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Introduction

Hip fractures are cracks or breaks in the top of the thigh bone (femur) close to the hip joint.

Doctors sometimes refer to hip fractures as proximal femoral fractures.

The hip joints

The hip joints attach your thigh bones (femurs) to your pelvis.

Hip joints are ball-and-socket joints. The ball is the rounded top part of the femur. The socket is the cup-shaped part of the pelvic bone that the rounded end of the femur sits inside.

A hip fracture is a crack or break in the top end (neck) of the femur, nearest the hip joint. It can either occur in the part of the femur inside the socket of the hip joint (intracapsular), or outside the socket (extracapsular).

Symptoms of a hip fracture 

Symptoms of a hip fracture include:

  • not being able to lift, move or rotate (turn) your leg

  • being unable to stand or put weight on your leg, although in some cases this is possible

  • a shorter leg, or your leg turning outwards more on the injured side

If you think you've fractured your hip, you'll need to go to hospital as soon as possible. Dial 999 to request an ambulance.

Try not to move while you're waiting for the ambulance and make sure you keep warm.

What causes hip fractures? 

Hip fractures are often the result of a fall. Falls are very common in older people due to other health problems, such are reduced vision and mobility and balance problems.

A fall can cause a hip fracture if a person has osteoporosis (weak and fragile bones).

Some people find it hard to recover after a hip fracture, up to one in three people die within 12 months of fracturing their hip (although most deaths aren't caused by the fall itself but by pre-existing illnesses).

This is why the National Institute for Health and Care Excellence (NICE) recommends a co-ordinated programme of care for people who've fractured a hip (see below).

Treating a hip fracture

Surgery is usually the only treatment option for hip fractures.

NICE recommends that someone with a hip fracture should have surgery on the day they're admitted to hospital or the day after being admitted.

In about half of all cases, a partial or complete hip replacement is needed. The rest require surgery to fix the fracture with plates and screws or rods.

The type of surgery you have will depend on a number of factors, including:

  • type of fracture (where on the femur it is)

  • your age

  • your level of mobility before the fracture

  • the condition of the bone and joint – for example, whether you havearthritis

Recovering from hip surgery

The aim after surgery is to speed up recovery to help regain your mobility.

The day after surgery, you should have a physiotherapy assessment and be given a rehabilitation programme that includes realistic goals for you to achieve during your recovery. The aim is to help you regain your mobility and independence so that you can return home as soon as possible.

How long you'll need to stay in hospital will depend on your condition and mobility. After a having hip replacement, it may be possible for you to be discharged in three to five days.

Evidence suggests that prompt surgery and a tailored rehabilitation programme that starts as soon as possible after surgery can significantly improve a person's life, reduce the length of their hospital stay and help them recover their mobility faster.

Complications of hip surgery

Complications that can occur after a hip operation include:

  • infection – occurs in about 1-3% of cases

  • blood clots – can form in the deep veins of the leg (deep vein thrombosis); they can be prevented using compression stockings, exercise and medication

  • pressure ulcers – can develop on an area of skin that's under constant pressure due to being in a chair or bed for long periods

Your surgeon will be able to discuss these and any other risks with you.

Preventing hip fractures

It may be possible to prevent hip fractures by taking steps to prevent falls and by treating osteoporosis.

You can reduce your risk of falling by:

  • using walking aids, such as a walking stick

  • assessing your home for hazards – such as loose carpeting – and making it safer

  • using exercises to improve your balance

 

Major public health issue

Hip fractures are a major public health issue due to an ever increasing ageing population (80 is the average age of a person who has a hip fracture).

Around 70,000-75,000 hip fractures occur in the UK each year. The annual cost for all hip fractures in the UK, including medical and social care, is about £2 billion.

Hip fractures are more common in women due to the higher incidence of osteoporosis (weak and fragile bones) in women.

Symptoms of a hip fracture 

If you have a fractured hip, your hip will be painful and you won't be able to lift, move or rotate your leg.

You'll usually be unable to stand or put weight on your leg, although occasionally this is possible.

Other signs of a hip fracture can include:

  • bruising and swelling around the hip area

  • a shorter leg on the injured side

  • your leg turning outwards more on the injured side

If you think you've fractured your hip, you'll need to get to hospital for treatment as soon as possible. Dial 999 for an ambulance and try to keep warm while you wait.

