01Approach to the Critical Patient/attcp45

Immediate stabilization

›Life-threatening fall etiology screen

›Syncope preceding fall

›Arrhythmia

›Acute coronary syndrome

›Vertebrobasilar stroke

›Hemodynamic instability suggesting occult hemorrhage

›SBP < 90 mmHg

›Heart rate > 100 beats/min

›If syncope or hemodynamic instability, treat underlying cause before hip management

›Cardiac monitoring

›12-lead ECG immediately

›Neurovascular threat to limb

›Absent distal pulses

›Dorsalis pedis

›Posterior tibial

›Motor or sensory deficit below fracture level

›Foot drop concern

›Sciatic nerve involvement in high-energy mechanism

›Open fracture with wound contamination

›Immediate orthopedic consultation

›Wound coverage and antibiotic initiation

Monitoring and targets

›Hemodynamic monitoring

›Continuous cardiac monitoring

›Arrhythmia detection

›Rate control if atrial fibrillation present

›Oxygen saturation

02History/hx77

Mechanism and presentation

›Mechanism of injury

›Low-energy ground-level fall (elderly)

›Most common mechanism

›Osteoporosis as underlying contributor

›High-energy trauma (younger patients)

›Motor vehicle collision

›Fall from height

›Stress or insufficiency fracture

›Insidious onset groin or buttock pain

›Worsened by weight-bearing and activity

›Female athlete triad or RED-S in young athletes

›Symptom pattern

›Anterior groin pain

›Hallmark symptom

›May radiate to ipsilateral thigh or knee

›Inability to bear weight

›Acute onset with inciting event for displaced fractures

›Partial weight-bearing possible with nondisplaced fractures

›Pain at rest

›Suggestive of displaced or unstable fracture

Risk factors and medications

›Fall risk-increasing drugs

›Opioids

›OR 1.60 for hip fracture

›Benzodiazepines

›OR 1.84 for hip fracture

›Antipsychotics

03Physical Exam/exam50

Limb alignment and deformity

›Classic displaced fracture appearance

›Shortened lower extremity

›Leg length discrepancy measurement

›Externally rotated foot

›Psoas and hip external rotators unopposed

›Abducted lower extremity

›Gravitational positioning

›Nondisplaced fracture exam

›Minimal or no visible deformity

›High diagnostic miss risk without imaging

›Log roll test

›Pain with passive internal and external rotation

›High sensitivity for occult fracture

›Axial loading test

›Pain with heel tap along limb axis

›Positive test supports fracture

Neurovascular assessment

›Distal pulses

›Dorsalis pedis

›Compare bilateral symmetry

›Posterior tibial

›Absent pulse triggers urgent vascular consultation

›Sensory and motor function

›Foot dorsiflexion strength

›Common peroneal nerve territory

›Toe plantar flexion

›Tibial nerve territory

04Differential Diagnosis/ddx43

Proximal femur fractures

›Intertrochanteric fracture

›ICD-10 S72.1

›Extracapsular location

›More common ecchymosis to medial thigh

›Similar presentation but extends between trochanters

›Managed with intramedullary nail or sliding hip screw

›Avascular necrosis risk lower than femoral neck

›Subtrochanteric fracture

›High-energy mechanism in young patients

›Or atypical insufficiency fracture in bisphosphonate users

›Requires intramedullary fixation

›Varus deformity at fracture site

Pelvic and acetabular fractures

›Pubic ramus fracture

›ICD-10 S32.5

›Groin and anterior pelvic pain

›May coexist with femoral neck fracture

›Visible on AP pelvis radiograph

›Conservative management for isolated non-displaced

›Acetabular fracture

›High-energy mechanism typical

›CT required for characterization

›Posterior wall fracture with posterior hip dislocation

›Urgent reduction required

Soft tissue and other diagnoses

›Hip dislocation

›Posterior dislocation classic posture

05Laboratory Tests/lt49

Core preoperative labs

›Complete blood count

›Baseline hemoglobin for transfusion planning

›Transfusion threshold Hgb < 80 g/L (8 g/dL) in asymptomatic patients

›Higher threshold if symptomatic or cardiac disease

›Platelet count

