Hip Fracture

"Hip fracture" means a break in the upper end of the femur (femur) or in the socket it sits in. The exact pattern matters enormously, because each one heals through a different operation. In many older patients the right operation is a hip replacement, not a repair of the broken bone. The hip is a ball-and-socket joint. The ball is the femoral head at the top of the femur. The socket is the acetabulum in the pelvis, and the femoral neck connects the ball to the shaft. Just below the neck sit the greater and lesser trochanters, the bony bumps where the major hip muscles attach.

Hip fractures happen to two groups of people. The first, and by far the larger, is the older adult with a low-energy fall. Bone weakened by osteoporosis can break with surprisingly little force; a fall from standing height is enough. These patients arrive with severe groin pain and cannot put weight on the leg. The leg often looks shortened and rotated outward, the classic look of a displaced femoral neck fracture. The second group is the younger patient with a high-energy injury: car crashes, falls from height, the rare sports injury. Here the break can involve the upper shaft of the femur, the socket, or the pelvic ring, and it is often one part of a larger trauma picture.

The four anatomic patterns we see most:

What makes hip fracture in the elderly a medical problem as much as a surgical one is time. Mortality at one year after a hip fracture in an older adult is around 20-30%. The danger is not the fracture itself. It is the chain of immobility, blood clots, pneumonia, loss of strength, and other medical conditions getting worse during a hospital stay. The single biggest predictor of survival is getting the patient up and walking quickly. That means getting to the OR within 24-48 hours when medically possible. Time to surgery is one of the things that affects how well a patient does.

Each of these has its own page covering how it happens, how we diagnose it, and how we treat it:

• Hip dislocationBall out of socket, emergent reduction, often with associated fracture

The classic story: an older adult who fell, has severe groin pain, can't bear weight, and has a leg that looks shortened and rotated outward. Sometimes the patient was found on the floor and can't recall the fall. In any older adult who goes down and can't stand back up, the working assumption is a hip fracture until X-rays say otherwise.

The less obvious version is the nondisplaced hip fracture, where the broken pieces have not shifted. The patient walked into the ER. The groin pain is worse with movement but bearable at rest, and the X-rays look normal. These exist and are missed regularly. Any older adult with lasting post-fall hip pain and a normal X-ray gets an MRI before going home. A missed nondisplaced neck fracture that is walked on can shift and lose its blood supply.

Some signs are not typical and raise the urgency. Severe pain spreading into the lower belly and pelvis suggests the pelvic ring or socket is involved. Low blood pressure with a fast heart rate is an alarm, because pelvic ring fractures can bleed massively. An open fracture (bone through skin) is rare but goes straight to the OR. Numbness or weakness spreading in the leg also raises urgency, since the sciatic nerve can be injured in high-energy patterns.

Evaluation begins at the bedside: how the injury happened, how the patient functioned before, the position of the leg, and a check of nerves and blood flow. Then we go straight to imaging. An X-ray of the pelvis and a side view of the hip make the diagnosis in nearly all cases. MRI is the gold standard when X-rays are negative but suspicion is high. An MRI of the pelvis finds the hidden fracture before the patient walks on it and shifts it. CT is used to plan surgery in socket and pelvic ring fractures, where the 3D shape matters and X-rays don't show it.

The medical work-up runs at the same time. Older adults with a hip fracture follow a set pathway. We get heart clearance when needed. We review blood thinners; most patients on the newer ones can safely have surgery. We support nutrition, bring in geriatric medicine when available, and set a clear plan to get out of bed the day after surgery. The surgical choice, fix or replace and which implant, comes after the medical plan, not before it.

When We Treat It Without Surgery

Treating a true hip fracture without surgery is rare in adults. We reserve it for patients whose medical condition makes surgery more dangerous than the fracture itself. The other candidates are the small group of nondisplaced, wedged-together patterns that are genuinely stable, when the patient accepts the risk of late shifting. Non-operative care means strict bed-to-chair activity, pain control, and repeat X-rays over time. The trade-offs are real. Avoiding the OR avoids surgical risk, but it accepts the medical risks of immobility, and the leg may end up shorter even if the bone heals. For nearly every patient who reaches our clinic with a hip fracture, surgery is the right answer; the question is which operation.

Surgery is offered for nearly every hip fracture in an adult who can tolerate an operation. The alternative, months of bed rest while the bone heals, carries higher risk than the operation itself in most patients. The choice of operation is the interesting part:

Matching the Operation to the Fracture

• Femoral neck fracture, displaced, in an older adult, usually a hip replacement. Lower-demand patients get a partial replacement (hemiarthroplasty). Higher-functioning patients get a total hip. Fixing a displaced neck in older bone fails too often, with lost blood supply and a repeat operation.
• Femoral neck fracture, nondisplaced or in a younger patient, fixed with parallel screws or a sliding hip screw. This keeps your own joint when the blood supply has a fighting chance.
• Intertrochanteric fracture, a nail down the femur, almost always. The blood supply isn't the issue; the geometry is, and the nail handles it.
• Subtrochanteric fracture, a long nail, with care to restore length, alignment, and rotation against the muscle pull on the upper fragment.
• Acetabular fracture, open surgery with plates and screws when the joint surface has shifted more than a couple of millimeters. Badly fragmented or weak-bone patterns sometimes go straight to a total hip replacement.
• Pelvic ring fracture, coordinated with a Level-1 trauma center for high-energy unstable patterns; stable patterns can be managed.

If non-operative care is not enough, these procedures are offered here for this condition:

• Anterior total hip replacementHip

Providers Who Treat Hip Fracture

Michael S. Vrana, M.D.

David B. Templin, M.D.

Trent Twitero, M.D.

External patient-education references and related OSI pages for additional background:

• AAOS OrthoInfo, patient education library
• OSI glossary, orthopedic terminology in plain language