What is the appropriate emergency department management and treatment for a hip fracture (femoral neck fracture)?

Emergency Department Management of Hip Fractures

Hip fracture patients in the ER require immediate protocol-driven fast-track admission with early analgesia, diagnostic imaging, and preparation for surgical fixation within 48 hours, as surgery is the definitive treatment that reduces both mortality and morbidity. 1

Immediate Recognition and Triage

Upon arrival, rapidly identify the classic presentation:

• Hip pain with inability to weight-bear
• Shortened, externally rotated leg on the affected side
• Obtain AP pelvis and lateral hip radiographs within 27 minutes of arrival 1, 2

Implement fast-track triage systems to bypass standard ED queues—this allows early radiographic confirmation and direct ward admission, avoiding prolonged ED stays that increase cardiac complications and hospital length of stay 1, 2.

Pain Management Protocol

Analgesia is the first priority after diagnosis, as hip fractures are extremely painful and early fracture fixation provides the most effective pain relief 1.

Structured Analgesic Approach:

1. Paracetamol (acetaminophen): Administer routinely on a scheduled basis unless contraindicated 1

2. Opioids: Use cautiously—40% of hip fracture patients have moderate renal dysfunction (GFR <60), so check urea and electrolytes before dosing 1

3. Regional nerve blocks (femoral nerve block or fascia iliaca compartment block): Strongly recommended and can be administered by trained ED physicians 1, 3, 4. These blocks reduce pain scores and decrease risk of acute confusion without causing motor weakness with newer techniques.

4. Avoid NSAIDs: Relatively contraindicated due to high prevalence of renal dysfunction 1

Document pain scores at rest and with movement before and after analgesia administration 1.

Critical ED Management Elements

Resuscitation and Monitoring:

• IV fluid therapy: Many patients are volume depleted
• Patient warming: Prevent hypothermia
• Pressure care: Begin immediately to prevent decubitus ulcers 1

Time-Sensitive Goals:

• Admit to orthopaedic ward within 4 hours of ED arrival 1
• Avoid ED stays ≥5 hours: Associated with increased cardiac events (10.1% vs 4.6%) and prolonged hospitalization 2

Laboratory Workup:

• Complete blood count (baseline hemoglobin)
• Urea and electrolytes (assess renal function before opioid dosing)
• Basic metabolic panel
• Coagulation studies if on anticoagulation

Multidisciplinary Coordination

Initiate orthogeriatric consultation in the ED 1, 3. Interdisciplinary care programs decrease complications and improve outcomes (strong recommendation). The hospitalist or geriatrician should:

• Assess and optimize medical comorbidities (70% are ASA 3-4)
• Clear patient for surgery
• Begin discharge planning early

Surgical Planning

Target surgery within 24-48 hours of admission 1, 5. The definitive treatment is surgical fixation, which:

• Provides superior analgesia
• Enables early mobilization
• Reduces mortality and morbidity

Key Surgical Considerations to Communicate:

• Displaced femoral neck fractures: Arthroplasty preferred over fixation 3
• Stable intertrochanteric fractures: Sliding hip screw or cephalomedullary device 3
• Cemented femoral stems recommended for arthroplasty 3
• Tranexamic acid should be administered to reduce blood loss 3

Common Pitfalls to Avoid

1. Inadequate analgesia: Only 56% of patients historically receive pain medication in the ED—this is unacceptable 6
2. Prolonged ED boarding: Delays beyond 4-5 hours increase complications 1, 2
3. Failure to check renal function before opioid dosing: 40% have significant renal impairment 1
4. Delaying nerve blocks: These should be administered early by trained ED staff, not waiting for anesthesia consultation 4
5. Missing associated injuries: In younger patients with high-energy mechanisms, evaluate for head, chest, abdominal, and other musculoskeletal injuries 7

Documentation Requirements

Record in the ED chart:

• Time of injury and arrival
• Pain scores (at rest and with movement)
• Neurovascular status of affected limb
• Time to imaging and diagnosis confirmation
• Analgesia administered and response
• Medical optimization initiated
• Time of orthogeriatric consultation
• Anticipated time to surgery

The ED visit represents a critical window for initiating the care pathway that determines patient outcomes—delays and inadequate pain management directly impact morbidity and mortality in this vulnerable population 1, 2.