›Neuraxial anesthesia planning

›Threshold > 80 x10^9/L for spinal anesthesia

›Metabolic panel

›Electrolytes

›Sodium derangement common in elderly

›Potassium for cardiac monitoring context

›Renal function

›eGFR for DOAC management

›Contrast administration planning if CT with contrast needed

›Glucose

›Perioperative glycemic management planning

›Coagulation studies

›PT/INR for warfarin users

›INR > 1.5 requires reversal before surgery

›Vitamin K plus 4-factor PCC for urgent reversal

›Anti-Xa level

›DOAC use with uncertain last dose timing

›Apixaban and rivaroxaban quantification

Cardiac and infection labs

›Troponin

›If cardiac event suspected as fall etiology

›High-sensitivity troponin preferred

06Diagnostic Tests/dt108

Scoring Systems

›Garden classification

›Type I

›Incomplete or valgus-impacted fracture

›Low displacement risk

›Type II

›Complete, nondisplaced fracture

›Cortical trabecular alignment maintained

›Type III

›Complete, partially displaced

›Trabecular angle altered

›Type IV

›Complete, fully displaced

›No cortical contact

›Clinical utility

›Displaced (III-IV) versus nondisplaced (I-II) is the key distinction

›Interobserver reliability poor for full four-type classification

›Displaced fractures in patients >= 65 years favor arthroplasty

›Pauwels classification

›Type I: fracture line angle < 30 degrees

›Compression forces predominate

›Better fixation prognosis

›Type II: fracture line angle 30 to 50 degrees

›Intermediate shear

›Type III: fracture line angle > 50 degrees

›Shear forces predominate

›Higher fixation failure risk

›FRAX score

›10-year fracture probability calculator

›Integrates parental hip fracture, prior fracture, BMI, smoking, alcohol, corticosteroids

›Guides bisphosphonate therapy initiation

›Not for acute ED use

›Secondary prevention planning tool

›Posterior tilt angle

›Measured on lateral radiograph

›Angle > 20 degrees predicts fixation failure

›Favor arthroplasty over internal fixation when > 20 degrees

MRI

›MRI hip indications

›Gold standard for occult femoral neck fractures

›Sensitivity 100%

›Obtain when radiograph negative and clinical suspicion high

›Abbreviated protocol acceptable

›Coronal T1 plus STIR sequences

›Protocol reduces scan time without diagnostic loss

›Fracture characterization

›Bone marrow edema pattern

›Incomplete versus complete fracture line delineation

›MRI findings

›T1 hypointense fracture line

›Traversing femoral neck

›STIR hyperintensity

›Bone marrow edema surrounding fracture

›Soft tissue edema

›Capsular hematoma

›Hip joint effusion

›MRI limitations

›Availability and time constraints

›CT first for speed if MRI delayed

›Contraindications

›Certain pacemakers and implants

›Combative or claustrophobic patients

›ACR Appropriateness Criteria

›MRI hip without contrast usually appropriate for negative radiograph with high suspicion

CT

›CT hip indications

›Occult fracture

›Sensitivity 79 to 94% for occult femoral neck fractures

›Faster than MRI when immediate surgical planning needed

›Fracture characterization

›Comminution pattern

›Posterior wall involvement

›Posterior tilt angle measurement

›Surgical planning

›Implant selection

›Acetabular involvement assessment

›CT protocol

›AP pelvis radiograph first

›If fracture confirmed, CT for operative planning

›Without contrast for fracture evaluation

›Contrast only if vascular injury suspected

›Thin-slice reconstruction

›1 to 2 mm cuts through proximal femur

›CT limitations

›Lower sensitivity than MRI for occult fractures

›If CT negative and suspicion persists, obtain MRI

›Radiation exposure

›Relevant in younger patients and stress fracture evaluation

Ultrasound

›POCUS for regional anesthesia guidance

›Fascia iliaca compartment block

›Ultrasound-guided technique reduces pain within 30 minutes

›Reduces opioid consumption

›Reduces delirium risk

›ACEP Level B recommendation for ED nerve blocks

›PENG block (pericapsular nerve group)

