Neck of Femur Fracture

Garden Classification (1961)

Based on degree of displacement and alignment of trabecular lines on AP radiograph. Correlates with AVN risk and guides treatment.

Garden I - Incomplete/Impacted Valgus:

• Fracture line visible but incomplete
• Femoral head tilted into valgus (impacted position)
• Trabecular lines remain continuous across fracture
• AVN risk: 0-10%
• Treatment: Cannulated screw fixation

Garden II - Complete, Non-Displaced:

• Complete fracture line visible
• No displacement - trabecular lines of head align with acetabulum and neck
• Head remains in neutral position
• AVN risk: 10-20%
• Treatment: Cannulated screw fixation

Garden III - Complete, Partially Displaced:

• Complete fracture with partial displacement
• Trabecular lines of head misaligned with neck
• Head partially rotated but still some contact with neck
• AVN risk: 20-30%
• Treatment: Arthroplasty (elderly), urgent reduction and fixation (young)

Garden IV - Complete, Fully Displaced:

• Complete fracture with total displacement
• Trabecular lines of head align with acetabulum but not with neck
• Head fully dissociated from neck
• AVN risk: 30-100%
• Treatment: Arthroplasty (elderly), urgent reduction and fixation (young)

Clinical Simplification: Garden I-II (undisplaced) = FIX. Garden III-IV (displaced) = REPLACE (in elderly).

Reliability: Inter-observer agreement only moderate (kappa 0.4-0.6). Many surgeons simplify to just displaced vs undisplaced.

Pauwels Classification (1935)

Measures the angle of the fracture line to the horizontal on AP radiograph. Predicts shear forces and fixation failure risk.

Pauwels Type I: Fracture angle less than 30 degrees

• Mostly compressive forces across fracture
• Relatively stable
• Good healing potential
• Low failure rate with screw fixation (less than 5%)

Pauwels Type II: Fracture angle 30-50 degrees

• Mixed compression and shear forces
• Moderate stability
• Intermediate failure rate (10-15%)

Pauwels Type III: Fracture angle greater than 50 degrees (vertical)

• Predominantly shear forces across fracture
• Very unstable
• High failure rate with standard screw fixation (30-40%)
• Requires augmented fixation: Sliding hip screw with derotation screw, or fixed-angle device

Clinical Significance: Pauwels III fractures in young patients are challenging - high failure rate necessitates stronger constructs than simple cannulated screws.

AO/OTA Classification

Comprehensive fracture description system from the AO Foundation/Orthopaedic Trauma Association.

31-B1: Subcapital fracture 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) fracture

• Through middle of femoral neck
• Less common than subcapital
• AVN risk similar to subcapital

31-B3: Basicervical fracture

• At base of femoral neck (junction with intertrochanteric region)
• Extracapsular (outside joint capsule)
• Lower AVN risk but higher fixation failure risk
• Often requires sliding hip screw rather than screws alone

Clinical Use: More detailed than Garden but less commonly used clinically. Useful for research and registries.

Delbet Classification

Specific classification for pediatric femoral neck fractures (rare, less than 1% of pediatric fractures).

Type I: Transepiphyseal (through growth plate)

• Highest AVN risk (100%)
• Surgical emergency

Type II: Transcervical

• High AVN risk (50%)
• Urgent fixation required

Type III: Cervicotrochanteric (base of neck)

• Moderate AVN (25%)
• Surgical treatment preferred

Type IV: Intertrochanteric

• Low AVN risk (less than 10%)
• Best prognosis

Significance: Pediatric NOF fractures are surgical emergencies due to very high AVN risk. All require urgent reduction and fixation.

Treatment: Internal fixation with cannulated screws (typically 3 screws in inverted triangle configuration).

Rationale: Blood supply is preserved. Screw fixation stabilizes the fracture and allows healing.

Caution: Garden I (impacted valgus) can displace if not fixed. Most surgeons recommend fixation.

Post-op: Protected weight-bearing initially. Monitor for AVN and nonunion.

Treatment: Arthroplasty (hemiarthroplasty or total hip replacement).

