Hip Fracture

A hip fracture is a break in the upper portion of the thighbone that most commonly affects older adults and requires prompt medical attention. Each year, more than 300,000 people in the United States sustain a hip fracture, with most occurring in adults 65 or older following household or community falls.

Table of contents

• What is a hip fracture?
• Understanding hip anatomy
• Types of hip fractures
• What causes hip fractures?
• Who is at risk?
• Signs and symptoms
• How hip fractures are diagnosed
• Treatment options
• Recovery and rehabilitation
• Preventing future fractures

What is a hip fracture?

A hip fracture is the medical name for breaking the upper part of your thigh bone, called the femur, near your hip joint. The femur is the longest and strongest bone in your body, so it usually takes a serious fall, car accident, or other trauma to break it^[4].

Hip fractures are serious injuries that can be life-changing, especially for older adults. They are medical emergencies that need immediate treatment in hospital^[14]. Almost everyone who breaks a hip needs surgery to repair the fracture, and many people need a hip replacement. It usually takes several weeks or months to recover after surgery^[4].

Hip fractures are associated with increased mortality. Between 12% and 17% of patients with a hip fracture die within the first year, and the long-term risk of death is doubled^[15]. Of those who survive, only about half walk independently again, and 20% must move to a long-term care facility^[15].

• Hip joint
• Femur (thighbone)
• Pelvis

Understanding hip anatomy

The hip is a ball-and-socket joint. The ball is the head of the femur, which is the upper part of the thighbone. The socket is called the acetabulum, which is part of the pelvis bone. It has a rounded shape that fits around the femoral head^[1].

The upper part of the femur has several key areas:

• Femoral head: The rounded cap at the top end of your femur that forms the ball of the hip joint
• Femoral neck: The bridge between the femur’s rounded head and the long shaft that runs down through your thigh
• Greater and lesser trochanters: Bumps of bone that stick out just around the femoral neck, where muscles and tendons attach

Types of hip fractures

Healthcare providers classify broken hips based on where the femur breaks. A hip fracture can cause injury to one of four areas of the upper femur^[1]:

Femoral head fractures: These occur at the ball of the femur that sits in the socket. Femoral head fractures are extremely rare and are usually the result of a high-energy event^[1].

Femoral neck fractures (also called subcapital or intracapsular fractures): These occur in the area of the femur below the ball. The femoral neck is the most common place for hips to break^[2][4]. This type of fracture is common among older adults and can be related to osteoporosis, which is a disease that weakens bones. These fractures may cause complications because the break usually cuts off the blood supply to the head of the thighbone^[6].

Intertrochanteric fractures: These happen in the area below the neck of the femur and above the long part, or shaft, of the femur. This region is marked by two bony landmarks: the greater trochanter and the lesser trochanter^[1][2]. This type of fracture does not usually interrupt the blood supply to your bone and may be easier to repair^[6].

Subtrochanteric fractures: These occur in the upper part of the shaft of the femur below the greater and lesser trochanters^[1].

Intertrochanteric and femoral neck fractures are the most common types of hip fracture, occurring in relatively equal numbers^[1][6].

What causes hip fractures?

Most hip fractures result from low-energy falls in elderly people who have weakened or osteoporotic bone. In these people, even a simple twisting or tripping injury may lead to a fracture^[1]. Most hip fractures sustained by older people result from falls at home or in the community^[1].

In some cases, the bone may be so weak that the fracture occurs spontaneously while someone is walking or standing. When this happens, it is often said that “the break occurs before the fall.” Spontaneous fractures usually occur in the femoral neck^[1].

When a hip fracture occurs in a younger patient, it is typically the result of a high-energy event, such as a fall from a height, motor vehicle or motorcycle collision, or serious injuries^[1][7]. These patients are likely to have incurred multiple injuries and should be assessed and managed appropriately^[3].

Around 5% of hip fractures have no history of trauma. In these cases, an alternative cause should be suspected. A pathological fracture is defined as a fracture caused by a disease process and not related to trauma. The two most frequent causes related to hip fractures are cancer and bisphosphonate use^[3].

Who is at risk?

Anyone can experience sudden trauma and break a hip, but some people are more likely to, including^[4]:

• Adults older than 65
• People with health conditions that weaken their bones, like osteoporosis or osteopenia
• Women (who experience 80% of all hip fractures)^[4][12]
• Athletes who play contact sports

The average age of patients presenting with a hip fracture is 80 years old, and almost all patients are older than 65 years^[3][4]. Women older than 85 years are 10 times more likely to sustain a hip fracture than those 60 to 69 years of age^[15]. Hip fractures occur in women about three times more often than they do in men. Women lose bone density faster than men do, in part because the drop in estrogen levels that occurs with menopause accelerates bone loss^[5].

Risk factors for falls in the elderly population include a previous history of falls, gait abnormalities, the use of walking aids, vertigo, Parkinson’s disease, and antiepileptic medications^[3]. Additional risk factors include a family history of hip fracture, low socioeconomic status, and a previous hip fracture^[15].

Certain medications can also increase your risk, including levothyroxine (which decreases bone density), loop diuretics (which impair calcium absorption in kidneys), proton pump inhibitors (which reduce calcium absorption), and selective serotonin reuptake inhibitors or sedatives (which increase risk of falls caused by sedation)^[15].

