Hip fractures

Diagnostic approach

• Neurovascular exam
• Assess for associated injuries and acute complications (e.g., compartment syndrome).
• X-ray hip and pelvis
• MRI or CT hip if occult fracture is suspected
• CBC
• BMP
• Type and screen
• ECG if there is unexplained syncope
• Additional diagnostics in trauma as needed (e.g., FAST, CT head)
• Preoperative assessment

Red flag features

• Intracapsular fracture (e.g., femoral head and neck)
• Open fracture
• Neurovascular injury
• Compartment syndrome
• Fracture-dislocation

Management checklist

• ATLS algorithm for unstable patients or those with polytrauma
• Consult orthopedic surgery urgently.
• Peripheral nerve block and opioid-sparing acute pain management
• Treat acute comorbidities (e.g., anemia, AKI).
• Periprocedural management of oral anticoagulants as needed
• VTE prophylaxis if surgery is delayed

Hip fractures are classified as intracapsular (femoral head, femoral neck) or extracapsular (intertrochanteric, trochanteric, or subtrochanteric). Hip fractures in older adults are typically low-impact injuries and are often associated with osteoporosis. Hip fractures in younger patients are usually caused by a high-energy impact (e.g., motor vehicle collision). Clinical features include groin pain and deformity of the hip. X-rays are usually diagnostic, but an MRI may be required to diagnose occult fractures or pathologic fractures. Comorbid conditions (e.g., anemia, acute kidney injury, delirium) are common with hip fractures. Management typically includes multidisciplinary consultation, early pain management, IV fluid hydration, venous thromboembolism prophylaxis, and early surgical fixation. Nonoperative management may be considered for patients with severe comorbidities, although it is associated with a high mortality rate. Older adults are at the highest risk of morbidity and mortality; early involvement of geriatric care specialists is recommended for these patients. Thromboembolism and osteonecrosis of the femoral head are common severe complications. Hip fractures can be associated with hip dislocation. Posterior hip dislocations account for 90% of hip dislocations and typically follow a dashboard injury. Early reduction is vital to avoid vascular compromise and sciatic nerve injury.

• Peak incidence: > 70 years [1]
• Sex: ♀ > ♂ [1]

Epidemiological data refers to the US, unless otherwise specified.

• Mechanism of injury [2]
  • Older adults
    • Fall onto greater trochanter/lateral hip
    • Forced lateral rotation (e.g., from tripping)
    • Chronic overburdening can lead to insufficiency fractures, which can then completely fracture spontaneously.
    • Pathological fracture due to metastases
  • Children and young adults: high-speed trauma (e.g., motor vehicle accidents or falls from great heights) or underlying disease (e.g., fibrous dysplasia)
• Risk factors [2]
  • Osteoporosis (especially postmenopausal women and older individuals)
  • Muscle weakness
  • Difficulty walking and impaired coordination
  • Estrogen deficiency
  • Low body weight
  • Poor nutrition (vitamin D deficiency or calcium deficiency)
  • Smoking, alcohol use

Approach

• All patients
  • Identify associated injuries and complications that affect immediate management (e.g., open fracture, fracture-dislocation, neurovascular injury).
  • Initiate multimodal pain management without delay (e.g., for confirmatory imaging).
  • Obtain hip and pelvis x-rays and other hip fracture diagnostics as needed.
  • Consult orthopedic surgery urgently.
  • Manage comorbidities that affect short-term outcomes (see "Acute management of comorbidities”).
  • Admit to hospital and begin multidisciplinary care.
  • Provide definitive hip fracture treatment based on fracture type (see “Subtypes and variants”).
• Unstable patients or those with polytrauma
  • Follow the ATLS algorithm.
  • Obtain bedside pelvis x-ray; defer other hip imaging until the patient is stabilized.
  • Perform emergency preoperative assessment.

Pain management [3][4][5]

• Preoperative peripheral nerve blocks [6]
  • Recommended for all patients without contraindications. [3][5][6]
  • Options: femoral block or fascia iliaca block by a trained specialist
• Systemic analgesics [5][7]
  • Use an opioid-sparing strategy (see “Acute pain management” for details).
  • Use NSAIDs with caution; comorbid acute kidney injury (AKI) is common.
  • Avoid anticholinergics, muscle relaxants, benzodiazepines, and gabapentinoids because they increase the risk of delirium.

