Neck of femur fracture

12 min read Last updated April 8, 2026

Surgical approach

  • Operation depends on fracture type and patient factors
    • Intracapsular (subcapital/transcervical): usually hemiarthroplasty (cemented common) or total hip arthroplasty (THA) in selected fitter patients
    • Extracapsular (intertrochanteric/subtrochanteric): dynamic hip screw (DHS) or intramedullary nail (IM nail)
  • Typical steps (hemiarthroplasty/THA)
    • Position: lateral decubitus (common) or supine depending on approach; padding and pressure area care
    • Incision and approach: posterior (common), lateral/anterolateral; dislocation of hip, femoral head removal
    • Femoral canal preparation (reaming/broaching) → implant insertion
    • If cemented: canal lavage/drying, cement insertion, prosthesis insertion; risk period for BCIS
    • Reduction, haemostasis, closure; drain sometimes used
  • Typical steps (DHS / IM nail)
    • Position: supine on traction table; fracture reduction under image intensifier
    • DHS: guidewire, reaming, lag screw into femoral head, side plate fixation
    • IM nail: entry point, reaming, nail insertion, proximal and distal locking screws
  • Blood loss: variable (often moderate); higher with arthroplasty/complex fractures; transfusion not uncommon

Anaesthetic management (overview)

  • Type of anaesthesia: GA or neuraxial (spinal) ± sedation; peripheral nerve blocks for analgesia
    • Choice driven by physiology, anticoagulation, delirium risk, airway/aspiration risk, urgency, patient preference and local expertise
  • Airway: GA usually ETT (aspiration risk common); SGA only if low aspiration risk and short uncomplicated case
  • Duration: typically 1–2.5 hours (DHS/IM nail often 1–1.5 h; hemiarthroplasty ~1–2 h; THA can be longer)
  • How painful: high (fracture pain pre-op; significant postoperative pain). Multimodal analgesia and regional techniques strongly beneficial
  • Key intra-op risks: hypotension (spinal/GA), bleeding, hypothermia, delirium triggers, myocardial ischaemia, aspiration, BCIS (cemented arthroplasty), VTE

Epidemiology and significance

  • Common emergency in older adults; high 30-day and 1-year mortality; major driver of perioperative morbidity (cardiac, respiratory, delirium, VTE, pressure sores)
  • Aim: early surgery (often within 24–48 h if feasible) after optimisation; avoid unnecessary delays (especially for reversible issues)

Fracture classification (practical)

  • Intracapsular: risk of disrupted femoral head blood supply → avascular necrosis/non-union; often treated with arthroplasty in older adults
  • Extracapsular: better blood supply; treated with fixation (DHS/IM nail); can bleed significantly due to cancellous bone and soft tissue trauma

Preoperative assessment and optimisation

  • History: baseline function/frailty, cognitive status, time since last meal, pain control, comorbidities (IHD/HF/valvular disease, COPD, CKD, diabetes), previous anaesthetic issues
  • Examination: volume status (often dehydrated), anaemia, sepsis (UTI/pneumonia), heart murmurs (aortic stenosis), chest status, pressure areas
  • Investigations: FBC (anaemia), U&E (AKI), coagulation (anticoagulants), group & save/crossmatch, ECG (all), CXR if indicated; consider troponin/echo only if changes management and does not cause harmful delay
  • Analgesia early: paracetamol + opioid sparing strategy; fascia iliaca block (FICB) or PENG block; avoid excessive opioids (delirium/resp depression)
  • Fluids: correct dehydration; cautious in HF/CKD; treat hypotension; consider balanced crystalloid; monitor urine output if catheterised
  • Delirium prevention bundle: pain control, avoid benzodiazepines where possible, maintain sleep-wake cycle, glasses/hearing aids, treat infection, avoid hypoxia/hypotension/hypoglycaemia, early mobilisation
  • Anticoagulation/antiplatelets (typical UK principles; follow local policy): assess neuraxial safety and surgical bleeding risk
    • Warfarin: aim INR ≤ 1.5 for surgery/neuraxial; reverse with vitamin K ± PCC depending on urgency and bleeding risk
    • DOACs: timing depends on agent/renal function; neuraxial requires longer interval; consider anti-Xa level where available; discuss with haematology if urgent
    • LMWH: neuraxial timing critical (e.g., avoid spinal within 12 h of prophylactic dose; longer for treatment dosing—follow guidelines)
    • Clopidogrel: neuraxial usually avoided until appropriate washout; surgery may proceed with surgical plan; aspirin alone usually not a contraindication to spinal

Choice of anaesthetic technique (GA vs spinal)

