Hip Fracture in Older Adults

What is a hip fracture?

A hip fracture is a break in the upper part of the thigh bone, close to the hip joint. Depending on where the break is, there are several types, such as femoral neck, intertrochanteric and subtrochanteric fractures; femoral neck and intertrochanteric fractures are the most common ^[2].

In older people most hip fractures are caused by simple falls from standing height in people whose bones have become weak ^[2]. Hip fractures are more common in older people and in those with osteoporosis ^[1].

What are the symptoms?

After a fall, the following signs suggest a hip fracture ^[1]⁠^[2]:

• Pain in the hip, groin or upper thigh
• Being unable to stand up or put weight on the leg
• Difficulty moving the hip and leg
• The leg looking shorter than the other or turned outwards
• Swelling and bruising around the hip

Causes and risk factors

The main cause is a fall, and older age and osteoporosis clearly raise the risk ^[1]⁠^[2]. With some fractures where the bone has not moved, pain may be mild at first and the person may still be able to walk for a while, so groin pain that does not settle after a fall should be taken seriously ^[2].

Things that raise the risk of falling include reduced balance and muscle strength, eyesight and hearing problems, medicines that can affect balance, poorly fitting footwear and trip hazards at home ^[6].

How is it diagnosed?

A hip fracture is usually confirmed with an X-ray, which also helps decide on the treatment ^[1]⁠^[2]. A CT scan can give extra detail for planning surgery ^[2].

If the symptoms point to a fracture but the X-ray looks normal, an MRI scan is recommended; if MRI cannot be done within 24 hours, a CT scan is considered ^[3].

Treatment: why surgery, and how soon?

Surgery is the standard treatment for a hip fracture in older people ^[1]. Staying in bed for a long time can lead to serious problems such as blood clots, pneumonia, pressure sores and confusion; surgery aims to reduce these risks by getting the patient moving early ^[2]. Patients managed without surgery have been found to have a higher risk of death, so non-surgical treatment is considered only in selected situations ^[5].

Guidelines recommend surgery on the day of, or the day after, hospital admission. Correctable problems such as anaemia, blood thinners, fluid and salt imbalance or uncontrolled diabetes should be dealt with straight away so that surgery is not delayed ^[3]. In a large systematic review, surgery within 48 hours was linked with better mobility, fewer complications, shorter hospital stays and lower death rates, with further benefits reported for surgery within 24 hours ^[4].

The type of operation depends on the fracture pattern and the person's condition ^[1]⁠^[3]:

• Displaced femoral neck fractures: partial (hemiarthroplasty) or total hip replacement
• Undisplaced femoral neck fractures: fixation with screws or a plate and screws
• Intertrochanteric fractures: a sliding hip screw or an intramedullary nail
• Subtrochanteric fractures: an intramedullary nail

Care before and during surgery

Good pain control matters; if medicines are not enough, trained staff can give nerve blocks, but these should not delay surgery ^[3]. Guidelines recommend a multidisciplinary hip fracture programme in which orthopaedic surgeons and older-person specialists work together, and an operation that allows the patient to put full weight on the leg straight away ^[3].

Recovery and rehabilitation

A physiotherapy assessment and getting out of bed start the day after surgery unless there is a medical reason not to, and continue every day ^[3]. The hospital stay is usually between one and four weeks, and exercises to continue at home are given on discharge ^[1].

Early movement helps prevent complications of being bed-bound and helps the person keep their independence. Some patients continue rehabilitation in a care or rehabilitation facility, while others receive physiotherapy at home ^[2].

Recovery takes weeks to months, and some people may not regain their previous strength fully ^[1]. People who have had a hip fracture should have their bone health and fall risk assessed and be referred to services that help prevent further fractures ^[1]⁠^[3].

To prevent new falls, it is advised to remove trip hazards at home, fit grab rails in the bathroom, wear well-fitting shoes with good grip, have regular eye tests, ask whether any medicines affect balance, and do strength and balance exercises at least twice a week ^[6].

When to seek urgent care

If an older person cannot get up after a fall because of pain in the hip, groin or thigh, cannot put weight on the leg, or the leg looks short and turned outwards, call for emergency help straight away ^[1]⁠^[2]. Even if pain is mild, difficulty walking that continues after a fall needs assessment, because undisplaced fractures can be missed at first ^[2]⁠^[3].