A preoperative peripheral nerve block is recommended to improve pain control and reduce opioid consumption and the risk of perioperative delirium. [8]

Acute management of comorbidities

The following conditions are commonly associated with hip fractures and should be managed early as they can impact perioperative outcomes. See “Hip fracture in older adults” for age-related comorbidities.

• Anemia: Consider blood transfusion in symptomatic patients and/or those with hemoglobin < 8 g/dL. [3][9]:
• AKI
  • See “Management of AKI” for the approach to fluid replacement and hemodynamic monitoring.
  • Withhold ACEIs and ARBs before surgery (see “Perioperative medication management” for details).
• Venous thromboembolism (VTE) [10]
  • Preoperative VTE prophylaxis: indicated if surgery is delayed [7]
    • Administer LMWH (e.g., enoxaparin) up to 12 hours before surgery.
    • See dosage for “Medical inpatients” in “Approach to VTE prophylaxis.”
  • Postoperative VTE prophylaxis
    • Resume LMWH after surgery and continue for 5 weeks.
    • See dosage for “Surgical patients” in “Approach to VTE prophylaxis.”
• Acquired coagulopathy from antithrombotic agents [7]
  • Aspirin for management of ASCVD is typically continued.
  • Adjustment of dual antiplatelet therapy requires specialist consultation.
  • VKA use may require anticoagulant reversal (e.g., with vitamin K).
  • Surgery may need to be delayed for patients using DOACs.
  • Further details
    • See “Perioperative medication management.”
    • See “Periprocedural management of oral anticoagulants.”
    • See “Anticoagulant reversal.”

Disposition [11]

All individuals with hip fractures require hospital admission and multidisciplinary care.

• Consult orthopedics to determine if operative treatment is indicated.
• Consult medical specialists for the comanagement of medical comorbidities as required.
• Follow local protocols and admitting service agreements.
  • Patients > 70 years of age are likely best treated in comprehensive geriatrics units (see “Hip fracture in older adults”). [11]
  • Patients with hip fractures are often admitted to the hospitalist service or internal medicine.
• Consult other specialists as needed (e.g., physical therapist, occupational therapist, nutritionist, social worker).

Clinical evaluation [12]

Perform the following prior to imaging of suspected hip fractures because they can impact acute management. See “Subtypes and variants” for clinical features by fracture type.

• Neurovascular examination
  • Femoral artery injury
    • Assess femoral, popliteal, dorsalis pedis, and posterior tibial artery pulses.
    • Compare to the contralateral side if there is concern for arterial insufficiency.
  • Sciatic nerve injury (The sciatic nerve branches into the tibial nerve and common peroneal nerve.)
• Evaluation for severe complications (e.g., clinical features of acute compartment syndrome, skin laceration suggestive of open fracture)

Imaging [13]

• X-ray hip and pelvis (first line) [14][15]
  • Hip: AP view and lateral views
  • Pelvis: AP view
• MRI hip and pelvis: preferred if an occult fracture is suspected [13]
• Other: CT hip or bone scan

Suspect occult fracture despite normal x-rays in patients with characteristic clinical features of hip fracture. [13]

Laboratory studies

• CBC: Evaluate for acute blood loss. [16]
• BMP: Evaluate for AKI. [17]
• Type and screen. [18]
• Additional preoperative testing for intermediate-risk surgery as indicated

Additional studies [12]

Consider the following based on clinical presentation:

• Concurrent trauma: e.g., CT head (See “Diagnostics in trauma.”)
• Unexplained syncope: e.g., ECG, cardiac monitoring (See “Syncope workup.”)
• See also “Hip fracture in older adults.”

General principles

• Treatment can vary depending on the fracture type and patient characteristics:
  • See “Hip fractures in older adults.”
  • See “Femoral head fracture” and “Femoral neck fracture.”
  • See “Trochanteric fracture” and “Subtrochanteric fracture.”
  • See “Hip fracture-dislocation.”
• Operative intervention is recommended for most patients.

