1.60: Escalation thresholds
Ambulance service & NHSD alerts - SPOA
1.60: Escalation thresholds
1.60: Escalation thresholds
1.60: Escalation thresholds
1.60: Escalation thresholds
1.60: Escalation thresholds
1.60: Escalation thresholds
1.60: Escalation thresholds
1.60: Escalation thresholds
1.60: Escalation thresholds
1.70: Red Flags
Critically ill pts via blue light due to acute comorbidity
3.40: Definitive Treatments (Tx)
3.40: Definitive Treatments (Tx)
3.40: Definitive Treatments (Tx)
3.40: Definitive Treatments (Tx)
3.40: Definitive Treatments (Tx)
3.40: Definitive Treatments (Tx)
3.40: Definitive Treatments (Tx)
3.40: Definitive Treatments (Tx)
3.40: Definitive Treatments (Tx)
3.40: Definitive Treatments (Tx)
4.40: Definitive Treatments (Tx)
4.40: Definitive Treatments (Tx)
4.40: Definitive Treatments (Tx)
4.40: Definitive Treatments (Tx)
4.40: Definitive Treatments (Tx)
4.40: Definitive Treatments (Tx)
4.40: Definitive Treatments (Tx)
4.40: Definitive Treatments (Tx)
4.40: Definitive Treatments (Tx)
4.40: Definitive Treatments (Tx)
4.42: Tx of new / existing medical problems
Requiring specialist medical / geriatric input
dietician & pharmacist review
4.42: Tx of new / existing medical problems
4.42: Tx of new / existing medical problems
4.42: Tx of new / existing medical problems
4.42: Tx of new / existing medical problems
4.42: Tx of new / existing medical problems
4.42: Tx of new / existing medical problems
4.42: Tx of new / existing medical problems
4.42: Tx of new / existing medical problems
4.42: Tx of new / existing medical problems
4.43: MDT, PT & OT Tx.
Rehab to optimise mobility & ADL. Home assessment, equipment, adaptations & care package. SW input4.44: Info & reassurance
How to improve Bone health eg
safe transfers, avoiding falls, mobilizing, healthy diet & exercise
4.50: Discharge - inc Rehabilitation, Review & QoL measurement
Discharge to own home / intermediate care facility or rehab unit / intermediate care at home / long term care facility .
For secondary prevention of falls and fracture post discharge refer to secondary prevention of falls pathway
4.50: Discharge - inc Rehabilitation, Review & QoL measurement
4.50: Discharge - inc Rehabilitation, Review & QoL measurement
4.50: Discharge - inc Rehabilitation, Review & QoL measurement
4.50: Discharge - inc Rehabilitation, Review & QoL measurement
4.50: Discharge - inc Rehabilitation, Review & QoL measurement
4.50: Discharge - inc Rehabilitation, Review & QoL measurement
4.50: Discharge - inc Rehabilitation, Review & QoL measurement
4.50: Discharge - inc Rehabilitation, Review & QoL measurement
4.50: Discharge - inc Rehabilitation, Review & QoL measurement
4.41: Ongoing post-op care
Thrombop -rophylaxyis, analgesia,
nutritional supplemen -tation
4.41: Ongoing post-op care
4.41: Ongoing post-op care
4.41: Ongoing post-op care
4.41: Ongoing post-op care
4.41: Ongoing post-op care
4.41: Ongoing post-op care
4.41: Ongoing post-op care
4.41: Ongoing post-op care
4.41: Ongoing post-op care
4.45: Fall Prevention
Extra to rehab & discharge plan4.46: Bone health Tx
Commence Tx for secondary prevention of fracture. Consider other causes
3.00: Peri-operative (inc full pre-op assessment)
Anaesthetic & Surgical Ax
Aim to operate within 24 hrs if / when fit on dedicated trauma list with senior anaesthetists & surgeon involvement. Only delay / cancel if pt medically unfit for surgery, as assessed by consultant in elderly medicine or orthogeriatrician
3.00: Peri-operative (inc full pre-op assessment)
3.00: Peri-operative (inc full pre-op assessment)
3.00: Peri-operative (inc full pre-op assessment)
3.00: Peri-operative (inc full pre-op assessment)
3.00: Peri-operative (inc full pre-op assessment)
3.00: Peri-operative (inc full pre-op assessment)
3.00: Peri-operative (inc full pre-op assessment)
3.00: Peri-operative (inc full pre-op assessment)
3.00: Peri-operative (inc full pre-op assessment)
2.70: Red Flags
Physiologically deterirorating / critically ill pts