  • Both GA and spinal are acceptable; outcomes depend heavily on overall perioperative care (analgesia, haemodynamic stability, delirium prevention, early mobilisation)
  • Spinal advantages: avoids airway instrumentation, may reduce early postoperative pain/opioid use; disadvantages: hypotension, limited duration, positioning difficulty, contraindications (anticoagulation, sepsis at site, severe AS relative/controversial)
  • GA advantages: controlled airway/ventilation, predictable duration; disadvantages: aspiration risk, haemodynamic swings, PONV, more opioids unless blocks used
  • Sedation with spinal: use minimal titrated sedation (e.g., low-dose propofol infusion) to reduce delirium/airway obstruction; avoid deep sedation in frail patients

Regional analgesia options (perioperative)

  • Fascia iliaca compartment block (FICB): simple, good for pre-op analgesia; variable obturator coverage; can be landmark or ultrasound-guided
  • PENG block: targets articular branches (femoral/obturator/accessory obturator); good analgesia with less quadriceps weakness (technique dependent)
  • Femoral nerve block: effective but more quadriceps weakness; may hinder mobilisation; consider catheter in selected cases
  • Lateral femoral cutaneous nerve block: adjunct for surgical incision analgesia (especially lateral approaches)
  • Intrathecal opioids: can improve analgesia but increase pruritus/urinary retention/resp depression risk; use caution in frail elderly

Intraoperative management (key points)

  • Monitoring: standard + consider invasive arterial line for significant cardiac disease, anticipated haemodynamic instability, or BCIS risk; temperature monitoring
  • Positioning: careful transfers; pressure area protection; traction table risks (perineal post pressure, nerve injury) for DHS/IM nail
  • Haemodynamics: avoid hypotension (linked to myocardial injury/AKI/delirium). Treat promptly with fluids (if responsive) and vasopressors (metaraminol/phenylephrine/noradrenaline infusion as appropriate)
  • Spinal technique: consider lower-dose local anaesthetic to reduce hypotension; left uterine displacement not relevant; ensure block height adequate; be prepared to convert to GA
  • GA technique: RSI often appropriate due to aspiration risk; maintain with volatile or TIVA; use multimodal analgesia and regional blocks to reduce opioids
  • Antibiotics: per local protocol (usually pre-incision); ensure timely administration
  • Tranexamic acid: often used in arthroplasty/fixation to reduce blood loss unless contraindicated (follow local policy)
  • Temperature: active warming; elderly are high risk of hypothermia and coagulopathy

Bone Cement Implantation Syndrome (BCIS)

  • Occurs around cementation, prosthesis insertion, joint reduction, or tourniquet release (less relevant here); due to embolic load + mediator release → increased PVR, RV failure, hypoxia, hypotension, arrhythmias, cardiac arrest
  • Risk factors: cemented arthroplasty, older/frail, ASA 3–4, pulmonary HTN, RV dysfunction, severe AS, COPD, hypovolaemia, pathological fractures
  • Recognition: sudden drop in ETCO2, hypoxia, hypotension, bronchospasm, arrhythmias; may progress to PEA arrest
  • Prevention/mitigation: optimise volume status, high FiO2 at cementation, communicate with surgeon, consider invasive BP monitoring, avoid deep anaesthesia at critical moments, prepare vasopressors/inotropes
  • Management: call for help; 100% O2; treat as acute RV failure—support BP (noradrenaline/vasopressin), consider adrenaline if severe, manage arrhythmias, CPR if arrest; consider echo if available; post-op HDU/ICU

Postoperative care

  • Analgesia: continue regional benefit where used; regular paracetamol; cautious opioids (renal function, delirium); consider NSAID only if appropriate (renal/GI/bleeding risk)
  • Delirium: screen (e.g., 4AT), treat pain/retention/constipation/infection; avoid sedatives; ensure orientation and sensory aids
  • Respiratory: oxygen as needed, early mobilisation, physiotherapy, treat atelectasis; consider CPAP if OSA/CO2 retainers as appropriate
  • Cardiovascular: monitor for myocardial injury after non-cardiac surgery (MINS) in high-risk patients; manage hypotension/anaemia; consider HDU for significant comorbidity/BCIS/hypotension
  • VTE prophylaxis: mechanical + pharmacological per local guidance; coordinate timing with neuraxial/blocks and surgical haemostasis
  • Haemoglobin and transfusion: treat symptomatic anaemia; consider restrictive strategy but individualise (IHD symptoms, ongoing bleeding, frailty)
You are asked to anaesthetise an 86-year-old with a displaced intracapsular NOF fracture for cemented hemiarthroplasty. How do you assess and optimise preoperatively?

Structure: patient factors (frailty/delirium), comorbidities, physiology (volume/anaemia), analgesia, anticoagulation, and avoiding unnecessary delay.

