Neck of Femur Fracture: Junior Doctor Guide & Clerking Template

Q: What are the red flags for a neck of femur (hip) fracture?

Long lie — think rhabdomyolysis, AKI, pressure sores, hypothermia; Syncope, chest pain, palpitations before the fall — think cardiac cause of the fall; New confusion — think delirium — 4AT; Fever, cough, dysuria — think infection as cause; Minimal trauma + night pain / weight loss — think pathological fracture; Pain but X-ray normal — think occult fracture — MRI

Q: What is the initial management of a neck of femur (hip) fracture?

Analgesia now (IV paracetamol, opioids titrated; avoid NSAIDs in the frail); Nerve block (fascia iliaca or femoral block (supplements opioids)); Bloods + G&S (FBC, U&E, CK if long lie, clotting, glucose, group and save); ECG ± CXR (arrhythmia, ischaemia); Delirium screen (4AT on admission); Ortho + orthogeriatrics (theatre on day of or day after admission)

Q: What diagnoses must you not miss in a neck of femur (hip) fracture?

Cause of the fall (MI · stroke · sepsis · arrhythmia); Long-lie complications (rhabdo · AKI · pressure); Occult hip fracture (pain but normal X-ray); Pathological fracture (minimal trauma)

Q: What investigations should a junior doctor order for a neck of femur (hip) fracture?

X-ray: AP pelvis + lateral hip; full-length femur if pathology suspected.; Bloods: FBC, U&E, CK, clotting, glucose, G&S/crossmatch.; ECG ± CXR: Arrhythmia, ischaemia, infection; anaesthetic assessment.; MRI: Suspected occult fracture.

Q: Admit or discharge: how is the plan decided for a neck of femur (hip) fracture?

Ortho / orthogeriatric ward: Surgery on day of/after admission, orthogeriatric review within 72 h, delirium prevention, VTE prophylaxis, early mobilisation (day after surgery), bone health and falls assessment.; Escalate: Haemodynamic instability, significant medical cause of fall, severe AKI, or end-of-life considerations — senior discussion.

Settle them, and check the basics

pain · why did they fall?

Red flags — what each should make you think

Long lierhabdomyolysis, AKI, pressure sores, hypothermia Syncope, chest pain, palpitations before the fallcardiac cause of the fall New confusiondelirium — 4AT Fever, cough, dysuriainfection as cause Minimal trauma + night pain / weight losspathological fracture Pain but X-ray normaloccult fracture — MRI

🩺

Pearl

Always ask why they fell. A hip fracture is often the result of something else: a stroke, an arrhythmia, sepsis, postural hypotension or too many sedatives. Finding and treating that cause matters as much as fixing the bone.

First actions (NICE CG124)

💊Analgesia now
🗡Nerve block
🩸Bloods + G&S
ECGECG ± CXR
4ATDelirium screen
☎Ortho + orthogeriatrics

Understand the injury & the patient

classify · optimise

Classification and operation (NICE)

Intracapsular, undisplaced — internal fixation (screws) or hemiarthroplasty if unfit
Intracapsular, displaced — arthroplasty (blood supply disrupted → AVN/non-union risk). Total hip replacement if able to walk independently outdoors with no more than a stick, not cognitively impaired, and medically fit; otherwise hemiarthroplasty
Extracapsular — trochanteric — sliding hip screw (DHS) for stable fractures; intramedullary nail for reverse oblique or unstable patterns
Subtrochanteric — intramedullary nail

Optimise without delaying

Aim for surgery on the day of or the day after admission
Correct reversible problems (fluids, electrolytes, anaemia), but don't delay for non-urgent tests
Anticoagulants: follow local guidance (DOAC timing, warfarin reversal with vitamin K)
Echo only if it will change management and won't delay surgery (e.g. suspected severe aortic stenosis)
Calculate the Nottingham Hip Fracture Score; discuss ceilings of care

Work A–E — assess and act as you go

AAirway. ——

BBreathing. Chest infection, aspiration.oxygen if hypoxic

CCirculation. HR, BP, murmur (aortic stenosis), dehydration.IV fluids, ECG

DDisability. GCS, delirium (4AT), head injury from the fall, glucose.CT head if indicated

EExposure. Shortened, externally rotated leg; pressure areas; other injuries (wrist, head); temperature.pressure area care

The diagnoses you must not miss

tap to open each

What points toward it, what would rule it in, and how to manage it.

points toward it

Collapse, syncope, chest pain, focal neurology, infection.

rule in

ECG, troponin if indicated, CT head, septic screen.

manage it

Treat the cause alongside the fracture.

