Key Facts

Hip fractures are one of the most common and serious injuries in older adults. They represent a major public health burden, associated with significant mortality, morbidity, loss of independence, and healthcare costs. Optimal management requires a multidisciplinary orthogeriatric approach.

Epidemiology

Approximately 80,000 hip fractures per year in England alone. Mean age is ~80 years; 73% occur in women. Incidence doubles every decade after age 50. Hip fractures cost the NHS approximately £2 billion annually. The UK has one of the highest hip fracture rates in Europe.

Aetiology

• Osteoporosis: Present in >90% of hip fracture patients
• Falls: Low-energy fall from standing height is the typical mechanism
• Risk factors for falls: Polypharmacy, visual impairment, cognitive impairment, muscle weakness, environmental hazards
• Pathological: Metastases, Paget's disease, primary bone tumours (rare)

Pathophysiology

Hip fractures are classified anatomically:

1. Intracapsular (subcapital/transcervical): Within the joint capsule — risk of avascular necrosis due to disrupted retinacular blood supply from the medial circumflex femoral artery
2. Extracapsular: Intertrochanteric or subtrochanteric — blood supply usually preserved

Garden classification (intracapsular):

• I: Incomplete/impacted
• II: Complete, undisplaced
• III: Complete, partially displaced
• IV: Complete, fully displaced

Typical Presentation

• Elderly patient after a fall
• Hip pain (may radiate to knee — referred pain via obturator nerve)
• Inability to weight-bear
• Shortened, externally rotated leg (displaced fracture)

Undisplaced/Impacted Fractures

• May be ambulant with groin pain
• Normal leg length and rotation
• Pain on axial loading and log-rolling

Associated Conditions

• Delirium (present in ~35% of hip fracture patients)
• Pressure sores
• UTI, chest infection (common post-operative complications)
• Constipation (opioid use + immobility)

Red Flags

• Hip fracture with head injury — CT head if GCS drop or anticoagulated
• Multiple fragility fractures — investigate for myeloma, metastases
• Hip fracture in young patient — consider high-energy mechanism or pathological cause
• Chest pain/dyspnoea post-operatively — consider PE, MI, chest infection

Bedside

• Observations: NEWS2, pain assessment
• ECG: Pre-operative assessment, arrhythmia screening
• Cognitive assessment: AMT (Abbreviated Mental Test) or 4AT (delirium screening)
• Pressure area assessment: Waterlow score

Bloods

• FBC: Anaemia is common; transfuse if Hb <80 g/L (or <100 with cardiac disease)
• U&Es: Renal function, electrolytes
• Coagulation/INR: Important if on warfarin/DOACs
• Group and save: Pre-operative
• Bone profile, vitamin D: Baseline for bone protection
• TFTs: Screen for secondary causes of osteoporosis

Imaging

• AP pelvis + lateral hip X-ray: First-line — diagnoses >95% of hip fractures
• MRI hip: If X-ray normal but clinical suspicion high — gold standard for occult fractures (perform within 24 hours)
• CT hip: If MRI unavailable or contraindicated
• CXR: Pre-operative assessment

Special Tests

• DEXA scan: Formal osteoporosis assessment (arrange outpatient)
• FRAX/QFracture: Fracture risk assessment tools
• Falls assessment: Multifactorial — vision, medication review, postural BP, home hazards

Non-pharmacological

• Early surgery: Within 36 hours (NICE CG124); aim for next available trauma list
• Orthogeriatric co-management: Joint care from admission — reduces mortality
• Delirium prevention/management: Avoid precipitants, early mobilisation, orientation strategies
• Early mobilisation: Day 1 post-operatively with physiotherapy
• Pressure sore prevention: Pressure-relieving mattress, regular repositioning
• Nutrition: Protein supplementation, dietitian input

Pharmacological

• Analgesia: Paracetamol 1g QDS + fascia iliaca block (bupivacaine 0.25% 30-40mL) — avoid excessive opioids in elderly
• VTE prophylaxis: LMWH (enoxaparin 40mg SC OD) for minimum 28 days
• Bone protection: Start before discharge — alendronate 70mg weekly OR denosumab 60mg SC 6-monthly + calcium 1000mg + vitamin D3 800IU daily
• Warfarin reversal: Vitamin K 5mg IV + prothrombin complex concentrate if INR >1.5
• DOAC management: Follow local protocol for reversal/timing before surgery
• Blood transfusion: Transfuse if Hb <80 g/L (FOCUS trial — restrictive strategy is safe)

Surgical/Interventional

Intracapsular (displaced — Garden III/IV):

• Age >65: Hemiarthroplasty (cemented) or THR (if independently mobile, not cognitively impaired)
• Age <65: Internal fixation (cancellous screws) — preserve native hip

Intracapsular (undisplaced — Garden I/II):

• Internal fixation (cancellous screws or DHS)

Extracapsular (intertrochanteric):

• Dynamic hip screw (DHS): Standard treatment for stable patterns
• Intramedullary nail (e.g., gamma nail): For unstable intertrochanteric or subtrochanteric fractures

Referral Criteria

• All hip fractures — immediate orthopaedic referral
• Orthogeriatric review within 72 hours (BPT requirement)
• Falls service referral post-discharge
• Fracture liaison service for bone health assessment

• 30-day mortality: ~6-8% overall; higher if surgery delayed >36 hours
• 1-year mortality: ~30%; male sex, cognitive impairment, and ASA grade are strongest predictors
• Functional outcome: Only ~50% return to pre-fracture mobility; ~25% require residential care post-fracture
• Second hip fracture: Risk approximately 5-10% within 2 years
• Avascular necrosis: Occurs in ~10-30% of displaced intracapsular fractures treated with fixation
• Best Practice Tariff compliance: Reduces 30-day mortality by approximately 1.5 percentage points

Garden Classification (Intracapsular Fractures)

Best Practice Tariff Criteria

Key Trials