Deep Dive: ED Hip Fracture Management
Hello Team,
Today's post-shift pearl is all about the hip.
This topic came up on shift recently and prompted me to review the literature on preoperative hip fracture management, particularly the role of Buck's traction. I thought I'd share a few practical pearls from that review.
1. EM Cases Review
Check out this EM Cases episode on hip emergencies. It provides a comprehensive review of the ED management of hip pathology. Below are a few hip fracture-specific pearls.
Hip fractures carry significant morbidity and mortality in older adults. Getting patients to the OR within 24 hours is associated with decreased delirium, pneumonia, pressure injuries, deconditioning, and other downstream complications of immobilization.
For elderly patients, our role in the ED is to expedite preoperative requirements and remove barriers that delay the operating room.
Immobilize comfortably using pillows rather than routine skin traction.
Complete the preoperative workup, clarify anticoagulation timing, and keep the patient NPO.
Use multimodal analgesia. Consider a fascia iliaca block, PENG block, or femoral nerve block to reduce opioid requirements and potentially decrease delirium.
Be cautious of the occult hip fracture. Approximately 2–10% of hip fractures are radiographically occult. Use your history and physical examination to identify patients who may require advanced imaging despite normal radiographs.
CT is helpful but not perfect. MRI may be necessary to identify nondisplaced femoral neck fractures, intertrochanteric extension of greater trochanter fractures, early marrow edema, and subchondral insufficiency fractures.
Know whether the fracture is intracapsular or extracapsular. Intracapsular fractures are at risk for avascular necrosis. Extracapsular fractures can bleed substantially, creating transfusion risk in elderly anticoagulated patients. In younger patients with high-energy injuries, consider the possibility of thigh compartment syndrome. These patients may not be ideal candidates for peripheral nerve blocks if serial pain examinations are important.
When calling orthopedics, communicate the mechanism of injury, fracture description, baseline function, comorbidities and medications, pertinent laboratory concerns, analgesia provided, and NPO status.
2. What do the AAOS Guidelines Recommend?
The 2022 AAOS Clinical Practice Guideline provides a nice case-based review of hip fracture management. A few notable recommendations include:
Time to surgery within 24–48 hours after admission (limited evidence, moderate recommendation)
Multimodal analgesia, including peripheral nerve blocks (strong evidence, strong recommendation)
Routine preoperative skin traction should not be used (strong evidence, strong recommendation)
Interestingly, the guideline's illustrative case was a comminuted displaced intertrochanteric fracture (like the patient who prompted this review). The patient was positioned comfortably with two pillows, and no preoperative traction was used.
3. What is Buck's Traction?
Buck's traction is a form of skin traction applied to the lower extremity. Historically, the proposed benefits were:
Pain reduction through immobilization of fracture fragments and decreased muscle spasm
Restoration of limb length and alignment to theoretically facilitate surgery
4. What Does the Evidence Show?
Multiple studies have demonstrated little benefit from routine preoperative skin traction.
A 2011 Cochrane Review evaluated 11 randomized trials and found no evidence that routine skin traction improved outcomes in patients with hip fractures.
Key findings included:
No improvement in pain scores or analgesic requirements compared with comfortable positioning using pillows
No improvement in fracture reduction
No improvement in fracture healing
The review also noted that available studies did not adequately evaluate whether specific fracture patterns might benefit differently. The AAOS guideline similarly makes no fracture-pattern exceptions when recommending against routine traction.
Skin traction is also not without downsides. Reported complications include skin shearing, allergic reactions to the strapping, vascular compromise, and the additional burden associated with traction during hospitalization.
5. More Recent Evidence
A 2023 randomized controlled trial (Kheiri et al., n = 229) specifically evaluated patients with isolated intertrochanteric fractures. There was no significant difference in pain scores or morphine consumption between patients treated with skin traction and those positioned comfortably with pillows alone.
Bottom Line
My biggest takeaway from reviewing this topic was that the evidence consistently favors comfortable positioning with pillows and multimodal analgesia, including a peripheral nerve block when appropriate, rather than routine preoperative skin traction for most hip fractures.
As always, if anyone has additional thoughts or different experiences, I'd love to hear them.
Best,
Dillon
