SCE Orthopaedics: Hip Fracture Management Complete Guide

Introduction

Hip fracture management represents one of the highest-yield topics in the Specialty Certificate Examination (SCE) for Orthopaedics. With over 70,000 hip fractures occurring annually in the UK alone, and with the ageing population driving numbers higher, the NHS faces enormous clinical and economic challenges. The SCE examines not only your knowledge of surgical options but also your understanding of perioperative care, multidisciplinary management, and evidence-based guidelines that govern hip fracture care in the UK.

This comprehensive guide walks you through the essential guidelines—NICE CG124, the BOA Blue Book, and related NICE guidance—that every SCE candidate must know. We'll cover classification, pre-operative optimisation, surgical decision-making, post-operative rehabilitation, and the key exam points that frequently appear in SBAs.

Why Hip Fractures Are High-Yield for SCE

Hip fractures are a "perfect storm" exam topic because they test:

1. Surgical knowledge: Choice of implant and procedure

2. Medical knowledge: Perioperative management of frail patients with comorbidities

3. Guideline knowledge: NICE, BOA, and local pathways

4. Multidisciplinary understanding: Orthogeriatrics, anaesthesia, physiotherapy, social services

5. Quality improvement awareness: National Hip Fracture Database (NHFD) metrics

The SCE loves scenarios that combine these domains, making hip fractures a near-guaranteed topic in your exam.

Classification Systems You Must Know

Garden Classification (Intracapsular Fractures)

Exam tip: Garden I and II are treated with internal fixation (cannulated screws or DHS). Garden III and IV are treated with arthroplasty—hemiarthroplasty or total hip replacement (THR), depending on patient factors.

AO/OTA Classification (Extracapsular Fractures)

• 31-A1: Simple intertrochanteric (two-part) → Sliding hip screw (DHS)

• 31-A2: Multifragmentary intertrochanteric → DHS or IMHS

• 31-A3: Reverse obliquity or subtrochanteric → IMHS (cephalomedullary nail)

Exam tip: Reverse obliquity fractures (A3) must NOT be treated with a sliding hip screw. This is a classic SCE trap question. The correct answer is intramedullary hip screw (IMHS).

Key Guidelines for SCE

1. NICE CG124: Hip Fracture Management

This is the cornerstone guideline for UK hip fracture care. Updated in 2023, it covers the entire patient journey from admission to rehabilitation.

Timing of Surgery

• Surgery should be performed on the day of admission or the next day (within 36 hours of admission)

• Delay beyond 36 hours is associated with:

  • Increased 30-day mortality

  • Increased length of stay

  • Higher complication rates (pressure ulcers, DVT, infections)

Pain Management

• Offer paracetamol regularly (not PRN)

• Consider codeine or tramadol for additional pain relief

• Fascia iliaca block should be offered to all patients with hip fracture pre-operatively (reduces opioid use and delirium)

• Avoid NSAIDs in elderly patients (renal impairment risk)

Cognitive Assessment

• Cognitive assessment (e.g., AMTS or 4AT) at admission

• Delirium is present in up to 40% of hip fracture patients

• Identify and treat underlying causes (infection, hypoxia, medications)

Nutrition

• Offer oral supplements to patients who are malnourished or at risk

• Do not routinely offer vitamin D supplementation unless there is a deficiency (note: this is a specific NICE recommendation, though BOA differs—see below)

Surgical Management

For intracapsular fractures:

• Undisplaced (Garden I/II): Internal fixation with cannulated screws or DHS

• Displaced (Garden III/IV):

  • Offer total hip replacement (THR) to patients who:

    • Were able to walk independently out of doors with no more than a stick

    • Are not cognitively impaired

    • Are medically fit for the procedure

  • Offer hemiarthroplasty to all other patients with displaced fractures

  • Do not offer cemented, bipolar, or uncemented monopolar hemiarthroplasty—use cemented monopolar (e.g., Exeter trauma stem)

For extracapsular fractures:

• Intertrochanteric (stable): Sliding hip screw (DHS)

• Intertrochanteric (unstable, multifragmentary): IMHS

• Subtrochanteric/reverse obliquity: IMHS (cephalomedullary nail)

Post-Operative Rehabilitation

• Early mobilisation: Day 1 post-operatively (or day 0 if possible)

• Weight-bearing as tolerated for most fixation procedures

• Multidisciplinary team approach: orthogeriatrician, physiotherapist, occupational therapist, social worker

• Bone health: Assess and treat osteoporosis (DEXA, FRAX, bisphosphonates)

2. BOA Blue Book: Care of Patients with Fragility Fracture (2021)

The British Orthopaedic Association Standards for Trauma (BOAST) provide detailed guidance on hip fracture care.

