Hip Fractures

Patient information — Dr Christopher Spelman, Orthopaedic Surgeon

Overview

A hip fracture is a break in the upper part of the thigh bone (femur), near where it meets the pelvis. Most hip fractures occur in older people following a fall, often on a background of osteoporosis (thinning of the bones). They are a significant injury that almost always requires surgery, both to relieve pain and to allow the person to get moving quickly, which reduces the serious complications associated with prolonged bed rest.

Types of hip fracture

The type of fracture determines the operation required:

●      Intracapsular (femoral neck) fractures – breaks at the neck of the femur, close to the ball of the hip joint. Because the blood supply to the ball can be disrupted, a displaced fracture is often treated with a partial (hemiarthroplasty) or total hip replacement, while an undisplaced fracture may be fixed with screws.

●      Extracapsular (intertrochanteric and subtrochanteric) fractures – breaks below the neck, where the blood supply is better; these are usually fixed with a plate and screws or an intramedullary nail.

Treatment

Surgery aims to allow early mobilisation, ideally getting the patient standing and walking with assistance the day after the operation. The choice between fixing the fracture and replacing the hip depends on the fracture type and displacement and the patient’s pre-injury function. Care is best delivered by a combined orthopaedic and geriatric medical team (orthogeriatric care), with attention to pain relief, medical optimisation, bone health and prevention of further falls.

Outcomes and what the evidence shows

A hip fracture is a marker of frailty as well as an injury, and it carries a significant mortality risk – pooled data report one-year mortality of around 22% (higher in the very elderly and those with other medical conditions). This reflects the patient’s overall health as much as the fracture itself.

The timing of surgery matters. A large population study found that waiting more than 24 hours from presentation to surgery was associated with a higher risk of death and complications within 30 days. A large international randomised trial (HIP ATTACK) found that ultra-accelerated surgery within six hours did not significantly reduce mortality compared with standard care, though it was associated with faster mobilisation and shorter hospital stay. The overall message is to avoid unnecessary delay while ensuring the patient is safely prepared for surgery.

Complications

Hip fracture surgery carries meaningful risks, partly because of the injury and partly because patients are often elderly and medically frail. Important complications include:

●      Medical complications and mortality – chest infection, heart complications, delirium (confusion) and, in around one in five patients, death within a year, largely reflecting underlying health.

●      Avascular necrosis and non-union (after femoral neck fixation) – loss of blood supply to the ball of the hip occurs in roughly 9–18% and failure of the bone to heal in up to around 20–30% of displaced fractures treated by fixation, which is why replacement is often preferred for displaced neck fractures.

●      Dislocation of a hip replacement – after hemiarthroplasty or total replacement for fracture, the new joint can dislocate (reported between about 1% and 15%, influenced by the surgical approach).

●      Infection – wound or deep infection around the implant, which may require further surgery.

●      Blood clots – deep vein thrombosis and pulmonary embolism; preventive measures are routinely used.

●      Loss of fixation or leg-length difference – screws or nails can occasionally cut out or the bone can shorten.

●      Pressure sores and loss of independence – prolonged immobility can lead to pressure areas, and many patients need increased support or a change in living arrangements after the injury.

Bone health and preventing the next fracture

Because most hip fractures are related to osteoporosis, assessment and treatment of bone health after the fracture is essential to reduce the risk of future fractures, alongside measures to prevent further falls. This is a core part of modern hip-fracture care.