Rationale: Displaced fractures have high AVN and nonunion rates (up to 30-50%). Fixation in elderly has poor outcomes.

Hemiarthroplasty vs THR:

• Hemiarthroplasty (unipolar or bipolar): Frail, limited mobility, cognitive impairment, shorter life expectancy, lower dislocation risk.
• THR (cemented): Cognitively intact, independently mobile (walk outdoors), expected survival greater than 4 years. Better function but higher dislocation risk.

NICE guidelines recommend THR for independently mobile patients.

Young patients (less than 60-65 years old) with displaced NOF fractures:

Treatment: Attempt urgent reduction and internal fixation within 6 hours to minimize AVN risk.

Rationale: Preserving the native hip is important. Even though AVN risk is still present (20-30%), avoiding arthroplasty at a young age is preferable.

Technique: Closed or open reduction. 3 cannulated screws or sliding hip screw.

Counsel: High risk of complications (AVN, nonunion). May need arthroplasty later.

Early Complications - First Days After Surgery

Mortality:

• 30-day mortality: 6-8%
• 1-year mortality: 25-30%
• Higher in elderly, frail, multiple comorbidities
• Delayed surgery (greater than 48 hours) increases mortality significantly

Medical Complications:

• Pressure sores: Prolonged immobility pre-operatively
• Pneumonia: Aspiration, reduced mobility, general anesthesia
• DVT/PE: High risk in elderly immobile patients
• UTI: Catheterization, dehydration
• Delirium: 20-50% of elderly post-op (pain, medications, unfamiliar environment)
• Myocardial infarction: Surgical stress, cardiac demand

Surgical Complications:

• Bleeding: Arthroplasty (300-500mL blood loss), may require transfusion
• Infection: Superficial (2-3%) or deep periprosthetic (less than 1%)
• Nerve injury: Sciatic (posterior approach, less than 1%), femoral (anterior, rare)
• Vascular injury: Femoral vessels (anterior approach - rare but catastrophic)

Intermediate Complications - Weeks to Months Post-Surgery

Specific to Internal Fixation:

• Avascular necrosis (AVN):
  • 20-30% in displaced fractures (young patients with fixation)
  • 10% in undisplaced fractures
• Nonunion: 10-30% (depends on displacement and fixation quality)
• Implant failure: Screw cut-out (backing out through femoral head)
• Malunion: Varus collapse, shortening

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Specific to Arthroplasty:

• Dislocation: 2-10%
  • Higher in THR than hemiarthroplasty
  • Posterior approach greater than anterior
• Periprosthetic fracture:
  • Intraoperative (during stem insertion)
  • Post-operative (fall on prosthesis)
• Aseptic loosening: More common with uncemented
• Acetabular erosion: Hemiarthroplasty (femoral head erodes acetabulum → groin pain)

Late Complications - Months to Years Post-Surgery

Functional Outcomes:

• Loss of independence: 40% don't return to pre-fracture mobility
• Chronic pain: Hip, groin, or thigh pain (10-20%)
• Reduced quality of life: Loss of function, institutionalization

Fracture-Related:

• AVN (late presentation): Femoral head collapse, severe pain, arthritis
• Post-traumatic arthritis: Cartilage damage → degenerative change
• Leg length discrepancy: More common with arthroplasty
• Heterotopic ossification: Bone formation in soft tissues (more with THR)

Secondary Fragility Fractures:

• Contralateral hip fracture: 5-10% within 5 years
• Vertebral fractures, wrist fractures: Untreated osteoporosis
• Prevention CRITICAL: Bisphosphonates, calcium, Vitamin D, falls programs

Internal Fixation for Undisplaced or Young Patients

Indications:

• Undisplaced fractures (Garden I-II) all ages
• Displaced fractures (Garden III-IV) in physiologically young patients (less than 60-65 years)

Patient Positioning:

• Supine on fracture table with gentle traction
• Image intensifier for AP and lateral views

Reduction Technique (if displaced):

• Leadbetter maneuver: Gentle longitudinal traction, flexion 15-30°, abduction 20-30°, internal rotation 15°
• Check fluoroscopy (Pauwels' lines less than 160° lateral, less than 180° AP)
• Acceptable criteria: Less than 20° angulation, less than 2mm displacement
• If closed reduction fails → Open reduction (Watson-Jones or Smith-Petersen approach)