›Motor-sparing alternative to FICB

›Promising early randomized trial data

›Targets articular branches of femoral and obturator nerves

›POCUS hemodynamic assessment

›IVC diameter and collapsibility

›Fluid responsiveness estimate

›Limited by respiratory variation artifacts

›Left ventricular function

›Gross systolic function screen

›Pericardial effusion exclusion

›Ultrasound-guided procedures

›IV access in difficult peripheral access

›Antecubital or basilic vein

›Hip joint effusion assessment

›Hematoma characterization

›Not routinely required for diagnosis

07Disposition/dispo38

Admission and surgical planning

›All confirmed femoral neck fractures require admission

›Immediate orthopedic surgery consultation

›Surgical timing target 24 to 48 hours from injury

›Early surgery associated with reduced mortality and complications

›Orthogeriatrics or hospitalist co-management

›AAOS strong recommendation

›Reduces 30-day complications and length of stay

›Surgical timing considerations

›Ultra-early surgery (< 12 hours) versus early (12 to 48 hours)

›Cochrane 2024 review: no significant mortality difference

›Ultra-early may reduce pain and time to mobilization

›Delay acceptable for active medical optimization

›Unstable cardiac conditions

›Active bleeding requiring reversal

›Poorly controlled electrolyte derangements

Nonoperative management indications

›Nonambulatory patients at baseline

›Limited functional gain expected from surgery

›Goals of care discussion required

›Severe frailty or terminal illness

›Palliative approach consideration

›Patient refusal after informed consent

›Document capacity assessment

›Ensure delirium excluded before consent obtained

›Advance directives guiding management

Transfer criteria

›Transfer to higher level of care

08Treatment/t128

Analgesia and regional blocks

›Multimodal analgesia

›Acetaminophen IV or PO

›1000 mg every 6 hours

›Preferred baseline analgesic

›Hepatic dose reduction if liver disease

›Ketorolac IV

›15 to 30 mg IV every 6 hours

›Short course only (< 5 days)

›Avoid if eGFR < 30 or active GI bleeding

›Low-dose opioid rescue

›Hydromorphone 0.2 to 0.4 mg IV PRN

›Minimize total dose to reduce delirium risk

›Reassess pain score every 30 minutes

›Fascia iliaca compartment block

›Ultrasound-guided preferred technique

›Needle insertion below inguinal ligament lateral to femoral vessels

›Inject 30 to 40 mL of 0.25% bupivacaine

›Onset 15 to 30 minutes

›Reduces opioid consumption by approximately 50%

›Meta-analysis evidence supporting ED use

›JAMA 2025 systematic review supports nerve blocks for hip fracture

›PENG block alternative

›Targets articular branches at anterior inferior iliac spine

›Motor-sparing advantage over FICB

›2025 RCT data (Di Pietro et al.) supports comparable efficacy to FICB

›Avoid

›Benzodiazepines

›High delirium risk

›Long-acting opioids

›Accumulation risk in elderly with renal impairment

Anticoagulation reversal

›Warfarin reversal

›4-factor prothrombin complex concentrate (PCC)

›25 to 50 IU/kg IV based on INR and weight

›Target INR < 1.5 for surgery

›Vitamin K 10 mg IV

›Adjunct to PCC

›Delayed effect 6 to 12 hours

›DOAC management

›Apixaban or rivaroxaban

›Surgery safe if last dose > 36 hours ago and eGFR > 60

›Anti-Xa level < 50 ng/mL supports safety

›Dabigatran

›Idarucizumab 5 g IV for urgent reversal

›Surgery safe if last dose > 48 hours ago with normal renal function

›Andexanet alfa

›Reversal agent for factor Xa inhibitors in life-threatening bleeding

›Not routinely required for hip fracture surgical reversal

Surgical management

›Nondisplaced fractures (Garden I to II)