2.60: Transfer to ward or theatre
Transfer directly to appropraite clinical area within 2hrs 2.60: Transfer to ward or theatre
2.60: Transfer to ward or theatre
2.60: Transfer to ward or theatre
2.60: Transfer to ward or theatre
2.60: Transfer to ward or theatre
2.60: Transfer to ward or theatre
2.60: Transfer to ward or theatre
2.60: Transfer to ward or theatre
2.60: Transfer to ward or theatre
4.24: Falls Ax
All pts to have falls risk factor Ax as per NICE & secondary prevention pathway
4.23: Bone health Ax
As per NICE
guidelines
Follow up DXA scan if needed
4.22: MDT
Appropriate nursing / OT / Physio / Social Worker Ax
3.24: Nutritional Ax
Standard -ised Ax with nutritional plan - BAPEN guidelines 3.22: Further imaging
Re- xray, CT, MRI or isotope scan
3.20: Assessments (Ax) & Diagnostics (Dx)
3.20: Assessments (Ax) & Diagnostics (Dx)
3.20: Assessments (Ax) & Diagnostics (Dx)
3.20: Assessments (Ax) & Diagnostics (Dx)
3.20: Assessments (Ax) & Diagnostics (Dx)
3.20: Assessments (Ax) & Diagnostics (Dx)
3.20: Assessments (Ax) & Diagnostics (Dx)
3.20: Assessments (Ax) & Diagnostics (Dx)
3.20: Assessments (Ax) & Diagnostics (Dx)
3.20: Assessments (Ax) & Diagnostics (Dx)
2.30: Decision aids
To support use of general Tx's
3.21: No diagnostic required
3.21: No diagnostic required
3.21: No diagnostic required
3.21: No diagnostic required
3.21: No diagnostic required
3.21: No diagnostic required
3.21: No diagnostic required
3.21: No diagnostic required
3.21: No diagnostic required
3.21: No diagnostic required
4.21: Post op reviews
For pain & medical / surgical comp -lications 3.10: Dx thresholds & decision aids
Locally agreed
anaesthetic protocol
3.10: Dx thresholds & decision aids
3.10: Dx thresholds & decision aids
3.10: Dx thresholds & decision aids
3.10: Dx thresholds & decision aids
3.10: Dx thresholds & decision aids
3.10: Dx thresholds & decision aids
3.10: Dx thresholds & decision aids
3.10: Dx thresholds & decision aids
3.10: Dx thresholds & decision aids
2.21: General Ax
Hypotension
pain,
infection
oxygen saturation
2.22: Basic screen
Bloods, ECG, cross match
2.23: Imaging
Hip x-ray
X-ray for other injuries
chest xray
2.24: Social, functional, cognitive assessment
Inc family & carers
2.24: Social, functional, cognitive assessment
2.24: Social, functional, cognitive assessment
2.24: Social, functional, cognitive assessment
2.24: Social, functional, cognitive assessment
2.24: Social, functional, cognitive assessment
2.24: Social, functional, cognitive assessment
2.24: Social, functional, cognitive assessment
2.24: Social, functional, cognitive assessment
2.24: Social, functional, cognitive assessment
3.23: Repeat investigations
Electrolytes, clotting, ECG, troponin, Hb
3.23: Repeat investigations
3.23: Repeat investigations
3.23: Repeat investigations
3.23: Repeat investigations
3.23: Repeat investigations
3.23: Repeat investigations
3.23: Repeat investigations
3.23: Repeat investigations
3.23: Repeat investigations
2.20: Assessments (Ax) & Diagnostics (Dx)
2.20: Assessments (Ax) & Diagnostics (Dx)
2.20: Assessments (Ax) & Diagnostics (Dx)
2.20: Assessments (Ax) & Diagnostics (Dx)
2.20: Assessments (Ax) & Diagnostics (Dx)
2.20: Assessments (Ax) & Diagnostics (Dx)
2.20: Assessments (Ax) & Diagnostics (Dx)
2.20: Assessments (Ax) & Diagnostics (Dx)
2.20: Assessments (Ax) & Diagnostics (Dx)
2.20: Assessments (Ax) & Diagnostics (Dx)
3.45: Palliative Care
Treatment of symptoms3.46: Patients requiring conservative Tx
Pts whose operative risk is too great/ refuse op/ fixation impossible due to state of bones
3.46: Patients requiring conservative Tx
3.46: Patients requiring conservative Tx
3.46: Patients requiring conservative Tx
3.46: Patients requiring conservative Tx
3.46: Patients requiring conservative Tx
3.46: Patients requiring conservative Tx
3.46: Patients requiring conservative Tx
3.46: Patients requiring conservative Tx
3.46: Patients requiring conservative Tx
3.44: Post op Care
Adequate analgesia
oxygenation & fluids.
