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## Complete Summary

#### GUIDELINE TITLE

Acute management and immediate rehabilitation after hip fracture amongst
people aged 65 years and over.

#### BIBLIOGRAPHIC SOURCE(S)

New Zealand Guidelines Group (NZGG). Acute management and immediate
rehabilitation after hip fracture amongst people aged 65 years and over.
Wellington (NZ): New Zealand Guidelines Group (NZGG); 2003 Jun. 26 p.
\[60 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory information
has been released.

-   [February 28, 2008, Heparin Sodium
    Injection](http://www.fda.gov/medwatch/safety/2008/safety08.htm#HeparinInj2):
    The U.S. Food and Drug Administration (FDA) informed the public that
    Baxter Healthcare Corporation has voluntarily recalled all of their
    multi-dose and single-use vials of heparin sodium for injection and
    their heparin lock flush solutions. Alternate heparin manufacturers
    are expected to be able to increase heparin production sufficiently
    to supply the U.S. market. There have been reports of serious
    adverse events including allergic or hypersensitivity-type
    reactions, with symptoms of oral swelling, nausea, vomiting,
    sweating, shortness of breath, and cases of severe hypotension.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Hip fractures

#### GUIDELINE CATEGORY

Management\
Rehabilitation\
Treatment

#### CLINICAL SPECIALTY

Emergency Medicine\
Family Practice\
Geriatrics\
Internal Medicine\
Orthopedic Surgery

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Emergency Medical Technicians/Paramedics\
Health Care Providers\
Nurses\
Patients\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To provide clinicians and people suffering hip fractures with evidence
for current best practice in acute management and immediate
rehabilitation after hip fracture

#### TARGET POPULATION

People in New Zealand aged 65 years and over with hip fractures

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Management**

**Pre-hospital Care**

Fluid replacement and catheterization as indicated

**Emergency Department Care**

1.  \"Fast Track\" protocol for assessment and admission

2.  Fluid replacement

3.  Preoperative traction (considered but not recommended)

4.  Systematic pain assessment and relief

    -   Administration of narcotics, paracetamol, ibuprofen,
        propoxyphene-containing compounds and local analgesic nerve
        blocks

5.  Oxygen therapy

**Ward Care**

1.  Prophylaxis against venous thromboembolism

    -   Adequate fluid balance and early post-operative mobilisation

    -   Administration of either aspirin or low molecular weight heparin

    -   Foot or calf pumps

    -   Thromboembolism stockings (considered but not recommended)

2.  Antibiotic prophylaxis

3.  Prevention of pressure sores with high specification foam and
    pressure relieving mattresses

4.  Nutritional supplementation

5.  Urinary tract management

    -   Catheterisation

6.  Management of dementia/delirium

    -   Measurement of cognitive function

    -   Geriatric medical team

    -   \"Active reorientation\"

    -   Continuity of nursing care

**Surgical Management**

1.  Early (non-delayed) operation

2.  Regional anaesthesia

3.  Undisplaced intracapsular fractures

    -   Screws vs. unthreaded pins

4.  Displaced intracapsular fractures

    -   Open vs. closed reduction

    -   Arthroplasty vs. internal fixation

        -   Bone cement

    -   Unipolar hemi-arthroplasty vs. bipolar hemi-arthroplasty

    -   Total hip replacement (considered but not recommended)

5.  Extracapsular (trochanteric) fractures

    -   Sliding hip screw vs. fixed nail plate devices or intramedullary
        devices

6.  Surgical suction wound drains (considered but not recommended)

7.  Post-operative mobilisation

**Immediate Rehabilitation**

1.  Provision of formal hip fracture programmes

    -   Early multidisciplinary assessment teams

2.  Early Supported Discharge Programmes

#### MAJOR OUTCOMES CONSIDERED

-   Length of hospital stay

-   Incidence of main hospital complications

-   Proportion of patients returning to previous residential and
    mobility status

-   Readmission to hospital

-   Reoperation

-   Health--related quality of life measures

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The scope of the guideline and the topics to be researched were
established by consensus within the group, and a search for evidence
conducted. Guidelines developed by other countries and other
organisations and relevant medical literature were reviewed. These were
identified by searching the Internet, and the electronic databases, The
Cochrane Library, MEDLINE, EMBASE, and CINAHL, and reviewing references
cited in other guidelines and identified papers. Identified references
were screened for eligibility according to predetermined criteria shown
below, and the studies considered eligible were retrieved and underwent
critical appraisal using pre-determined templates.

