Blood supply at risk → avascular necrosis. Classified by Garden grade.
Blood supply preserved. Surgical fixation preferred. Lower AVN risk.
Key point: The Garden classification applies only to intracapsular fractures. Extracapsular fractures are described by anatomical location and degree of comminution.
Clinically: Garden I/II = undisplaced → fixation attempt. Garden III/IV = displaced → arthroplasty (age >65).
Best Practice Tariff (BPT): Surgery should occur within 36–48 hours of admission. Delays beyond 48h associated with increased mortality, pressure injuries, and delirium. Document reason for any delay.
Regional nerve block targeting femoral, lateral femoral cutaneous, and obturator nerves. Gold standard pre-op analgesia for NOF fractures.
Pre-op traction: NOT routinely recommended. No evidence of benefit. Causes pressure injuries and increases pain. Discontinue if in use.
Perform MMSE (Mini-Mental State Examination) on admission. Document baseline — essential for detecting post-op delirium (comparison point).
Avoid anticholinergic medications (cyclizine, promethazine, some antihistamines) — strongly associated with delirium in elderly.
Complete Waterlow score on admission. Hip fracture patients are very high risk — immobility, age, malnutrition, incontinence.
Document Waterlow and pressure area status in pre-op nursing assessment. Medicolegally important if litigation arises post-op.
| Fracture Type | Patient Factors | Procedure | Rationale |
|---|---|---|---|
| Intracapsular, displaced Garden III / IV |
<65 yr, active | Dynamic Hip Screw / IM Nail | Attempt fixation; preserve native hip |
| Intracapsular, displaced Garden III / IV |
>65 yr, mobile | Cemented Hemiarthroplasty | Cemented preferred — better function in elderly; avoids re-operation for AVN |
| Intracapsular, displaced Garden III / IV |
Active, cognitively intact | Total Hip Replacement (THR) | Better long-term outcomes in selected fit patients; hip precautions required |
| Intracapsular, undisplaced Garden I / II |
Any | Cannulated Screws / DHS | Preserve femoral head; good blood supply |
| Extracapsular Intertrochanteric |
Any | Dynamic Hip Screw (DHS) | Standard of care; allows controlled impaction |
| Extracapsular Subtrochanteric |
Any | Intramedullary Nail | High bending forces — nail superior to DHS here |
Bone Cement Implantation Syndrome: Transient hypotension during cemented hemiarthroplasty from methyl methacrylate monomer absorption.
Nursing role: pre-load with IV fluids, vasopressor (metaraminol/ephedrine) ready, alert anaesthetist at cement insertion moment.
Post-operative delirium is the most common complication after hip fracture surgery — incidence 25–65%. It is a medical emergency requiring immediate assessment and intervention.
| Item | Score |
|---|---|
| A — Alertness (normal = 0; abnormal = 4) | 0 or 4 |
| A — AMT4 (age, DOB, place, year — 4/4 = 0; <4 = 1) | 0 or 1 |
| A — Attention (list months backward — all correct = 0; 1 error = 1; >1 error = 2) | 0–2 |
| T — Acute change / fluctuating course (yes = 4; no = 0) | 0 or 4 |
Haloperidol: Use only for severe agitation causing harm to patient/staff. Not first-line. Non-pharmacological management preferred.
Emergency: Sudden severe hip pain, leg shortened + externally/internally rotated post-hemiarthroplasty or THR. Requires urgent reduction (within hours).
Catastrophic complication. Deep infection of the prosthesis. High morbidity, often requires multi-stage revision surgery.
Document pressure area status on every nursing entry. Grade any wounds using European Pressure Ulcer Advisory Panel (EPUAP) grading.
The orthogeriatric model is the gold standard for hip fracture care — reduces mortality, length of stay, and re-admission rates.
| Team Member | Role |
|---|---|
| Geriatrician | Medical optimisation, delirium management, medication review |
| Orthopaedic Surgeon | Surgical decision, follow-up, complication management |
| Physiotherapist | Mobilisation, gait retraining, strength exercises, stairs |
| Occupational Therapist | ADL assessment, home visit, equipment provision |
| Clinical Nurse Specialist | Hip fracture pathway coordination, patient education |
| Social Worker | Discharge planning, carer assessment, home support |
| Dietician | Nutritional assessment, supplementation plan |
Target: 80% of patients return to pre-fracture level of mobility with early surgery and structured orthogeriatric rehabilitation.
| Grade | Description | Displacement | Management |
|---|---|---|---|
| I | Incomplete / Impacted | None | Cannulated screws |
| II | Complete, undisplaced | None | Cannulated screws |
| III | Partial displacement | Partial | <65yr: DHS fixation; >65yr: hemiarthroplasty |
| IV | Full displacement | Complete | <65yr: DHS fixation; >65yr: hemiarthroplasty / THR |
Memory: I = Incomplete, II = Intact alignment, III = Tilted (partial), IV = Fully apart
Note: Hip precautions for hemiarthroplasty are similar but may be less strict depending on surgical approach (posterior vs anterior).
Preserve native femoral head
Controlled fracture impaction during healing
High bending moment — DHS would fail here
A 72-year-old woman falls and has a painful shortened, externally rotated right leg. X-ray shows a Garden IV intracapsular fracture. What is the most appropriate surgical management?
What is the maximum time from admission to surgery recommended by Best Practice Tariff guidelines for hip fracture patients?
A post-operative THR patient is found with sudden severe hip pain and a shortened, internally rotated leg on day 2. What has occurred and what is the immediate nursing action?
What is the 4AT score threshold that suggests possible delirium and requires escalation?
Why is vitamin D supplementation considered universal in GCC hip fracture patients regardless of blood levels?
A patient on warfarin is admitted with a hip fracture. INR is 3.1. What pre-operative steps should be taken to proceed to surgery within 36 hours?
Which fracture type is the Fascia Iliaca Compartment Block most effective for, and what nerves does it block?