The issue
When an older adult breaks a hip, deciding which hospital service “owns” the admission — medicine or orthopedic surgery — can affect speed of surgery, complication rates, and even survival. A New England Journal of Medicine Clinical Decisions article lays out the debate, citing evidence that medical teams are better at managing complex comorbidities, while surgical teams can get patients to the operating room hours sooner.
What do I need to know?
Hip‑fracture patients are almost always frail and medically complex: atrial fibrillation, delirium, acute kidney injury, and anticoagulation problems are common on arrival. Observational studies show lower in‑hospital mortality when a geriatric or internal‑medicine team directs care with orthopedics consulting, yet randomized data also link surgery within 6 hours to fewer infections and less delirium. The article’s two experts therefore frame the choice as a balance between rapid fracture fixation and intensive medical oversight — both essential, but seldom delivered together on standard wards.
Potential risk of sub‑optimal hip‑fracture care
Stable patient with few co‑existing illnesses and readily reversible anticoagulation.
Recommended Actions
Admit to orthopedic surgery to streamline access to the operating room.
Ensure same‑day medicine consult to review drugs, fluids, and pain control.
Start delirium‑prevention bundle (frequent re‑orientation, early mobilization).
Imminent risk of sub‑optimal care
Multiple active conditions (rapid‑rate atrial fibrillation, acute kidney injury, possible delirium) that need close titration.
Recommended Actions
Admit to internal‑medicine (or geriatric) service with orthopedics consulting.
Monitor vitals and labs every 4 h; adjust beta‑blocker, fluids, and anticoagulation.
Target surgery within 24 h once medical issues are optimized.
Confirmed high‑risk situation
Severe frailty, unstable vitals, high bleeding or cardiac risk — delays or management missteps could be fatal.
Recommended Actions
Push for an orthogeriatric “shared‑care” pathway (jointly staffed ward or daily co‑rounding).
If no formal program exists, designate one lead clinician (geriatrician or hospitalist) to coordinate all specialties and ensure surgery occurs as soon as safely possible.
Plan early rehab, bone‑protection meds, and meticulous discharge reconciliation to avoid the 30 % post‑discharge drug‑error rate noted in trials.
What can I do?
Tell the emergency‑department team: “Given my (or my loved one’s) medical issues, am I at potential, imminent, or confirmed risk of complications, and which admitting service will best manage that risk while still getting the fracture fixed quickly?” Make sure someone tracks heart rhythm, kidney function, pain, and mental status every few hours before and after surgery. Ask to see both the orthopedic and medical teams daily — or request transfer to a dedicated ortho‑geriatric unit if your hospital has one. Family members can help by listing pre‑fracture medications (especially blood thinners), confirming they are restarted or stopped appropriately, and preparing the home for safe return with walkers, raised toilet seats, and fall‑prevention fixes.