Guidewire Placement:

• 3 wires in inverted triangle configuration
• Inferior wire along calcar (inferior neck)
• Two superior wires divergent
• Parallel in sagittal plane
• All within 5mm of subchondral bone
• Critical: Avoid joint penetration (check lateral view)

Screw Insertion:

• Partially threaded cannulated screws (6.5mm or 7.3mm diameter)
• Threads cross fracture site
• Compression by tightening screws
• Inferior screw provides calcar support (prevents varus collapse)

Biomechanics:

• Inverted triangle = best rotational stability
• Parallel configuration = compression
• Screws span fracture and engage far cortex

Post-operative:

• Touch weight-bearing initially, advance as tolerated

Capsulotomy:

• Controversial for AVN prevention
• FAITH trial: No benefit demonstrated
• Consider if delayed presentation (greater than 12 hours)

Sliding Hip Screw for Vertical Fractures

Indications:

• Pauwels Type III fractures (greater than 50°, high shear forces)
• Basicervical fractures (31-B3)
• Failed initial screw fixation
• Large or osteoporotic patients

Advantages over Cannulated Screws:

• Greater fixation strength for vertical fractures
• Allows controlled compression along lag screw
• Derotation screw prevents rotation
• Better for osteoporotic bone

Operative Technique:

1. Approach: Lateral approach to proximal femur
2. Guide wire: Center on AP/lateral, tip 5mm from subchondral bone
3. Reaming: Over guide wire
4. Lag screw: Insert (typically 80-110mm length)
5. Side plate: Fix with cortical screws
6. Derotation screw: Above lag screw
7. Compression: Tighten lag screw

Critical Technical Points:

• Tip-apex distance less than 25mm (reduces cut-out risk)
• Center-center position in femoral head (AP and lateral)
• Adequate screw length (within 5mm of subchondral bone)

For Displaced Fractures in Elderly (Low Demand)

Surgical Approaches:

1. Posterior (Moore/Southern) - Most common

• Between gluteus maximus fibers
• External rotators divided (piriformis, obturators)
• Excellent acetabular exposure
• Must repair external rotators (reduces dislocation 10% → 2-3%)
• Sciatic nerve at risk (less than 1%)

2. Anterolateral (Hardinge)

• Split gluteus medius
• Lower dislocation risk (2-3%)
• More muscular trauma, limp risk

3. Anterior (Smith-Petersen)

• Internervous plane
• Lowest dislocation (less than 1%)
• Difficult femoral exposure

Implant Selection:

Head Type:

• Bipolar (Bateman, Christiansen): Most common - dual articulation
• Unipolar (Austin Moore, Thompson): Less used - higher acetabular erosion

Fixation:

• Cemented preferred (Level 1 evidence - BMJ 2022):
  • Lower mortality
  • Less pain, better mobility
  • Lower periprosthetic fracture risk
  • BCIS risk 0.5-1%
• Uncemented: Rarely used (higher fracture risk 5-8%)

Cementing Technique:

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

Operative Steps:

1. Lateral position, posterior approach
2. Capsulotomy, identify fracture
3. Femoral neck osteotomy (remove head)
4. Femoral preparation: Broach to size
5. Cement technique
6. Stem insertion, cement curing
7. Trial reduction (check stability, leg length)
8. Final head insertion
9. Repair external rotators and capsule
10. Closure

Challenges:

• Fracture comminution → difficult version/leg length control
• Weak bone → intraoperative fracture risk
• Calcar deficiency → subsidence risk (use calcar-replacing stems)

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For Active, Cognitively Intact Elderly

Indications (Choose THR over Hemiarthroplasty if):

• Cognitively intact
• Independently mobile (walks outdoors)
• Life expectancy greater than 4 years
• Pre-existing hip arthritis

Implant Selection:

Femoral Stem:

• Cemented preferred for osteoporotic bone
• Common stems: Exeter, CPT, Charnley

Acetabular Cup:

• Cemented preferred for elderly
• Some use uncemented if good bone

Bearing Surface:

• Metal or ceramic head on polyethylene (standard for elderly)
• Head size: 32mm or 36mm (larger = less dislocation)

Dislocation Prevention:

• Repair external rotators and capsule (reduces 10% → 2-3%)
• Dual mobility cups: Very low dislocation (less than 1%), higher cost
• Constrained liners: 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/press-fit cup
6. Femoral preparation: Broach to size
7. Cement technique: Clean canal, restrictor, retrograde cement, pressurization
8. Stem insertion, cement curing
9. Trial reduction (stability, leg length)
10. Final head/liner insertion
11. Capsular and external rotator repair
12. Closure in layers

Advantages over Hemiarthroplasty:

• Better pain relief
• Better function (Oxford Hip Score)
• No acetabular erosion
• Suitable for active patients

Challenges:

• Longer operative time
• Higher dislocation risk if poor repair
• More complex revision if fails

Forces Acting on Femoral Neck

The femoral neck experiences complex loading during weight-bearing:

Compressive Forces (Primary):

• Body weight transmitted from acetabulum to femoral head
• Magnitude: 3-5x body weight (walking), up to 8x (running)
• Concentrated on superomedial femoral head (weight-bearing zone)

Tensile Forces:

• Along inferomedial cortex (calcar femorale)
• Generated by moment arm of body weight
• Resisted by thick cortical bone at calcar

Shear Forces:

• Parallel to fracture line
• Increase with fracture verticality (Pauwels angle)
• Pauwels III (greater than 50°): Predominantly shear → high failure risk

Rotational Forces:

• Torsion from muscle attachments (gluteus medius, iliopsoas)
• Cause rotation and displacement of fracture fragments

Trabecular Architecture

The femoral neck contains two main trabecular systems:

Primary Compressive Trabeculae (Vertical):

• Run from medial calcar to superior femoral head
• Resist compressive loads during weight-bearing
• Strongest trabecular system

Primary Tensile Trabeculae (Arcuate):

• Arc from lateral cortex to inferior femoral head
• Resist tensile forces along inferior neck
• Important for fracture stability

Secondary Compressive Trabeculae:

• From greater trochanter to femoral head
• Provide additional support

Ward's Triangle:

• Area of relative weakness (few trabeculae)
• Located in femoral neck between trabecular systems
• Common site of fracture initiation in osteoporotic bone

Cannulated Screw Biomechanics

Optimal Configuration:

• 3 screws provide best stability (better than 2, minimal advantage with 4)
• Inverted triangle: Superior resistance to rotational forces
  • Base of triangle anteriorly (lateral view)
  • Apex posteriorly
  • Spreads load across femoral head
• Inferior screw along calcar: Critical for preventing varus collapse
• Thread engagement: Partial threading allows interfragmentary compression

Screw Placement Principles:

• All screws should be parallel (frontal and sagittal planes)
• Tip-apex distance less than 5mm from subchondral bone
• Avoid penetration into joint (check lateral view)
• Spread screws maximally within head (wider spread = better rotation resistance)

Biomechanical Weakness:

• No resistance to shear in vertical fractures (Pauwels III)
• No sliding/compression mechanism (unlike DHS)
• Relies entirely on fracture reduction quality and bone healing

Sliding Hip Screw Biomechanics

Advantages:

• Dynamic compression: Lag screw slides through barrel, continuously compressing fracture
• Greater purchase: Larger lag screw diameter (12-13mm vs 6.5-7.3mm cannulated)
• Derotation screw: Prevents rotation
• Better for vertical fractures: Resists shear forces better than screws alone

Biomechanical Principles:

• Lag screw positioned center-center or inferior-posterior (AP/lateral views)
• Tip-apex distance less than 25mm (predictor of cut-out)
  • Formula: (AP distance + lateral distance) x magnification factor
  • Greater than 25mm = 4x higher cut-out risk
• Barrel angle typically 135° (matches anatomic angle)
• Side plate distributes load to femoral shaft

Failure Modes:

• Cut-out: Lag screw backs out through femoral head (most common)
  • Risk factors: Poor reduction, superior screw position, tip-apex greater than 25mm
• Cut-through: Screw penetrates medially through head into pelvis
• Z-effect: Lateral migration of screw, medial migration of neck

Biological vs Mechanical Stability

Absolute Stability (Goal for Intracapsular Fractures):

• No motion at fracture site
• Required for primary bone healing (direct osteonal remodeling)
• Achieved by: Anatomic reduction + compression + adequate fixation
• Intracapsular fractures MUST have absolute stability (no periosteal callus possible)

Relative Stability (Not Acceptable for NOF):

• Controlled micromotion allowed
• Permits secondary bone healing (callus formation)
• Used for extracapsular fractures (pertrochanteric) but NOT intracapsular

Why Displaced Fractures Fail Fixation

Biological Factors:

• Vascular disruption: Lateral epiphyseal vessels torn → AVN
• Synovial fluid: Washes out hematoma, impairs healing
• No periosteum: Intracapsular location prevents periosteal callus

Mechanical Factors:

• Loss of calcar continuity: Medial support lost → varus collapse
• Comminution: Posterior neck comminution prevents stable reduction
• Vertical fracture angle: Pauwels III has high shear forces
• Fracture gap: Even 2mm gap significantly impairs healing

Result: Combination of poor biology (AVN) + mechanical instability (collapse) = high failure rate in elderly (30-50%). This is why arthroplasty preferred for displaced fractures in elderly.

Post-operative Mobilization

Early Mobilization (Day 1 Post-op):

• Goal: Out of bed within 24 hours of surgery
• Strong evidence that early mobilization reduces:
  • Pneumonia (40% reduction)
  • Pressure sores (50% reduction)
  • DVT/PE (30% reduction)
  • Delirium (20% reduction)

Weight-Bearing Status:

After Arthroplasty (Hemiarthroplasty or THR):

• Weight-bearing as tolerated (WBAT) immediately
• No need for protected weight-bearing (implant is load-bearing)
• Encourage full weight-bearing as pain allows
• Walking aids (frame, crutches) for balance support initially

After Internal Fixation (Undisplaced Garden I-II):

• Touch weight-bearing for 6 weeks (some surgeons allow WBAT if stable fixation)
• Progress to partial weight-bearing (50%) at 6 weeks (if X-ray shows healing)
• Full weight-bearing at 12 weeks (if united)
• Risk of displacement if full weight-bearing too early

After Internal Fixation (Displaced Garden III-IV in Young):

• Strict non weight-bearing for 6-12 weeks
• High risk of fixation failure, AVN, nonunion
• Advance weight-bearing very cautiously based on serial X-rays

Hip Precautions (After Arthroplasty)

For Posterior Approach (Most Common):

• Avoid:
  • Hip flexion greater than 90 degrees (no low chairs, toilet seats)
  • Hip adduction across midline (no crossing legs)
  • Internal rotation (avoid twisting inward)
• Duration: 6 weeks (some surgeons recommend 12 weeks)
• Risk: Posterior dislocation if precautions violated
• Note: If external rotators repaired well, some surgeons omit precautions (evidence mixed)

For Anterior/Anterolateral Approach:

• Avoid hip extension and external rotation
• Less restrictive than posterior approach precautions
• Lower dislocation risk overall

Phase 1 (Days 1-3 Post-op):

• Bed mobility (rolling, sitting up)
• Transfer training (bed to chair, toilet)
• Gait re-education with walking aid
• Active range of motion exercises
• Isometric quadriceps and gluteal exercises

Phase 2 (Week 1-6):

• Progressive weight-bearing (if fixation)
• Strengthening exercises (hip abductors, extensors, quadriceps)
• Balance and proprioception training
• Stairs training
• Aim for independent mobility with single-point stick

Phase 3 (Week 6-12):

• Functional strengthening
• Return to activities of daily living
• Falls prevention strategies
• Home hazard assessment and modification

Outcomes After NOF Fracture

Mortality:

• 30-day mortality: 6-8%
• 1-year mortality: 25-30%
• 5-year mortality: 50%
• Mortality higher than age-matched controls (excess mortality persists for 10 years)