  • Assess baseline: frailty, functional capacity, cognition/dementia, residence, mobility aids, ceiling of care and DNACPR discussions where appropriate
  • Comorbidities: IHD/HF, valvular disease (especially aortic stenosis), arrhythmias/AF, COPD, CKD, diabetes, previous stroke/TIA
  • Physiology: check hydration (often hypovolaemic), BP trends, oxygenation, infection/sepsis, Hb and renal function; correct reversible issues
  • Investigations: ECG, FBC/U&E/coag, group & save (crossmatch if high risk), CXR/ABG only if indicated; avoid tests that won’t change management
  • Analgesia: early FICB/PENG + paracetamol; avoid high-dose opioids; treat nausea/constipation; consider catheter for retention monitoring
  • Anticoagulants: clarify warfarin/DOAC/LMWH/antiplatelets and plan neuraxial feasibility and reversal if needed
  • Delirium prevention: pain control, oxygenation, hydration, avoid benzodiazepines, maintain normothermia and glucose control, ensure hearing aids/glasses
Discuss your choice of anaesthetic technique for hip fracture surgery (GA vs spinal).

Examiners look for balanced discussion, contraindications, and how you minimise complications rather than claiming one technique is always superior.

  • Both GA and spinal are appropriate; outcomes depend on haemodynamic stability, analgesia, delirium prevention, and early mobilisation
  • Spinal: benefits include reduced airway manipulation and good early analgesia; risks include hypotension, limited duration, positioning difficulty, and contraindications (coagulopathy/anticoagulation, sepsis at site, patient refusal)
  • GA: benefits include secured airway and controlled ventilation; risks include aspiration, PONV, delirium from drugs/physiological disturbance; mitigate with RSI where appropriate and opioid-sparing blocks
  • Sedation with spinal: keep light and titrated; avoid deep sedation/benzodiazepines in frail elderly; be prepared to manage airway obstruction
  • Individualise: severe respiratory disease may favour neuraxial; high aspiration risk or inability to tolerate positioning may favour GA; anticoagulation may preclude spinal
How would you provide analgesia for a patient with a NOF fracture from admission to postoperative period?

Aim: rapid pain relief, minimise opioids, facilitate positioning for spinal and early mobilisation.

  • Immediate: paracetamol + antiemetic; cautious opioid titration (small IV doses) with monitoring; avoid IM opioids
  • Regional: FICB or PENG early in ED/ward; consider repeat/single-shot vs catheter depending on pathway and expertise
  • Intra-op: neuraxial local anaesthetic ± minimal intrathecal opioid (careful in frail); or GA with regional block and multimodal analgesia
  • Post-op: continue regular paracetamol; opioid only if needed (consider oxycodone low dose; avoid accumulation in CKD); consider NSAID only if suitable; manage constipation and delirium risk
Describe Bone Cement Implantation Syndrome (BCIS) and how you would prevent and manage it during cemented hemiarthroplasty.

BCIS is a common FRCA viva topic for NOF fracture surgery.

  • Definition: peri-cementation cardiopulmonary compromise (hypoxia, hypotension, arrhythmias, cardiac arrest) associated with cemented arthroplasty
  • Pathophysiology: embolic load (fat/marrow/cement/air) + mediator release → ↑PVR → RV strain/failure → reduced LV filling and hypotension; V/Q mismatch → hypoxia; ETCO2 often falls
  • Risk factors: elderly/frail, ASA 3–4, pulmonary HTN/RV dysfunction, severe AS, COPD, hypovolaemia, cemented prosthesis, pathological fracture
  • Prevention: optimise volume, communicate ‘cement time’, increase FiO2, consider arterial line, have vasopressors ready; avoid profound hypovolaemia and excessive anaesthetic depth
  • Management: 100% O2, support RV and BP (noradrenaline/vasopressin; adrenaline if severe), treat arrhythmias, consider fluids if appropriate, CPR if arrest; plan HDU/ICU post-op
An 82-year-old with AF on apixaban presents with a hip fracture. The surgeon wants to operate tomorrow. How do you plan anaesthesia and manage anticoagulation issues?

Focus on neuraxial safety, renal function, timing of last dose, bleeding risk, and pragmatic planning to avoid harmful delay.

  • Clarify: last apixaban dose time, renal function (eGFR), indication (stroke prevention), other antiplatelets, bleeding history
  • Neuraxial: spinal usually requires an appropriate drug-free interval (longer if renal impairment) per guidelines; if interval not met, avoid spinal and use GA + peripheral nerve block
  • Surgery timing: coordinate with orthopaedics/haematology; consider DOAC level/anti-Xa where available if timing unclear; avoid unnecessary postponement
  • Intra-op: anticipate bleeding; ensure group & save/crossmatch as indicated; consider TXA per policy; meticulous haemodynamic management
  • Post-op: restart anticoagulation when haemostasis secure and per surgical plan; ensure VTE prophylaxis strategy aligns with neuraxial/blocks used
You perform a spinal anaesthetic for DHS fixation. Shortly after positioning supine the BP falls to 70/40 with nausea. How do you manage this?

