Neck of Femur Fracture

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Garden (1961) grades the fracture by the degree of displacement and the alignment of the trabecular lines on the AP radiograph. It correlates with AVN risk and guides treatment.

The simplification that survives. Garden I-II are undisplaced and are fixed; Garden III-IV are displaced and, in the elderly, are replaced.

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Reliability, the number that matters. The four-type system is only moderately reproducible. Thomsen (Int Orthop 1996) had six observers classify 96 fractures and all six agreed on just 14 (15%), kappa 0.39; Cazzato (BMC Musculoskelet Disord 2022) found kappa 0.28-0.73 (mean 0.49) across six surgeons and 150 fractures, with greater experience giving no improvement. Collapse the system to undisplaced versus displaced and reliability rises to kappa 0.68-0.90; stage II versus III is the weak point. The 2018 AO/OTA revision performed worse (mean kappa 0.30), so no radiographic system is clearly superior, and Garden remains the everyday language despite the limitation.

What Garden does not see. Posterior comminution is visible only on the lateral film and predicts loss of reduction even when the AP looks acceptable.

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Pauwels (1935) measures the angle of the fracture line to the horizontal on the AP radiograph and predicts the shear force across the fracture, and with it the risk of fixation failure.

Why it matters. Pauwels III fractures in young patients are challenging: the failure rate with simple cannulated screws demands a stronger construct.

The reliability caveat. The three-way grade is poorly reproducible, with inter-observer kappa around 0.19 to 0.31 across studies, below both Garden and the AO system, and surgical experience does not improve it. The shear biomechanics are sound; the II-versus-III boundary is not.

How to measure the angle. Draw a horizontal reference line along the superior margin of the sacral ala or the ischial tuberosities, then a line along the fracture plane; the angle between them is the Pauwels angle. Measure on the AP radiograph, since the lateral assesses sagittal displacement, not the Pauwels angle. Minor hip or pelvic rotation shifts the measured angle, which is part of why the grade is so poorly reproducible.

How to answer in a viva. Quote the angle you measured, call the fracture vertical and high-shear, acknowledge that the II-versus-III boundary is poorly reproducible, then justify your construct from the biomechanics. That is a stronger answer than defending a grade the literature cannot agree on.

AO/OTA is the comprehensive fracture description system of the AO Foundation and the Orthopaedic Trauma Association. It is more detailed than Garden but less commonly used clinically, and is useful for research and registries.

• 31-B1, subcapital with slight displacement (Garden I-II equivalent): B1.1 impacted valgus (Garden I); B1.2 non-impacted (Garden II); B1.3 varus impacted (rare, very unstable)
• 31-B2, transcervical (midcervical): through the middle of the neck; less common than subcapital; AVN risk similar to subcapital
• 31-B3, basicervical: at the base of the neck at the junction with the intertrochanteric region; extracapsular, so a lower AVN risk but a higher fixation failure risk; often requires a sliding hip screw rather than screws alone

Delbet classifies paediatric femoral neck fractures, which are rare (less than 1% of paediatric fractures). All are surgical emergencies because of the very high AVN risk, and all require urgent reduction and fixation.

Who. Undisplaced fractures (Garden I-II) at any age, and displaced fractures (Garden III-IV) in physiologically young patients under 60-65.

Set-up. Supine on a fracture table with gentle traction, with the image intensifier positioned for AP and lateral views.

Reduction, if the fracture is displaced. The Leadbetter manoeuvre: gentle longitudinal traction, flexion 15-30 degrees, abduction 20-30 degrees and internal rotation 15 degrees. If closed reduction fails, open reduction through a Watson-Jones or Smith-Petersen approach.

