult hip fracture

In people with a continuing suspicion of a hip fracture but whose radiographs are normal,
what is the clinical and cost effectiveness of CT compared with MRI, in confirming or
excluding the fracture?

Why this is important

The Guideline Development Group's consensus decision to recommend CT over a
radionuclide bone scan as an alternative to MRI to detect occult hip fractures reflects
current NHS practice but assumes that advances in technology have made the reliability of
CT comparable with that of MRI. If modern CT can be shown to have similar reliability and
accuracy to MRI, then this has considerable implications because of its widespread
availability out of hours and lower cost. It is therefore a high priority to confirm or refute
this assumption by direct randomised comparison. The study design would need to retain
MRI as the 'gold standard' for cases of uncertainty and to standardise the criteria,
expertise and procedures for radiological assessment. Numbers required would depend on
the degree of sensitivity and specificity (the key outcome criteria) set as target
requirement for comparability, but need not necessarily be very large. [2011]

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2 Anaesthesia
What is the clinical and cost effectiveness of regional versus general anaesthesia on
postoperative morbidity in people with hip fracture?

Why this is important

No recent randomised controlled trials were identified that fully address this question. The
evidence is old and does not reflect current practice. In addition, in most of the studies the
patients are sedated before regional anaesthesia is administered, and this is not taken into
account when analysing the results. The study design for the proposed research would be
best addressed by a randomised controlled trial. This would ideally be a multicentre trial
including 3,000 participants in each arm. This is achievable given that there are about
70,000 to 75,000 hip fractures a year in the UK. The study should have 3 arms that look at
spinal anaesthesia versus spinal anaesthesia plus sedation versus general anaesthesia;
this would separate those with regional anaesthesia from those with regional anaesthesia
plus sedation. The study would also need to control for surgery, especially type of
fracture, prosthesis and grade of surgeon.

A qualitative research component would also be helpful to study patient preference for
type of anaesthesia. [2011]

3 Undisplaced intracapsular hip fractures

For people with undisplaced (or non-displaced) intracapsular hip fracture, what features
should be used to characterise the injury and what are the optimal clinical and cost-
effective management strategies?

Why this is important

Between 5% and 15% of people with an intracapsular hip fracture will have an undisplaced
fracture. There is variation in the UK in how undisplaced intracapsular hip fractures are
recognised, resulting in some people not being offered the most appropriate treatment.
Research is needed to help healthcare professionals understand the clinical characteristics
of people who have undisplaced hip fracture (on anterior-posterior and lateral X-rays) and
how this relates to the effectiveness of different treatment strategies.

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The committee also noted a paucity of evidence for 2 of the interventions (total hip
replacement and hemiarthroplasty) that could potentially be useful for people with
undisplaced intracapsular hip fracture. A randomised controlled trial comparing these
interventions would be beneficial. [2017]

4 Intensive rehabilitation therapies after hip

fracture
What is the clinical and cost effectiveness of additional intensive physiotherapy and/or
occupational therapy (for example, progressive resistance training) after hip fracture?

Why this is important

The rapid restoration of physical and self-care functions is critical to recovery from hip
fracture, particularly where the goal is to return the person to preoperative levels of
function and residence. Approaches that are worthy of future development and
investigation include progressive resistance training, progressive balance and gait training,
supported treadmill gait re-training, dual task training and activities of daily living training.
The optimal time point at which these interventions should be started requires
clarification.

The ideal study design is a randomised controlled trial. Initial studies may have to focus on
proof of concept and be mindful of costs. A phase 3 randomised controlled trial is required
to determine clinical effectiveness and cost effectiveness. The ideal sample size will be
around 400 to 500 patients, and the primary outcome should be physical function and
health-related quality of life. Outcomes should also include falls. A formal sample size
calculation will need to be undertaken. Outcomes should be followed over a minimum of
1 year, and compare if possible, either the recovery curve for restoration of function or
time to attainment of functional goals. [2011]

5 Early supported discharge in care home patients

What is the clinical and cost effectiveness of early supported discharge on mortality,
quality of life and functional status in people with hip fracture who are admitted from a
care home?