**Eligibility and Inclusion Criteria**

*Types of studies*

Systematic reviews and meta-analyses, descriptive reviews where no
systematic review were found, randomised controlled trials (RCTs),
non-randomised controlled clinical trials (CCTs), cohort studies,
case-control studies, and cross-sectional studies. For each topic, a
final decision on the level of study admissibility was made following
completion of the initial search. For selected topics, qualitative
studies were admissible.

*Types of study participants*

Older people who had sustained a proximal femoral (hip) fracture. Data
specifically dealing with hip fractures in children, younger adults, or
resulting from metastatic malignancy were excluded. For selected topics,
qualitative data were admissible.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

**1++**

High quality meta-analyses/systematic reviews of randomised controlled
clinical trials (RCTs), or RCTs with a very low risk of bias

**1+**

Well-conducted meta-analyses/systematic reviews, or RCTs with a low risk
of bias

**1-**

Meta-analyses/systematic reviews, or RCTs with a high risk of bias

**2++**

High quality systematic reviews of case-control or cohort studies

High quality case-control or cohort studies with a very low risk of
confounding or bias and a high probability that the relationship is
causal

**2+**

Well-conducted case-control or cohort studies with a low risk of
confounding or bias and a moderate probability that the relationship is
causal

**2-**

Case-control or cohort studies with a high risk of confounding or bias
and a significant risk that the relationship is not causal

**3**

Non-analytic studies (e.g., case reports). Case series

**4**

Expert opinion

Qualitative material was systematically appraised for quality, but was
not ascribed a level of evidence.

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Retrieved studies were obtained and their content reviewed for relevance
to the various topics of the review. Each topic was assigned to two
members of the group who read the retrieved reports, agreed on what
would be included in the guideline, and appraised the included material
using the pathway in the original guideline to filter the included
material (see original guideline supporting material). The strength of
the evidence was defined using the revised Scottish Intercollegiate
Guidelines Network (SIGN) criteria, which are described in the text of
the original guideline document.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Grades of Recommendations**

**A**

At least one meta-analysis, systematic review, or randomized controlled
trial (RCT) rated 1++ and directly applicable to the target population

or

A body of evidence consisting principally of studies rated as 1+,
directly applicable to the target population, and demonstrating overall
consistency of results

**B**

A body of evidence consisting principally of studies rated as 2++,
directly applicable to the target population, and demonstrating overall
consistency of results

or

Extrapolated evidence from studies rated as 1++, or 1+

**C**

A body of evidence consisting principally of studies rated as 2+,
directly applicable to the target population, and demonstrating overall
consistency of results

or

Extrapolated evidence from studies rated as 2++

**D**

Evidence level 3 or 4

or

Extrapolated evidence from studies rated as 2+

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

A draft of the guideline was widely circulated to over 30
individuals/organisations for peer review.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Definitions for the Levels of Evidence (1++ to 4) and Grades of
Recommendation (A to D) are given at the end of the \"Major
Recommendations\" field.

**Non-Surgical Management**

**Pre-hospital Care**

**D** In isolated areas, fluid replacement and catheterisation prior to
transport to hospital may be indicated.

**Emergency Department Care**

**C** Hospitals treating hip fracture should have formal \"fast track\"
protocols for assessment and admission of people aged 65 years and over.

**Fluid Replacement**

**D** After hip fracture, there is a risk of dehydration because of
inability to gain access to sufficient fluids. Careful fluid management
is required, as there is also risk of fluid overload when fluid
replacement is given intravenously.