Judging the reduction. Quality of reduction is the factor most clearly linked to outcome, so know how to say it is acceptable:

• Garden alignment index: on the AP the principal compression trabeculae of the head should meet the medial femoral cortex at about 160 degrees; on the lateral they should be roughly colinear, about 180 degrees. An acceptable reduction sits between 155 and 180 degrees on both views. Varus (under about 155 degrees) or marked deviation predicts fixation failure and AVN. Do not confuse the index with the Pauwels fracture-line angle
• Lowell's lines: the cortical outlines of head and neck should form continuous, smooth S and reversed-S curves where a convex meets a concave. A tangency or cusp, two curves meeting at a point rather than flowing, signals malreduction
• Shenton's line restored, with no residual varus or posterior tilt
• Acceptable criteria: less than 20 degrees of angulation and less than 2 mm of displacement

Guidewires. Three wires in an inverted triangle: the inferior wire along the calcar at the inferior neck, the two superior wires divergent, all parallel in the sagittal plane and all within 5 mm of subchondral bone. Check the lateral view to avoid joint penetration.

Screws. Partially threaded cannulated screws of 6.5 or 7.3 mm diameter, with the threads crossing the fracture so that tightening compresses it. The inferior screw provides calcar support and prevents varus collapse.

Why this configuration. Three screws give the best stability, better than two and with minimal advantage from a fourth. The inverted triangle gives superior resistance to rotation, spreading load across the femoral head, with the base of the triangle anterior and the apex posterior on the lateral view; the wider the spread within the head, the better the rotational resistance. Screws that are parallel in the frontal and sagittal planes allow compression, partial threading allows interfragmentary compression, and each screw spans the fracture and engages the far cortex.

Where it is weak. Parallel screws offer no resistance to shear in a vertical (Pauwels III) fracture and have no sliding or compression mechanism of the kind a DHS has, so the construct relies entirely on the quality of the reduction and on bone healing.

Capsulotomy at the time of fixation is optional; the tamponade argument and the FAITH result are set out under Pathophysiology.

Afterwards. Touch weight-bearing initially, advanced as tolerated; the protocol is under Rehabilitation.

Who. Pauwels III fractures (over 50 degrees, high shear), basicervical fractures (31-B3), failed initial screw fixation, and large or osteoporotic patients.

Why it holds where screws do not. The lag screw slides through the barrel, so the fracture is continuously compressed as it settles (dynamic compression). The lag screw is 12-13 mm in diameter against 6.5-7.3 mm for a cannulated screw, so its purchase is greater, and it is better for osteoporotic bone; the barrel angle, typically 135 degrees, matches the anatomic angle, and the side plate distributes load to the shaft. A derotation screw prevents rotation. Together this resists shear in a vertical fracture better than screws alone.

The clinical counterweight. "Pauwels III needs a DHS" is a biomechanical argument. FAITH, carded below, randomised 1,108 patients and found no reoperation advantage for the sliding hip screw over cancellous screws, with more avascular necrosis in the sliding hip screw group (9% vs 5%); its subgroups suggest smokers and displaced or basicervical fractures may do better with a sliding hip screw. Use the biomechanics to choose the construct, and hold the instruction loosely.

Technique.

1. Lateral approach to the proximal femur
2. Guide wire centred on AP and lateral, tip 5 mm from subchondral bone
3. Ream over the guide wire
4. Insert the lag screw, typically 80-110 mm long
5. Fix the side plate with cortical screws
6. Derotation screw above the lag screw
7. Tighten the lag screw to compress

Tip-apex distance. Keep it under 25 mm: the AP distance plus the lateral distance, multiplied by the magnification factor. Over 25 mm the cut-out risk is four times higher. Position the lag screw centre-centre, or inferior-posterior, on the AP and lateral views.

How it fails.

• Cut-out, the most common: the lag screw backs out through the femoral head. Risk factors are poor reduction, a superior screw position and a tip-apex distance over 25 mm
• Cut-through: the screw penetrates medially through the head into the pelvis
• Z-effect: lateral migration of the screw with medial migration of the neck

Who. Displaced fractures in the elderly, low-demand patient.

