Hip Fracture: Symptoms, Causes & Emergency Treatment

What Is a Hip Fracture?

A hip fracture is a break in the upper portion of the femur (thigh bone) near the hip joint. It most commonly occurs in elderly people after a fall and is considered a serious medical emergency requiring immediate hospitalization and usually surgical treatment within 24-48 hours.

The hip joint is a ball-and-socket joint where the rounded head of the femur fits into a cup-shaped socket (acetabulum) in the pelvis. A hip fracture typically occurs in one of three locations: the femoral neck (the area just below the ball of the hip joint), the intertrochanteric region (the area between the femoral neck and the main shaft of the femur), or the subtrochanteric region (below the trochanters). Understanding the location of the fracture is crucial because it determines the type of surgical treatment required.

Hip fractures represent one of the most significant injuries affecting older adults worldwide. According to the World Health Organization, approximately 1.6 million hip fractures occur globally each year, and this number is expected to increase substantially as the population ages. The burden of hip fractures on healthcare systems is enormous, with costs in the billions of dollars annually in developed countries. Beyond the financial impact, hip fractures have profound effects on patients' quality of life, independence, and survival.

The mechanism of injury differs between younger and older patients. In elderly individuals, hip fractures typically result from low-energy trauma such as a fall from standing height. The bones of older people, particularly those with osteoporosis, are significantly weakened and can fracture with relatively minor force. In some cases, the bone may actually break first due to its weakened state, causing the patient to fall rather than the fall causing the fracture. In younger patients, hip fractures usually require high-energy trauma such as motor vehicle accidents, falls from significant heights, or sports injuries.

Types of Hip Fractures

Hip fractures are classified based on their anatomical location, which has important implications for treatment and prognosis. Each type of fracture has distinct characteristics and may require different surgical approaches for optimal outcomes.

Femoral neck fractures occur in the narrow section of bone that connects the femoral head (the ball of the hip joint) to the main shaft of the femur. These fractures are particularly problematic because they can disrupt the blood supply to the femoral head, potentially leading to a condition called avascular necrosis where the bone tissue dies due to lack of blood flow. Femoral neck fractures are further classified by the Garden classification system, which grades them from I to IV based on displacement, helping surgeons decide between internal fixation and hip replacement.

Intertrochanteric fractures occur between the greater and lesser trochanters, which are bony prominences where muscles attach to the femur. These fractures typically have a better blood supply than femoral neck fractures, which generally leads to better healing. However, they can be unstable and may involve multiple bone fragments, making surgical repair more challenging. Intertrochanteric fractures are the most common type of hip fracture in the elderly population.

Subtrochanteric fractures occur in the area just below the lesser trochanter, extending into the upper shaft of the femur. These fractures experience significant mechanical stress from the body's weight and muscle forces, making them prone to complications during healing. They often require more robust surgical fixation and may have longer recovery times.

What Are the Symptoms of a Hip Fracture?

The main symptoms of a hip fracture include severe pain in the hip or groin, inability to walk or put weight on the affected leg, a visibly shortened or outwardly rotated leg, and significant swelling or bruising around the hip. These symptoms typically appear immediately after a fall or injury.

Recognizing the signs and symptoms of a hip fracture is crucial for getting prompt medical attention. While some symptoms are obvious, others may be more subtle, particularly in elderly patients who may have difficulty communicating or who have cognitive impairment. Understanding what to look for can help ensure that appropriate emergency care is sought without delay.

The severity of symptoms can vary depending on the type of fracture and its degree of displacement. Complete fractures with significant displacement typically cause more obvious symptoms, while incomplete or impacted fractures may present with less dramatic findings. However, any suspected hip fracture should be treated as a medical emergency regardless of symptom severity.

Immediate Symptoms After Injury

The most common and characteristic symptoms of a hip fracture include:

• Severe pain in the hip or groin area: The pain is typically intense and worsens with any attempt to move the leg. Patients often describe it as deep, aching pain that may radiate to the thigh or knee.
• Inability to walk or bear weight: Most patients with a hip fracture cannot stand or put any weight on the affected leg. Even attempting to do so causes severe pain.
• Shortened and externally rotated leg: The affected leg often appears shorter than the other leg and may turn outward (external rotation). This classic presentation is caused by muscle spasm and the position of the broken bone fragments.
• Swelling and bruising: The area around the hip may become swollen and develop bruising, though this may take several hours to become apparent.
• Stiffness and limited movement: Any movement of the hip joint is extremely painful and often impossible without assistance.