Source: Collapsed patient page

points toward it

On the floor for hours.

rule in

CK, U&E, K⁺, temperature, skin check.

manage it

IV fluids, warm, pressure care, monitor kidneys.

Source: AKI page

points toward it

Unable to weight bear, pain on hip movement, normal X-ray.

rule in

MRI (CT if MRI not available within 24 h) — NICE.

manage it

Treat per findings; consider pubic rami/acetabular fractures too.

Source: NICE CG124

points toward it

Known cancer, night pain, weight loss, lytic lesion.

rule in

X-ray full femur, bloods (calcium, myeloma screen).

manage it

Orthopaedic/oncology planning — fixation differs.

Source: BOA metastatic bone disease guidance

Investigate — what to order, when, and what it tells you

test with a question in mind

X-ray

Views

AP pelvis + lateral hip; full-length femur if pathology suspected.

Bloods

Must-do

FBC, U&E, CK, clotting, glucose, G&S/crossmatch.

If relevant

Troponin, cultures, calcium.

ECG ± CXR

Why

Arrhythmia, ischaemia, infection; anaesthetic assessment.

MRI

When

Suspected occult fracture.

How the plan comes together

disposition · handover

ortho / orthogeriatric ward

Surgery on day of/after admission, orthogeriatric review within 72 h, delirium prevention, VTE prophylaxis, early mobilisation (day after surgery), bone health and falls assessment.

escalate

Haemodynamic instability, significant medical cause of fall, severe AKI, or end-of-life considerations — senior discussion.

Hand over: fracture type, analgesia/block time, anticoagulants, cause of fall, 4AT, NHFS.

🩺

Pearl

Analgesia and a block early, find out why they fell, optimise without delaying, and operate within a day. And treat the person, not only the hip: delirium, pressure areas, nutrition and bone health all matter. Nicely done getting here.

✎

Clerking template

copy or download

Neck of femur fracture — documentation structure

A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement.

HIP FRACTURE — CLERKING TEMPLATE PRESENTING COMPLAINT: HISTORY OF PRESENTING COMPLAINT Fall — mechanism / time / long lie (hours): Pre-fall symptoms — syncope / chest pain / palpitations / dizziness: Pre-fracture mobility / walking aids / residence: Cognition baseline: Anticoagulants / antiplatelets: RED FLAGS ASKED (record present or absent) [ ] Long lie -> rhabdomyolysis, AKI, pressure sores, hypothermia [ ] Syncope, chest pain, palpitations before the fall -> cardiac cause of the fall [ ] New confusion -> delirium — 4AT [ ] Fever, cough, dysuria -> infection as cause [ ] Minimal trauma + night pain / weight loss -> pathological fracture [ ] Pain but X-ray normal -> occult fracture — MRI SCORES / KEY CHECKS Fracture type: intracapsular (displaced / undisplaced) / intertrochanteric / subtrochanteric Nerve block (type / time): 4AT: Nottingham Hip Fracture Score: CK: Hb: K+: Surgery planned (date): PAST MEDICAL HISTORY: DRUG HISTORY: ALLERGIES: SOCIAL HISTORY (lives with / carers / mobility / stairs / falls history): FAMILY HISTORY: OBSERVATIONS: RR SpO2 ( % O2) HR BP Temp GCS NEWS2 EXAMINATION A - B - C - D - (GCS pupils glucose ) E - INVESTIGATIONS ORDERED: IMPRESSION: DIFFERENTIALS CONSIDERED: [ ] Cause of the fall [ ] Long-lie complications [ ] Occult hip fracture [ ] Pathological fracture [ ] Pubic rami fracture [ ] Acetabular fracture [ ] Hip dislocation (prosthetic) [ ] Soft-tissue injury PLAN: 1. 2. 3. ESCALATION / SENIOR DISCUSSION: Discussed with: Time: Advice: SAFETY NET / IF DETERIORATES: Documented by: Grade: Date/Time:

Test yourself

active recall

Cover the answer, say it out loud, then reveal. Retrieval beats re-reading.

0 / 10 known

Red flag

Long lie — what should it make you think?

rhabdomyolysis, AKI, pressure sores, hypothermia

Red flag

Syncope, chest pain, palpitations before the fall — what should it make you think?

cardiac cause of the fall

Red flag

New confusion — what should it make you think?

delirium — 4AT

Red flag

Fever, cough, dysuria — what should it make you think?

infection as cause

Red flag

Minimal trauma + night pain / weight loss — what should it make you think?

pathological fracture

Red flag

Pain but X-ray normal — what should it make you think?

occult fracture — MRI

Must not miss

How do you rule in cause of the fall?

ECG, troponin if indicated, CT head, septic screen.

Must not miss

How do you rule in long-lie complications?

CK, U&E, K⁺, temperature, skin check.

Must not miss

How do you rule in occult hip fracture?

MRI (CT if MRI not available within 24 h) — NICE.

Must not miss

How do you rule in pathological fracture?

X-ray full femur, bloods (calcium, myeloma screen).

Frequently asked questions

quick answers

What are the red flags for a neck of femur (hip) fracture?

Long lie — think rhabdomyolysis, AKI, pressure sores, hypothermia
Syncope, chest pain, palpitations before the fall — think cardiac cause of the fall
New confusion — think delirium — 4AT
Fever, cough, dysuria — think infection as cause
Minimal trauma + night pain / weight loss — think pathological fracture
Pain but X-ray normal — think occult fracture — MRI

What is the initial management of a neck of femur (hip) fracture?

Analgesia now — IV paracetamol, opioids titrated; avoid NSAIDs in the frail
Nerve block — fascia iliaca or femoral block (supplements opioids)
Bloods + G&S — FBC, U&E, CK if long lie, clotting, glucose, group and save
ECG ± CXR — arrhythmia, ischaemia
Delirium screen — 4AT on admission
Ortho + orthogeriatrics — theatre on day of or day after admission

Always alongside senior support and your local guideline.

What diagnoses must you not miss in a neck of femur (hip) fracture?

Cause of the fall — MI · stroke · sepsis · arrhythmia
Long-lie complications — rhabdo · AKI · pressure
Occult hip fracture — pain but normal X-ray
Pathological fracture — minimal trauma

Open each one in the must-not-miss section for what points toward it, how to rule it in, and how to manage it.

What investigations should a junior doctor order for a neck of femur (hip) fracture?

X-ray — AP pelvis + lateral hip; full-length femur if pathology suspected.
Bloods — FBC, U&E, CK, clotting, glucose, G&S/crossmatch.
ECG ± CXR — Arrhythmia, ischaemia, infection; anaesthetic assessment.
MRI — Suspected occult fracture.

Admit or discharge: how is the plan decided for a neck of femur (hip) fracture?

Ortho / orthogeriatric ward — Surgery on day of/after admission, orthogeriatric review within 72 h, delirium prevention, VTE prophylaxis, early mobilisation (day after surgery), bone health and falls assessment.
Escalate — Haemodynamic instability, significant medical cause of fall, severe AKI, or end-of-life considerations — senior discussion.

Is there a clerking template for a neck of femur (hip) fracture?

Yes — there is a free clerking template for a neck of femur (hip) fracture on this page, structured as presenting complaint, red flags asked, history, examination (A–E), investigations, differentials, plan and escalation. You can copy it or download it as a Word document. Jump to the template.

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