**Pre-operative Traction**

**A** Routine use of temporary leg traction appears to be unnecessary.

**Pain Relief**

**C** Use of systematic pain assessment tools helps to avoid
undertreatment or overtreatment of pain.

**D** As frail older people tolerate narcotics poorly, multiple
modalities should be considered for analgesia.

**D** Narcotic use must be carefully titrated and supervised.

**B** Paracetamol should be preferred to aspirin as their effects are
similar milligram for milligram, but paracetamol has fewer side effects.

**B** Ibuprofen is a non-steroidal anti-inflammatory drug (NSAID)
effective in post-operative pain and appears to have lower incidence of
adverse effects than other NSAIDs.

**B** Propoxyphene-containing compounds are not recommended in people
aged 65 years and over with hip fracture.

**A** The use of local analgesic nerve blocks reduces the need for
parenteral or oral analgesia.

**Oxygen Therapy**

**C** Oxygen should be administered to maintain adequate tissue
oxygenation, as indicated by oximetry and clinical status.

**Prophylaxis Against Venous Thromboembolism**

**D** Adequate fluid balance and early post-operative mobilisation lower
the risk of postoperative venous thromboembolism (VTE).

**A** Administration of either aspirin or low molecular weight heparin
is associated with reduced risk of VTE, but some increase in adverse
bleeding events.

**A** Foot or calf pumps reduce the incidence of VTE, but have some
adverse skin effects and compliance problems.

**B** There is insufficient evidence to confirm the effectiveness of
thromboembolism stockings after hip fracture.

**Prophylaxis Against Wound and Other Infections**

**A** Antibiotic prophylaxis is effective in reducing wound infection
after hip fracture surgery.

**Use of Beds, Mattresses and Cushions to Prevent Pressure Sores**

**A** The use of high specification foam bed mattresses and pressure
relieving mattresses on operating tables reduces the incidence of
pressure sores.

**Nutritional Supplementation after Hip Fracture**

**A** Oral multinutrient feeds reduce unfavourable outcome (death or
post-operative complication) after hip fracture.

**Management of Urinary Retention**

**D** Routine catheterisation after hip fracture is not recommended.

**A** When urinary retention occurs, intermittent catheterisation
results in quicker restoration of normal voiding than indwelling
catheterisation.

**Management of Dementia/Delirium**

**C** Initial admission data should include a formal measure of
cognitive function.

**B** Early involvement of a geriatric medical team in hip fracture care
has been associated with a significant reduction in the incidence of
post-operative delirium.

**A** Active reorientation by provision of clock, calendar, radio,
television, and telephone does not appear to reduce post-operative
cognitive deterioration.

**D** Continuity in nursing care may reduce post-operative cognitive
deterioration.

**Surgical Management**

**Delay Before Surgery**

**C** Early operation (within 24 hours) for people aged 65 years and
over with hip fracture is associated with shorter hospital stay and
decreased mortality/morbidity.

**Anaesthesia**

**A** Regional anaesthesia for hip fracture surgery is associated with a
lower rate of deep venous thrombosis than general anaesthesia, but no
significant differences in mortality or other measures of morbidity.

**Undisplaced Intracapsular Fractures**

**B** Screws appear to provide better fixation and fracture healing than
unthreaded pins.

**Displaced Intracapsular Fractures**

**A** Any benefit of open reduction over closed reduction of a femoral
neck fracture prior to internal fixation is unproven.

**A** Evidence for the superiority of arthroplasty compared with
internal fixation for displaced intracapsular fractures of the hip,
reflected by lower re-operation, is limited.

**A** Arthroplasty is associated with a lower re-operation rate than
internal fixation.

**A** In arthroplasty after hip fracture, the use of bone cement may be
associated with less late pain in the limb.

**A** Unipolar hemi-arthroplasty appears as effective as bipolar
hemi-arthroplasty, and is less expensive.

**A** There is insufficient evidence to identify whether the use of
total hip replacement is superior to the use of hemi-arthroplasty in
displaced fracture of the femoral neck.

