Definitions for the Levels of Evidence (1++ to 4) and Grades of Recommendation (A to D) are given at the end of the "Major Recommendations" field.
Non-Surgical Management
Pre-hospital Care
D In isolated areas, fluid replacement and catheterisation prior to transport to hospital may be indicated.
Emergency Department Care
C Hospitals treating hip fracture should have formal "fast track" protocols for assessment and admission of people aged 65 years and over.
Fluid Replacement
D After hip fracture, there is a risk of dehydration because of inability to gain access to sufficient fluids. Careful fluid management is required, as there is also risk of fluid overload when fluid replacement is given intravenously.
Pre-operative Traction
A Routine use of temporary leg traction appears to be unnecessary.
Pain Relief
C Use of systematic pain assessment tools helps to avoid undertreatment or overtreatment of pain.
D As frail older people tolerate narcotics poorly, multiple modalities should be considered for analgesia.
D Narcotic use must be carefully titrated and supervised.
B Paracetamol should be preferred to aspirin as their effects are similar milligram for milligram, but paracetamol has fewer side effects.
B Ibuprofen is a non-steroidal anti-inflammatory drug (NSAID) effective in post-operative pain and appears to have lower incidence of adverse effects than other NSAIDs.
B Propoxyphene-containing compounds are not recommended in people aged 65 years and over with hip fracture.
A The use of local analgesic nerve blocks reduces the need for parenteral or oral analgesia.
Oxygen Therapy
C Oxygen should be administered to maintain adequate tissue oxygenation, as indicated by oximetry and clinical status.
Prophylaxis Against Venous Thromboembolism
D Adequate fluid balance and early post-operative mobilisation lower the risk of postoperative venous thromboembolism (VTE).
A Administration of either aspirin or low molecular weight heparin is associated with reduced risk of VTE, but some increase in adverse bleeding events.
A Foot or calf pumps reduce the incidence of VTE, but have some adverse skin effects and compliance problems.
B There is insufficient evidence to confirm the effectiveness of thromboembolism stockings after hip fracture.
Prophylaxis Against Wound and Other Infections
A Antibiotic prophylaxis is effective in reducing wound infection after hip fracture surgery.
Use of Beds, Mattresses and Cushions to Prevent Pressure Sores
A The use of high specification foam bed mattresses and pressure relieving mattresses on operating tables reduces the incidence of pressure sores.
Nutritional Supplementation after Hip Fracture
A Oral multinutrient feeds reduce unfavourable outcome (death or post-operative complication) after hip fracture.
Management of Urinary Retention
D Routine catheterisation after hip fracture is not recommended.
A When urinary retention occurs, intermittent catheterisation results in quicker restoration of normal voiding than indwelling catheterisation.
Management of Dementia/Delirium
C Initial admission data should include a formal measure of cognitive function.
B Early involvement of a geriatric medical team in hip fracture care has been associated with a significant reduction in the incidence of post-operative delirium.
A Active reorientation by provision of clock, calendar, radio, television, and telephone does not appear to reduce post-operative cognitive deterioration.
D Continuity in nursing care may reduce post-operative cognitive deterioration.
Surgical Management
Delay Before Surgery
C Early operation (within 24 hours) for people aged 65 years and over with hip fracture is associated with shorter hospital stay and decreased mortality/morbidity.
Anaesthesia
A Regional anaesthesia for hip fracture surgery is associated with a lower rate of deep venous thrombosis than general anaesthesia, but no significant differences in mortality or other measures of morbidity.
Undisplaced Intracapsular Fractures
B Screws appear to provide better fixation and fracture healing than unthreaded pins.
Displaced Intracapsular Fractures
A Any benefit of open reduction over closed reduction of a femoral neck fracture prior to internal fixation is unproven.
A Evidence for the superiority of arthroplasty compared with internal fixation for displaced intracapsular fractures of the hip, reflected by lower re-operation, is limited.
A Arthroplasty is associated with a lower re-operation rate than internal fixation.
A In arthroplasty after hip fracture, the use of bone cement may be associated with less late pain in the limb.
A Unipolar hemi-arthroplasty appears as effective as bipolar hemi-arthroplasty, and is less expensive.
A There is insufficient evidence to identify whether the use of total hip replacement is superior to the use of hemi-arthroplasty in displaced fracture of the femoral neck.
Extracapsular (trochanteric) Fractures
A Fixation with a sliding hip screw gives superior results to fixed nail plate devices or intramedullary devices.
Surgical Suction Wound Drains
A The usefulness of surgical suction wound drains after hip fracture surgery is unproven.
Post-operative Mobilisation
D People with hip fracture should be mobilised, weight bearing with support as tolerated, as soon as possible after surgery.
Immediate Rehabilitation
A Hospitals providing treatment for people aged 65 years and over with hip fracture should provide formal hip fracture programmes which include early multidisciplinary assessment by a geriatric team.
A Early Supported Discharge Programmes reduce mean hospital stay and are associated with a higher rate of effective return to previous residential status.
Definitions:
Levels of Evidence
1++
High quality meta-analyses/systematic reviews of randomised controlled clinical trials (RCTs), or RCTs with a very low risk of bias
1+
Well-conducted meta-analyses/systematic reviews, or RCTs with a low risk of bias
1-
Meta-analyses/systematic reviews, or RCTs with a high risk of bias
2++
High quality systematic reviews of case-control or cohort studies
High quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+
Well-conducted case-control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2-
Case-control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3
Non-analytic studies (e.g., case reports). Case series
4
Expert opinion
Qualitative material was systematically appraised for quality, but was not ascribed a level of evidence.
Grades of Recommendations
A
At least one meta-analysis, systematic review, or RCT rated 1++ and directly applicable to the target population
or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B
A body of evidence consisting principally of studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results
or
Extrapolated evidence from studies rated as 1++, or 1+
C
A body of evidence consisting principally of studies rated as 2+, directly applicable to the target population, and demonstrating overall consistency of results
or
Extrapolated evidence from studies rated as 2++
D
Evidence level 3 or 4
or
Extrapolated evidence from studies rated as 2+