Operative treatment

• Timing: Ideally within 24–48 hours of admission [3][19]
• Surgical technique depends on fracture location and characteristics [19]
  • Cancellous screws: nondisplaced femoral neck fracture
  • Dynamic hip screw: nondisplaced base of femoral neck fracture
  • Arthroplasty or hemiarthroplasty: displaced femoral neck fracture
• Postoperative management:
  • Initiate weight-bearing activity immediately after surgery to decrease complications. [20]
  • Initiate an enhanced recovery after surgery program (ERAS) if available at the local institution. [7][21][22]
    • ERAS programs decrease the time to surgery, length of stay, and complication rate. [22]
    • Program components include peripheral nerve blocks, avoidance of prolonged fasting, early removal of drains, and early ambulation. [21]

Expedite medical evaluation and perioperative optimization to facilitate an operative repair within 48 hours of admission. [7]

Nonoperative treatment

Nonoperative management of hip fractures is uncommon as mortality rate is high. [19][23][24]

• Indications [1][7]
  • Extremely high perioperative risk (e.g., acute heart failure)
  • Limited benefit of surgery (e.g., the patient has a terminal illness, severe dementia, and/or is nonambulatory)
  • Some stable femoral neck fractures or simple avulsion fractures
• Treatment includes pain management, bed rest, and/or assisted mobilization. [25]

Weight-bearing status is determined by orthopedics. Clarify weight-bearing precautions and range of motion prior to consulting physical and occupational therapy.

Hip fractures in older adults

The following additional considerations apply to older adults with hip fractures (see also “Trauma in older adults”):

• Diagnostics
  • Diagnostics for osteoporosis (e.g., to establish a pretreatment baseline) [26]
  • Syncope workup and/or fall risk assessment [27]
  • Preoperative cardiac assessment (e.g., echocardiogram, ECG, cardiac biomarkers) based on individual risk [7]
• Management
  • Geriatric assessment
  • Bone health optimization and pharmacotherapy for osteoporosis (e.g., bisphosphonates) [28]
  • Delirium prevention or treatment of agitation in delirium
  • Measures to minimize physical deconditioning
  • Postoperative pulmonary rehabilitation (e.g., incentive spirometry) and aspiration precautions to prevent postoperative pneumonia [29]
• Disposition: admission to a comprehensive geriatric service or orthogeriatric service where available [11][19]
• Advance care planning: Consider early, especially in patients with a high frailty scale score.
• Prognosis [19][30][31]
  • 30-day mortality in patients with pulmonary complications (e.g., pneumonia, atelectasis, PE): up to 17% [29]
  • 1-year mortality: ∼ 35%
  • 50% of patients do not regain prefracture functionality.

Older adults have higher morbidity and mortality following a hip fracture because of coincident frailty and/or other complex medical problems. [19][30][31]

Hip fractures are classified as follows:

• Intracapsular
  • Femoral head
  • Femoral neck
• Extracapsular
  • Trochanteric
  • Intertrochanteric
  • Subtrochanteric

• Occurrence: uncommon but often associated with a posterior hip dislocation following a dashboard injury
• Clinical features
  • Groin pain
  • Local swelling and ecchymosis
• Diagnostics
  • Hip x-ray (AP with internal rotation and lateral view; should include the proximal thigh) : abnormal trabecular pattern, cortical defects, shortening and angulation of the femoral neck [32]
  • MRI if findings are unclear or if an occult fracture is suspected

A patient with an MVA dashboard injury may present with a femoral head fracture and hip dislocation.

Watch out for sciatic nerve injury in patients with femoral head fractures.

• Clinical features
  • Groin pain
  • Shortened and externally rotated leg
  • Minimal bruising
• Diagnostics
  • X-ray (AP and lateral view of the pelvis with internal rotation of the affected limb)
  • MRI or bone scan if clinical suspicion is high despite absent findings on x-ray

• Treatment
  • Conservative management
    • Indication: stable, nondisplaced fractures, especially abduction fractures , mostly in debilitated patients
    • Methods
      • Temporary bed rest; or use of crutches followed by mobilization with physical therapy
      • Venous thromboembolism prophylaxis [33]
  • Surgery (usually within 72 hours ; ) is indicated for unstable fractures , typically adduction fractures, and fragment dislocation
    • For children and young adults
      • Attempt preservation of the femoral head
      • Early open reduction internal fixation (ORIF) (within 6 hours)
    • For older adults: total hip replacement (THR) or hip hemiarthroplasty