Signs and symptoms

Most hip fractures can be diagnosed, or at least suspected, from history alone. Classically a fall leads to a painful hip with an associated inability to walk^[3]. The most common hip fracture symptoms include^[4][5]:

• Severe pain in the hip or groin area
• Inability to get up from a fall or to walk
• Inability to put weight on the leg on the side of the injured hip
• Not being able to move your hip or leg (limited mobility)
• Swelling and bruising in and around the hip area
• A bump you can feel or see
• Shorter leg on the side of the injured hip
• Outward turning of the leg on the side of the injured hip
• Your hip looking noticeably different (deformity)

During the physical examination, displaced fractures present with external rotation and abduction, and the leg will appear shortened^[15].

How hip fractures are diagnosed

A healthcare provider will diagnose a broken hip with a physical exam and imaging tests. Providers in the emergency room might diagnose the fracture in the emergency room if you experience a severe fall or other trauma^[4].

A healthcare professional can often diagnose a hip fracture based on symptoms and the unusual position of the hip and leg. An X-ray usually will confirm the fracture and show where the fracture is^[2]. Plain radiography with cross-table lateral view of the hip and anteroposterior view of the pelvis usually confirms the diagnosis^[15].

If your X-ray doesn’t show a fracture but you still have hip pain, your healthcare professional might order additional imaging tests. An MRI (magnetic resonance imaging) or bone scan can look for a hairline fracture^[2]. If an occult hip fracture is suspected and plain radiography is normal, magnetic resonance imaging should be ordered^[15].

Treatment options

Hip fractures can be very painful. Treating the fracture and getting the patient out of bed as soon as possible will help prevent medical complications such as bed sores, blood clots, and pneumonia. In very old patients, prolonged bed rest can also lead to disorientation, which makes rehabilitation and recovery much more difficult. For these reasons, prompt surgical treatment is recommended^[1].

Treatment for a hip fracture usually involves a combination of prompt surgical repair, rehabilitation, and medicine to manage pain and to prevent blood clots and infection^[2].

Most hip fractures are treated surgically unless the patient has significant comorbidities or reduced life expectancy^[3]. Hip fracture surgery should be performed 24 to 48 hours after a fracture unless a delay is needed to stabilize other health conditions^[12].

The type of surgery generally depends on where and how severe the fracture is and whether the broken bones aren’t properly aligned. Your age and underlying health conditions also play a role. The consulting orthopedic surgeon will choose the surgical procedure^[2][3]. Options include^[2]:

Internal repair using screws: Metal screws are inserted into the bone to hold it together while the fracture heals. Sometimes screws are attached to a metal plate that runs down the thigh bone.

Total hip replacement: The upper femur and the socket in the pelvic bone are replaced with artificial parts called prostheses.

Partial hip replacement (hemiarthroplasty): In some cases, only part of the hip joint is replaced.

Patients should receive prophylactic antibiotics, particularly against Staphylococcus aureus, before surgery. In addition, patients should receive thromboembolic prophylaxis, preferably with low-molecular-weight heparin, to prevent blood clots^[3][12].

Recovery and rehabilitation

A broken hip usually takes several weeks or months to heal, but it can take longer. You’ll usually spend around 1 to 4 weeks in hospital^[14]. Recovery after hip surgery is a long process. You may stay in the hospital for a few days after surgery. You will need rehabilitation with a physical therapist^[8].

Soon after surgery you will start having regular physiotherapy to help you start standing and moving again. When you leave hospital, you’ll be given exercises to continue doing at home^[14]. Most patients can expect to be out of bed on the first day after surgery and participating in physical therapy^[16].

Sometimes rehabilitation can take place at home, but many patients need to stay in a rehabilitation hospital for several weeks. The goal is to get you moving so that you can get back to normal activity^[8]. It’s important to do the exercises recommended by your physiotherapist regularly. This will help you recover and improve your strength and movement^[14].

You may never get back the same strength and movement as you had before your break, and you may need to use a walking stick or frame^[14]. Some people need help from carers or other health professionals when they move back home^[14].

With regard to functional independence, 50% of patients recover prefracture capability of activities of daily living, and 25% recover full capability of their instrumental activities of daily living^[15].

Preventing future fractures

Unless contraindicated, bisphosphonate therapy should be used to reduce the risk of another hip fracture^[3]. Following a hip fracture, patients should usually be treated with a bisphosphonate, regardless of their bone mineral density, unless contraindicated^[12].

You should make an appointment to see your family doctor within the first few weeks after discharge to talk about any changes in your condition since your hip fracture and surgery. You may want to ask your doctor if you should start taking medicine for osteoporosis^[17].

Following a hip fracture, most patients should have a formal fall-prevention assessment^[12]. Some patients may benefit from a fall-prevention assessment to reduce the risk of future falls^[3].

Staying physically active is important. You need to start exercises right after surgery to help your bones heal as they should. Some exercises help prevent blood clots. Others make your muscles stronger to help you get out of bed and get moving^[17].

Here’s what you can do to make another fracture less likely^[8]:

• Stay physically active
• Take medicine to treat osteoporosis, if needed
• Have your doctor arrange for a home safety check to make sure there are not items in your home that make you more likely to fall and break your hip again