Hip fractures

Ideally, surgery should be carried out within 48 hours of admission on a planned trauma list.1 The nature of the operation will be influenced by fracture site, displacement, and the patient’s functional status. NICE guidelines have been published offering recommendations on the choice of fixation method or implant to be used in particular situations (table⇓): extracapsular fractures at or above the level of the lesser trochanter should be managed with a dynamic hip screw (fig 2⇓). Fractures within the subtrochanteric region should receive an intramedullary nail. Displaced intracapsular fractures should be treated with a cemented arthroplasty procedure, either total hip replacement (femoral head and acetabulum replaced) or hemiarthroplasty (femoral head alone replaced). Patients who were independently mobile before their fracture, who are not cognitively impaired, and who are medically fit for anaesthesia should be offered a total hip replacement. Patients who do not fulfil these mobility and cognitive requirements should be offered a hemiarthroplasty based on a recognised total hip stem—for example, Exeter, Stanmore—and not one of the older hemiarthroplasty devices such as the Austin-Moore or Thompson (fig 3⇓). NICE does not mention undisplaced intracapsular fractures in its guidance. Internal fixation with either cannulated screws (fig 4⇓) or a dynamic hip screw is preferred to non-operative management of these fractures, however, which is associated with a 20% risk of non-union or fracture displacement.1011