Approaches. Three are in common use:

• Posterior (Moore, Southern), the most common: between the fibres of gluteus maximus, dividing the external rotators (piriformis, obturators). Excellent acetabular exposure; the sciatic nerve is at risk (less than 1%). The external rotators must be repaired, which reduces dislocation from 10% to 2-3%
• Anterolateral (Hardinge): splits gluteus medius. Lower dislocation risk (2-3%), at the cost of more muscular trauma and a risk of limp
• Anterior (Smith-Petersen): an internervous plane with the lowest dislocation risk (less than 1%), but a difficult femoral exposure

Head. A bipolar head (Bateman, Christiansen) with its dual articulation is the most common choice; unipolar designs (Austin Moore, Thompson) are less used because acetabular erosion is higher.

Fixation. Cemented is preferred on level 1 evidence (BMJ 2022): lower mortality, less pain, better mobility and a lower periprosthetic fracture risk, against a bone cement implantation syndrome risk of 0.5-1%. Uncemented stems are rarely used, with a fracture risk of 5-8%.

Cementing technique.

1. Pulsatile lavage
2. Cement restrictor
3. Retrograde fill
4. Pressurisation

Operative steps.

1. Lateral position, posterior approach
2. Capsulotomy and identification of the fracture
3. Femoral neck osteotomy and removal of the head
4. Femoral preparation, broaching to size
5. Cement technique
6. Stem insertion and cement curing
7. Trial reduction, checking stability and leg length
8. Final head insertion
9. Repair of the external rotators and capsule
10. Closure

Where it gets difficult. Fracture comminution makes version and leg length hard to control, weak bone risks intraoperative fracture, and a deficient calcar risks subsidence and calls for a calcar-replacing stem.

Who. The active, cognitively intact elderly patient; the indications, and the HEALTH caveat, are set out under Management. Over hemiarthroplasty it offers better pain relief, better function on the Oxford Hip Score, no acetabular erosion and suitability for the active patient.

Implants. A cemented stem is preferred for osteoporotic bone (Exeter, CPT and Charnley are common); a cemented cup is preferred in the elderly, though some use an uncemented cup in good bone. The bearing is a metal or ceramic head on polyethylene, the standard for the elderly, with a 32 or 36 mm head, since a larger head dislocates less.

Preventing dislocation. Repair the capsule and external rotators, as for hemiarthroplasty. Dual mobility cups bring dislocation below 1% at a higher cost; a constrained liner is the last resort for recurrent dislocation.

Operative steps, posterior approach.

1. Lateral position
2. Posterior approach
3. Capsulotomy
4. Femoral neck osteotomy
5. Acetabular preparation: ream, trial, cement or press-fit the cup
6. Femoral preparation, broaching to size
7. Cement technique: clean the canal, restrictor, retrograde cement, pressurisation
8. Stem insertion and cement curing
9. Trial reduction for stability and leg length
10. Final head and liner insertion
11. Capsular and external rotator repair
12. Closure in layers

The cost. A longer operation, a higher dislocation risk if the repair is poor, and a more complex revision if it fails.

The first days. The mortality figures are under Rehabilitation and Outcomes. The medical complications of the first days, and what drives each:

• Pressure sores from prolonged pre-operative immobility
• Pneumonia from aspiration, reduced mobility and general anaesthesia
• DVT and PE, a high risk in the elderly immobile patient
• UTI from catheterisation and dehydration
• Delirium in 20-50% of the elderly post-operatively (pain, medication, an unfamiliar environment)
• Myocardial infarction from surgical stress and cardiac demand

Surgical complications.

• Bleeding: arthroplasty loses 300-500 mL and may need transfusion
• Infection: superficial in 2-3%, deep periprosthetic in less than 1%
• Nerve injury: sciatic with the posterior approach (less than 1%), femoral with the anterior approach (rare)
• Vascular injury: the femoral vessels with the anterior approach, rare but catastrophic

After internal fixation.

• Avascular necrosis: 20-30% in displaced fractures fixed in young patients, 10% in undisplaced fractures
• Nonunion: 10-30%, depending on the fracture pattern, displacement and the quality of fixation
• Implant failure: screw cut-out, the screw backing out through the femoral head
• Malunion: varus collapse and shortening

After arthroplasty.