If you have fallen

You may feel shaken or shocked after a fall, but try not to panic. Try to get someone’s attention by:

  • calling out for help

  • banging on the wall or the floor

  • using your aid call button (if you have one)

When someone arrives, ask them to dial 999 for an ambulance. If you're on your own, try to crawl to a telephone to call an ambulance.

If you've had a fall and were able to get up, and you have persistent pain in your hip, don't ignore it. See your GP as soon as possible.

If you've fallen, you may also have other injuries, such as a knock to the head. If you don't get help immediately, you may also experience:

  • hypothermia – when your body temperature drops below 35C (95F) as a result of being in a cold environment

  • dehydration – when your body loses more fluid than you take in

Causes of a hip fracture 

In older people, most hip fractures are due to falls, often in thehome.

Hip fractures that occur in younger people are usually the result of serious accidents, such as a fall from height or a car crash.

About three out of 10 people who are 65 years of age or over will have at least one fall a year. Half of all people aged 80 or over will have at least one fall a year.

Falls are common in older people because they're more likely to have other health problems that increase their risk of falling, such as:

  • muscle weakness

  • balance problems

  • low blood pressure (hypotension), which can cause dizziness and fainting

  • reduced mobility

  • dementia

  • poor vision

Osteoporosis

A fall can lead to a hip fracture if your bones are weak due to a condition called osteoporosis.

From about 35 years of age, you gradually lose bone density (how solid the bone is). This is a normal part of the ageing process, but for some people it can lead to osteoporosis.

Healthy bones are very dense and the spaces inside the bones are small. But in osteoporosis the spaces become much larger making the bones weaker, less flexible and more likely to break.

Diagnosing a hip fracture 

As hip fractures often occur as a result of a fall, diagnosis usually takes place at a hospital.

Hospital assessment

After arriving at hospital with a suspected hip fracture, your overall condition will be assessed. The doctor carrying out the assessment may:

  • ask how you were injured and whether you've had a fall

  • ask you whether this is the first time you've fallen (if you've had a fall)

  • ask about any other medical conditions you have, such as a heart problem

  • ask whether you're taking any medication

  • assess how much pain you're in

  • assess your mental state – for example, if you also hit your head you may be confused or unconscious

  • take your temperature 

  • make sure you're not dehydrated (where the normal water content of your body is reduced)

Depending on the outcome of your assessment, you may be given:

  • painkilling medication

  • a local anaesthetic injection near your hip

  • intravenous fluid (fluid through a needle into a vein in your arm)

The healthcare professionals treating you will make sure you're warm and comfortable. After a while, you may be moved from the emergency department to a ward, such as an orthopaedic ward.

Imaging tests

Imaging tests will be used to confirm whether your hip has been fractured. There are a number of tests that you may have, which are briefly described below.

X-ray

X-rays are a type of radiation used to create an image of the inside of your body.

As X-rays are very effective at detecting problems with bones, such as fractures, an X-ray is likely to be the first imaging test you have.

MRI scan

A magnetic resonance imaging (MRI) scan may be used if the diagnosis is uncertain. MRI scans use strong magnetic fields and radio waves to produce a detailed image of the inside of the body. They're very effective at confirming even subtle hip fractures.

CT scan

A computerised tomography (CT) scan may be used if you're not able to have an MRI scan, or if there's not one available quickly.

Treating a hip fracture 

Hip fractures are usually treated in hospital with surgery.

Most people will need surgery to fix the fracture or replace all or part of their hip, ideally on the day they're admitted to hospital or the day after.

There are a number of different operations which are described below. The type of surgery you have will depend on:

  • the type of fracture you have (where in the femur the fracture is)

  • your age

  • how physically mobile you were before the hip fracture

  • your mental ability to take part in the post-surgery rehabilitation programme

  • the condition of the bone and joint – for example, if you have arthritis (pain and inflammation of a joint)

Internal fixation

Internal fixation means fixing the fracture (break in the bone) using devices to hold the bone in place while it heals. These include:

  • pins

  • screws

  • rods

  • plates

Internal fixation tends to be used for fractures outside the socket of the hip joint (extracapsular), or fractures inside the socket of the hip joint (intracapsular) which are stable and haven't moved significantly (undisplaced).

If internal fixation is used for an intracapsular fracture, you'll need follow up appointments over several months with X-rays to check you're healing.

