Guideline 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 American Academy of Orthopaedic Surgeons (AAOS 2022), the World Falls Guidelines (WFG 2022), the American College of Obstetricians and Gynecologists (ACOG 2022; 2021), the American Association of Family Physicians (AAFP 2022), 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 Eastern Association for the Surgery of Trauma (EAST 2016), and the Osteoporosis Canada Foundation (OC 2010). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Guidelines 1. Diagnostic investigations Diagnostic imaging: https://web.pathway.md/diseases/recRdaocxVoiEsSMc 1/9 6/24/23, 12:45 PM Hip fracture Pathway As per AAFP 2022 guidelines, obtain cross-table lateral hip and anteroposterior pelvis radiography as initial evaluation for suspected hip fracture. B As per ACR 2019 guidelines: Obtain hip and pelvis X-rays as initial imaging of the hip with acute pain, fall or minor trauma, and suspected fracture. B Obtain hip and pelvis MRI or CT as subsequent imaging for evaluating acute hip pain from a fall or minor trauma with negative X-ray and suspected fracture. B Functional tests: Perform a musculoskeletal examination using the following tests and tools: assessment of knee extension strength in all settings B the Verbal Rating Scale for pain in all settings B the Gait Speed Test, documenting comfortable or maximum speed, walking aid, and rolling start or static start in all settings in patients not requiring human assistance B the Cumulated Ambulation Score to measure basic mobility in the acute and post-acute clinical settings until independent ambulation has been reached B the Timed Up and Go Test, documenting comfortable or maximum speed and walking-aid use, to measure mobility and risk for falls in all settings in patients not requiring human assistance B the New Mobility Score to assess the pre-fracture status in the early period/inpatient setting and the current status and recovery of pre-fracture status in the post-acute and community settings B the Falls Efficacy Scale-International to measure concern about falling in all settings. B Consider using the following tools in all settings: the Short Physical Performance Battery, recognizing that completion may not be feasible in the early postoperative period depending on ability the Activity Measure for Post-Acute Care using the 3-level version of the EuroQol-5 dimensions scale to measure health-related quality of life the 10-item physical functioning scale of the Medical Outcomes Study 36-Item Short-Form Health Survey to measure physical functioning the Medical Outcomes Study 36-Item Short-Form Health Survey to measure health-related quality of life. C 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 https://web.pathway.md/diseases/recRdaocxVoiEsSMc 2/9 6/24/23, 12:45 PM Hip fracture Pathway Insufficient evidence to recommend for the preference of selective NSAIDs (COX-2 inhibitors) or nonselective NSAIDs. I As per AOPT 2021 guidelines: Implement strategies to minimize fracture-related pain during physical therapy sessions to optimize the patient's mobility. Consider offering the following strategies for nonpharmacological pain management: appropriate timing of medication consultation with the interprofessional team psychologically informed physical therapy approaches. E Consider offering electrical stimulation for pain if it is not sufficiently managed with usual strategies. C Management of osteoporosis, indications: As per ACOG 2022 guidelines, initiate pharmacotherapy for osteoporosis in patients at high risk of fracture. A As per ACE/AACE 2020 guidelines, initiate pharmacologic therapy in patients with osteopenia or low bone mass and a history of a fragility fracture of the hip or spine. A Show 2 more As per ES 2020 guidelines, initiate pharmacotherapy in postmenopausal patients with osteoporosis at high risk of fractures, especially in patients with a recent fracture. A Management of osteoporosis, regimens: As per ACP 2023 guidelines, initiate bisphosphonates for initial pharmacologic treatment to reduce the risk of fractures in postmenopausal patients with primary osteoporosis. A Show 4 more As per ACOG 2022 guidelines, initiate bisphosphonates as initial therapy in most postmenopausal patients at increased risk of fracture. A Show 5 more As per ACE/AACE 2020 guidelines, initiate alendronate, risedronate, or zoledronate as initial therapy to reduce hip, non-vertebral, and spine fractures in most postmenopausal patients with osteoporosis at high risk of fracture. A Show 5 more As per ES 2020 guidelines, initiate bisphosphonates (alendronate, risedronate, zoledronic acid, or ibandronate) as initial therapy to reduce fracture risk in postmenopausal patients with osteoporosis at high risk of fractures. A Show 10 more As per OC 2010 guidelines, initiate alendronate, risedronate, zoledronic acid, or denosumab as first-line therapy for the prevention of fractures in menopausal females requiring treatment for osteoporosis. A Show 17 more