Beyond Hip Fractures: An End-to-End Model for Fragility Fracture Management

Background 

Singapore has a high hip fracture incidence with substantial morbidity and cost burden. At Woodlands Hospital, a new hospital, it was recognised that high-value fragility fracture care must go beyond hip fractures, beyond the inpatient episode, and beyond osteoporosis.

Programme Description 

Building on established orthogeriatric co-management, the Programme for Osteoporosis Management, Insufficiency fractures and Sarcopenia in the Elderly (PROMISE) was implemented at hospital opening. It manages hip and non-hip fragility fractures across acute, rehabilitative, and outpatient settings through multidisciplinary partnerships.

Key strategies include ultrasound-guided nerve blocks delivered in the Emergency Department by trained Emergency physicians for early analgesia, fast-track echocardiogram and cardiac risk assessment workflows co-developed with Cardiology to rationalise pre-operative investigations, weekend pre-operative assessment to reduce surgical delays, seamless acute-to-community hospital transition to facilitate early rehabilitation and nurse-led post-fracture outpatient clinics for secondary fracture prevention.

Results 

From May 2024 to December 2025, PROMISE managed 420 inpatients (256 hip fractures, 134 femur and other lower limb fractures, 28 upper limb fractures, 2 spinal compression fractures) and 141 patients in the outpatient nurse-led fragility fracture clinic.

Emergency Department nerve blocks (n=83) achieved effective early analgesia (post-block pain score 2.2 vs 8.1) with minimal complications, and were associated with shorter length of stay (−1.3 days; 8.8 vs 10.1) and reduced opioid use (−33.1%; 3.59 vs 5.37 MME/day) compared to patients who received no block. 53.9% of hip fracture patients underwent surgery within 48 hours. The integrated acute to community hospital transition for hip fracture cases achieved an average stay of 8.65 days in acute hospital, comparing favourably with reported Singapore benchmarks of 9-14 days, and 24.13 days in the community hospital. The programme achieved a low readmission U-turn rate of 5.9%. Osteoporosis screening completion within 6 months was high, including BMD scan in 71.6% of patients.

Conclusion 

Upstream ED nerve blocks illustrate how targeted early intervention creates cascading patient and system benefits including reduced pain, opioid burden and inpatient stay. The integrated acute-to-community hospital pathway enables rehabilitation continuity beyond the acute episode. Structured cross-departmental workflows, from ED analgesia to nurse-led secondary prevention, are central to PROMISE's replicability as a multidisciplinary model for fragility fracture care in ageing populations.