Implementing guidance on hip fracture

Editor—Dr Foster's case notes by Bottle et al quote the Scottish Intercollegiate Guidelines Network (SIGN) recommendation that patients with fractured neck of femur are operated on as soon as possible, ideally within 48 hours after admission.¹

Patients with femoral neck fracture who are fit on admission are usually operated on early. Those who are not have their medical conditions treated and a later operation. The fit group do better than the unfit group, hence time to operation merely reflects general fitness on admission. The timing of operation does not itself cause the difference in mortality.

In a study performed in Newcastle all patients who were fit enough, or could be made fit enough, were treated surgically.² A point was made of treating concurrent medical problems, particularly dehydration and chest infection before operation was undertaken. The overall six month mortality of the group was 17%, and the six month mortality of the group operated on was 9.6%. Our mortality figures compare favourably with the literature on mortality after femoral neck fracture.

From our study the key to success seems to be, maximise the patient's general condition first, and operate as soon as possible thereafter. This is generally what happens anyway, and the resulting figures for mortality viewed against time of operation, inevitably follow from this policy.

We found that mortality after femoral neck fracture is most heavily influenced by the mental ability of the patient at the time of admission. Comparisons of mortality after femoral neck fracture not taking mental test score into account are unhelpful.