Functional Outcomes:

• 40% do NOT return to pre-fracture mobility level
• 30% require increased care (from independent to assisted living or nursing home)
• 25% remain non-ambulatory at 1 year
• 20% have persistent pain (hip or thigh)
• Better outcomes after arthroplasty than fixation (especially if fixation fails)

Quality of Life:

• Significant reduction in quality of life scores (EQ-5D, SF-36)
• Loss of independence is major factor
• Depression common (30-40%)
• Social isolation

Return to Independence:

• Strong predictors of return to independence:
  • Pre-fracture independent mobility
  • Absence of dementia
  • Living at home (not nursing home)
  • Younger age (less than 85 years)
  • No major medical comorbidities
  • Early surgery (less than 48 hours)
  • Orthogeriatric co-management

Fixation vs Arthroplasty Outcomes:

• Fixation (for undisplaced):

  • Lower surgical morbidity
  • Preserves anatomy
  • Risk of AVN (10%), nonunion (10-15%), reoperation (20%)
  • If fails, requires salvage arthroplasty (worse outcomes than primary)

• Arthroplasty (for displaced):

  • Immediate stability, early mobilization
  • Lower reoperation rates (5-8%)
  • Better pain relief
  • Small risk dislocation (2-10%), infection (less than 1%)

Secondary Fracture Prevention

Osteoporosis Management (Essential):

• DEXA scan: All patients post-fracture
• Bisphosphonates: Alendronate 70mg weekly or zoledronic acid 5mg IV yearly
  • Evidence: 35% reduction in subsequent hip fractures
  • Start after surgical wounds healed (typically 2 weeks post-op)
  • Continue for 3-5 years minimum
• Vitamin D and Calcium: Universal supplementation (Vitamin D 1000IU daily, Calcium 1200mg daily)
• Falls prevention program: Mandatory
• Fracture liaison service: Coordinates osteoporosis care

Falls Prevention:

• Home hazards assessment: Remove trip hazards, improve lighting, install grab rails
• Medication review: Reduce sedatives, antihypertensives if contributing
• Vision assessment: Correct cataracts, update glasses
• Balance and strength training: Ongoing physiotherapy
• Vitamin D: Reduces falls risk independent of bone effect
• Hip protectors: Controversial (poor compliance, limited evidence)

Multidisciplinary Hip Fracture Pathway:

Modern hip fracture care requires coordinated multidisciplinary approach:

• Orthopaedic surgeon: Surgical management
• Geriatrician/Orthogeriatrician: Medical optimization, delirium prevention
• Anaesthetist: Regional anesthesia, perioperative optimization
• Physiotherapist: Early mobilization, rehabilitation
• Occupational therapist: ADL assessment, home modifications
• Dietitian: Nutritional support (many elderly malnourished)
• Pharmacist: Medication reconciliation, avoid inappropriate drugs
• Fracture liaison coordinator: Osteoporosis treatment, follow-up
• Social worker: Discharge planning, care needs

Hip Fracture Care Standards (ACSQHC Australia):

1. Surgery within 48 hours (target greater than 85%)
2. Orthogeriatric involvement within 72 hours
3. DVT prophylaxis (LMWH or fondaparinux)
4. Bone protection initiated before discharge
5. Nutritional assessment and supplementation
6. Pressure area care
7. Early mobilization (day 1 post-op)
8. Falls and bone health assessment
9. Multidisciplinary rehabilitation
10. Fracture liaison service follow-up

Mechanism: Usually high-energy trauma (RTA, fall from height)

Key Differences:

• Preserve femoral head at almost any cost - avoid arthroplasty if possible
• Even if AVN risk 30%, preferable to THR at age 40-50 (revision burden)
• Urgent surgery (ideally less than 6 hours) to minimize AVN
• Anatomic reduction mandatory - accept nothing less
• Strong fixation: Consider DHS for vertical fractures (Pauwels III)
• Prolonged follow-up: Monitor for AVN (can occur 2-5 years post-fixation)

If Fixation Fails:

