Fractures Requiring Hospital Admission in Adults
All proximal femoral (hip) fractures, displaced distal femur fractures, open fractures, and fragility fractures in patients over 50 years require hospital admission for multidisciplinary management and surgical intervention within 24-48 hours.
Hip and Proximal Femoral Fractures
All hip fractures mandate immediate hospital admission regardless of displacement or patient age, as these are admission-level injuries requiring urgent surgical management 1. The evidence is unequivocal:
- Surgery must occur within 48 hours of hospital admission to reduce mortality, minimize complications (pressure sores, pneumonia, thromboembolic events), and shorten hospital stay 1
- Ideally, surgery should be performed within 24 hours when resources allow, as high-volume centers demonstrate improved outcomes with earlier intervention 2, 3
- Delaying surgery beyond 48 hours significantly increases morbidity and mortality 1, 3
Critical Management Requirements
- Immediate admission to an orthogeriatric ward with multidisciplinary expertise within 4 hours of emergency department arrival 1
- Orthogeriatric co-management is mandatory for elderly patients, as this model reduces length of stay, complications, and 1-year mortality 1
- Multimodal analgesia including nerve blocks must be initiated immediately, as surgery itself is the definitive analgesic 1, 2, 3
Distal Femur Fractures
Displaced distal femur fractures require hospital admission for surgical management, particularly in elderly patients with fragility fractures 2:
- Surgery within 24-48 hours is recommended, with expedited surgery to within 24 hours preferred when feasible 2
- Experienced surgical and anesthesia teams are essential, as these complex fractures require appropriate expertise 2
- Early mobilization within days of surgery is critical to prevent knee stiffness and muscular atrophy 2
Open Fractures
All open fractures mandate immediate hospital admission for urgent surgical debridement and management, regardless of location 4, 5:
- Definitive surgical management within 24 hours reduces complications, ARDS, pneumonia, sepsis, and shortens ICU and hospital stays 4
- Open tibial fractures specifically require surgical treatment within 12 hours when possible to optimize outcomes 5
Fragility Fractures in Patients ≥50 Years
All fragility fractures in patients aged 50 and older require hospital admission for comprehensive assessment and management 1, 6:
- These fractures indicate underlying bone fragility and significantly increase risk of subsequent fractures 6
- Multidisciplinary clinical system management is mandatory, including preoperative assessment, adequate pain relief, fluid management, and surgery within 48 hours 1
- Systematic evaluation for secondary fracture risk must be performed, including DXA scanning, vertebral fracture imaging, and falls risk assessment 1
Pelvic, Acetabular, and Spine Fractures in Polytrauma
Mechanically unstable fractures of the pelvis, acetabulum, and thoracolumbar spine in patients with Injury Severity Score ≥18 require admission 4:
- Early definitive management within 24 hours reduces ICU days (5.1 vs 8.4 days), total hospital stay (10.5 vs 14.3 days), and overall complications (24.0% vs 35.8%) compared to delayed fixation 4
- Fewer cases of ARDS (1.7% vs 5.3%) and pneumonia (8.6% vs 15.2%) occur with early versus delayed fixation 4
Common Pitfalls to Avoid
- Never delay hip fracture surgery beyond 48 hours unless there are clear reversible medical conditions, as delay increases mortality and complications 1, 3
- Do not discharge fragility fracture patients without osteoporosis evaluation and treatment initiation, as secondary prevention is essential 2, 3, 6
- Avoid using opioids as sole analgesic for hip fractures; multimodal analgesia with nerve blocks is superior 3
- Do not perform internal fixation for displaced femoral neck fractures due to high risk of avascular necrosis; arthroplasty is indicated 3