Atypical Presentations

Some hip fractures may present with less obvious symptoms, which can delay diagnosis and treatment. This is particularly common in certain situations that healthcare providers and caregivers should be aware of.

Impacted or incomplete fractures occur when the broken bone ends are pushed together rather than separated. In these cases, patients may actually be able to walk, though with pain and a limp. This can lead to delayed diagnosis, which is dangerous because continued weight-bearing can cause the fracture to displace and become more severe.

Elderly patients with dementia may not be able to effectively communicate their pain or describe what happened. They may simply appear confused, agitated, or refuse to stand or walk. Caregivers should be suspicious of a hip fracture in any elderly person with dementia who has experienced a fall or has unexplained changes in mobility or behavior.

Stress fractures develop gradually from repetitive stress rather than sudden trauma. Patients may have had hip or groin pain for weeks before the fracture becomes complete. This is more common in athletes and people with osteoporosis.

What Causes Hip Fractures?

Hip fractures are primarily caused by falls in elderly people with weakened bones due to osteoporosis. In younger people, high-energy trauma such as car accidents or sports injuries is usually required. Risk factors include age over 65, female gender, osteoporosis, previous fractures, and certain medications.

Understanding the causes and risk factors for hip fractures is essential for both prevention and appropriate treatment. While falls are the most common direct cause, multiple underlying factors contribute to hip fracture risk. These factors can be divided into those that increase the likelihood of falling and those that weaken the bones, making them more susceptible to fracture.

The intersection of these risk factors explains why hip fractures are so common in elderly populations. An 80-year-old woman with osteoporosis who takes multiple medications and has poor balance faces a dramatically higher hip fracture risk than a healthy young adult. Identifying and addressing modifiable risk factors is a key component of prevention strategies.

Primary Causes

Falls from standing height account for approximately 90% of hip fractures in elderly individuals. Even a seemingly minor fall can cause a hip fracture when bones are weakened by osteoporosis. The direction of the fall matters as well—falling sideways directly onto the hip is most likely to cause a fracture. Many falls occur during routine activities such as walking, getting out of bed, or using the bathroom.

Osteoporosis is the underlying condition that makes bones vulnerable to fracture. In osteoporosis, the internal structure of bone becomes porous and weak, significantly reducing its ability to withstand force. Women are particularly affected due to the accelerated bone loss that occurs after menopause when estrogen levels decline. By age 80, the average woman has lost about 30% of her peak bone mass.

High-energy trauma such as motor vehicle accidents, falls from significant heights, or high-impact sports injuries can cause hip fractures in people of any age with normal bone density. These fractures tend to be more severe and may be associated with other injuries. In younger patients, hip fractures should prompt evaluation for underlying conditions that may have weakened the bone.

Risk Factors

Multiple factors contribute to hip fracture risk, and they often interact with each other to compound the overall risk:

• Age: Hip fracture risk increases dramatically with age, with most fractures occurring in people over 65. The risk doubles approximately every 5-7 years after age 50.
• Gender: Women are 2-3 times more likely to experience a hip fracture than men, due to higher rates of osteoporosis, longer life expectancy, and typically smaller bone structure.
• Previous fractures: Having had a previous fracture, particularly a hip fracture or vertebral compression fracture, significantly increases the risk of future hip fractures.
• Family history: A family history of hip fractures or osteoporosis increases risk, suggesting genetic factors in bone density and structure.
• Low body weight: Being underweight (BMI less than 20) is associated with lower bone density and less protective soft tissue around the hip.
• Medications: Certain medications increase fall risk or contribute to bone loss. These include sedatives, blood pressure medications, antidepressants, and long-term corticosteroid use.
• Medical conditions: Conditions that affect balance, vision, or cognitive function increase fall risk. Conditions affecting bone metabolism (such as hyperthyroidism, hyperparathyroidism, or vitamin D deficiency) contribute to bone weakness.
• Lifestyle factors: Smoking, excessive alcohol consumption, physical inactivity, and inadequate calcium and vitamin D intake all contribute to osteoporosis and fall risk.

