Hip Fractures, Particularly in Older People: Urgency, Surgery and Recovery

A hip fracture is a break in the upper part of the thighbone (femur), close to the hip joint. Its location directly determines treatment: the two commonest groups are femoral neck fractures, in the neck joining the rounded head to the shaft, and trochanteric fractures, involving the prominent region just below it. Because the blood supply to the femoral head can be disrupted easily by a neck fracture, treatment differs between these two groups.

In young adults, hip fractures result from high-energy injuries such as road traffic accidents or falls from height. In older adults, reduced bone strength means that tripping over a rug, slipping in the bathroom or landing heavily from a seated position can be enough. A hip fracture after 65 is therefore often the first serious warning of osteoporosis.

A hip fracture is not only a bone problem; by confining the patient to bed, it affects the whole body. Prolonged immobility rapidly increases the risks of chest infection, leg-vein clots, urinary tract infection, pressure sores and muscle loss. The current approach therefore favours early surgery and early mobilisation as far as the patient's medical condition allows.

An older person with hip pain who cannot stand after a fall should not wait at home. If fracture is suspected, call for help without moving them; do not try to straighten or "put back" the leg.

If any of the following occur after a fall, suspect a hip fracture and attend hospital without delay:

• Severe groin and hip pain, inability to stand or take a step
• The painful leg looks shorter and the foot turns outwards
• A marked increase in pain when trying to move the leg
• Swelling and bruising around the hip
• Some patients can walk with support despite a fracture; being able to walk does not exclude a fracture

Diagnosis is made by emergency-department examination and pelvic and hip X-rays. If the fracture line is unclear and symptoms persist, CT or MRI is requested; undisplaced occult fractures may be missed on initial X-rays. Further investigation is therefore needed when someone sent home after a "normal X-ray" still cannot stand.

Alongside identifying the fracture, general health is assessed: blood tests, heart and lung assessment, and review of anticoagulants and diabetes or blood-pressure medicines. The timing of surgery is decided with the anaesthetic team according to these findings.

The method depends on fracture type, displacement, age and preoperative walking ability. There are two main approaches:

• Fracture fixation (osteosynthesis): fragments are secured with screws, plates or a nail inside the bone (intramedullary nail). It is commonly used for trochanteric and undisplaced femoral-neck fractures.
• Replacement: If a femoral-neck fracture compromises blood supply to the head, the joint surface is replaced rather than the fracture fixed. Depending on age and joint condition, a hemiarthroplasty or total hip replacement may be chosen.

After surgery, the aim is to help suitable patients stand with a walker on the first day. Pain control, breathing exercises, clot-prevention treatment and nutritional support are integral to this period. Hospital stay depends on general condition and support needs.

A walking frame or crutches are used in the first weeks; the duration depends on the fracture and operation. Regaining muscle strength takes months and progresses with regular exercise. In older patients, pre-fracture walking ability and accompanying illnesses are major determinants of recovery, so realistic goals are set individually.

Plan care at home after discharge: bathroom grab rails, a high chair, night lighting, removing slippery rugs and checking glasses and hearing aids help prevent further falls.

A person who has had a hip fracture has an increased risk of another fracture. Treatment therefore extends beyond the operation to address bone health and fall risk together. Bone density is measured, vitamin D and calcium status assessed, and osteoporosis treatment started if needed. See osteoporosis for details.

Effective fall-prevention measures are simple: balance and leg-strengthening exercises, removing trip hazards at home, suitable soles, reviewing medicines that cause dizziness with a doctor, and an eye examination. The wider approach is described on the orthopaedics for older adults page.

Osteoporotic fractures most often affect the hip, wrist and spine. Wrist fractures usually result from falling onto an outstretched hand; vertebral compression fractures may occur without a clear fall, sometimes when bending forwards, causing back pain and height loss. These fractures are covered on their own pages rather than here.

For general questions about casting versus surgery, healing time and non-union, see fracture treatment.

• Fracture Treatment — Cast or Surgery
• Hand Surgery and the Wrist
• Orthopaedics for Older Adults