Neck of Femur (NOF) Fracture

NOF fracture presents with a shortened, externally rotated leg and is classified by the Garden classification (I–IV). Intracapsular fractures Garden III/IV require total hip replacement (THR); Garden I/II may have hemiarthroplasty or THR…

NHFD / NICE CG124

The pathway

1 · Confirm diagnosis

X-ray hip and pelvis (AP + lateral)
Garden classification: I/II (undisplaced intracapsular), III/IV (displaced intracapsular), extracapsular (intertrochanteric/subtrochanteric)
Assess neurovascular status of the limb

2 · Analgesia

Fascia iliaca block: 30ml 0.25% bupivacaine — reduces opioid requirement, safe in elderly
Regular paracetamol 1g QDS
Avoid NSAIDs and excess opioids (delirium and fall risk)

3 · Optimise for theatre

ECG, CXR, bloods (FBC, U&E, clotting, G&S)
Stop/bridge anticoagulation per protocol (warfarin → vitamin K, DOAC → withhold)
MDT assessment: anaesthetics, orthogeriatrics, physiotherapy

4 · Surgery within 36 hours

NHFD standard: surgery within 36 hours of admission (unless medically unfit)
Garden I/II intracapsular: hemiarthroplasty or THR (THR preferred if independently mobile pre-morbidly)
Garden III/IV intracapsular: THR if independently mobile; hemiarthroplasty if not
Extracapsular: DHS (stable) or IM nail (unstable or subtrochanteric)

5 · VTE prophylaxis

LMWH (e.g. enoxaparin 40mg SC OD) within 12 hours post-op unless haemostasis concern
TED stockings to contralateral leg
Continue LMWH for 28 days post-operatively

6 · Post-op delirium prevention

Avoid anticholinergic drugs (oxybutynin, TCAs, promethazine)
Early mobilisation from day 1 post-op
Adequate analgesia, reorient patient, minimise catheter duration
CAM (Confusion Assessment Method) screening daily

7 · Secondary prevention

DEXA scan and fracture risk assessment
Vitamin D + calcium supplementation
Bisphosphonate (e.g. alendronate 70mg PO weekly) if DEXA confirms osteoporosis
Refer to falls prevention service

Drugs

Drug	Dose	Route	Notes
Bupivacaine 0.25%	30ml	Fascia iliaca block	Ultrasound-guided preferred. Single-shot; effective 6–12 hours. Do not exceed 2mg/kg total dose.
Paracetamol	1g QDS	IV or PO	Regular analgesia — reduces opioid requirement. Reduce to 500mg QDS if weight <50kg.
Enoxaparin	40mg OD	SC	Post-op VTE prophylaxis. Reduce to 20mg OD if CrCl <30 ml/min. Continue 28 days.
Vitamin K	1–5mg	IV or PO	Warfarin reversal pre-op. Combine with 4-factor PCC if urgent reversal needed.
Alendronate	70mg weekly	PO	Post-discharge osteoporosis treatment. Take 30 minutes before food, remain upright. Give with calcium/vitamin D.

When to escalate

Haemodynamic instability — suspect associated injury (ipsilateral femur shaft, pelvic ring fracture),Neurovascular compromise distal to fracture — vascular surgery urgently,Surgery delayed >36 hours in medically fit patient — escalate to orthopaedic consultant,Post-op acute confusion with agitation posing dislocation or fall risk — 1:1 nursing, psychiatric liaison, review medications,Suspected avascular necrosis developing (Garden III/IV managed non-operatively) — urgent orthopaedic review

Reference: NICE CG124 Hip Fracture 2011 (updated 2023) / NHFD Best Practice Tariff Standards

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