• Salvage options: Valgus osteotomy (if nonunion), arthroplasty (if AVN)
• THR considerations in young: Uncemented implants, hard-on-hard bearings (ceramic-on-ceramic, highly cross-linked polyethylene), anticipate multiple revisions over lifetime

Challenges:

• Cannot comply with precautions (high dislocation risk with THR)
• Cannot comply with protected weight-bearing (not suitable for fixation of displaced fractures)
• Poor functional outcomes (many do not mobilize post-operatively)
• High mortality (50% at 1 year)

Management Approach:

• Hemiarthroplasty preferred over THR (lower dislocation risk, simpler surgery, shorter operative time)
• Consider constrained liner or dual mobility if very high dislocation risk
• Optimize analgesia (fascia iliaca block, multimodal analgesia, avoid opioids if possible - increase delirium)
• Aggressive delirium prevention: Familiar environment, avoid restraints, minimize medications, treat pain, encourage mobilization
• Early involvement of geriatrician
• Realistic goals: May not return to pre-fracture mobility, focus on comfort and basic transfers

Causes:

• Metastatic disease: Breast, lung, kidney, thyroid, prostate most common
• Myeloma: Common in elderly
• Primary bone tumors: Rare (osteosarcoma, chondrosarcoma)

Clinical Clues:

• Minimal trauma or atraumatic
• Persistent pain before fracture (weeks to months)
• Known primary malignancy
• Constitutional symptoms (weight loss, night pain, fatigue)
• Lytic or sclerotic lesion on X-ray

Investigations:

• Staging CT: Chest, abdomen, pelvis
• Bone scan or PET: Full skeletal survey
• Myeloma screen: SPEP, UPEP, serum free light chains, bone marrow biopsy
• Biopsy: If unknown primary (intraoperative or pre-operative CT-guided)

Management:

• Almost always arthroplasty (fixation will fail - diseased bone won't heal)
• Long-stem cemented prosthesis if metaphyseal or diaphyseal involvement
• Consider THR (not hemiarthroplasty) if acetabular metastases present
• Post-operative radiotherapy: Reduces local recurrence, pain
• Bisphosphonates: Zoledronic acid for bony metastases
• Oncology referral: Systemic treatment if appropriate

Common Scenarios:

• Warfarin: For atrial fibrillation, mechanical heart valves, VTE
• DOACs: Apixaban, rivaroxaban, dabigatran (increasingly common)
• Dual antiplatelet therapy: Aspirin + clopidogrel/ticagrelor (post-coronary stent)

Management Principles:

• Do NOT delay surgery waiting for natural clearance - increases mortality
• Active reversal to achieve surgery within 48 hours

Warfarin Reversal:

• Target INR less than 1.5 for surgery
• Prothrombin complex concentrate (PCC): 25-50 units/kg IV (rapid reversal in 15-30 minutes)
• Vitamin K: 5-10mg IV (slower reversal, 6-24 hours, but more sustained)
• Avoid FFP: Requires large volumes (15-20mL/kg), slower reversal
• Restart warfarin: 24-48 hours post-op when hemostasis secure, bridge with LMWH if high stroke risk (CHA2DS2-VASc greater than 4)

DOAC Management:

• Half-life: Apixaban/rivaroxaban 8-12 hours, dabigatran 12-17 hours
• Hold for 48 hours (2-3 half-lives) before surgery if renal function normal
• Check anti-Xa levels (rivaroxaban, apixaban) or thrombin time (dabigatran) if available
• Reversal agents if emergency:
  • Idarucizumab for dabigatran (specific reversal)
  • Andexanet alfa for apixaban/rivaroxaban (specific reversal, very expensive)
  • PCC as alternative (off-label but effective)
• Restart: 24-48 hours post-op

Dual Antiplatelet Therapy (Post-Coronary Stent):

• High bleeding risk if continue aspirin + clopidogrel
• High stent thrombosis risk if stop both
• Consult cardiology: Timing since stent, type of stent (bare metal vs drug-eluting)
• General approach: Continue aspirin, hold clopidogrel/ticagrelor for 5-7 days before surgery if possible
• If recent stent (less than 3 months): May need to operate on dual antiplatelets (accept higher bleeding risk - stent thrombosis is catastrophic)

