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BOAST Guidelines
BOAST 1
Trauma

Patients Sustaining a Fragility Hip Fracture

Covers the acute multidisciplinary assessment, surgical timing, anaesthetic standards, and rehabilitation protocols for older patients presenting with fragility hip fractures.

Key standards

  • ›Operate on the day of or day after admission, targeting surgery within 36 hours of initial presentation.
  • ›Obtain prompt MRI within 24 hours (or CT if MRI contraindicated/unavailable) for suspected occult fractures with negative plain radiographs.
  • ›Provide routine multimodal analgesia, incorporating early peripheral nerve blocks (e.g., fascia iliaca compartment block).
  • ›Deliver care within an integrated orthogeriatric pathway featuring comprehensive geriatric assessment.
  • ›Select surgical interventions that permit immediate, unrestricted postoperative weight-bearing.
  • ›Screen routinely for cognitive impairment and delirium using validated tools such as the 4AT.
  • ›Mobilise out of bed with physiotherapist review on postoperative day one.
  • ›Mandate data submission for all admitted hip fracture patients to the National Hip Fracture Database (NHFD).

Introduction

Hip fractures in frail and older individuals represent a major trauma emergency requiring coordinated orthogeriatric and orthopaedic intervention. The clinical goals center on timely physiological stabilisation, surgical fixation or arthroplasty that enables early full weight-bearing, pain control, and rapid multidisciplinary rehabilitation.

Multidisciplinary Care & Pathway

  • Establish a dedicated Hip Fracture Programme with joint care between orthopaedic surgeons, orthogeriatricians, anaesthetists, and allied health professionals.
  • Commence formal orthogeriatric assessment and joint medical optimisation promptly upon admission.
  • Ensure clear protocols cover out-of-hours, weekend, and bank holiday reviews to prevent perioperative delays.

Investigation & Occult Fractures

  • Obtain high-quality anteroposterior pelvis and dedicated cross-table lateral hip radiographs.
  • In patients unable to bear weight following trauma with negative or non-diagnostic standard plain films, arrange an urgent MRI of the hip within 24 hours.
  • If MRI is contraindicated or unavailable within 24 hours, perform a thin-slice pelvic and hip CT scan.

Preoperative Optimisation & Timing

  • Perform surgery on the day of or day after admission (aiming within 36 hours of presentation) on a planned daytime trauma list.
  • Identify and correct reversible physiological derangements (electrolytes, dehydration, acute anaemia) promptly without unnecessary postponement.
  • Establish local network policies for rapid reversal of oral anticoagulants.
  • Operation lists should have consultant-led or senior-level supervision across surgical and anaesthetic disciplines.

Pain Management & Regional Anaesthesia

  • Deliver prompt and scheduled multimodal systemic analgesia supplemented by peripheral nerve blocks (such as fascia iliaca or femoral nerve blocks) at initial assessment.
  • Tailor opioid usage to renal function and frail physiology while avoiding routine use of non-steroidal anti-inflammatory agents.

Surgical Standards

  • Select surgical constructs and implants that permit immediate full postoperative weight-bearing.
  • Undisplaced intracapsular fractures: internal fixation or arthroplasty based on individual baseline activity and bone quality.
  • Displaced intracapsular fractures: hemiarthroplasty or total hip arthroplasty (THA) in eligible patients meeting cognitive, independent mobility, and medical criteria.
  • Intertrochanteric fractures: sliding hip screw (extramedullary) or cephalomedullary nail depending on fracture stability and subtrochanteric extension; subtrochanteric fractures require intramedullary nailing.

Postoperative Care & Governance

  • Mobilise patients with dedicated physiotherapy input on postoperative day one.
  • Screen for delirium using validated tools (e.g., 4AT) and institute secondary fragility fracture prevention (falls assessment, bone protection therapy).
  • Ensure institutional submission of all case episodes to the National Hip Fracture Database (NHFD) to monitor performance against national standards.

Exam-tested points

  • ›Indications for Total Hip Arthroplasty (THA) in displaced intracapsular fractures vs hemiarthroplasty: independent outdoor ambulation (with no more than one stick), intact baseline cognition (AMTS > 8 or no dementia), and medically fit for the longer procedure.
  • ›Investigation algorithm for occult hip fractures: MRI pelvis/hip within 24 hours is the primary modality; non-contrast CT is acceptable if MRI is contraindicated or unavailable within that timeframe.
  • ›Target surgical timing cutoff: surgery within 36 hours of admission to optimize 30-day mortality and qualify for Best Practice Tariff (BPT).
  • ›Implant selection criteria for trochanteric patterns: extramedullary fixation (sliding hip screw) for stable 2-part fractures; cephalomedullary nails for unstable configurations (loss of medial calcar support, reverse obliquity) or subtrochanteric extension.
  • ›Criteria defining Best Practice Tariff (BPT): surgery within 36 hours, joint admission under orthogeriatrician and surgeon, perioperative orthogeriatric assessment within 72 hours, multidisciplinary rehabilitation, routine falls/bone health assessment, and 4AT delirium screening.
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