• Dislocation in 2-10%, higher after THR than hemiarthroplasty and with the posterior approach than the anterior
• Periprosthetic fracture, intraoperative during stem insertion or post-operative from a fall on the prosthesis
• Aseptic loosening, more common with uncemented stems
• Acetabular erosion after hemiarthroplasty, the femoral head eroding the acetabulum and causing groin pain

Fracture-related. Late AVN presents with femoral head collapse, severe pain and arthritis; post-traumatic arthritis follows cartilage damage. Leg length discrepancy is more common after arthroplasty, and heterotopic ossification, bone forming in the soft tissues, is more common after THR. The functional cost of the fracture (loss of independence, persistent pain, quality of life) is under Rehabilitation and Outcomes.

Secondary fragility fractures. The contralateral hip fractures in 5-10% within 5 years, and vertebral and wrist fractures follow untreated osteoporosis. Prevention is under Secondary Prevention.

Out of bed on day one. The goal is out of bed within 24 hours of surgery. There is strong evidence that early mobilisation reduces pneumonia (by 40%), pressure sores (50%), DVT and PE (30%) and delirium (20%).

Weight-bearing after arthroplasty. Weight-bearing as tolerated immediately: the implant is load-bearing, so there is no need for protection, and full weight-bearing is encouraged as pain allows, with a frame or crutches for balance initially.

Weight-bearing after fixation of an undisplaced fracture. Touch weight-bearing for 6 weeks, though some surgeons allow weight-bearing as tolerated if the fixation is stable; partial (50%) weight-bearing at 6 weeks if the radiograph shows healing; full weight-bearing at 12 weeks if united. Full weight-bearing too early risks displacement.

Weight-bearing after fixation of a displaced fracture in the young. Strict non-weight-bearing for 6-12 weeks, because the risk of fixation failure, AVN and nonunion is high, and advance very cautiously on serial radiographs.

Hip precautions after a posterior approach. For 6 weeks, and some surgeons say 12, the patient avoids:

• Hip flexion beyond 90 degrees (no low chairs or toilet seats)
• Adduction across the midline (no crossing the legs)
• Internal rotation (no twisting inward)

The risk is posterior dislocation if the precautions are violated. If the external rotators were repaired well, some surgeons omit the precautions; the evidence is mixed.

Hip precautions after an anterior or anterolateral approach. Avoid hip extension and external rotation. The precautions are less restrictive than after a posterior approach, and the dislocation risk is lower overall.

Phase 1, days 1-3. Bed mobility (rolling, sitting up), transfer training (bed to chair, to toilet), gait re-education with a walking aid, active range-of-motion exercises, and isometric quadriceps and gluteal exercises.

Phase 2, weeks 1-6. Progressive weight-bearing after fixation, strengthening of the hip abductors, extensors and quadriceps, balance and proprioception training, and stairs, aiming for independent mobility with a single-point stick.

Phase 3, weeks 6-12. Functional strengthening, return to the activities of daily living, falls prevention strategies, and home hazard assessment and modification.

Mortality. 6-8% at 30 days, 25-30% at one year and 50% at five years, and the excess over age-matched controls persists for 10 years. It is higher in the elderly, the frail and those with multiple comorbidities, and in observational data delay to surgery beyond 48 hours is associated with higher mortality.

Function. The fracture costs independence:

• 40% do not return to their pre-fracture mobility
• 30% need more care, moving from independent to assisted living or a nursing home
• 25% remain non-ambulatory at one year
• Persistent hip, groin or thigh pain in 10-20%
• Outcomes are better after arthroplasty than fixation, especially where fixation fails

Quality of life. Scores fall significantly (EQ-5D, SF-36), and loss of independence is the major factor. Depression is common, in 30-40%, and so is social isolation.

Who gets back to independence. The strong predictors are pre-fracture independent mobility, absence of dementia, living at home rather than in a nursing home, age under 85, no major medical comorbidity, early surgery (within 48 hours) and orthogeriatric co-management.