Thrombo- prophylaxis, pressure area care, nutrition, bowel care
3.43: ICU / HDU
Some pts will require
post-op stay in HDU / ICU so ensure access
3.42: Surgical Tx of fracture
Either
fixation or joint replacement.
Type of anaesthetic depends on individual risk Ax. Bone biopsy
3.42: Surgical Tx of fracture
3.42: Surgical Tx of fracture
3.42: Surgical Tx of fracture
3.42: Surgical Tx of fracture
3.42: Surgical Tx of fracture
3.42: Surgical Tx of fracture
3.42: Surgical Tx of fracture
3.42: Surgical Tx of fracture
3.42: Surgical Tx of fracture
3.41: Info & reassurance
Consent & marking (NB mental incapacity)
related to surgical Tx & post op recovery
2.41: Info & reassurance
Patient focused & relevant family info -rmation & individualized discharge pathway . Home / Carer needs2.42: Active monitoring
Observe & respond
- pain
- vital signs
- infections
- current illness
2.43: Pressure relief
Pressure relieving mattress & assess pressure risk via a tool eg Waterlow score2.44: Medication
IV Fluids
analgesia
oxygen
DVT prophylaxis
NICE
2.40: General Treatments (Tx)
2.40: General Treatments (Tx)
2.40: General Treatments (Tx)
2.40: General Treatments (Tx)
2.40: General Treatments (Tx)
2.40: General Treatments (Tx)
2.40: General Treatments (Tx)
2.40: General Treatments (Tx)
2.40: General Treatments (Tx)
2.40: General Treatments (Tx)
3.50: End of Life Care
Refer to the Liverpool Care Pathway
Can be in hospital, hospice, social care, community or home. Consider wider family needs & preferences
3.60: Review predicted rehab outcomes & length of stay by day 3 post op
inc discharge destination3.60: Review predicted rehab outcomes & length of stay by day 3 post op
3.60: Review predicted rehab outcomes & length of stay by day 3 post op
3.60: Review predicted rehab outcomes & length of stay by day 3 post op
3.60: Review predicted rehab outcomes & length of stay by day 3 post op
3.60: Review predicted rehab outcomes & length of stay by day 3 post op
3.60: Review predicted rehab outcomes & length of stay by day 3 post op
3.60: Review predicted rehab outcomes & length of stay by day 3 post op
3.60: Review predicted rehab outcomes & length of stay by day 3 post op
3.60: Review predicted rehab outcomes & length of stay by day 3 post op
4.00: Post-op care
Ongoing assessment & treatment for post op complications or medical problems
Rehab & discharge planning
Secondary fracture & falls prevention
4.10: Dx thresholds & decision aids
NICE secondary prevention of fragility #4.10: Dx thresholds & decision aids
4.10: Dx thresholds & decision aids
4.10: Dx thresholds & decision aids
4.10: Dx thresholds & decision aids
4.10: Dx thresholds & decision aids
4.10: Dx thresholds & decision aids
4.10: Dx thresholds & decision aids
4.10: Dx thresholds & decision aids
4.10: Dx thresholds & decision aids
2.00: Initial assessment of patients hip # & general Ax
- Full cinical examination
- Clinical examination of hip
- Pain Ax
- Other injuries eg fracture / Head injury
- Medication review - eg Warfarin
- Medical current co-morbidities eg infection / confusion / dehydration / hypotension
2.00: Initial assessment of patients hip # & general Ax
2.00: Initial assessment of patients hip # & general Ax
2.00: Initial assessment of patients hip # & general Ax
2.00: Initial assessment of patients hip # & general Ax
2.00: Initial assessment of patients hip # & general Ax
2.00: Initial assessment of patients hip # & general Ax
2.00: Initial assessment of patients hip # & general Ax
2.00: Initial assessment of patients hip # & general Ax
2.00: Initial assessment of patients hip # & general Ax
3.30: Decision aids
Local thrombopro -phylaxis protocol
4.30: Decision aids