Management of osteoporosis, duration: https://web.pathway.md/diseases/recRdaocxVoiEsSMc 3/9 6/24/23, 12:45 PM Hip fracture Pathway As per ACOG 2022 guidelines, consider discontinuing bisphosphonates to allow a drug holiday for low-to-moderate risk postmenopausal patients being stable after 5 years of treatment with oral bisphosphonates or after 3 years of therapy with IV zoledronic acid. Consider continuing treatment for longer durations of up to 10 years for oral bisphosphonates or up to 6 years for IV zoledronic acid in patients at high risk of fracture. C As per ACE/AACE 2020 guidelines, limit treatment with abaloparatide and teriparatide to 2 years and follow abaloparatide or teriparatide therapy with a bisphosphonate or denosumab. A Show 6 more 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 Show 2 more 4. Perioperative care Preoperative analgesia: administer multimodal analgesia incorporating preoperative nerve block for pain after hip fracture. A Preoperative traction: do not perform routine preoperative traction in older patients with hip fractures. D Perioperative antibiotics: administer antibiotics with activity against S. aureus 1-2 hours before hip surgery and 24 hours postoperatively. A Perioperative thromboprophylaxis: As per AAFP 2022 guidelines, administer chemoprophylaxis over mechanical prophylaxis alone, as patients with hip fractures are at high risk of VTE caused by immobility. A As per AAOS 2022 guidelines, administer VTE prophylaxis in older patients with hip fractures. B Perioperative blood transfusion: As per AAFP 2022 guidelines, set a Hgb level of 8 g/dL as the threshold for blood transfusion in asymptomatic postoperative patients with a hip fracture unless cardiac contraindications exist. B As per AAOS 2022 guidelines: Consider setting a blood transfusion threshold of 8 g/dL in asymptomatic postoperative patients. C Administer tranexamic acid to reduce blood loss and blood transfusion in older patients with hip fractures. A https://web.pathway.md/diseases/recRdaocxVoiEsSMc 4/9 6/24/23, 12:45 PM Hip fracture Pathway 5. Surgical interventions Surgical management, timing: As per AAFP 2022 guidelines, 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 As per AAOS 2022 guidelines, consider performing hip fracture surgery in older patients within 24-48 hours of admission for better outcomes. C Surgical management (anesthesia): administer either spinal or general anesthesia in older patients with hip fractures. A Surgical management (approach): perform arthroplasty over fixation in older patients with unstable (displaced) femoral neck fractures. A Show 4 more Surgical management (technical considerations): use cemented femoral stems in older patients undergoing arthroplasty for femoral neck fracture. A Show 5 more 6. 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 Prevention of falls, environmental modifications: As per WFG 2022 guidelines, provide counseling for modifications of the physical home environment for fall hazards as part of a multidomain falls prevention intervention. A As per ACOG 2021 guidelines, offer fall prevention strategies, including weight-bearing and muscle-strengthening exercises, in patients at risk of falls. E As per DHA 2018 guidelines, consider offering changes to improve the safety in the home environment of elderly adults at risk of falls living at home. C As per EAST 2016 guidelines, consider offering physical environment modification to prevent falls in frail elderly people. C Prevention of falls, exercise interventions: As per WFG 2022 guidelines, offer an exercise program based on an individual assessment. E https://web.pathway.md/diseases/recRdaocxVoiEsSMc 5/9 6/24/23, 12:45 PM Hip fracture Pathway Show 6 more As per DHA 2018 guidelines: Consider offering balance training in elderly adults at risk of falls living at home or in institutional care. C Consider offering movement concepts, such as Tai Chi, yoga, dance, or dance-like training in elderly adults at risk of falls living at home. C As per DHA 2018 guidelines, offer fall prevention strategies, including weight-bearing and muscle-strengthening exercises, in patients at risk of falls. E As per USPSTF 2018 guidelines, offer exercise interventions to prevent falls in community- dwelling 65 years old adults at increased risk for falls. B As per EAST 2016 guidelines, consider offering evidence-based exercise programs for frail elderly individuals. C As per OC 2010 guidelines, consider offering exercises focusing on balance, such as Tai Chi, or on balance and gait training in individuals at risk of falls. B Prevention of falls, multifactorial interventions: As per WFG 2022 guidelines, offer multidomain interventions, informed by a multiprofessional, multifactorial falls risk assessment, in community-dwelling older adults at high risk of falls. A As per ACOG 2021 guidelines, offer fall prevention strategies, including individualized multifactorial interventions such as vision assessment and treatment, balance training, and