• Etiology
  • Greater trochanteric fracture
    • Avulsion of the greater trochanter apophysis due to forceful contraction of the gluteus medius and minimus muscles (typically during physical activity)
    • Direct trauma to the greater trochanter (e.g., due to a fall onto the hip)
  • Lesser trochanteric fracture
    • Avulsion of the lesser trochanter apophysis due to forceful contraction of the iliopsoas muscle
    • Most commonly seen in physically active young adults, particularly those who participate in high-impact sports such as wrestling
• Clinical features
  • Greater trochanteric fracture: local pain exacerbated by abduction
  • Lesser trochanteric fracture: groin pain, which radiates to the knee or posterior thigh and worsens with hip flexion and rotation
• Diagnostics
  • X-ray showing avulsion of the greater or lesser trochanter
  • MRI if a pathological fracture is suspected or in individuals at risk of fracture extension (e.g., patients with osteoporosis)
• Treatment [12]
  • Typically self-limiting and conservative treatment suffices (e.g., no weight-bearing on the affected leg, ice, and physical therapy).
  • Surgical repair in fractures with displacement > 1 cm

• Clinical features
  • Hip pain and swelling
  • Shortened and externally rotated leg
  • Significant ecchymosis
  • Often associated with other injuries (e.g. other extremity fractures)
• Diagnostics
  • X-ray (AP view with maximal internal rotation and lateral view): proximal femur fracture between the greater and lesser trochanters
  • MRI if a pathological fracture is suspected
• Treatment
  • Nonsurgical approach for high risk patients
  • Surgery
    • Dynamic hip screw (DHS) for stable fractures
    • Intramedullary nail (Gamma nail) for stable or unstable fractures, fractures extending into the subtrochanteric region, or reverse oblique fractures
    • Arthroplasty may be considered for comminuted fractures, pathological fractures, or if other surgical modalities fail.

• Clinical features
  • Hip pain with swelling
  • Shortened and externally rotated leg
  • Significant ecchymosis
• Diagnostics [12]
  • X-ray : fracture between the lesser trochanter up to 5cm below that (distally)
  • MRI if a pathological fracture is suspected
• Treatment
  • Consider conservative approach (e.g., traction) in surgically unstable patients
  • Surgery is indicated in displaced/nondisplaced fractures in adults, especially if associated with multiple trauma, an open fracture, or pathological fractures
    • Long intramedullary nail with a lag screw
    • Locking plate may be considered for complicated fractures (e.g., pre-existing femoral deformity, associated femoral neck fracture)

General principles

• Hip fractures, especially fractures of the femoral head, can be associated with a hip dislocation.
• Hip fracture-dislocations require urgent orthopedic intervention; the decision to perform an urgent closed reduction or open reduction depends on fracture and dislocation characteristics.

Hip fracture-dislocations are associated with a high risk of osteonecrosis of the femoral head.

Overview of hip dislocation

Hip dislocation can occur in isolation or be associated with pelvic fractures (e.g., acetabular fractures) and/or hip fractures.

• Osteonecrosis of the femoral head
• Thromboembolism
• Infection
• Chronic pain and posttraumatic arthritis
• Nonunion
• Dislocation
• Nerve injury, e.g., sciatic nerve injury

Thrombolytic therapy reduces the risk of deep vein thrombosis in patients with hip fractures.

We list the most important complications. The selection is not exhaustive.

• Intracapsular fractures (e.g., femoral head and neck fractures) have an increased rate of nonunion which leads to AVN
• Intertrochanteric fractures have a good prognosis following surgery
• Subtrochanteric fractures have a high rate of implant failure

Hip fractures have a high rate of associated morbidity and mortality in older adults.

• Fall risk assessment, for example with the Tinetti-Test, which is used to evaluate a patient's gait and balance
• Implementation of fall prevention strategies
• Early preventative efforts such as fall training, physical therapy, removal of tripping hazards, and appropriate shoes
• Osteoporosis prophylaxis