Hemiarthroplasty

Hemiarthroplasty means replacing the femoral head with a prosthesis (false part). The femoral head is the rounded top part of the femur (upper thigh bone) that sits in the hip socket.

The procedure is often the preferred option for fractures inside the socket of the hip joint (intracapsular), which occur in people who already have reduced mobility prior to the fracture. 

Complete hip replacement

A complete hip replacement is an operation to replace both the natural socket in the hip and the femoral head with prostheses (false parts).

This is a more major operation than hemiarthroplasty and isn't necessary in most patients but may be considered if you already have a condition that affects your joints, such as arthritis, or you're very active.

Pre-operative assessment

Providing you're in a stable condition, you'll ideally have surgery within 36 hours of arriving at hospital.

You'll have a pre-operative assessment to check your overall health and make sure you're ready for surgery.

During your assessment you'll be asked about any medications you're currently taking, and any necessary tests and investigations will be carried out.

You'll also have an anaesthetic assessment to decide what type of anaesthesia to use. Different types include:

  • spinal or epidural anaesthesia that's used to numb the nerves in the lower half of your body so you can't feel anything in this area

  • general anaesthetic which makes you unconscious and prevents your brain recognising any signals from your nerves, so you can't feel anything

Before surgery

Hip fractures can be very painful. During diagnosis and treatment, you should be given medication to relieve your pain. Initially, pain relief is usually given intravenously (through a needle into a vein in your arm), with a local anaesthetic injection near the hip.

Before your operation you'll be given antibiotics. This is to reduce the risk of your wound becoming infected after surgery.

Surgery carries the risk of a blood clot forming in a vein, so steps will be taken to reduce this risk. For example, you may have injections of medication, such as heparin, which is an anticoagulant that reduces the blood's ability to clot.

You'll continue to be monitored for venous thromboembolism (VTE, blood clot in a vein) during your stay in hospital. You may still need medication after you're discharged. 

Your operation

Depending on which type of surgery you're having (see above), the operation will last around two hours.

If you have any questions about your operation, ask your surgeon or another member of your care team.

After the operation, you'll begin your rehabilitation programme. This may take place in a different ward to the one where you had surgery.

Conservative treatment

Conservative treatment is the alternative to surgery. It involves a long period of bed rest and isn't often used because it can:

  • make people more unwell in the long-term

  • involve a longer stay in hospital

  • slow down recovery

However, conservative treatment may be necessary if surgery isn't possible – for example, if someone is too fragile to cope with surgery, or if the fracture occurred a few weeks earlier and has already started to heal.

Recovering from a hip fracture 

After fracturing a hip, you'll have a tailored rehabilitation programme to help you regain your mobility and independence as soon as possible.

Prompt surgery and an effective rehabilitation programme has been proven to significantly improve the life of a person who's had a hip fracture, reduce the length of their hospital stay and help them recover their mobility faster.

Multi-disciplinary team

Your rehabilitation will usually involve a multi-disciplinary team (a team of different healthcare professionals working together). The team may include:

  • physiotherapists – healthcare professionals trained in using physical methods, such as massage and manipulation, to promote healing and wellbeing.

  • occupational therapists – therapists who identify problem areas in everyday life, such as dressing yourself or getting to the shops, and will help you work out practical solutions

  • social workers  people involved in providing social services, who can advise on practical issues, such as benefits, housing and day care

  • an orthopaedic surgeon  a surgeon who specialises in surgery for conditions involving the skeleton, particularly the spine and surrounding joints

  • a geriatrician – a doctor who specialises in the healthcare of the elderly (if you're an older person)

  • a liaison nurse  a healthcare professional who may be involved in planning your discharge and keeping you and your family informed about the care you're receiving

Rehabilitation in hospital

In their guidance about the Quality Standard for Hip Fracture (PDF, 250kb), the National Institute for Health and Care Excellence (NICE)recommends that a physiotherapy assessment and mobilisation, such as weight-bearing exercises, should begin the day after hip fracture surgery.

While you're in hospital, your rehabilitation may take place in:

  • an orthopaedic ward  a ward for people with conditions that involve the skeleton

  • a rehabilitation ward  a ward for people undergoing rehabilitation programmes

  • a geriatric orthopaedic rehabilitation unit (GORU)  a rehabilitation unit specifically for older people with orthopaedic conditions

Being discharged

How long you need to stay in hospital will depend on your condition and how soon you regain your mobility. If you're otherwise healthy, after a hip replacement you may be able to leave hospital in three to five days.