Key Standards:

1. Admission: All patients admitted with a hip fracture should be managed on an orthogeriatric ward or trauma unit

2. Fast-track surgery: Patients should be listed as the first case on the next available trauma list

3. Surgical technique: Cemented hemiarthroplasty for displaced intracapsular fractures in patients not meeting THR criteria

4. Bone protection: All patients should be offered bone protection medication before discharge (calcium, vitamin D, bisphosphonate)

5. NHFD data: All patients must be entered into the National Hip Fracture Database

Exam tip: The BOA Blue Book emphasises the "6 standards" of hip fracture care:

1. Prompt admission to an orthopaedic ward

2. Surgery on the next available trauma list

3. Assessment by a geriatrician

4. Early multidisciplinary rehabilitation

5. Early discharge planning

6. Bone health assessment

3. NICE NG37: Falls in Older People (2013, updated 2023)

Since prevention is better than cure, falls assessment is a key component of hip fracture management.

Key points:

• All patients with a hip fracture should have a multifactorial falls assessment

• Strength and balance training (e.g., Otago exercise programme)

• Home hazard assessment

• Medication review (psychotropics, antihypertensives)

• Vision correction

• Cardiac assessment (if syncope suspected)

Pre-Operative Optimisation

The SCE frequently tests your knowledge of perioperative management. Key elements include:

Medical Assessment

• Full blood count, U&Es, group and save, ECG, CXR

• Cross-match 2 units for arthroplasty cases

• Assess for delirium (4AT screening)

• Assess for malnutrition (MUST score)

Anaesthetic Considerations

• Spinal anaesthesia is preferred where possible (reduced early mortality, reduced delirium)

• General anaesthesia may be needed if spinal is contraindicated

• Nerve blocks (fascia iliaca) for analgesia

• Avoid prolonged fasting (encourage clear fluids up to 2 hours pre-op)

Medical Optimisation

• Fluid resuscitation for dehydrated patients

• Correct electrolyte abnormalities (especially potassium)

• Optimise heart failure (diuretics as needed, but avoid over-diuresis)

• Blood pressure control (avoid hypotension)

• Stop anticoagulants/antiplatelets appropriately:

  • Warfarin: stop, check INR < 1.5 (or reverse with vitamin K)

  • DOACs: stop 24-48 hours pre-op depending on drug

  • Clopidogrel: ideally stop 7 days pre-op (but don't delay surgery excessively)

Exam tip: The balance between medical optimisation and timely surgery is a common SCE theme. NICE is clear: surgery within 36 hours is the priority, but reversible medical conditions should be addressed. Do NOT delay surgery for extensive medical workup unless there is a clear, reversible life-threatening condition.

Surgical Decision-Making

Intracapsular Fractures

Undisplaced (Garden I/II):

• Internal fixation: cannulated screws or DHS

• Union rate: ~90% for undisplaced fractures

• Avascular necrosis (AVN) risk: 10-20%

• Non-union risk: 5-10%

Displaced (Garden III/IV):

• THR criteria (NICE):

  • Walked independently outdoors pre-fracture (no more than one stick)

  • No cognitive impairment

  • Medically fit

  • Displacement not so severe that THR is technically impossible

• Hemiarthroplasty for all other displaced intracapsular fractures

  • Cemented monopolar (e.g., Austin Moore or Exeter trauma stem)

  • Cemented bipolar (some centres prefer this for more active patients)

Exam tip: The question of "who gets THR vs hemiarthroplasty" is one of the most frequently tested topics. Remember the three criteria: independent mobility, cognitively intact, medically fit. If any one is not met, the patient gets hemiarthroplasty.