How Is a Hip Fracture Diagnosed?

Hip fractures are diagnosed through physical examination and imaging studies. X-rays are the primary diagnostic tool and can identify most hip fractures. If X-rays appear normal but a fracture is still suspected based on symptoms, MRI or CT scans may be ordered to detect occult fractures.

Prompt and accurate diagnosis of hip fractures is essential for initiating appropriate treatment without delay. The diagnostic process begins with a thorough assessment of the patient's history and physical examination, followed by imaging studies to confirm the diagnosis and characterize the fracture. Healthcare providers must maintain a high index of suspicion, particularly in elderly patients after falls, even when initial findings are subtle.

The diagnostic approach must also consider the patient's overall health status, as this information is crucial for surgical planning and risk assessment. Elderly patients often have multiple medical conditions that affect their treatment and prognosis, making comprehensive evaluation essential.

Physical Examination

The physical examination provides important diagnostic information and helps guide the urgency of further evaluation. Key findings that suggest a hip fracture include:

Leg position: The classic presentation is a leg that is shortened and externally rotated. This occurs because the muscles around the hip pull the broken bone fragments into this position. However, not all hip fractures cause obvious leg shortening or rotation, particularly if the fracture is impacted or incomplete.

Pain with movement: Any attempt to move the leg, particularly rotation of the hip, causes severe pain. Gentle passive movement of the hip during examination helps assess the extent of injury. However, forceful manipulation should be avoided as it can displace the fracture or cause additional harm.

Swelling and bruising: The area around the hip may be swollen and tender to touch. Bruising may not be immediately apparent but typically develops within 12-24 hours of injury.

Neurovascular assessment: Healthcare providers check blood flow and nerve function in the leg to ensure the fracture hasn't damaged important structures. This includes checking pulses at the foot and ankle, assessing sensation, and evaluating toe movement.

Imaging Studies

Plain X-rays are the first-line imaging study for suspected hip fractures and can identify approximately 90-95% of hip fractures. Standard views include anteroposterior (front-to-back) and lateral (side) views of the hip. The X-ray reveals the location of the fracture, the degree of displacement, and helps classify the fracture type, all of which influence treatment decisions.

Magnetic Resonance Imaging (MRI) is used when X-rays are negative or inconclusive but clinical suspicion for fracture remains high. MRI is highly sensitive and can detect occult fractures (those not visible on X-ray) that may be present in up to 10% of patients with clinical signs of hip fracture. MRI can also identify bone marrow edema and soft tissue injuries.

Computed Tomography (CT) scans provide detailed three-dimensional images of the bone and are useful for surgical planning in complex fractures. CT is also used when MRI is contraindicated (such as in patients with certain implants) or unavailable. CT can detect occult fractures but is less sensitive than MRI for very early or subtle fractures.

Bone scan (nuclear medicine) is occasionally used but has largely been replaced by MRI due to the superior accuracy and immediate availability of MRI results. Bone scans may show increased uptake at the fracture site, but changes may not be apparent for 24-72 hours after injury.

How Are Hip Fractures Treated?

Hip fractures are almost always treated surgically, with the goal of performing surgery within 24-48 hours of injury. The type of surgery depends on the fracture location and patient factors, ranging from internal fixation with screws to partial or total hip replacement. Non-surgical treatment is reserved only for patients who cannot tolerate surgery.

The treatment of hip fractures has evolved significantly over the past several decades, with strong evidence supporting early surgical intervention for the vast majority of patients. Surgery aims to stabilize the fracture, relieve pain, and allow early mobilization, which is essential for preventing the serious complications associated with prolonged bed rest. The specific surgical approach is tailored to each patient based on the fracture type, bone quality, patient age, activity level, and overall health.

Multidisciplinary care involving orthopedic surgeons, anesthesiologists, geriatricians, physical therapists, and nurses is the standard of care for hip fracture patients. This team approach has been shown to improve outcomes, reduce complications, and shorten hospital stays. Care pathways that standardize management have been implemented in many hospitals worldwide.

