Hip Fractures

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• Hip fractures are an important topic in trauma and orthopaedics
• Hip fractures lead to significant morbidity and mortality
• The 30-day mortality rate for hip fractures is 5-10%
• Half of patients become less independent after a hip fracture
• Increasing age and osteoporosis are major risk factors for hip fractures
• Females are affected more often than males by hip fractures
• Hip fractures are generally prioritised on the trauma list with the aim to perform surgery within 48 hours
• There is a specialty called orthogeriatrics that focuses on identifying and optimising the medical co-morbidities and complications of inpatients on the orthopaedic ward, particularly elderly patients with hip fractures
• Categories of Hip fractures

  • Intra-capsular fractures
  • Extra-capsular fractures
• Basic Anatomy of the top of the femur

  • Head
  • Neck
  • Greater trochanter (lateral)
  • Lesser trochanter (medial)
  • Intertrochanteric line
  • Shaft (body)
• Capsule of the hip joint


  • Strong fibrous structure that attaches to the rim of the acetabulum on the pelvis and the intertrochanteric line on the femur. It surrounds the neck and head of the femur
• Head of the femur blood supply

  • Retrograde blood supply from the medial and lateral circumflex femoral arteries. Avascular necrosis can occur if this blood supply is damaged in a displaced intra-capsular fracture
• Patients with a displaced intra-capsular fracture may need a hemiarthroplasty or total hip replacement to replace the femoral head
• Treatment for displaced intra-capsular fracture

  Hemiarthroplasty or total hip replacement
• Understanding and remembering the concept of the retrograde blood supply to the head of the femur is important in determining the choice of operation
• Identification of the type of hip fracture on an x-ray (intra-capsular or extra-capsular) and justifying the choice of operation is crucial in trauma meetings
• Intra-Capsular Fractures

  Fractures within the capsule of the hip joint, affecting the area proximal to the intertrochanteric line
• Garden classification for intra-capsular neck of femur fractures

  • Grade I – incomplete fracture and non-displaced
  • Grade II – complete fracture and non-displaced
  • Grade III – partial displacement (trabeculae are at an angle)
  • Grade IV – full displacement (trabeculae are parallel)
• Non-displaced intra-capsular fractures


  May have an intact blood supply to the femoral head, can be treated with internal fixation to hold the femoral head in place
• Displaced intra-capsular fractures

  Disrupt the blood supply to the head of the femur, requiring the head of the femur to be removed and replaced
• Hemiarthroplasty


  Replacing the head of the femur while leaving the acetabulum in place, generally offered to patients with limited mobility or significant co-morbidities
• Total hip replacement


  Replacing both the head of the femur and the socket, generally offered to patients who can walk independently and are fit for surgery
• Extra-Capsular Fractures

  Fractures that leave the blood supply to the head of the femur intact, not requiring replacement of the femoral head
• Treatment for Intertrochanteric fractures

  Dynamic hip screw (sliding hip screw)
• Treatment for Subtrochanteric fractures

  Intramedullary nail (metal pole inserted through the greater trochanter into the central cavity of the shaft of the femur)
• Conditions to assess in patients with a new hip fracture

  • Anaemia
  • Electrolyte imbalances
  • Arrhythmias
  • Heart failure
  • Myocardial infarction
  • Stroke
  • Urinary or chest infection
• Identifying other acute illnesses in patients with a new hip fracture is crucial for optimising the patient and minimizing surgery delays
• Identifying patients early for optimisation before surgery

  Ensure minimal delays in surgery
• TOM TIP: 'The term “mechanical fall” is often used to imply a simple explanation for why the patient fell, such as tripping over an object or being knocked over. It is worth exploring the fall in more detail. In many cases, there may be a correctable underlying medical cause for the fall, such as anaemia, arrhythmia or even underlying Parkinson’s disease. There may also be social contributors to the fall, such as dehydration, incorrect eyewear, poor footwear or obstacles in the home. If you identify an underlying reversible cause, you could make a big difference to that patient and impress your orthogeriatric colleagues.'
• Imaging X-rays

  1. Initial investigation of choice

  2. Two views are essential to avoid missing fractures: Anterior-to-posterior (AP) and lateral views

  3. Shenton’s line can be seen on an AP x-ray of the hip, formed by the medial border of the femoral neck continuing to the inferior border of the superior pubic ramus

  4. MRI or CT scanning may be used if x-ray is negative but fracture is still suspected
• Management on admission

  1. Appropriate analgesia

  2. Investigations for diagnosis (e.g., x-rays)

  3. Venous thromboembolism risk assessment and prophylaxis (e.g., low molecular weight heparin)

  4. Pre-operative assessment (including bloods and an ECG) to ensure fitness for surgery

  5. Orthogeriatrics input
• NICE guidelines (updated 2017) recommend surgery within 48 hours of admission, allowing immediate weight-bearing post-operation to start mobilisation and rehabilitation
• Post-operative analgesia is crucial to encourage early mobilisation
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