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Why this is important

Residents of care and nursing homes account for about 30% of all people with hip fracture
admitted to hospital. Two-thirds of these come from care homes and the remainder from
nursing homes. These people are frailer, more functionally dependent and have a higher
prevalence of cognitive impairment than people admitted from their own homes. One-third
of those admitted from a care home are discharged to a nursing home and one-fifth are
readmitted to hospital within 3 months. There are no clinical trials to define the optimal
rehabilitation pathway following hip fracture for these people and therefore represent a
discrete cohort where the existing meta-analyses do not apply. As a consequence, many
people are denied structured rehabilitation and are discharged back to their care home or
nursing home with very little or no rehabilitation input.

Given the patient frailty and comorbidities, rehabilitation may have no effect on clinical
outcomes for this group. However, the fact that they already live in a home where they are
supported by trained care staff clearly provides an opportunity for a systematic approach
to rehabilitation. Early multidisciplinary rehabilitation based in care homes or nursing
homes would take advantage of the day-to-day care arrangements already in place and
provide additional NHS support to deliver naturalistic rehabilitation, where problems are
tackled in the person's residential setting.

Early supported multidisciplinary rehabilitation could reduce hospital stay, improve early
return to function, and affect both readmission rates and the level of NHS-funded nursing
care required.

The research would follow a 2-stage design: (1) an initial feasibility study to refine the
selection criteria and process for reliable identification and characterisation of those
considered most likely to benefit, together with the intervention package and measures for
collaboration between the Hip Fracture Programme team, care-home staff and other
community-based professionals and (2) a cluster randomised controlled comparison (for
example, with 2 or more intervention units and matched control units) set against agreed
outcome criteria. The latter should include those specified above, together with measures
of the impact on care-home staff activity and cost, as well as qualitative data from
patients on relevant quality-of-life variables. [2011]

6 Long-term effectiveness of total hip replacement

What is the long-term clinical and cost effectiveness for adults (including different

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subgroups) undergoing total hip replacement compared with hemiarthroplasty for

displaced intracapsular hip fracture? [2023]

For a short explanation of why the committee made this recommendation for
research, see the rationale section on total hip replacement versus hemiarthroplasty.

Full details of the evidence and the committee's discussion are in evidence review B:
total hip replacement versus hemiarthroplasty.

7 Femoral component design

In adults undergoing hemiarthroplasty for displaced intracapsular hip fracture (including in
different subgroups), which femoral component design has the best long-term outcomes?
[2023]

For a short explanation of why the committee made this recommendation for
research, see the rationale section on femoral component design used for
hemiarthroplasties.

Full details of the evidence and the committee's discussion are in evidence review A:
femoral component design used for hemiarthroplasties.

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Rationale and impact

These sections briefly explain why the committee made the recommendations and how
they might affect practice.

Total hip replacement versus hemiarthroplasty

Recommendation 1.6.3

Why the committee made the recommendation

The committee discussed the clinical evidence on total hip arthroplasty versus
hemiarthroplasty. They agreed that although some studies showed greater benefits for
total hip arthroplasty, this was not clinically or statistically significant for most outcomes.
However, a combination of the clinical evidence and the health economic model developed
as part of the guideline indicated that total hip arthroplasty may have some benefits and
be more cost effective than hemiarthroplasty beyond 2 years. The committee noted that
although recommendation 1.6.2 states that clinicians should offer arthroplasty (either total
hip arthroplasty or hemiarthroplasty) to people with a displaced intracapsular hip fracture,
hemiarthroplasty tends to be used more often than total hip arthroplasty. The evidence
was not strong enough for them to recommend total hip arthroplasty for everyone with a
displaced intracapsular fracture.

Based on their clinical knowledge and experience, the committee discussed how the long-
term outcomes considered in the health economic model were important but may not be
relevant to some people. For example, older people may not live long enough to
experience the long-term benefits of total hip arthroplasty, and people who are not very
mobile may be less concerned about the potential consequences of having a
hemiarthroplasty, such as wear on the acetabulum. The committee agreed that
hemiarthroplasty was a less complicated procedure than total hip arthroplasty and could
result in lower dislocation rates and less blood loss.

The health economic evidence on the long-term cost effectiveness and potential clinical
benefits of total hip arthroplasty led the committee to recommend that clinicians should
consider the procedure for those who are most likely to benefit from it beyond 2 years.
The list of criteria in the recommendation represents the past (a person's level of

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independence before the fracture), present (how they currently present in hospital and if
they are fit for the procedure on that day) and future (how much they are likely to benefit
beyond 2 years). Including this list gives clinicians more discretion over who to offer total
hip arthroplasty to and prevents the procedure being offered to some people who may get
the same, or more, benefit from hemiarthroplasty.