NICE guideline on falls preventionHip Fracture including the secondary prevention of further fractures related to falls and bone fragility v3 May 2009
2.45: High risk patients
REMOVE BOx
2.50: Orthogeriatric assessment & treatment
Assistance with ongoing treatment of acute illnesses, identifying
current LTC's & treatments
need for further interventions to achieve fitness for surgery
eg ECHO, Warfarin reversal, antibiotics, insulin sliding scale,
pacemaker check, assessment of frailty, mortality risk & CPR status
2.50: Orthogeriatric assessment & treatment
2.50: Orthogeriatric assessment & treatment
2.50: Orthogeriatric assessment & treatment
2.50: Orthogeriatric assessment & treatment
2.50: Orthogeriatric assessment & treatment
2.50: Orthogeriatric assessment & treatment
2.50: Orthogeriatric assessment & treatment
2.50: Orthogeriatric assessment & treatment
2.50: Orthogeriatric assessment & treatment
1.30: Prevention of index fall or fracture
NOGG & NICE CG21 falls guidelines
NICE Oesteoporosis guidance
RCP report on falls & fracture services
1.30: Prevention of index fall or fracture
1.30: Prevention of index fall or fracture
1.30: Prevention of index fall or fracture
1.30: Prevention of index fall or fracture
1.30: Prevention of index fall or fracture
1.30: Prevention of index fall or fracture
1.30: Prevention of index fall or fracture
1.30: Prevention of index fall or fracture
1.30: Prevention of index fall or fracture
1.20: Incidence & Prevalence
70,00 hip fractures per yr in people over 60 yrs
BOA sheet
NSF for older people
NHS Institute focus on # NoF
1.20: Incidence & Prevalence
1.20: Incidence & Prevalence
1.20: Incidence & Prevalence
1.20: Incidence & Prevalence
1.20: Incidence & Prevalence
1.20: Incidence & Prevalence
1.20: Incidence & Prevalence
1.20: Incidence & Prevalence
1.20: Incidence & Prevalence
1.10: Symptom Description
Loss of mobility, fall &/or pain
Correct identification of fracture & establish if any old fractures or previous hip surgery exist
1.10: Symptom Description
1.10: Symptom Description
1.10: Symptom Description
1.10: Symptom Description
1.10: Symptom Description
1.10: Symptom Description
1.10: Symptom Description
1.10: Symptom Description
1.10: Symptom Description
2.45: High risk patients
Discussions between
ortho-
geriatrician, surgical & anaesthetic team regarding patient management
2.30: Decision aids
If not fit only delay if poss to optimize fitness with medical Tx or conservative Mx4.20: Assessments (Ax)
4.2.1 For complications related to surgery eg problems with fixation, wound infection, infected prosthesis & inc post op x-ray
4.2.2 Fracture due to bone fragility or pathological fracture eg from malignancy, myeloma etc - may inc blood tests & imaging
4.2.3 Include structured documentation of rehab progress and goals - Blue book , NHS Institute Focus on fractured neck of femur2.70: Red Flags
If x-ray shows no # then exit to seconday falls & fractures prevention pathway3.20: Assessments (Ax) & Diagnostics (Dx)
3.20: Assessments (Ax) & Diagnostics (Dx)
3.20: Assessments (Ax) & Diagnostics (Dx)
3.20: Assessments (Ax) & Diagnostics (Dx)
3.20: Assessments (Ax) & Diagnostics (Dx)
3.20: Assessments (Ax) & Diagnostics (Dx)
3.20: Assessments (Ax) & Diagnostics (Dx)
3.20: Assessments (Ax) & Diagnostics (Dx)
3.20: Assessments (Ax) & Diagnostics (Dx)
3.20: Assessments (Ax) & Diagnostics (Dx)
2.20: Assessments (Ax) & Diagnostics (Dx)
2.2.1 Hip x-ray confirms / excludes fracture
2.2.2 Infection treatment eg UTI, Pneumonia
2.20: Assessments (Ax) & Diagnostics (Dx)
2.20: Assessments (Ax) & Diagnostics (Dx)
2.20: Assessments (Ax) & Diagnostics (Dx)
2.20: Assessments (Ax) & Diagnostics (Dx)
2.20: Assessments (Ax) & Diagnostics (Dx)