Treat the osteoporosis. Every patient has a DEXA scan after the fracture and starts bone protection:

• Bisphosphonates: alendronate 70 mg weekly or zoledronic acid 5 mg IV yearly, which reduce subsequent hip fractures by 35%; start once the surgical wounds have healed (typically 2 weeks post-operatively) and continue for a minimum of 3-5 years
• Vitamin D and calcium for everyone: vitamin D 1000 IU daily, calcium 1200 mg daily
• A falls prevention programme, which is mandatory
• A fracture liaison service to coordinate the osteoporosis care

Prevent the next fall.

• Home hazards assessment: remove trip hazards, improve lighting, install grab rails
• Medication review: reduce sedatives, and antihypertensives if they are contributing
• Vision: correct cataracts, update glasses
• Balance and strength training through ongoing physiotherapy
• Vitamin D, which reduces falls risk independently of its effect on bone
• Hip protectors are controversial, with poor compliance and limited evidence

The team. Modern hip fracture care is a coordinated multidisciplinary effort:

• Orthopaedic surgeon: surgical management
• Geriatrician or orthogeriatrician: medical optimisation, delirium prevention
• Anaesthetist: regional anaesthesia, perioperative optimisation
• Physiotherapist: early mobilisation, rehabilitation
• Occupational therapist: assessment of daily activities, home modification
• Dietitian: nutritional support, since many elderly patients are malnourished
• Pharmacist: medication reconciliation, avoidance of inappropriate drugs
• Fracture liaison coordinator: osteoporosis treatment and follow-up
• Social worker: discharge planning and care needs

The care standards these teams are audited against are set out under Guidelines, Registries & Global Practice.

Epidemiology and Registry Snapshot (ANZHFR)

National and regional registries quantify the burden and benchmark outcomes. The ANZHFR (Australia and New Zealand) figures below are illustrative of the orders of magnitude seen across high-income settings:

Incidence and Burden (ANZHFR 2023):

• Approximately 20,000-22,000 hip fractures annually across the binational catchment
• Incidence rate: 150-200 per 100,000 population over age 65
• Female:male ratio approximately 3:1
• Projected to double by 2050 due to aging populations
• Annual economic burden: large by any measure — multi-billion-dollar costs in acute care, rehabilitation and long-term care in high-income health economies worldwide

Mortality (ANZHFR 2023):

• 30-day mortality: 6.2% (national average)
• 1-year mortality: 27.3%
• 5-year mortality: approximately 50%
• Casemix-adjusted variation between centres: top-quartile hospitals achieve 5-6% 30-day mortality, while rural/remote and under-resourced sites report 8-10%

Geographic and Equity Variation (global theme):

• Rural/remote vs urban: rural areas show slightly higher mortality and longer time to surgery (access and transfer logistics)
• Under-served and Indigenous populations: Registry data show hip fractures occur 10-15 years earlier in Indigenous populations, with higher mortality — a disparity mirrored in other under-served groups worldwide
• Remote communities: significant challenges with evacuation, surgical access and rehabilitation

Australian Hip Fracture Registry (ANZHFR)

The ANZHFR is a binational registry (Australia and New Zealand) established in 2015 to monitor and improve hip fracture care quality.

Key Performance Indicators (2023 National Report):

• Surgery within 48 hours: 82.4% nationally (target greater than 85%)
  • Best performers: 90-95% (major metropolitan hospitals)
  • Challenges: Rural hospitals, weekend admissions, medically complex patients
• Orthogeriatric assessment within 72 hours: 76.8% (target greater than 80%)
• Bone protection prescribed at discharge: 68.5% (target greater than 80%)
• Post-discharge fracture liaison service contact: 45.2% (target greater than 70% - needs improvement)

Registry Data Insights:

• Hospitals with dedicated hip fracture pathways have 30-40% lower mortality
• Orthogeriatric co-management associated with 2-day reduction in length of stay
• Weekend admissions have 15% longer time to surgery (resource constraints)

Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR)

THR for Fracture Outcomes (AOANJRR 2023 Report):