Before you're discharged, an occupational therapist may assess your home to see whether you'll need any mobility aids fitted, such as hand rails. You may also be given a walking aid, such as a walking stick or crutch.

Your GP and carer (if you have one) may be told when you're being discharged so that plans can be made to support you. After you've been discharged you may need to:

  • return to hospital for a rehabilitation appointment

  • see your GP for a follow-up appointment

  • have visits or telephone calls at home from healthcare professionals involved in your care

This will be discussed with you before you're discharged.

Rehabilitation programme

Following a hip fracture, you'll have a rehabilitation programme that includes exercises to help improve your strength and mobility.

Your individualised programme will depend on your current level of fitness and mobility and may involve some of the following:

  • weight-bearing exercises – where your feet and legs support your weight, such as walking

  • non-weight-bearing exercises – where your feet and legs don't support your weight, such as swimming or cycling

  • treadmill exercises – such as walking at different speeds and inclines

  • intensive physical training – such as meeting with an exercise instructor three or more times a week to exercise

  • strength training and balance training – such as exercises where you use your body weight to build and strengthen muscles and joints, and exercises to improve your balance, stability and posture

It's extremely important that you follow your rehabilitation programme after a hip fracture to ensure you regain as much fitness and mobility as possible.

 

Care and support

The care guide has information about the practical help, support and advice that's available for carers and those being cared for.

Age UK

Age UK, a charity for older people, has more useful information and advice about healthy bones and keeping fit.

Complications of a hip fracture 

Some people may take a while to recover from a hip fracture while others might never be as mobile as they were. Complications can also arise from surgery. 

Slow recovery

Not everyone will recover completely after having a hip fracture. It depends on how healthy you were before the fracture.

Some people may not regain their previous level of mobility and will no longer be able to live at home.

About three in every 10 people who've had a hip fracture die within a year. Around a third of these deaths are directly related to the fracture.

Complications from surgery

All types of surgery carry risks. Complications that can arise after a hip operation include:

  • infection – the risk is reduced by using antibiotics at the time of surgery and careful sterile techniques; infection occurs in about 1-3% of cases and requires further treatment and often further surgery

  • blood clots – can form in the deep veins of the leg, known asdeep vein thrombosis (DVT), due to reduced movement, but can be prevented using special stockings, exercise and medication

  • pressure ulcers (bedsores) – can occur on areas of skin that are under constant pressure from being in a chair or bed for long periods

Your surgeon will discuss these and any other possible risks and complications with you before your surgery.

Preventing a hip fracture 

It may be possible to prevent hip fractures by taking steps to prevent falls and by treating osteoporosis (weak and fragile bones).

If you're diagnosed with osteoporosis, follow your treatment plan. Improving your bone health may help lower your fracture risk.

Preventing falls

People over 65 years of age have an increased risk of falling. To help reduce your risk of falling you can:

  • use a walking aid, such as a walking stick 

  • assess your home for hazards and make it safer

  • use exercises to improve your balance

Hip protectors

Hip protectors can be used to reduce the impact of a fall, and are particularly useful for preventing hip fractures in older people.

Hip protectors are devices that use padded material and plastic shields attached to specially designed underwear. The pads absorb the shock of a fall and the plastic shields divert the impact away from vulnerable areas of the hip.

In the past, one of the biggest issues with hip protectors was that many people found them uncomfortable and stopped wearing them. Modern hip protectors have tried to address this by having a more comfortable fit and additional features, such as ventilation to reduce sweating.

Guidelines produced by the National Institute for Health and Care Excellence (NICE) – falls: assessment and prevention of falls in older people – suggest that hip protectors may be useful for older people in care homes who are considered to be at high risk of a fall.

However, they're thought to be less effective for elderly people who remain active and live in their own home.

Frax tool

The FRAX tool has been developed to help predict a person's fracture risk. It's based on bone mineral density (BMD), plus other relevant risk factors such as age and sex.

The FRAX tool

The World Health Organization (WHO) has developed a 10 yearFracture Risk Assessment Tool to help predict a person's risk of fracture in an age range between 40-90 years.

The tool is based on bone mineral density (BMD) and other relevant risk factors such as age and sex.

The algorithms used give a 10-year probability of hip fracture and a 10-year probability of major fracture in the spine, hip, shoulder or forearm.

Fractured hip

Fractured hip