›Internal fixation with cancellous screws

›Three parallel cannulated screws in inverted triangle

›Sliding hip screw alternative for basicervical patterns

›Valgus-impacted fractures

›Internal fixation in most patients

›Nondisplacement does not guarantee stability without fixation

›Displaced fractures in elderly patients (Garden III to IV, age >= 65)

›Hemiarthroplasty

›Unipolar or bipolar femoral head replacement

›Faster operative time

›Lower dislocation rate than THA in low-demand patients

›Total hip arthroplasty (THA)

›Preferred for higher-demand patients with good functional status

›Better long-term function and less acetabular erosion than hemiarthroplasty

›Cochrane 2022 network meta-analysis supports THA in fit elderly

›Displaced fractures in young or active patients

›Closed reduction and internal fixation

›Preserve native femoral head

›Emergency reduction required

›Avascular necrosis risk up to 9.7% despite fixation

VTE prophylaxis

›Pharmacologic prophylaxis

›Low-molecular-weight heparin

›Enoxaparin 40 mg SC daily (CrCl > 30 mL/min)

›Enoxaparin 20 mg SC daily if CrCl 15 to 30 mL/min

›Initiate within 12 hours postoperatively

›Aspirin alternative

›Aspirin 81 mg PO daily

›PREVENT CLOT trial (NEJM 2023): aspirin non-inferior to LMWH for VTE prevention in fracture patients

›Safe, effective, and inexpensive alternative per ACCP guidelines

›DOACs

›Rivaroxaban 10 mg PO daily starting postoperative day 1

›Apixaban 2.5 mg PO twice daily

›Minimum duration 10 to 14 days

›Extended prophylaxis up to 35 days recommended by ACCP

›Mechanical prophylaxis

›Sequential compression devices

›Until pharmacologic prophylaxis initiated

›Adjunct not replacement

Perioperative antibiotics

›Prophylactic antibiotic

›Cefazolin 2 g IV within 60 minutes before incision

›Redose every 3 to 4 hours during prolonged surgery

›Continue 24 hours postoperatively

›Vancomycin 15 to 20 mg/kg IV if cephalosporin allergy or MRSA risk

›Administer over 60 minutes before incision

›Renal dosing adjustment required

Delirium prevention

›Nonpharmacologic multicomponent interventions

›Reorientation and cognitive stimulation

›Familiar objects and family presence

›Consistent nursing care

›Sleep-wake cycle preservation

›Minimize nighttime interruptions

›Avoid anticholinergic sleep aids

›Early mobilization within 24 hours postoperatively

›Physical therapy day 1 postoperative

›Weight-bearing as tolerated unless specified otherwise

›Hearing and vision aids in place

›Provide hearing aids and glasses immediately

›Adequate hydration and nutrition

›Early oral intake postoperatively

›Proactive geriatrics consultation

›Reduces delirium incidence by 36% in RCT data

›ACEP recommendation for orthogeriatrics co-management

›Avoidance of high-risk medications

›Benzodiazepines

›Anticholinergics

›Diphenhydramine

Osteoporosis secondary prevention

›Bisphosphonate therapy initiation

›Zoledronic acid 5 mg IV infusion

›Can be given 2 weeks postoperatively

›Annual dosing

›Requires adequate vitamin D and calcium before infusion

›Alendronate 70 mg PO weekly

›Alternative oral bisphosphonate

›Must be taken fasting with full glass of water

›ACP 2023 living guideline supports bisphosphonate as first-line

›Calcium and vitamin D supplementation

›Calcium 1000 to 1200 mg elemental daily (dietary preferred)