Initial Emergency Management

Before definitive surgical treatment, several important steps are taken to stabilize the patient and prepare for surgery:

• Pain management: Adequate pain control is essential and typically involves a combination of medications. Nerve blocks (such as femoral nerve block) are increasingly used as they provide excellent pain relief with fewer side effects than systemic opioids.
• Immobilization: The leg is positioned comfortably, often with pillows or a foam boot, to prevent further displacement of the fracture.
• Medical optimization: Patients are assessed for other injuries and medical conditions that need stabilization before surgery. Dehydration, electrolyte imbalances, and anemia are corrected. Anticoagulation medications may need adjustment.
• Thromboprophylaxis: Measures to prevent blood clots are initiated, typically including compression devices on the legs and blood-thinning medications.

Surgical Treatment Options

The choice of surgical procedure depends primarily on the type and location of the fracture, as well as patient-specific factors:

Internal fixation involves using metal screws, plates, or rods to hold the broken bone pieces together while they heal. This approach is typically used for intertrochanteric fractures and for non-displaced or minimally displaced femoral neck fractures in younger patients. Common devices include sliding hip screws and intramedullary nails. Internal fixation preserves the patient's natural hip joint but requires the bone to heal, which may be problematic in elderly patients with poor bone quality.

Hemiarthroplasty (partial hip replacement) replaces the femoral head with a metal prosthesis while leaving the natural socket (acetabulum) intact. This is commonly used for displaced femoral neck fractures in older patients because the disrupted blood supply to the femoral head makes healing unreliable. Hemiarthroplasty allows immediate weight-bearing and eliminates the risk of the femoral head not healing.

Total hip arthroplasty (total hip replacement) replaces both the femoral head and the acetabular socket. This may be recommended for patients with pre-existing hip arthritis, for younger, more active patients with displaced femoral neck fractures, or when the acetabulum has also been damaged. Total hip replacement generally provides better long-term function but is a more extensive surgery.

Timing of Surgery

Evidence strongly supports early surgical treatment, ideally within 24-48 hours of injury. Delays in surgery are associated with increased mortality, higher complication rates, longer hospital stays, and worse functional outcomes. However, a brief delay may be appropriate to medically optimize patients with unstable conditions such as uncontrolled diabetes, severe anemia, or acute cardiac problems. The decision to delay surgery must carefully weigh the risks of waiting against the risks of operating on an unstable patient.

What Is the Recovery Process After Hip Fracture Surgery?

Recovery from hip fracture surgery typically takes 4-6 months, with full recovery potentially taking up to one year. Physical therapy begins within 24-48 hours of surgery and is essential for regaining mobility. Most patients can walk with assistance within a few days and regain independent mobility within 3-6 months with proper rehabilitation.

Recovery from a hip fracture is a gradual process that requires patience, commitment to rehabilitation, and comprehensive medical support. The goals of recovery are to restore mobility, strength, and independence while preventing complications. Success depends on many factors, including the patient's pre-fracture health and activity level, the type of fracture and surgery, the quality of rehabilitation, and adequate management of underlying conditions such as osteoporosis.

The recovery journey can be physically and emotionally challenging, particularly for elderly patients who may fear falling again or who struggle with the temporary loss of independence. Support from family, caregivers, and healthcare professionals is essential throughout the recovery process.

Hospital Recovery Phase

The initial recovery phase takes place in the hospital and typically lasts 3-7 days, though this varies based on the patient's condition and progress. Key components of hospital recovery include:

Early mobilization: Physical therapy typically begins within 24-48 hours after surgery. Initially, this may involve sitting at the edge of the bed, standing with assistance, and taking a few steps with a walker. Early mobilization is crucial for preventing complications such as blood clots, pneumonia, and muscle weakness.

Pain management: Adequate pain control is essential for participation in physical therapy. A multimodal approach using different types of pain medications helps minimize opioid use and its associated side effects.

