A hip fracture in an older patient is a medical emergency with a surgical solution, and at the CST management and clinical station the answer is analgesia, optimisation without delay, and surgery on the day of or the day after admission. According to NICE CG124, last updated in January 2023, correctable comorbidities are identified and treated immediately so that surgery is not delayed, and the National Hip Fracture Database measures that as surgery within 36 hours of arrival. Say the 36 hours, and say what you would fix in that window.

Key takeaways

  • NICE CG124 says to perform hip fracture surgery on the day of, or the day after, admission, on a planned trauma list with consultant or senior supervision
  • The NHFD Best Practice Tariff defines prompt surgery as within 36 hours from arrival in the emergency department, or time of diagnosis if an inpatient, to the start of anaesthesia
  • NHFD's live data show 57% of patients getting prompt surgery and 90% getting prompt orthogeriatric review, across 71,011 cases to the end of July 2026
  • CG124 lists the comorbidities to correct immediately: anaemia, anticoagulation, volume depletion, electrolyte imbalance, uncontrolled diabetes, uncontrolled heart failure, correctable arrhythmia or ischaemia, acute chest infection and exacerbation of chronic chest disease
  • Analgesia is paracetamol, opioids if needed, and nerve blocks by trained staff if those are insufficient; NSAIDs are not recommended and blocks are not a substitute for early surgery
  • A displaced intracapsular fracture gets a replacement arthroplasty with cemented implants, and total hip replacement is considered for the fit, independently mobile patient

How do I assess an older patient with a suspected hip fracture?

Assess a suspected hip fracture with the CCrISP structure: immediate ABCDE management including analgesia, then a full assessment of why they fell, what they take and what needs correcting, then a plan that ends in theatre within the window.

CG124 asks for pain to be assessed immediately on presentation, within 30 minutes of the first analgesia, hourly until settled on the ward, and then as part of routine observations. Immediate analgesia is offered to everyone, including people with cognitive impairment.

The full assessment is a medical one: the collapse or the fall, the anticoagulant, the delirium, the pressure areas, and the fluid status. This is why CG124 asks for an orthogeriatric assessment from admission.

Which investigations confirm a hip fracture?

A hip fracture is confirmed on plain radiographs of the pelvis and hip, and CG124 says to offer MRI if a fracture is suspected despite negative films of adequate standard, with CT if MRI is not available within 24 hours or is contraindicated.

Bloods are a full blood count, urea and electrolytes, clotting if anticoagulated, a group and save, and glucose. An ECG and a chest radiograph complete the pre-operative picture, and a bone profile serves the bone health conversation later.

What is the 36-hour target and where does it come from?

The 36-hour target is the NHFD Best Practice Tariff standard for time to surgery, measured from arrival in the emergency department, or the time of diagnosis for an inpatient, to the start of anaesthesia.

According to the tariff user guide, 36 hours was chosen rather than the 48 hours in the earlier BOA and British Geriatrics Society Blue Book, and the tariff also requires a geriatrician assessment within 72 hours of admission.

NICE CG124 puts the same idea as surgery on the day of, or the day after, admission. The panel wants both phrasings and the fact that the NHFD publishes the achievement rate.

What do I optimise before theatre, and what must not delay surgery?

Optimise the comorbidities CG124 names, immediately, so that surgery is not delayed: anaemia, anticoagulation, volume depletion, electrolyte imbalance, uncontrolled diabetes, uncontrolled heart failure, a correctable arrhythmia or ischaemia, an acute chest infection or an exacerbation of chronic chest disease.

The word in the guideline is immediately. A potassium of 6, a haemoglobin of 70 or an INR of 4 are reasons to act tonight, not reasons to postpone the list. Anticoagulant reversal follows the local haematology protocol.

What must not delay surgery is an investigation that will not change the operation, or a nerve block used instead of an operation. CG124 says explicitly that blocks are not a substitute for early surgery.

What is the right analgesia for a hip fracture?

The right analgesia for a hip fracture under CG124 is paracetamol every 6 hours unless contraindicated, additional opioids if paracetamol alone is insufficient, and a nerve block if those two do not control the pain or to limit opioid dose.

Nerve blocks are given by trained personnel, and the guideline says to consider intraoperative blocks for everyone having surgery. NSAIDs are not recommended. Analgesia must be enough to allow the movement needed for investigations and nursing care.

Which operation, and does the choice change the plan?

The operation depends on the fracture: a displaced intracapsular fracture gets a replacement arthroplasty, and CG124 says to consider a total hip replacement rather than a hemiarthroplasty for a patient who walked independently outdoors with no more than a stick, has no comorbidity that makes it unsuitable, and is expected to manage daily activities independently beyond two years.

Cemented implants are used for arthroplasty, and hospitals should aim to use a single type of cemented femoral component for hemiarthroplasty. Extracapsular fractures are fixed. The choice does not change the timing: the same 36-hour window applies.

CG124 also says to offer a choice of spinal or general anaesthesia after discussing risks and benefits, and to schedule the case on a planned trauma list with consultant supervision of trainees.

What happens after surgery, and why does it matter for the target?

After surgery CG124 asks for a physiotherapy assessment and mobilisation on the day after the operation unless contraindicated, then mobilisation at least once a day, inside a formal Hip Fracture Programme with orthogeriatric review.

The programme includes rapid optimisation, early goal setting for rehabilitation, and liaison with falls, bone health, mental health and social services. NHFD's live data show 82% of patients promptly out of bed and 75% returning to their original residence.

Who do I escalate a hip fracture to, and when?

Escalate a hip fracture to the orthopaedic registrar on diagnosis so it is on tomorrow's trauma list, to the orthogeriatrician on admission, and to the anaesthetist and your consultant the moment a correctable problem threatens the 36-hour window.

Say that you would raise a patient on a direct oral anticoagulant, a patient with a new arrhythmia, or a patient with a chest infection that night, because each is on the CG124 list and each is a reason the NHFD records for delay.

How this comes up at the CST interview

The hip fracture scenario is usually an 84-year-old on apixaban admitted overnight, with the panel asking what you do so that she is on tomorrow's list, and then what you say when the list is full.

Follow-ups include the difference between the NICE wording and the tariff wording, why NSAIDs are avoided, and how you would explain a total hip replacement rather than a hemiarthroplasty to a fit patient.

The coresurgeryinterview bank has a scored hip fracture scenario with AI-marked spoken practice among its 299 questions: /Question-Bank/Sample-Questions.