• 10-year cumulative revision rate: 6.9% for THR performed for fracture
• Comparison: Lower than revision rate for primary OA THR at 10 years (7.2%)
• 15-year survivorship: 94.8% for THR, 89.2% for hemiarthroplasty
• Revision reasons: Dislocation (30%), infection (25%), aseptic loosening (20%), periprosthetic fracture (15%)

Hemiarthroplasty Outcomes:

• 10-year cumulative revision rate: 11.2%
• Higher revision rate than THR (predominantly due to acetabular erosion causing pain)
• Cemented vs Uncemented: Cemented hemiarthroplasty has lower revision rate (9.8% vs 14.5% at 10 years)

Implant Performance:

• Most commonly used stems for fracture: Exeter (cemented), CPT (cemented), Corail (uncemented)
• Most commonly used hemiarthroplasty heads: Bipolar designs (Bateman, Christiansen)
• Dual mobility cups increasingly used for high dislocation risk patients (revision rate only 3-4% at 5 years)

Hip Fracture Care Quality Standards (International Consensus)

The following quality indicators are common to national hip-fracture programmes worldwide (e.g. ACSQHC Clinical Care Standard, Australia; NICE Hip Fracture Programme/NHFD, UK; AAOS guidance, USA). The ACSQHC standard (2016, updated 2021) is a representative example:

Mandatory Quality Indicators:

1. Surgery within 48 hours of presentation (benchmark greater than 85%)

   • Delays permissible only for medical optimization (e.g., severe cardiac instability, active anticoagulation requiring reversal)
   • "Stop the clock" provisions for unavoidable delays (transfer to specialist center, patient refusal)

2. Orthogeriatric involvement within 72 hours

   • Comprehensive Geriatric Assessment (CGA)
   • Delirium prevention and management
   • Medical comorbidity optimization
   • Bone health and falls assessment

3. DVT prophylaxis initiated within 24 hours

   • Pharmacological: LMWH (enoxaparin 40mg daily or dalteparin 5000 units daily) or fondaparinux 2.5mg daily
   • Mechanical: TED stockings and/or intermittent pneumatic compression
   • Duration: Minimum 10-14 days, extended if high VTE risk

4. Bone protection initiated before discharge

   • Bisphosphonates: Alendronate 70mg weekly (oral) or zoledronic acid 5mg IV (annual)
   • Vitamin D: 1000-2000 IU daily
   • Calcium: 1200mg daily (dietary + supplementation)
   • DEXA scan arranged (if not done acutely, within 3 months)

5. Pressure injury prevention

   • Pressure-relieving mattress for all patients
   • Regular repositioning
   • Nutritional assessment and supplementation
   • Early mobilization

6. Early mobilization (day 1 post-operatively)

   • Physiotherapy review within 24 hours of surgery
   • Out of bed and walking (or attempting) within 24 hours
   • Progressive weight-bearing as tolerated (arthroplasty) or per fracture protocol (fixation)

7. Falls and bone health assessment

   • Comprehensive falls risk assessment
   • Home hazards evaluation
   • Vitamin D and calcium supplementation
   • Fracture Liaison Service (FLS) referral before discharge

8. Multidisciplinary rehabilitation plan

   • Physiotherapy, occupational therapy, dietitian, social work input
   • Discharge planning from day 1
   • Clear goals and timeline

9. Nutrition screening and support

   • Malnutrition Universal Screening Tool (MUST) on admission
   • Dietitian referral if malnourished (albumin less than 30 g/L, BMI less than 20, weight loss)
   • Protein supplementation (aim 1.2-1.5g/kg/day)
   • Vitamin and mineral supplementation

10. Fracture Liaison Service contact post-discharge

    • Follow-up within 4-6 weeks
    • Ensure osteoporosis treatment ongoing
    • Monitor bisphosphonate adherence
    • Coordinate DEXA scan if not done

Antibiotic and VTE Prophylaxis (Consensus Dosing)

Antibiotic Prophylaxis (Surgical):