Treat promptly; hypotension is common and harmful in frail elderly.

  • Immediate actions: call for help, check pulse/ECG, confirm NIBP cycle/arterial trace, assess block height, give high-flow oxygen
  • Treat: vasopressor boluses (metaraminol/phenylephrine depending on HR) and consider infusion; give fluid bolus if likely hypovolaemic and not fluid-overloaded
  • Consider causes: high spinal, hypovolaemia, bleeding, myocardial ischaemia/arrhythmia, anaphylaxis (antibiotics), BCIS (if cementation—less likely in DHS)
  • Escalate: arterial line, noradrenaline infusion, convert to GA if airway/ventilation compromised or surgery cannot proceed safely
What postoperative complications are common after hip fracture surgery and how do you reduce them?

Think: delirium, respiratory, cardiac, VTE, pressure sores, infection, pain, anaemia/AKI.

  • Delirium: minimise opioids/sedatives, treat pain/retention/constipation/infection, maintain oxygenation and BP, orientate patient, early mobilisation
  • Respiratory: prevent atelectasis (analgesia, physio, mobilisation), cautious oxygen in CO2 retainers, treat pneumonia early
  • Cardiac: avoid hypotension and anaemia; monitor high-risk patients for MINS/arrhythmias; consider HDU if unstable
  • VTE: mechanical + pharmacological prophylaxis; ensure correct timing around neuraxial/blocks
  • Renal/haematology: avoid nephrotoxins, maintain perfusion, monitor Hb and transfuse if symptomatic/ongoing bleeding
Hip fracture surgery: outline an anaesthetic plan for an elderly patient, including perioperative analgesia and delirium prevention.

A complete answer covers pre-op, intra-op, post-op, and team-based care.

  • Pre-op: rapid assessment, treat pain with FICB/PENG, correct dehydration, identify sepsis/anaemia, review anticoagulants; consent and capacity; plan ceiling of care
  • Technique: GA or spinal; justify choice; plan for haemodynamic stability (arterial line if needed) and temperature management
  • Analgesia: multimodal and opioid-sparing; regional blocks; avoid benzodiazepines; antiemetics; bowel regimen
  • Delirium prevention: avoid hypotension/hypoxia, maintain sleep and orientation, treat triggers, early mobilisation, involve orthogeriatrics
  • Post-op: monitor for MINS/respiratory issues, VTE prophylaxis, fluid balance, pressure area care, physiotherapy and discharge planning
Bone cement implantation syndrome: describe the syndrome, grading, and immediate management during cemented hemiarthroplasty.

Include recognition, risk factors, prevention, and resuscitation priorities.

  • Recognition: sudden hypoxia, hypotension, fall in ETCO2, arrhythmias, loss of consciousness/cardiac arrest around cementation/prosthesis insertion/reduction
  • Grading (commonly taught): Grade 1 moderate hypoxia (SpO2 <94%) or hypotension (>20% fall); Grade 2 severe hypoxia (SpO2 <88%) or hypotension (>40% fall) or unexpected LOC; Grade 3 cardiovascular collapse requiring CPR
  • Immediate management: 100% O2, inform surgeon/stop stimulus if possible, vasopressors/inotropes (noradrenaline/adrenaline), treat RV failure, CPR if needed
  • Prevention: optimise volume, arterial line in high risk, high FiO2 at cementation, close communication, readiness with drugs and post-op HDU
Discuss the anaesthetic implications of aortic stenosis in an elderly patient requiring urgent hip fracture surgery.

Key is balancing urgency with safe haemodynamics; avoid hypotension and tachycardia.

  • Risks: fixed outflow obstruction → coronary perfusion depends on diastolic pressure; hypotension and tachycardia poorly tolerated; high risk of perioperative MI and collapse
  • Assessment: symptoms (syncope/angina/dyspnoea), murmur, ECG; echo if not recent and if it will change management without undue delay
  • Technique: GA often chosen for tight symptomatic AS; neuraxial may cause profound vasodilation—if used, consider very low-dose incremental techniques with invasive monitoring and vasopressors immediately available (local policy varies)
  • Intra-op goals: maintain sinus rhythm, preload, SVR; treat hypotension with alpha-agonists; avoid hypovolaemia and anaemia; consider arterial line
  • Post-op: HDU, careful analgesia and fluid balance, monitor for ischaemia/arrhythmias

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