2.20: Assessments (Ax) & Diagnostics (Dx)
2.20: Assessments (Ax) & Diagnostics (Dx)
2.20: Assessments (Ax) & Diagnostics (Dx)
2.20: Assessments (Ax) & Diagnostics (Dx)
1.20: Incidence & Prevalence
1.20: Incidence & Prevalence
1.20: Incidence & Prevalence
1.20: Incidence & Prevalence
1.20: Incidence & Prevalence
1.20: Incidence & Prevalence
1.20: Incidence & Prevalence
1.20: Incidence & Prevalence
1.20: Incidence & Prevalence
1.20: Incidence & Prevalence
1.10: Symptom Description
1.10: Symptom Description
1.10: Symptom Description
1.10: Symptom Description
1.10: Symptom Description
1.10: Symptom Description
1.10: Symptom Description
1.10: Symptom Description
1.10: Symptom Description
1.10: Symptom Description
1.60: Escalation thresholds
1.60: Escalation thresholds
1.60: Escalation thresholds
1.60: Escalation thresholds
1.60: Escalation thresholds
1.60: Escalation thresholds
1.60: Escalation thresholds
1.60: Escalation thresholds
1.60: Escalation thresholds
1.60: Escalation thresholds
2.60: Transfer to ward or theatre
BOAST 3 Hip # pts require nursing, orthogeriatric, medicine & surgical expertise2.60: Transfer to ward or theatre
2.60: Transfer to ward or theatre
2.60: Transfer to ward or theatre
2.60: Transfer to ward or theatre
2.60: Transfer to ward or theatre
2.60: Transfer to ward or theatre
2.60: Transfer to ward or theatre
2.60: Transfer to ward or theatre
2.60: Transfer to ward or theatre
3.60: Review predicted rehab outcomes & length of stay by day 3 post op
3.60: Review predicted rehab outcomes & length of stay by day 3 post op
3.60: Review predicted rehab outcomes & length of stay by day 3 post op
3.60: Review predicted rehab outcomes & length of stay by day 3 post op
3.60: Review predicted rehab outcomes & length of stay by day 3 post op
3.60: Review predicted rehab outcomes & length of stay by day 3 post op
3.60: Review predicted rehab outcomes & length of stay by day 3 post op
3.60: Review predicted rehab outcomes & length of stay by day 3 post op
3.60: Review predicted rehab outcomes & length of stay by day 3 post op
3.60: Review predicted rehab outcomes & length of stay by day 3 post op
3.00: Peri-operative (inc full pre-op assessment)
Anaesthetic Ax - review of fitness for surgery & decision on type of anaesthetic eg GA / Spinal
Surgical Ax - review of operation planned
3.00: Peri-operative (inc full pre-op assessment)
3.00: Peri-operative (inc full pre-op assessment)
3.00: Peri-operative (inc full pre-op assessment)
3.00: Peri-operative (inc full pre-op assessment)
3.00: Peri-operative (inc full pre-op assessment)
3.00: Peri-operative (inc full pre-op assessment)
3.00: Peri-operative (inc full pre-op assessment)
3.00: Peri-operative (inc full pre-op assessment)
3.00: Peri-operative (inc full pre-op assessment)
2.00: Initial assessment of patients hip # & general Ax
Full clinical examination determines if pts priority is medical or orthopaedic
Including ambulance services - provision of care & community system of alerting primary care
2.00: Initial assessment of patients hip # & general Ax
2.00: Initial assessment of patients hip # & general Ax
2.00: Initial assessment of patients hip # & general Ax
2.00: Initial assessment of patients hip # & general Ax
2.00: Initial assessment of patients hip # & general Ax
2.00: Initial assessment of patients hip # & general Ax
2.00: Initial assessment of patients hip # & general Ax
2.00: Initial assessment of patients hip # & general Ax
2.00: Initial assessment of patients hip # & general Ax
2.40: General Treatments (Tx)
2.4.1 EDD (expected discharge date) where possible. Identify any home or carer issues to be resolved2.40: General Treatments (Tx)
2.40: General Treatments (Tx)
