The guideline review group found no evidence directly relating to the emergency management of patients with hip fracture. The recommendations contained in this section are therefore mainly based on the 1989 report from the Royal College of Physicians of London.⁵³

4.1 Assessment in A&E

Assessment in A&E should include all relevant medical, nursing and social factors as well as the orthopaedic injury.^53,54 Evidence level 4

Early assessment, in A&E or on the ward, should include a formal recording of: pressure sore risk hydration and nutrition fluid balance pain core body temperature using a low reading thermometer continence co-existing medical problems mental state previous mobility previous functional ability social circumstances.

Patients suspected of having a fractured hip should be assessed by medical staff as soon as possible, preferably within one hour.

4.2 Immediate management

Steps should be taken to prevent the development of pressure sores. Patients at high risk of developing pressure sores can be identified using assessment tools,⁵⁵ although the evidence for the accuracy of pressure sore risk scales is confusing, and the scales themselves may not be an improvement on clinical judgement.⁵⁶ Use of foam based low-pressure mattress, rather than a standard hospital mattress, has been shown to reduce the occurrence of pressure sores.^57,58 Evidence level 2++

Patients judged to be at very high risk of pressure sores should ideally be nursed on a large-cell, alternating-pressure air mattress or similar pressure-decreasing surface.

The Royal College of Physicians of London report⁵³ on fractured neck of femur has produced a number of recommendations which should be applied to all patients in A&E: Evidence level 4

Patients admitted to A&E with a suspected hip fracture should be managed as follows: use soft surfaces to protect the heel and sacrum from pressure damage keep the patient warm administer adequate pain relief to allow for regular, comfortable change of patient position instigate early radiology measure and correct any fluid and electrolyte abnormalities.

4.3 Fast tracking

Whilst transfer to the ward within one hour has been recommended in some guidelines,⁵³ the guideline review group found no evidence to suggest that fast tracking improves patient outcome. However, evidence on pressure care suggests that fast tracking is a good standard of clinical care.⁵⁹ The Clinical Standards Board for Scotland draft standards for older people in acute care require people with confirmed or suspected hip fracture to begin transfer within two hours of arrival in A&E. Evidence level 3

Patients should be transferred to the ward within two hours of their arrival in A&E.

4.4 Diagnosis

The vast majority of hip fractures are easily identified on plain radiographs, but a normal x-ray does not necessarily exclude a fractured hip. Where there is doubt regarding the diagnosis, for example, a radiologically normal hip in a symptomatic patient, and where the radiographs have been reviewed by a radiologist, alternative imaging should be performed. Repeating the plain radiographs (perhaps with additional views) 24-48 hours after admission, a radioisotope bone scan any time from 12 hours after injury onwards, or magnetic resonance (MR) imaging are useful additional investigations. Where available, a limited MR sequence allows definitive diagnosis and immediate formulation of a management plan. Such a policy has been shown to require few additional images.^{60, 61, 62, 63} Evidence level 3

MR imaging is the investigation of choice where there is doubt regarding the diagnosis. If MR is not available or not feasible, a radioisotope bone scan or repeat plain radiographs (after a delay of 24-48 hours) should be performed.

4.5 Pain relief

Pain relief should be tailored to the individual patient. Adequate and appropriate analgesia is probably best achieved by titration of intravenous opiates. In selected cases local nerve block may be appropriate.⁶⁴ Analgesia must be administered early, in anticipation of painful procedures, such as the movement of the patient for radiological investigation. If delay occurs, repeat administration of analgesia may be required. Evidence level 3

Adequate and appropriate pain relief should be administered before the patient is transferred from a trolley to the x-ray table.

If necessary, pain relief should be given as quickly as possible using intravenous opiate analgesia, titrated for effect. If this is not possible (e.g. due to lack of appropriate supervision) then analgesia using entonox should be considered.