To update evidence-based guidelines for the treatment of proximal femoral fractures published in the Journal in 2003. Systematic search of MEDLINE, CINAHL and EMBASE for articles published from October 2001 to June 2008, and the Cochrane Database of Systematic Reviews (most recent issue searched – Issue 2, 2008). Randomised controlled trials and meta-analyses of all aspects of acute-care hospital treatment and rehabilitation for proximal femoral fractures among participants aged 50 years or older with proximal femoral fractures not associated with metastatic disease or multiple trauma. All studies were reviewed independently by two assessors, who recorded individual study results, and an assessment of study quality and treatment conclusions was made according to Cochrane Collaboration protocols. If necessary, a third review was performed to reach consensus. 128 new studies were identified and 81 met our inclusion criteria. Recommendations for time to surgery, thromboprophylaxis, anaesthesia, analgesia, prophylactic antibiotics, surgical fixation of fractures, nutritional status, mobilisation and rehabilitation have been updated. Also, recommendations regarding surgical wound closure, management of postoperative delirium, osteoporosis treatment and hip protectors have been added. The guidelines include the current National Health and Medical Research Council grades of recommendations for clinical guidelines. Significant changes in recommendations have been made, particularly in relation to surgery, rehabilitation and tertiary prevention. Hip fracture should be treated according to the most up-to-date evidence to achieve the best possible outcomes and optimal use of limited resources.