**Extracapsular (trochanteric) Fractures**

**A** Fixation with a sliding hip screw gives superior results to fixed
nail plate devices or intramedullary devices.

**Surgical Suction Wound Drains**

**A** The usefulness of surgical suction wound drains after hip fracture
surgery is unproven.

**Post-operative Mobilisation**

**D** People with hip fracture should be mobilised, weight bearing with
support as tolerated, as soon as possible after surgery.

**Immediate Rehabilitation**

**A** Hospitals providing treatment for people aged 65 years and over
with hip fracture should provide formal hip fracture programmes which
include early multidisciplinary assessment by a geriatric team.

**A** Early Supported Discharge Programmes reduce mean hospital stay and
are associated with a higher rate of effective return to previous
residential status.

**Definitions**:

**Levels of Evidence**

**1++**

High quality meta-analyses/systematic reviews of randomised controlled
clinical trials (RCTs), or RCTs with a very low risk of bias

**1+**

Well-conducted meta-analyses/systematic reviews, or RCTs with a low risk
of bias

**1-**

Meta-analyses/systematic reviews, or RCTs with a high risk of bias

**2++**

High quality systematic reviews of case-control or cohort studies

High quality case-control or cohort studies with a very low risk of
confounding or bias and a high probability that the relationship is
causal

**2+**

Well-conducted case-control or cohort studies with a low risk of
confounding or bias and a moderate probability that the relationship is
causal

**2-**

Case-control or cohort studies with a high risk of confounding or bias
and a significant risk that the relationship is not causal

**3**

Non-analytic studies (e.g., case reports). Case series

**4**

Expert opinion

Qualitative material was systematically appraised for quality, but was
not ascribed a level of evidence.

**Grades of Recommendations**

**A**

At least one meta-analysis, systematic review, or RCT rated 1++ and
directly applicable to the target population

or

A body of evidence consisting principally of studies rated as 1+,
directly applicable to the target population, and demonstrating overall
consistency of results

**B**

A body of evidence consisting principally of studies rated as 2++,
directly applicable to the target population, and demonstrating overall
consistency of results

or

Extrapolated evidence from studies rated as 1++, or 1+

**C**

A body of evidence consisting principally of studies rated as 2+,
directly applicable to the target population, and demonstrating overall
consistency of results

or

Extrapolated evidence from studies rated as 2++

**D**

Evidence level 3 or 4

or

Extrapolated evidence from studies rated as 2+

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The advice on acute management and immediate rehabilitation after hip
fracture amongst people aged 65 years and over given in this guideline
is based on epidemiological and other research evidence, supplemented
where necessary by the consensus opinion of the expert development team
based on their own experience.

The evidence supporting the recommendations was derived from systematic
reviews and meta-analyses, descriptive reviews where no systematic
review were found, randomised controlled trials (RCTs), non-randomised
controlled clinical trials (CCTs), cohort studies, case-control studies,
and cross-sectional studies. For selected topics, qualitative studies
were admissible.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

By following the evidence-based recommendations, most older people
suffering hip fracture will be able to access the most effective
treatment and return quickly to their previous residence and activities.

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

While the guidelines represent a statement of best practice based on the
latest available evidence (at the time of publishing), they are not
intended to replace the health professional\'s judgment in each
individual case.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

**Implementation**

The recommendations of this guideline are intended to assist
decision-making, and are based on current best evidence. The guideline
is not intended to serve as, or be construed as, a standard of health
care. Adoption and implementation of the recommendations will be a
matter for Accident Compensation Corporation (ACC), District Health
Boards (DHBs), Independent Practitioners´ Associations (IPAs), Primary
Healthcare Organisations (PHOs), and local provider units to consider.
The guideline should provide a basis at local level for protocols,
continuing health professional education, audit, and quality assurance
activities. Suggestions for audit are described below.

**Dissemination**

The guideline will be sent to:

-   ACC

-   colleges and associations representing relevant health professional
    vocational groups

-   members of IPAs

-   PHOs

-   chief executives and chief medical officers of DHBs

-   tertiary education institutions offering health professional
    programmes

-   providers of Aged Care services in the community

-   selected others.

