Key Facts

Hip fracture is one of the most common reasons for emergency hospital admission in older adults and is associated with significant morbidity and mortality. Rapid surgery and comprehensive geriatric care are essential.

Epidemiology

• ~66,000 hip fractures/year in the UK
• Mean age: 83 years; 75% are women
• 30-day mortality: ~8%; 1-year mortality: ~30%
• Only 50% regain pre-fracture level of independence
• Annual cost: ~£2 billion

Aetiology

• Low-energy fall (standing height) in the context of osteoporosis (most common scenario)
• Risk factors: age, female sex, osteoporosis, falls risk factors, previous fracture, low BMI, smoking, alcohol, dementia
• High-energy trauma in younger patients (road traffic collision)

Pathophysiology

• Intracapsular (subcapital/transcervical — within joint capsule): disrupts blood supply to femoral head (retinacular vessels) → risk of avascular necrosis (AVN) and non-union
  • Garden classification: I-II (undisplaced); III-IV (displaced)
• Extracapsular (intertrochanteric/subtrochanteric — outside capsule): blood supply intact; lower AVN risk; heals well with fixation
• Subtrochanteric: higher mechanical forces; may be associated with bisphosphonate use (atypical fracture)

Typical Presentation

• Older adult after a fall (usually low-energy)
• Pain in hip/groin (may be referred to knee)
• Unable to weight-bear
• Shortened and externally rotated leg (displaced fracture)
• Pain on axial loading and log-roll

Occult Hip Fracture

• Pain on weight-bearing but X-ray appears normal
• May be ambulant
• Requires MRI (gold standard) or CT if MRI not available

Red Flags

• Pathological fracture (minimal/no trauma, known malignancy)
• Bilateral fractures or fracture in young patient (metabolic bone disease, malignancy)
• Neurovascular compromise (rare)
• Signs of long lie: pressure injury, rhabdomyolysis, hypothermia, dehydration

Bedside

• Hip examination: shortened, externally rotated limb, pain on log-roll
• Observations: HR, BP, temperature
• ECG (pre-operative)
• Cognitive screen (4AT for delirium; AMT for baseline cognition)
• Lying/standing BP if possible
• Fluid and nutritional assessment

Bloods

• FBC, U&Es, LFTs, bone profile, clotting
• Group and save/crossmatch
• CRP (baseline)
• CK if long lie (rhabdomyolysis)
• Vitamin D

Imaging

• AP pelvis + lateral hip X-ray: first-line imaging
• MRI hip: gold standard for occult fracture (X-ray normal but clinical suspicion)
• CT hip: alternative if MRI not available or contraindicated
• CXR: pre-operative assessment

Special Tests

• NHFD (National Hip Fracture Database): all patients entered
• Pre-operative anaesthetic assessment
• Echocardiography if significant murmur or cardiac history

Non-pharmacological

• Fast-track pathway: A&E → hip fracture pathway → orthopaedic ward
• Pain management: femoral nerve block (best practice) + regular analgesia (paracetamol 1g QDS, avoid/minimise opioids)
• Surgery within 36 hours (NICE NG124; BPT standard)
• Early mobilisation: physiotherapy from day 1 post-op; aim weight-bearing as tolerated
• Orthogeriatric review within 72 hours: CGA approach
• Delirium prevention: multicomponent intervention
• Thromboprophylaxis: LMWH (enoxaparin 40mg SC OD) for 28 days post-op (unless contraindicated)

Pharmacological

• Analgesia: paracetamol 1g QDS + nerve block; opioids PRN (reduced dose in elderly; monitor for delirium)
  • Fascia iliaca block (FIB): effective regional anaesthesia
• Bone protection: start before discharge
  • Alendronate 70mg weekly + vitamin D 800-1,000 IU daily + calcium (if dietary intake low)
  • Or denosumab/zoledronate if oral bisphosphonate not appropriate
• Falls prevention: as per CGA

Surgical/Interventional

• Intracapsular undisplaced (Garden I-II): cannulated screws (internal fixation) — preserves native hip
• Intracapsular displaced (Garden III-IV):
  • Hemiarthroplasty (cemented): standard for most elderly patients
  • Total hip replacement: for patients who were independently mobile outdoors, cognitively intact, and medically fit (NICE NG124)
• Extracapsular intertrochanteric: dynamic hip screw (DHS)
• Extracapsular subtrochanteric/reverse oblique: intramedullary nail (IM nail)

Referral Criteria

• All hip fractures: orthopaedic + orthogeriatric input
• Post-discharge: Fracture Liaison Service for bone protection
• Falls prevention service
• Community rehabilitation (physiotherapy, OT)

• 30-day mortality: ~8%
• 1-year mortality: ~30% (higher in men, frail, dementia, medical comorbidities)
• Surgery <36 hours: reduces 30-day mortality and morbidity
• Orthogeriatric care: reduces mortality by ~30%
• Only 50% regain pre-fracture mobility level; 25% require long-term care
• Hip fracture doubles the risk of a second hip fracture
• Alendronate post-hip fracture: reduces further fractures by 40-50%

Hip Fracture Classification and Surgical Management

NICE NG124 Best Practice Tariff Standards