›Supplement only if dietary intake inadequate

›Vitamin D3 800 to 2000 IU daily

›Target serum 25-OH-D >= 75 nmol/l

09Special Populations/sp65

Pregnancy

›Pregnancy considerations

›Femoral neck fracture in pregnancy is rare

›Transient osteoporosis of pregnancy as etiology

›Stress fracture pattern more common than traumatic

›Imaging approach

›AP pelvis radiograph with pelvic shielding if needed for diagnosis

›MRI without gadolinium preferred to avoid radiation

›CT only when MRI unavailable and clinical urgency demands

›Surgical management

›Internal fixation preferred over arthroplasty in pregnant patients

›Fetal monitoring perioperatively when viable gestation

›Spinal anesthesia with left uterine displacement preferred

›VTE prophylaxis in pregnancy

›LMWH preferred

›DOACs contraindicated in pregnancy

›Warfarin contraindicated in first trimester and near delivery

›Calcium and vitamin D supplementation throughout pregnancy

›Transient osteoporosis often self-limited postpartum

Geriatric

›Geriatric considerations

›Atypical presentation is common

›Nondisplaced fracture may present with ability to bear weight

›Maintain high diagnostic suspicion despite mild symptoms

›High delirium risk

›Incidence 22 to 44% perioperative delirium in hip fracture patients

›Multifactorial delirium prevention bundle mandatory

›Polypharmacy review

10Background/b76

Epidemiology

›Incidence and burden

›300,000 hip fractures annually in the United States

›Projected to exceed 500,000 by 2040 with aging population

›Women account for approximately 75% of hip fractures

›Women > 85 years have 10-fold higher risk than women in their 60s

›1-year mortality approximately 30%

›30-day mortality approximately 10% even with surgical management

›Men have higher mortality than women after hip fracture

›Risk factors epidemiology

›Osteoporosis T-score <= -2.5 is the primary modifiable risk factor

›Present in majority of hip fracture patients

›Low BMI (< 18.5 kg/m2)

›Associated with 1.5 to 2-fold increased risk

›Moderate to high alcohol intake (> 27 g/day)

›1.5 to 2-fold increased fracture risk

›High caffeine intake (> 3 cups/day)

›Additional 1.5-fold increased risk in low calcium intake states

›Femoral neck as intracapsular fracture

›Accounts for approximately 45 to 50% of all hip fractures

›Intertrochanteric fractures account for approximately 45%

›Subtrochanteric fractures approximately 5%

›Approximately 15% of femoral neck fractures are occult on initial radiographs

Pathophysiology

›Vascular anatomy vulnerability

›Blood supply to femoral head

›Medial femoral circumflex artery (MFCA) dominant supply

›Retinacular vessels travel along femoral neck within capsule

›Ligamentum teres artery (obturator artery branch) minor contribution

›Fracture disrupts retinacular vessels

›Displaced fractures cause higher vascular disruption

›Avascular necrosis risk proportional to displacement degree

›Intracapsular hematoma

›Increases intracapsular pressure

›Compresses vessels further

›Tamponade effect worsens ischemia

›Osteoporosis mechanism

›Trabecular bone loss

›Ward triangle region particularly vulnerable

›Cortical thinning of femoral neck

›Femoral neck geometry

›Wider neck-shaft angle increases stress

›Longer hip axis length increases fracture risk

›Fall biomechanics

›Fall direction matters

›Lateral fall directly onto greater trochanter highest risk

›Hip abductor muscle strength reduces impact transmission

›Impact attenuation

›Soft tissue padding in obese patients protective

›Low BMI patients have less cushioning

Therapeutic Considerations

›Surgical timing evidence

›Surgery within 24 to 48 hours of admission

›Associated with reduced 30-day and 1-year mortality

›Reduces pain duration and complication risk

›Medical optimization before surgery

›Delay acceptable for reversible acute conditions

›Chronic stable conditions should not delay surgery

›Cochrane 2024 review on ultra-early surgery

›Ultra-early (< 12 hours) versus early (12 to 48 hours): no significant mortality difference