The committee discussed how some people with significant cognitive impairments may be
at increased risk of dislocations and could be less likely to benefit from total hip
arthroplasty. However, they agreed that the evidence for this was too limited to make a
specific recommendation for this population. The risk of dislocation can also vary
depending on the severity and type of cognitive impairment, or how much support the
person has. They agreed that cognitive impairment is one of many important comorbidities
that should be considered when making treatment decisions. It is more important for
clinicians to think about comorbidities in the context of functionality rather than whether
or not a person has them. The committee also agreed that decisions about whether
someone is likely to benefit most from total hip arthroplasty or hemiarthroplasty would
normally be made as part of a multidisciplinary team.

The committee discussed the potential long-term benefit of total hip arthroplasty in
specific groups of people, in particular younger age groups with fewer or less severe
comorbidities. As the evidence did not provide much long-term data, and results were not
reported for different age categories, it was agreed that further research should be carried
out to inform future recommendations. A recommendation for research on long-term
effectiveness of total hip replacement was therefore included to highlight the importance
of comparing the effectiveness of total hip arthroplasty with hemiarthroplasty in the long
term and determining the effect of each type of arthroplasty on different population
subgroups.

How the recommendation might affect practice

The recommendation allows clinicians to use their discretion in deciding who is offered
total hip arthroplasty. It should prevent people with mild forms of cognitive impairment
being excluded from total hip arthroplasty unnecessarily. As more data becomes available
on the long-term benefits of total hip arthroplasty in specific subgroups, there may be an
increase in the number of people who are considered for total hip arthroplasty.

Return to recommendation

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Femoral component design used for

hemiarthroplasties
Recommendations 1.6.5 to 1.6.7

Why the committee made the recommendations

The committee discussed the evidence on people who had been given Thompson, Exeter/
Unitrax or Exeter Trauma Stem (ETS) components and agreed that health-related quality
of life, mobility, mortality, unplanned return to theatre and adverse-event outcomes were
similar across all groups. The committee noted that although there were no cost-
effectiveness studies, there was a large amount of variability in femoral component costs
across the country for a given type of femoral component and between different types of
femoral component.

The Thompson component was cheaper than the ETS or Exeter/Unitrax component, but
the committee were aware of future regulatory changes requiring data about implants,
meaning that some older designs are unlikely to be used in the future. Without further
evidence on other cemented components currently in use, they were unable to
recommend one femoral component over another.

To choose the most cost-effective option, the committee agreed it was important for
hospitals to consider not only the cost of the component itself, but also the cost of training
needs when switching to a new component, alongside any future costs relating to adverse
outcomes. There may also be other considerations, in addition to costs. For example,
some hospitals may choose to use a femoral component that is suitable for both
hemiarthroplasty and total hip arthroplasty to allow consistency and greater efficiency in
practice. The committee thought it was important from a training and development
perspective that medical teams become familiar with implanting 1 single type of
component as standard. They agreed that more research was needed on the effectiveness
of different components.

The committee agreed that although the observational evidence was for femoral
components not used in the UK, it did emphasise the importance of registry data in
exploring longer-term adverse outcomes such as periprosthetic fracture in trauma patients
who had undergone hemiarthroplasty. Recording data on hemiarthroplasties for
submission to a national registry, such as the National Joint Registry, will help to provide

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real-world data on the long-term effectiveness and safety of different femoral components
in trauma patients.

The committee commented that the 2011 recommendation to use a proven femoral
component design (based on Orthopaedic Device Evaluation Panel ratings) came from
evidence of people having elective surgery. They queried whether femoral component
designs for elective patients who have arthritis were appropriate for trauma patients, given
that arthritis often puts people at greater risk of fractures. Therefore, the committee
drafted a recommendation for research on femoral component design that would allow
data for this fragility fracture population to be captured. Registry data could also be used
to evaluate long-term effectiveness in specific subpopulations such as people from
different ethnic backgrounds and other groups for which there is currently no evidence.

How the recommendations might affect practice

By recommending 1 femoral component as standard for hemiarthroplasties, surgical teams
will become familiar operating with this prosthesis and need less training in different
components. Hospitals or trusts will also choose a component that provides the best value
for money, but within the context of training requirements, team familiarity and overall
costs.