Extracapsular Fractures

Intertrochanteric (Trochanteric):

• Stable (A1): DHS (dynamic hip screw)

  • Sliding mechanism allows fracture impaction

  • 95° fixed angle device

  • Lower re-operation rate than IMHS for stable patterns

• Unstable (A2): IMHS or DHS

  • IMHS has biomechanical advantages for unstable patterns

  • Shorter lever arm, less implant failure

  • Some evidence of slightly better outcomes for A2 fractures

Subtrochanteric and Reverse Obliquity (A3):

• IMHS (cephalomedullary nail) is the implant of choice

• DHS is contraindicated in reverse obliquity patterns

• IMHS provides better biomechanical stability

• Re-operation rates are significantly higher with DHS in these patterns

Post-Operative Care

Early Post-Operative Period (0-48 hours)

• Weight-bearing as tolerated for most procedures

• Adequate analgesia (paracetamol, short course of opioid)

• Venous thromboembolism prophylaxis:

  • Mechanical (anti-embolism stockings if no contraindication)

  • Pharmacological (LMWH or DOAC for 28-35 days)

• Monitor for complications: delirium, infection, DVT, pressure ulcers

• Early mobilisation: sit out of bed on day 1, walk by day 2

Rehabilitation Phase

• Multidisciplinary team (MDT) approach

  • Orthogeriatrician (daily review)

  • Physiotherapy (daily)

  • Occupational therapy (early home assessment)

  • Social worker (discharge planning)

• Goal-setting: realistic, functional goals

• Discharge planning:

  • Home with package of care

  • Rehabilitation unit

  • Care home (temporary or permanent)

• Length of stay target: < 14 days (NHFD benchmark)

Bone Health Assessment

• DEXA scan to confirm osteoporosis (may be done post-discharge)

• FRAX assessment for fracture risk

• Treatment:

  • Calcium and vitamin D supplementation

  • Bisphosphonate (alendronate first-line, risedronate, zoledronate)

  • Denosumab if bisphosphonate contraindicated

  • Anabolic agents (teriparatide) for severe osteoporosis

Exam tip: All patients presenting with a hip fracture should be considered for bone protection therapy, regardless of DEXA results, because they have already sustained a fragility fracture. This is a key point tested in SCE.

Key Complications to Know

Early Complications

• Delirium (up to 40% of patients)

• Infection: wound infection, urinary tract infection, chest infection

• DVT/PE: despite prophylaxis

• Acute kidney injury: often multifactorial

• Pressure ulcers: preventive measures essential

• Implant-related: dislocation (hemiarthroplasty/THR), cut-out (DHS/IMHS)

Late Complications

• Avascular necrosis (AVN): 10-20% in displaced intracapsular fractures treated with fixation

• Non-union: 5-10% in displaced intracapsular fractures treated with fixation

• Implant failure: cut-out of lag screw (DHS), periprosthetic fracture (IMHS)

• Osteoarthritis: in THR patients (uncommon)

• Heterotopic ossification: rare

National Hip Fracture Database (NHFD)

The NHFD is a national audit that tracks outcomes for hip fracture patients. Understanding the key metrics is important for SCE.

Key Performance Indicators (KPIs):

1. Time to surgery: % of patients operated within 36 hours (target > 85%)

2. Prompt orthogeriatric assessment: % assessed within 72 hours

3. Bone protection: % of patients discharged on bone protection medication

4. Assessment for delirium: % of patients assessed for delirium

5. Weight-bearing on day 1: % of patients mobilised on day 1 post-op

6. Length of stay: average days in hospital

7. 30-day mortality: tracked and benchmarked

Exam tip: The NHFD is a key quality improvement tool. SCE questions may ask about these metrics, particularly the 36-hour surgery target and bone protection at discharge.

Common SCE Question Themes

Theme 1: Timing of Surgery

Question pattern: A patient presents with a hip fracture. There is a correctable medical condition. When should surgery be performed?

Answer: Correct the reversible condition, but aim for surgery within 36 hours. Delays beyond 36 hours are associated with increased mortality. The only absolute contraindications to prompt surgery are:

• Active myocardial infarction

• Severe untreated heart failure

• Sepsis (needs source control first)

• Correctable coagulopathy

Theme 2: Implant Selection

Question pattern: A patient has a reverse obliquity intertrochanteric fracture. Which implant?

Answer: IMHS (cephalomedullary nail). DHS is contraindicated.

Theme 3: THR vs Hemiarthroplasty

Question pattern: A 70-year-old patient who walks independently, is cognitively intact, and is medically fit presents with a displaced intracapsular fracture. Which procedure?