Prevention of complications: Close monitoring for potential complications continues throughout the hospital stay. Blood-thinning medications or compression devices help prevent blood clots. Breathing exercises and early mobilization help prevent pneumonia. Skin care and position changes help prevent pressure ulcers.

Rehabilitation Phase

After discharge from the hospital, most patients continue recovery in a rehabilitation facility or at home with outpatient physical therapy. The rehabilitation phase typically lasts several weeks to months and focuses on progressively increasing strength, mobility, and independence.

Physical therapy is the cornerstone of recovery. Exercises focus on strengthening the hip, leg, and core muscles; improving balance and coordination; and relearning normal walking patterns. Therapy progresses from using a walker to a cane to walking independently, as the patient's strength and confidence improve.

Occupational therapy helps patients relearn activities of daily living such as bathing, dressing, and using the toilet safely. Occupational therapists also recommend adaptive equipment and home modifications to improve safety and independence.

Weight-bearing progression: The amount of weight a patient can put on the operated leg depends on the type of surgery and the stability of the repair. Patients with hip replacements can often bear full weight immediately, while those with internal fixation may have restrictions for several weeks until the bone begins to heal.

Long-Term Recovery Expectations

Full recovery from a hip fracture takes time, and expectations should be realistic. Key points about long-term recovery include:

• Timeline: Most patients achieve significant improvement within 4-6 months, though continued gains may occur for up to one year. Some patients never fully return to their pre-fracture level of function.
• Functional outcomes: Research shows that approximately 40-60% of patients regain their pre-fracture walking ability, though this varies widely based on individual factors. Patients with better pre-fracture function generally have better outcomes.
• Independence: Many patients require ongoing assistance with some activities, and some may need to transition to assisted living facilities. Planning for post-recovery living situations is an important part of the recovery process.
• Psychological recovery: Fear of falling is common after a hip fracture and can limit activity and recovery. Psychological support and gradual confidence-building through supervised activity are important components of recovery.

What Complications Can Occur After Hip Fracture?

Hip fractures can lead to serious complications including blood clots (DVT/pulmonary embolism), infections, pneumonia, pressure ulcers, and surgical complications such as implant failure or dislocation. The one-year mortality rate after hip fracture is approximately 20-30% in elderly patients, making prevention and prompt treatment of complications critical.

Hip fractures are associated with significant morbidity and mortality, particularly in elderly patients. Understanding potential complications helps patients, families, and caregivers recognize warning signs and seek prompt medical attention. Many complications can be prevented or minimized through appropriate preventive measures and early intervention.

The risk of complications is influenced by the patient's overall health status, the quality of medical care, and adherence to post-operative recommendations. Multidisciplinary care teams that proactively manage risk factors have been shown to significantly reduce complication rates.

Medical Complications

Venous thromboembolism (VTE) includes deep vein thrombosis (blood clots in leg veins) and pulmonary embolism (blood clots traveling to the lungs). Hip fracture patients are at very high risk for VTE due to immobility, surgical trauma, and the hypercoagulable state caused by injury. Prevention includes blood-thinning medications, compression stockings, and early mobilization. Warning signs include leg swelling, calf pain, shortness of breath, or chest pain.

Pneumonia is a common and serious complication, particularly in elderly patients who may have reduced lung function and difficulty clearing secretions while lying in bed. Prevention includes early mobilization, deep breathing exercises, and careful monitoring of swallowing function. Symptoms include cough, fever, shortness of breath, and confusion.

Pressure ulcers (bedsores) develop when prolonged pressure on the skin reduces blood flow, causing tissue damage. Common sites include the heels, sacrum, and back. Prevention includes frequent repositioning, special mattresses, and good nutrition. Once developed, pressure ulcers can be difficult to heal and may become infected.

Urinary tract infections are common, particularly in patients who require urinary catheters. Symptoms include burning with urination, frequent urination, fever, and confusion (especially in elderly patients).

Delirium (acute confusion) affects up to 50% of elderly hip fracture patients. It can be caused by pain, medications, infection, dehydration, or the stress of hospitalization. Delirium is associated with longer hospital stays, worse functional outcomes, and higher mortality.

Surgical Complications

Wound infection can occur after any surgery. Signs include increasing pain, redness, swelling, drainage from the incision, and fever. Deep infections involving the bone or prosthesis are more serious and may require additional surgery.