Epidemiology in Australia

Incidence and Burden:

• Approximately 20,000-22,000 hip fractures annually in Australia (ANZ Hip Fracture Registry - ANZHFR data 2023)
• 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 population
• Annual healthcare cost: Estimated AUD $1.2-1.5 billion (acute care, rehabilitation, long-term care)

Mortality Data (ANZHFR 2023):

• 30-day mortality: 6.2% (national average)
• 1-year mortality: 27.3%
• 5-year mortality: Approximately 50%
• Variation across states: Best performing states (VIC, NSW) achieve 5-6% 30-day mortality, while some rural/remote regions higher (8-10%)

Geographic Variation:

• Urban vs Rural: Rural areas have slightly higher mortality and longer time to surgery (access issues)
• Indigenous Australians: Hip fractures occur 10-15 years earlier than non-Indigenous Australians, higher mortality rates
• 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)

Australian Hip Fracture Care Standards

ACSQHC Clinical Care Standard (2016, updated 2021):

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

PBS (Pharmaceutical Benefits Scheme) Considerations

Bisphosphonates:

• Alendronate 70mg weekly: PBS-subsidized for osteoporosis with fragility fracture (no authority required)
• Zoledronic acid 5mg IV yearly: PBS-subsidized for osteoporosis with fracture (Streamlined authority - phone approval)
• Denosumab 60mg SC 6-monthly: PBS-subsidized as second-line if bisphosphonates contraindicated/intolerant

Anticoagulants:

• Warfarin: Fully PBS-subsidized
• DOACs (apixaban, rivaroxaban, dabigatran): PBS-subsidized for atrial fibrillation with CHA2DS2-VASc score greater than or equal to 2 (males) or greater than or equal to 3 (females)
• Prothrombin Complex Concentrate (Prothrombinex-VF): Section 100 approval required (emergency provision available)

Analgesia:

• Paracetamol, tramadol: Unrestricted PBS
• Oxycodone, morphine: Schedule 8 controlled drugs, prescription limits apply
• Fascia iliaca blocks not PBS-listed (hospital cost absorbed)

eTG (Therapeutic Guidelines) Recommendations

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)

State-Specific Programs

Victoria: HIP FRACTURE PATHWAY (Safer Care Victoria)

• Standardized care pathway across all Victorian public hospitals
• Pre-printed orders for analgesia, DVT prophylaxis, bone protection
• Mandatory orthogeriatric review
• State-wide data collection and benchmarking

New South Wales: GUIDE TO THE MANAGEMENT OF HIP FRACTURES IN OLDER PEOPLE (Agency for Clinical Innovation)

• Model of care recommendations
• Minimum Data Set collection
• Coordinated Fracture Liaison Services across Local Health Districts

Queensland: HIP FRACTURE CARE CLINICAL PATHWAY

• Integrated care pathway from emergency department to discharge
• Focus on rural and remote service delivery
• Telehealth orthogeriatric consultations for regional hospitals

South Australia: SA HIP FRACTURE REGISTRY (State-level registry complementing ANZHFR)

Western Australia: WA HIP FRACTURE MODEL OF CARE (Department of Health)

• Emphasizes pre-hospital care, ambulance protocols
• Regional transfer guidelines for complex cases

Challenges Specific to Australia

Geographic Remoteness:

• Retrieval and transfer: Some patients require Royal Flying Doctor Service (RFDS) evacuation from remote areas to surgical centers
• Delays: Transfer times can be 12-24 hours, impacting 48-hour surgery target
• Workforce: Rural hospitals may lack orthopedic or anesthetic cover 24/7

Indigenous Health:

• Hip fractures occur 10-15 years younger in Indigenous Australians
• Higher comorbidity burden (diabetes, renal disease, cardiovascular disease)
• Cultural considerations for rehabilitation and discharge planning
• Coordination with Aboriginal Medical Services for post-discharge care

Aged Care Facilities:

• 40-50% of hip fractures occur in patients residing in aged care
• Transfer delays from facility to hospital
• Challenges with return to aged care 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.