• First-line: Cefazolin 2g IV at induction (or within 60 minutes of incision)
• Penicillin allergy: Vancomycin 15-20mg/kg IV (infuse over 60-90 minutes, start 60-90 minutes before incision)
• Duration: Single dose (no post-operative doses recommended for routine cases)
• Extended prophylaxis: If surgery greater than 4 hours or significant blood loss, one additional dose

VTE Prophylaxis:

• Pharmacological: Enoxaparin 40mg SC daily or dalteparin 5000 units SC daily
• Start: 6-12 hours post-operatively (balance bleeding vs VTE risk)
• Duration: Minimum 10-14 days, extend to 35 days if additional VTE risk factors
• Contraindications: Active bleeding, severe renal impairment (CrCl less than 30 mL/min - reduce dose or use fondaparinux)

Standardized Pathways and Benchmarking

Across many health systems, hip-fracture care is now delivered through standardized, audited pathways rather than ad-hoc management. Common, transferable features — seen in national and regional programmes worldwide — include:

• Standardized care pathways with pre-printed orders for analgesia, VTE prophylaxis and bone protection
• Mandatory orthogeriatric review within 24-72 hours of admission
• State- or nation-wide data collection and public benchmarking of time-to-surgery, mortality and quality indicators
• Integrated pathways from emergency department to discharge, with telehealth orthogeriatric support for regional hospitals
• Pre-hospital and ambulance protocols plus regional transfer guidelines for complex cases

Registry-linked evaluation shows that hospitals running these structured pathways have 30-40% lower mortality and shorter length of stay.

Universal Access Challenges

Beyond any single national programme, several challenges recur across health systems and resource settings:

Geographic Remoteness:

• Retrieval and transfer: remote-area patients may need aeromedical evacuation to reach a surgical centre
• Delays: transfer times of 12-24 hours directly threaten the 48-hour surgery target
• Workforce: rural hospitals frequently lack round-the-clock orthopaedic or anaesthetic cover

Under-served and Indigenous Populations:

• Hip fractures occur 10-15 years earlier in under-served and Indigenous groups
• Higher comorbidity burden (diabetes, renal disease, cardiovascular disease)
• Cultural considerations for rehabilitation and discharge planning
• Coordination with community/Aboriginal medical services for post-discharge care

Residential Aged Care / Nursing-Home Residents:

• 40-50% of hip fractures occur in patients residing in aged-care/nursing-home facilities
• Transfer delays from facility to hospital
• Challenges returning to the facility post-surgery (bed availability, funding)
• Higher delirium and complication rates

How Practice Differs Internationally

While the core principles (early surgery, arthroplasty for displaced fractures in the elderly, cemented fixation, orthogeriatric co-management, secondary fracture prevention) are shared, real-world practice varies:

Surgical timing targets:

• UK (NICE/BPT): Strong financial and audit incentive to operate within 36 hours (Best Practice Tariff), driving high compliance via the National Hip Fracture Database (NHFD).
• Australia/New Zealand (ANZHFR): 48-hour benchmark; performance benchmarked nationally but without a tariff.
• USA: 24-48 hour guidance; timing more variable across systems.
• Evidence anchor: HIP ATTACK showed no survival benefit from emergent 6-hour surgery, so "within 48 hours" remains the defensible global standard.

THA vs hemiarthroplasty for displaced fractures:

• Higher THA use in the UK and parts of Europe for fit, independent patients (NICE-driven).
• Hemiarthroplasty remains the most common worldwide, especially where casemix is older/frailer.
• HEALTH trial tempered enthusiasm: the functional gain from THA is real but small.

Cemented vs uncemented hemiarthroplasty:

• UK/Australia strongly favour cemented (NICE, WHiTE 5, registry data).
• Some regions retain higher uncemented use despite higher periprosthetic fracture risk.

Fixation implant for fixable fractures:

• Cancellous/cannulated screws remain widely used; sliding hip screw favoured by some for displaced or basicervical patterns (FAITH subgroup signal).

Access and system factors:

• High-income systems: structured pathways, FLS, orthogeriatrics, registries.
• Low- and middle-income countries (where the burden is rising fastest - see Asia projection above): limited implant availability, delays to surgery, and lower rates of bone-protection follow-up are the dominant challenges.