Summary guidelines will also be prepared. The guidelines and summaries
will be posted on the NZGG website
[www.nzgg.org.nz](http://www.nzgg.org.nz/) and on the ACC website
[http://www.acc.co.nz](http://www.acc.co.nz/)

**Audit and Performance Indicators**

**Quality**

People aged 65 years and over suffering with hip fracture, service
providers, and funders of services to people with hip fracture all have
an interest in the quality of the care and management of people with hip
fractures. This places a responsibility on service providers to collect
information relevant to different perspectives. Suggestions include:

-   a minimum data set for collection relating to each individual with
    hip fracture aged 65 years and over

-   additional data for periodic audit (by an internal or external
    agency).

***Suggested data for routine collection***

-   Basic demographics of people at risk for hip fracture (age and
    gender)

-   Current living status (own home -- alone, residential, family
    support)

-   Maternal history of hip fracture

-   Smoker status. Number of attempts at quitting

-   Diabetes diagnosed. Using insulin?

-   Number of strokes

-   Number of falls in the previous 12 months

-   Previous fractures (hip, wrist, humerus, spine)

-   Current medications and dose levels (anticonvulsants,
    bisphosphonates, corticosteroids, opioids, hormone replacement
    therapy \[HRT\], psychotropic drugs, and type Ia antiarrhythmic)

-   Use of vitamin D supplements and calcium

-   Side effects of medication.

**Audit**

Audit is a systematic, independent, and documented process for obtaining
evidence and evaluating it objectively to determine the extent to which
a service, such as a primary health care practice, is meeting best
practice standards. In order to assess whether acute management and
immediate rehabilitation after hip fracture is being provided
effectively, performance indicators should be assessed.

***Suggested performance indicators***

Process indicators:

-   Average length of time in the emergency treatment

-   \% assessed systematically for pain and provided with appropriate
    analgesia

-   \% receiving operation in 12 hrs or less; 12 to 24 hrs; 24 to 36
    hrs; more

-   \% receiving prophylaxis for venous thromboembolism

-   \% receiving antibiotic prophylaxis

-   proportion of people with hip fracture requiring catheterisation who
    receive intermittent catheterisation

-   \% receiving early multidisciplinary geriatric assessment before
    discharge

-   \% referred to an early supported discharge programme

-   average length of hospital stay.

Outcome indicators:

-   \% who develop thromboembolic complications

-   \% who develop post-operative wound infection

-   \% requiring reoperation during primary admission

-   \% requiring readmission after discharge

-   \% receiving osteoporotic medications on discharge (with details of
    the medications prescribed).

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

New Zealand Guidelines Group (NZGG). Acute management and immediate
rehabilitation after hip fracture amongst people aged 65 years and over.
Wellington (NZ): New Zealand Guidelines Group (NZGG); 2003 Jun. 26 p.
\[60 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 Jun

#### GUIDELINE DEVELOPER(S)

New Zealand Guidelines Group - Private Nonprofit Organization

#### SOURCE(S) OF FUNDING

Ministry of Health

#### GUIDELINE COMMITTEE

Guideline Development Team

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Research and Writing Group Members*: William Gillespie, ChM, FRACS,
FRCPEd, Orthopaedic Surgeon, Dean, Hull York Medical School
(*Convenor*); John Campbell, MD, FRACP, Professor of Geriatric Medicine,
University of Otago Medical School; Melinda Gardner, Mphty, PhD,
Physiotherapist, Fall Prevention Research, Northern DHB Support Agency
Ltd; Lesley Gillespie, BSc (Soc Sci), MMedSci (Clin Epi), RGN, Trial
Search Coordinator for the Cochrane Musculoskeletal Injuries Group, The
University of York, Orthopaedic Nursing, Clinical Epidemiology; Jan
Jackson, Fractured Neck of Femur Clinical Nurse Specialist, Auckland
District Health Board; Clare Robertson, BSc (Hons), BCom, PhD, Senior
Research Fellow, Fall Prevention Research, Economic Evaluation,
University of Otago Medical School; Jean-Claude Theis, MD, MChOrth, FRCS
Ed, FRACS, Associate Professor of Orthopaedic Surgery, Dunedin School of
Medicine; Raymond Jones, Project Coordinator, Otago District Health
Board