The National Joint Registry already collects data on total hip arthroplasties. Collecting data
on hemiarthroplasties in this, or a similar database, may require some extra administrative
work. But the real-world data will be valuable in helping future decision makers choose the
most clinically and cost-effective femoral component. Having further research on the
effectiveness of different femoral components in people from different population groups
will also help inform decisions and address health inequalities in this area.

Return to recommendations

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Context
Hip fracture refers to a fracture occurring in the area between the edge of the femoral
head and 5 cm below the lesser trochanter (see figure 1 in the full guideline). These
fractures are generally divided into 2 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.

Hip fracture is a major public health issue due to an ever-increasing ageing population.
About 65,000 hip fractures occur each year and the annual cost (not including the
considerable cost of social care) for all UK hip fracture cases is about £1 billion. About 10%
of people with a hip fracture die within 1 month and about one-third within 12 months.
Most of the deaths are due to associated conditions and not to the fracture itself,
reflecting the high prevalence of comorbidity. Because the occurrence of fall and fracture
often signals underlying ill health, a comprehensive multidisciplinary approach is required
from presentation to subsequent follow-up, including the transition from hospital to
community.

This guideline covers the management of hip fracture from admission to secondary care
through to final return to the community and discharge from specific follow-up. It assumes
that anyone clinically suspected of having a hip fracture will normally be referred for
immediate hospital assessment. It excludes (other than by cross-reference) aspects
covered by parallel NICE guidance, most notably primary and secondary prevention of
fragility fractures, but recognises the importance of effective linkage to these closely
related elements of comprehensive care. Although hip fracture is predominantly a
phenomenon of later life (the National Hip Fracture Database reports the average age of a
person with hip fracture as 84 years for men and 83 for women), it may occur at any age in
people with osteoporosis or osteopenia, and this guidance is applicable to adults across
the age spectrum. Management of hip fracture has improved through the research and
reporting of key skills, especially by collaborative teams specialising in the care of older
people (using the general designation 'orthogeriatrics'). These skills are applicable in hip
fracture irrespective of age, and the guidance includes recommendations that cover the
needs of younger people by drawing on such skills in an organised manner.

Although not a structured service delivery evaluation, the Guideline Development Group
was required to extend its remit to cover essential implications for service organisation

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Hip fracture: management (CG124)

within the NHS where these are fundamental to hip fracture management, and this has
been done.

The NICE surveillance review identified new studies that were consistent with the current
recommendations. However, because of a low level of compliance (around 30% nationally)
with the recommendation to offer total hip replacement to people with displaced
intracapsular hip fractures, we have updated this part of the guideline. The 2017 update
also covers interventions for undisplaced intracapsular hip fractures, which were not
covered in the original guideline.

The guideline will assume that prescribers will use a drug's summary of product
characteristics to inform decisions made with individual patients.

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Finding more information and committee

details
To find NICE guidance on related topics, including guidance in development, see the NICE
topic page on injuries, accidents and wounds.

For full details of the evidence and the guideline committee's discussions, see the full
guideline, addendum and evidence reviews. You can also find information about how the
guideline was developed, including details of the committee.

NICE has produced tools and resources to help you put this guideline into practice. For
general help and advice on putting our guidelines into practice, see resources to help you
put NICE guidance into practice.

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Hip fracture: management (CG124)

Update information
January 2023: We have reviewed the evidence for the management of intracapsular hip
fracture and femoral component design used for hemiarthroplasties, and updated our
recommendations. These recommendations are marked [2023]. We also made 2 new
recommendations for research.

In some cases, minor changes have been made to the wording of other recommendations
to bring the language and style up to date, without changing the meaning. We also made a
clarification in recommendation 1.6.9 because of changes to the AO classification. This is
marked [2011, amended 2023] and it last had an evidence review in 2011.

Recommendations marked [2011],[2011, amended 2014] last had an evidence review in

2011. Recommendations marked [2017] last had an evidence review in 2017.

May 2017: Recommendations have been updated on the surgical management of hip
fracture. These are marked as [2017]. A link was added to recommendation 1.6.4 on
cemented implants to highlight safety guidance.

Where recommendations end [2011] or [2011, amended 2014], the evidence has not been
reviewed since the original guideline.

March 2014: The introduction to the full guideline and the wording of recommendation 1.1.1
have been amended to clarify how an occult fracture is identified and when an MRI scan
should be done.

ISBN: 978-1-4731-4923-6

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Hip fracture: management (CG124)

Accreditation

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