2.40: General Treatments (Tx)
2.40: General Treatments (Tx)
2.40: General Treatments (Tx)
2.40: General Treatments (Tx)
2.40: General Treatments (Tx)
2.40: General Treatments (Tx)
2.40: General Treatments (Tx)
3.40: Definitive Treatments (Tx)
3.4.2 Avoid cancellation for administrative reasons eg elective targets / list space. Bone biopsy if pathological # or past history of malignancy
3.4.4 Ongoing adequate analgesia inc nerve block where necessary & regular pain Ax
Thromboprophylaxis against DVT
Mx of immediate post op problems eg anaemia, infection
3.40: Definitive Treatments (Tx)
3.40: Definitive Treatments (Tx)
3.40: Definitive Treatments (Tx)
3.40: Definitive Treatments (Tx)
3.40: Definitive Treatments (Tx)
3.40: Definitive Treatments (Tx)
3.40: Definitive Treatments (Tx)
3.40: Definitive Treatments (Tx)
3.40: Definitive Treatments (Tx)
4.40: Definitive Treatments (Tx)
4.4.4 Commence Tx for secondary prevention of fracture where indicated eg Bisphosphonates, Calcium, Vit D, , Strongtium. If other cause of pathological fracture eg Paget's, Myeloma, malignancy may need specialist treatment - see tier 3 of secondary prevention pathway. NB in addition to rehab & discharge planning
4.40: Definitive Treatments (Tx)
4.40: Definitive Treatments (Tx)
4.40: Definitive Treatments (Tx)
4.40: Definitive Treatments (Tx)
4.40: Definitive Treatments (Tx)
4.40: Definitive Treatments (Tx)
4.40: Definitive Treatments (Tx)
4.40: Definitive Treatments (Tx)
4.40: Definitive Treatments (Tx)
4.10: Dx thresholds & decision aids
4.10: Dx thresholds & decision aids
4.10: Dx thresholds & decision aids
4.10: Dx thresholds & decision aids
4.10: Dx thresholds & decision aids
4.10: Dx thresholds & decision aids
4.10: Dx thresholds & decision aids
4.10: Dx thresholds & decision aids
4.10: Dx thresholds & decision aids
4.10: Dx thresholds & decision aids
3.10: Dx thresholds & decision aids
3.10: Dx thresholds & decision aids
3.10: Dx thresholds & decision aids
3.10: Dx thresholds & decision aids
3.10: Dx thresholds & decision aids
3.10: Dx thresholds & decision aids
3.10: Dx thresholds & decision aids
3.10: Dx thresholds & decision aids
3.10: Dx thresholds & decision aids
3.10: Dx thresholds & decision aids
4.50: Discharge - inc Rehabilitation, Review & QoL measurement
Secondary prevention of falls & fractures requires ongoing bone health Tx see 4.4.4 & monitoring & prescribing from primary care. Falls prevention & maintain safety - refer to secondary falls prevention pathway. Potential to reduce acute hospital spell by adequate capacity in community rehab models. In Autumn 2009 PBR quality metrics & sequin data available
4.50: Discharge - inc Rehabilitation, Review & QoL measurement
4.50: Discharge - inc Rehabilitation, Review & QoL measurement
4.50: Discharge - inc Rehabilitation, Review & QoL measurement
4.50: Discharge - inc Rehabilitation, Review & QoL measurement
4.50: Discharge - inc Rehabilitation, Review & QoL measurement
4.50: Discharge - inc Rehabilitation, Review & QoL measurement
4.50: Discharge - inc Rehabilitation, Review & QoL measurement
4.50: Discharge - inc Rehabilitation, Review & QoL measurement
4.50: Discharge - inc Rehabilitation, Review & QoL measurement
1.30: Prevention of index fall or fracture
RCP audit shows number of fractures per year1.30: Prevention of index fall or fracture
1.30: Prevention of index fall or fracture
1.30: Prevention of index fall or fracture
1.30: Prevention of index fall or fracture
1.30: Prevention of index fall or fracture
1.30: Prevention of index fall or fracture
1.30: Prevention of index fall or fracture
1.30: Prevention of index fall or fracture
1.30: Prevention of index fall or fracture
