Treatment of Upper Femur Fractures
Surgical intervention with appropriate internal fixation is strongly recommended as the primary treatment for upper femur fractures to optimize outcomes related to morbidity, mortality, and quality of life. 1
Surgical Management Based on Fracture Type
Femoral Neck Fractures
Stable/Non-displaced fractures:
Displaced fractures:
- Total hip arthroplasty (THA) is preferred for healthy, active, independent older adults without cognitive dysfunction 2
- Hemiarthroplasty is preferred for frail patients due to shorter operative time and lower dislocation risk 2
- Either unipolar or bipolar hemiarthroplasty may be equally beneficial (moderate recommendation) 1
- Cemented femoral stems are strongly recommended over uncemented stems 2, 1
Trochanteric Fractures
- Stable intertrochanteric fractures: Sliding hip screw is favored 2
- Unstable intertrochanteric fractures: Antegrade cephalomedullary nail 2
- Subtrochanteric or reverse oblique fractures: Cephalomedullary devices strongly recommended 2
Perioperative Management
Pain Management
- Multimodal analgesia incorporating preoperative nerve blocks is strongly recommended 2, 1
- Regular paracetamol administration throughout perioperative period 2
- Careful use of opioids, especially in patients with renal dysfunction 2
- Avoid NSAIDs in elderly patients, especially those with renal dysfunction 2
Blood Management
- Tranexamic acid should be administered to reduce blood loss and blood transfusion (strong recommendation) 2, 1
- Monitor hemoglobin levels closely, especially with extracapsular fractures which can have significant blood loss 2, 1
Thromboprophylaxis
- Venous thromboembolism prophylaxis strongly recommended 1
- Sequential compression devices during hospitalization followed by pharmacological prophylaxis for 4 weeks postoperatively 1
Postoperative Care
Immediate Care
- Interdisciplinary care programs should be used to decrease complications and improve outcomes (strong recommendation) 2
- Appropriate pain management with regular paracetamol and carefully prescribed opioid analgesia as needed 2
- Supplemental oxygen for at least 24 hours postoperatively 2
- Encourage early oral fluid intake rather than routine IV fluids 2
- Remove urinary catheters as soon as possible 2
Mobilization
- Immediate, full weight-bearing to tolerance after surgery is recommended for most upper femur fractures 1
- Early mobilization to improve oxygenation and respiratory function 2
Nutrition
- Up to 60% of patients with hip fracture are malnourished on admission 2
- Nutritional supplementation may reduce mortality and length of stay 2
Prevention of Subsequent Fractures
- Referral to a bone health clinic for osteoporosis evaluation and treatment is recommended 1
- Each patient aged 50+ with a recent fracture should be evaluated systematically for the risk of subsequent fractures 2
Complications to Monitor
- Postoperative cognitive dysfunction/acute confusional state (common in 25% of patients) 2
- Bone cement implantation syndrome (BCIS) - characterized by hypoxia, hypotension, or loss of consciousness during cementation 2
- Avascular necrosis (higher risk in acetabular fractures combined with proximal femur fractures) 3
- Infection (aggregate rate around 17% in complex cases) 3
- Secondary surgeries (required in more than 30% of complex cases) 3
Follow-up
- Regular imaging to assess healing progression, including follow-up radiographs at 2,6, and 12 weeks for surgically treated fractures 1
Upper femur fractures require prompt surgical intervention with appropriate fixation techniques based on fracture type and patient characteristics. The treatment approach should focus on reducing mortality and morbidity while optimizing functional outcomes and quality of life.