The problem. The patient with dementia cannot comply with hip precautions, so the dislocation risk with a THR is high, and cannot comply with protected weight-bearing, so fixation of a displaced fracture is unsuitable. Functional outcomes are poor, many never mobilise post-operatively, and mortality is 50% at one year.

The approach. A hemiarthroplasty is preferred over a THR for its lower dislocation risk, simpler surgery and shorter operative time, with a constrained liner or dual mobility considered if the dislocation risk is very high. Analgesia is optimised with a regional block (fascia iliaca) and multimodal analgesia, avoiding opioids where possible because they increase delirium. Delirium is prevented aggressively, with a familiar environment, no restraints, minimal medication, treated pain and encouraged mobilisation, and the geriatrician is involved early. Goals are realistic: the patient may not return to pre-fracture mobility, and the focus is comfort and basic transfers.

Causes. Metastatic disease, most commonly from breast, lung, kidney, thyroid and prostate; myeloma, which is common in the elderly; and, rarely, primary bone tumours such as osteosarcoma and chondrosarcoma.

The clues. Minimal or no trauma; persistent pain for weeks to months before the fracture; a known primary malignancy; constitutional symptoms (weight loss, night pain, fatigue); a lytic or sclerotic lesion on the radiograph.

Investigations.

• Staging CT of chest, abdomen and pelvis
• Bone scan or PET for a full skeletal survey
• Myeloma screen: SPEP, UPEP, serum free light chains, bone marrow biopsy
• Biopsy if the primary is unknown, intraoperative or pre-operative CT-guided

Management. Almost always arthroplasty, because fixation will fail: diseased bone will not heal. A long-stem cemented prosthesis is used where there is metaphyseal or diaphyseal involvement, and a THR rather than a hemiarthroplasty where there are acetabular metastases. Post-operative radiotherapy reduces local recurrence and pain, zoledronic acid is given for bony metastases, and the patient is referred to oncology for systemic treatment where appropriate.

The scenarios. Warfarin for atrial fibrillation, mechanical heart valves or VTE; the DOACs, apixaban, rivaroxaban and dabigatran, which are increasingly common; and dual antiplatelet therapy, aspirin with clopidogrel or ticagrelor, after a coronary stent.

The principle. Do not delay surgery waiting for the anticoagulant to clear naturally; delay is associated with higher mortality. Reverse actively so that surgery happens within 48 hours.

Warfarin. The target is an INR under 1.5 for surgery.

• Prothrombin complex concentrate 25-50 units/kg IV reverses rapidly, in 15-30 minutes
• Vitamin K 5-10 mg IV reverses more slowly, over 6-24 hours, but more durably
• Avoid FFP, which needs large volumes (15-20 mL/kg) and reverses more slowly
• Restart warfarin 24-48 hours post-operatively once haemostasis is secure, bridging with LMWH if the stroke risk is high (CHA2DS2-VASc over 4)

DOACs. Apixaban and rivaroxaban have a half-life of 8-12 hours and dabigatran 12-17 hours, so with normal renal function the drug is held for 48 hours (2-3 half-lives) before surgery. Check anti-Xa levels for rivaroxaban and apixaban, or thrombin time for dabigatran, where available. In an emergency the specific reversal agents are idarucizumab for dabigatran and andexanet alfa for apixaban and rivaroxaban (very expensive), with PCC as an off-label but effective alternative. Restart 24-48 hours post-operatively.

Dual antiplatelet therapy after a coronary stent. Continuing aspirin and clopidogrel means a high bleeding risk; stopping both means a high risk of stent thrombosis. Consult cardiology about the time since stenting and the type of stent, bare metal or drug-eluting. The general approach is to continue aspirin and hold clopidogrel or ticagrelor for 5-7 days before surgery if possible; with a recent stent (under 3 months) it may be necessary to operate on dual antiplatelets and accept the higher bleeding risk, because stent thrombosis is catastrophic.