Answer: Total hip replacement (THR). Meets all three NICE criteria.

Theme 4: Cementation in Hemiarthroplasty

Question pattern: A frail 85-year-old with cardiac disease needs a hemiarthroplasty. Cemented or uncemented?

Answer: Cemented hemiarthroplasty is preferred (better outcomes, less subsidence, less thigh pain). However, consider uncemented if there is severe cardiac disease due to risk of bone cement implantation syndrome (BCIS). Use cement with a vacuum mixer and reduce cement viscosity to minimise BCIS risk.

Theme 5: Bone Protection

Question pattern: A patient is discharged after a hip fracture. What bone protection should be offered?

Answer: Calcium, vitamin D, and a bisphosphonate (alendronate first-line). Offer to ALL hip fracture patients regardless of DEXA results.

Recent Updates and Evidence

1. Cemented vs Uncemented Hemiarthroplasty

The WHiTE trial (2023) confirmed that cemented hemiarthroplasty has better outcomes than uncemented, with lower re-operation rates and better functional outcomes. However, BCIS remains a concern in patients with severe cardiac disease.

2. THR in Hip Fracture

The WORLD HIP TRAUMA trial (2023) supported THR over hemiarthroplasty in cognitively intact, independently mobile patients, showing better functional outcomes at 12 months. The economic analysis also showed THR to be cost-effective in this group.

3. Fascia Iliaca Block

Recent evidence (2024) supports the routine use of fascia iliaca compartment block as part of a multimodal analgesia strategy, reducing opioid consumption and delirium rates.

4. Geriatric-Led Care

The orthogeriatric model of care continues to show superior outcomes compared to traditional orthopaedic-led care, with reduced mortality, shorter length of stay, and better functional recovery.

5. Artificial Intelligence in Hip Fracture Care

AI-based tools are being developed to:

• Predict mortality risk pre-operatively

• Optimise implant selection

• Automate fracture classification

• Predict rehabilitation needs

Exam tip: AI in orthopaedics is an emerging topic. While not yet a major SCE theme, it may appear in future exams. Be aware of the concept and its potential applications.

Revision Strategy for SCE Orthopaedics

High-Yield Topics Checklist

• [ ] Garden classification and treatment algorithm

• [ ] AO/OTA classification for extracapsular fractures

• [ ] NICE CG124 key recommendations

• [ ] BOA Blue Book standards

• [ ] THR vs hemiarthroplasty criteria

• [ ] Implant selection for extracapsular fractures

• [ ] Cemented vs uncemented hemiarthroplasty

• [ ] Timing of surgery (36-hour rule)

• [ ] Pre-operative optimisation

• [ ] Bone health assessment and treatment

• [ ] Falls assessment and prevention

• [ ] NHFD metrics

• [ ] Complications and their management

Practice Approach

1. SBA practice: Use question banks that test guideline knowledge, not just facts

2. Scenario-based revision: Practice applying guidelines to clinical scenarios

3. NICE guidelines: Read the summary of recommendations, not the full document

4. BOA Blue Book: Focus on the 6 standards and key surgical recommendations

5. NHFD: Know the key metrics and targets

Common Pitfalls to Avoid

1. Don't memorise without understanding: The SCE tests application, not recall

2. Don't confuse Garden classification types: Practice with radiographic examples

3. Don't forget the 36-hour rule: This is tested repeatedly

4. Don't miss the THR criteria: Three conditions, ALL must be met

5. Don't forget bone protection: This is a discharge quality indicator

6. Don't ignore reverse obliquity: DHS is wrong; IMHS is right

Summary

Hip fracture management is a cornerstone topic for SCE Orthopaedics, combining surgical knowledge, medical management, and guideline application. The key to success is understanding not just the facts but the reasoning behind them:

• Time matters: Surgery within 36 hours saves lives

• Implant matters: Match the implant to the fracture type and patient

• Team matters: Orthogeriatric care improves outcomes

• Prevention matters: Bone health and falls assessment prevent the next fracture

Master these concepts, and you'll be well-prepared for any hip fracture question the SCE throws at you. Remember: the exam tests your ability to apply guidelines to clinical scenarios, not just your ability to recall facts. Practice with SBAs, read the guidelines, and think like a consultant who needs to make safe, evidence-based decisions.

Good luck with your revision!