Implant failure or displacement can occur if the screws, plates, or prosthesis move out of position. This may require revision surgery. Risk factors include poor bone quality, inadequate surgical fixation, and excessive early activity.

Hip dislocation is a risk after hip replacement surgery, where the prosthetic ball can come out of the socket. This typically occurs during extreme hip movements and requires emergency treatment to relocate the joint. Patients are taught movement precautions to minimize this risk.

Avascular necrosis can occur after femoral neck fractures when the blood supply to the femoral head is disrupted. The bone tissue dies and may collapse, causing severe pain and disability. This complication may not become apparent until months after the injury and may require hip replacement.

How Can Hip Fractures Be Prevented?

Hip fractures can be prevented through a combination of strategies: treating osteoporosis with medications and calcium/vitamin D supplementation, regular exercise focusing on strength and balance, removing fall hazards from the home, reviewing medications that may cause dizziness, and using appropriate walking aids. Hip protectors may also reduce fracture risk in high-risk individuals.

Prevention of hip fractures is a crucial public health priority, given the significant burden of these injuries on patients, families, and healthcare systems. Effective prevention requires a multifaceted approach that addresses both the risk of falling and the underlying bone weakness that makes fractures likely. Many risk factors are modifiable, meaning that targeted interventions can substantially reduce hip fracture risk.

Prevention strategies should be tailored to individual risk profiles. A comprehensive risk assessment can identify those who would benefit most from specific interventions. Primary care providers, geriatricians, and other healthcare professionals play essential roles in implementing prevention programs.

Treating and Preventing Osteoporosis

Strengthening bones is a fundamental component of hip fracture prevention. Key strategies include:

Bone density screening: Dual-energy X-ray absorptiometry (DEXA) scans can identify osteoporosis before a fracture occurs. Screening is recommended for all women over 65 and younger postmenopausal women with risk factors.

Medications: Various medications can slow bone loss or increase bone formation. Bisphosphonates (such as alendronate and zoledronic acid) are first-line treatments that have been shown to reduce hip fracture risk by 40-50%. Other options include denosumab, raloxifene, and anabolic agents like teriparatide.

Calcium and vitamin D: Adequate intake of calcium (1000-1200 mg daily) and vitamin D (800-1000 IU daily) is essential for bone health. Many people, especially older adults, don't get enough of these nutrients from diet alone and may benefit from supplements.

Lifestyle factors: Not smoking, limiting alcohol intake, and maintaining a healthy weight all support bone health. Weight-bearing exercise also helps maintain bone density.

Fall Prevention

Since falls are the primary cause of hip fractures in elderly people, fall prevention is crucial. Effective strategies include:

Exercise programs: Regular physical activity that includes strength training, balance exercises, and flexibility work can reduce fall risk by 23% and fracture risk by 34-40%. Tai chi and other balance-focused exercises are particularly effective.

Home safety modifications: Removing fall hazards such as loose rugs, clutter, and poor lighting can prevent many falls. Installing grab bars in bathrooms, handrails on stairs, and ensuring adequate lighting throughout the home are important safety measures.

Medication review: Many medications can cause dizziness, drowsiness, or low blood pressure, increasing fall risk. Regular review of all medications by a healthcare provider can identify problematic drugs that might be discontinued or adjusted.

Vision and hearing care: Regular eye exams and updating glasses prescriptions help ensure good vision. Hearing aids for those with hearing loss improve awareness of surroundings and reduce fall risk.

Appropriate footwear: Wearing sturdy, well-fitting shoes with non-slip soles, and avoiding high heels or loose slippers, reduces fall risk.

Assistive devices: Using canes or walkers when needed, rather than struggling with balance, can prevent falls. Physical therapists can recommend and properly fit these devices.

Hip Protectors

Hip protectors are padded undergarments designed to absorb or deflect the impact of a fall away from the hip bone. While evidence for their effectiveness is mixed (largely due to compliance issues), they may provide protection for high-risk individuals who are willing to wear them consistently. Hip protectors are most appropriate for nursing home residents and others at very high fall risk.