›Larger RCTs ongoing

›Arthroplasty versus internal fixation for displaced fractures

›Cochrane 2022 network meta-analysis

›THA associated with better functional outcomes than hemiarthroplasty

›Both superior to internal fixation for displaced fractures in elderly

›Internal fixation failure rates

›Nonunion rate 18.5% for displaced fractures managed with fixation

›Avascular necrosis rate 9.7% for displaced fractures managed with fixation

›Revision surgery rates

›Internal fixation has higher revision rates than arthroplasty in elderly

›Nerve block evidence

›FICB versus systemic opioids

›Meta-analysis: FICB reduces pain score by approximately 3 points on 10-point scale

›Reduces opioid consumption by approximately 50%

›May reduce delirium incidence

›PENG block emerging data

›2025 RCT (Di Pietro et al., Anaesthesia) comparable efficacy to FICB

›Motor-sparing advantage permits earlier fall risk assessment

›JAMA 2025 review supports nerve block recommendation for hip fracture

11Patient Discharge Instructions/pdi53

copy discharge instructions

›Hip fracture home care instructions

›You have a hip fracture and have had surgery

›Follow all weight-bearing restrictions given by your surgeon

›Do not skip physiotherapy appointments

›Wound care

›Keep surgical incision clean and dry for 2 weeks

›No submerging in water until cleared by your surgeon

›Watch for signs of infection at the wound site

›Blood clot prevention

›Take blood-thinning medication as prescribed

›Compression stockings as instructed

›Leg exercises (ankle pumps) regularly while resting

›Medications after discharge

›Pain medications

›Take acetaminophen regularly as prescribed

›Use stronger painkillers only as needed and for the shortest time

›Bone medications

›Start bisphosphonate medication as instructed (usually 2 weeks after surgery)

›Take weekly bone pill on empty stomach with a full glass of water

›Sit or stand upright for 30 minutes after taking bone pill

›Calcium and vitamin D

›Take calcium and vitamin D supplements daily as prescribed

›Fall prevention at home

›Remove throw rugs and trip hazards from floors

›Especially at night pathways to bathroom

›Install grab bars in shower and beside toilet

›Use assistive device (walker or cane) as prescribed

12References/r56

Guidelines and key sources

›Orthopedic and trauma guidelines

›AAOS Management of Hip Fractures in Older Adults Evidence-Based Clinical Practice Guideline 2022

›Switzer JA, O'Connor MI, JAAOS 2022

›Strong recommendation for co-management model

›American College of Surgeons Best Practices Orthopaedic Trauma 2015

›Davis ML et al.

›WSES 2023 Guidelines on Trauma in Elderly and Frail Patients

›De Simone B et al., World Journal of Emergency Surgery 2024

›VTE prophylaxis evidence

›PREVENT CLOT Trial

›METRC Consortium, NEJM 2023

›Aspirin non-inferior to LMWH for fracture VTE prophylaxis

›ACCP Antithrombotic Therapy 9th Edition

›Falck-Ytter Y et al., Chest 2012

›Minimum 10 to 14 days pharmacologic prophylaxis

›Surgical approach evidence

›Cochrane Surgical Interventions for Intracapsular Hip Fractures 2022

›Lewis SR et al.

›THA versus hemiarthroplasty versus internal fixation network meta-analysis

›Cochrane Arthroplasties for Hip Fracture 2022

›Lewis SR et al.

›Cochrane Ultra-Early versus Early Surgery for Hip Fracture 2024

›Viamont-Guerra MR et al.

›Nerve block evidence

›Peripheral Nerve Blocks for Hip Fractures JAMA 2025

›Liu YT, Tovar Hirashima E, Yadav K

›Fascia Iliaca Block for Hip Fractures in ED Meta-Analysis

Evidence & Review