environmental assessment and modification, in patients at risk of falls. E As per USPSTF 2018 guidelines, offer multifactorial interventions to prevent falls in selective groups of 65 years old community-dwelling individuals at increased risk for falls. B Prevention of falls (vestibular rehabilitation): consider offering vestibular rehabilitation in elderly patients with diagnosed vestibular dysfunction. C Prevention of falls, vitamin D/calcium supplementation: As per USPSTF 2018 guidelines, do not use vitamin D supplements for the prevention of falls in community-dwelling 65 years old adults. D As per EAST 2016 guidelines, consider offering vitamin D and calcium supplementation for the prevention of fall-related injuries in frail elderly individuals. C Prevention of falls, medication review: As per WFG 2022 guidelines: Assess for fall history and the risk of falls before prescribing potential fall risk-increasing drugs in older adults. A Obtain a medication review and deprescribe fall risk-increasing drugs as part of multidomain fall prevention interventions. A Use a validated, structured screening and assessment tool to identify fall risk-increasing drugs when conducting a general medication review or medication review targeted to fall prevention. B As per DHA 2018 guidelines: https://web.pathway.md/diseases/recRdaocxVoiEsSMc 6/9 6/24/23, 12:45 PM Hip fracture Pathway Discontinue benzodiazepines in elderly adults in case of > 4 weeks of use, since benzodiazepines increase the risk of falls. B Keep selective serotonin receptor inhibitors only upon due consideration and only if non- pharmacological treatment has been ineffective, in > 65 years old adults with moderate depression, since selective serotonin receptor inhibitors may increase the risk of falling and the effect on depression and quality of life is likely to be negligible. B Hip protectors: As per EAST 2016 guidelines, consider offering hip protectors in frail elderly individuals in the appropriate environment. C As per OC 2010 guidelines, consider offering hip protectors in older adults at high risk for fracture residing in long-term care facilities. C 7. Follow-up and surveillance Serial clinical assessment: assess and document hip extensor and abductor muscle strength in post-acute clinical settings. B Show 5 more Discharge from hospital: Ensure a safe transfer of postoperative patients with hip fractures from the hospital to the community involving physical therapists in the interprofessional assessment and planning. E Obtain evaluation by the facility or home care physical therapist within 72 hours of transfer of care in patients with continued impairments and functional deficits after hip fracture (including patients in nursing homes). E Postoperative rehabilitation: As per AAFP 2022 guidelines: Offer early rehabilitation and weight-bearing within 24 hours postoperatively to improve mobility outcomes. A Ensure non-weight-bearing status and complete activity cessation while awaiting definitive imaging in patients with a suspected femoral neck stress fracture to reduce the risk of conversion to complete fracture. B As per AAOS 2022 guidelines, consider offering immediate, full weight-bearing to tolerance in older patients after surgery. C As per WSES 2022 guidelines, offer an individualized and progressive exercise program to improve mobility, including standing up, balance, walking, and climbing stairs, as a fall prevention strategy in older adults after sustaining a hip fracture. A Commence such programs in the hospital B and continue in the community. B As per AOPT 2021 guidelines, set individual goals for recovery of function, including independent basic mobility, achieving the prior level of function, return to pre-fracture residence, and activities to support long-term well-being. Review and revise goals throughout the continuum of care. E https://web.pathway.md/diseases/recRdaocxVoiEsSMc 7/9 6/24/23, 12:45 PM Hip fracture Pathway Show 9 more References 1. Mary I O'Connor, Julie A Switzer. AAOS Clinical Practice Guideline Summary: Management of Hip Fractures in Older Adults. J Am Acad Orthop Surg. 2022 Oct 15;30 20):e1291-e1296. Open 2. Danish Health Authority. National clinical guideline for the prevention of falls in elderly people: Quick guide. Sundhedsstyrelsen. 2018 Apr. Open 3. Patrick B Murphy, George Kasotakis, Elliott R Haut et al. Efficacy and safety of non-steroidal anti- inflammatory drugs NSAIDs) for the treatment of acute pain after orthopedic trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma and the Orthopedic Trauma Association. Trauma Surg Acute Care Open. 2023 Feb 21;8 1):e001056. Open 4. Pauline M Camacho, Steven M Petak, Neil Binkley et al. 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Expert Panel on Pediatric Imaging, Nabile M Safdar, Cynthia K Rigsby et al. ACR Appropriateness Criteria Acutely Limping Child Up To Age 5. J Am Coll Radiol. 2018 Nov;15 11S S252 S262. Open https://web.pathway.md/diseases/recRdaocxVoiEsSMc 9/9