*Consultation Group Members*: Marion Robinson (Dunedin); Heather Thomson
(Opotiki); Jim Reid (Dunedin)

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

**Declaration of Competing Interests**

**John Campbell** has received research funding from the Accident
Compensation Corporation (ACC).

#### ENDORSER(S)

Age Concern New Zealand, Inc. - Medical Specialty Society\
College of Nurses Aotearoa NZ - Academic Institution\
Hospitals Association, Inc. (New Zealand) - Professional Association\
New Zealand College of Practice Nurses (NZNO) - Professional
Association\
New Zealand Home and Health Association, Inc. - Professional
Association\
New Zealand Nurses Organization - Professional Association\
New Zealand Orthopaedic Association - Professional Association\
New Zealand Society of Physiotherapists - Professional Association\
NZ Geriatric Society - Professional Association\
Osteoporosis New Zealand - Medical Specialty Society\
Residential Care NZ, Inc. - Professional Association\
Royal New Zealand College of General Practitioners - Medical Specialty
Society\
Women\'s Health Action - Medical Specialty Society

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[New Zealand Guidelines Group Web
site](http://www.nzgg.org.nz/guidelines/0007/Hip_Fracture_Management_Fulltext.pdf).

Print copies: Available from the New Zealand Guidelines Group Inc.,
Level 10, 40 Mercer Street, PO Box 10 665, The Terrace, Wellington, New
Zealand; Tel: 64 4 471 4180; Fax: 64 4 471 4185; e-mail:
<info@nzgg.org.nz>

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   New Zealand Guidelines Group (NZGG). Guideline summary. Acute
    management and immediate rehabilitation after hip fracture amongst
    people aged 65 years and over. Wellington (NZ): New Zealand
    Guidelines Group (NZGG); 2003 Jun. 4 p. Available from in Portable
    Document Format (PDF) from the [New Zealand Guidelines Group Web
    site](http://www.nzgg.org.nz/guidelines/0007/ACF420.pdf).

-   New Zealand Guidelines Group (NZGG). Search strategy. Acute
    management and immediate rehabilitation after hip fracture amongst
    people aged 65 years and over. Wellington (NZ): New Zealand
    Guidelines Group (NZGG); 2003 Jun. 7 p. Available from in Portable
    Document Format (PDF) from the [New Zealand Guidelines Group Web
    site](http://www.nzgg.org.nz/guidelines/0007/Hip_Fracture_Management_Search.pdf).

Print copies: Available from the New Zealand Guidelines Group Inc.,
Level 10, 40 Mercer Street, PO Box 10 665, The Terrace, Wellington, New
Zealand; Tel: 64 4 471 4180; Fax: 64 4 471 4185; e-mail:
<info@nzgg.org.nz>

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on June 16, 2004. The information
was verified by the guideline developer on July 19, 2004. This summary
was updated on May 3, 2005 following the withdrawal of Bextra
(valdecoxib) from the market and the release of heightened warnings for
Celebrex (celecoxib) and other nonselective nonsteroidal
anti-inflammatory drugs (NSAIDs). This summary was updated by ECRI on
June 16, 2005, following the U.S. Food and Drug Administration advisory
on COX-2 selective and non-selective non-steroidal anti-inflammatory
drugs (NSAIDs). This summary was updated by ECRI Institute on June 22,
2007 following the U.S. Food and Drug Administration (FDA) advisory on
heparin sodium injection. This summary was updated by ECRI Institute on
March 13, 2008 following the updated FDA advisory on heparin sodium
injection.

#### COPYRIGHT STATEMENT

These guidelines are copyrighted by the New Zealand Guidelines Group.
They may be downloaded and printed for personal use or for producing
local protocols in New Zealand. Re-publication or adaptation of these
guidelines in any form requires specific permission from the Chief
Executive of the New Zealand Guidelines Group.

### DISCLAIMER

#### NGC DISCLAIMER

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<http://www.guideline.gov/about/inclusion.aspx> .

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008