Clinical review

Hip fracture
Martyn Parker, Antony Johansen

A proximal femoral or hip fracture is the most

common reason for admission to an acute orthopaedic
ward. About 86 000 such fractures occur each year in
the United Kingdom.w1 Global numbers were reported
as 1.3 million in 1990, and depending on secular
trends could be 7-21 million by 2050.1
In developed countries, the treatment of a hip fracture requires a wide range of disciplines, as the patient
will present to the ambulance service and the accident
and emergency unit, then pass through departments of
radiology, anaesthetics, orthopaedic surgery, medicine,
and rehabilitation. Medical and social services in the
community may be needed when the patient leaves
hospital.
Mortality associated with a hip fracture is about
5-10% after one month. One year after fracture about
a third of patients will have died, compared with an
expected annual mortality of about 10% in this age
group.2 3 w2 Thus, only a third of deaths are directly
attributable to the hip fracture itself, but patients and
relatives often think that the fracture has played a crucial part in the final illness.w2
More than 10% of survivors will be unable to
return to their previous residence. Most of the remainder will have some residual pain or disability.2 3

Search strategy
The musculoskeletal Cochrane review group has identified all randomised controlled trials on hip fractures
and most are summarised in Cochrane reviews (www.
Cochrane.org) and in Clinical Evidence articles.4
For aspects of hip fracture that cannot or have not
been subject to randomised controlled trials, we looked
at systematic review articles, the evidence based guidelines identified on this topic, and our personal libraries
of hip fracture references based on annual Medline
searches.57

Who fractures their hip?

The average age of patients with hip fracture is over 80,
and nearly 80% are women.2 The annual risk of hip
fracture is age related and reaches 4% in women over
85.w3
Most hip fractures result from a fall or stumble
only about 5% of cases have no history of injury.w4-w8
Injuries have a multifactorial origin, and they reflect
increased tendency to fall, loss of protective reflexes,
and reduced bone strength. Rates of hip fracture are
three times higher among people living in care homes
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Orthopaedic
Department,
Peterborough and
Stamford NHS
Foundation Trust,
Peterborough
PE3 6DA
Martyn Parker
orthopaedic research
fellow
Trauma Unit,
Cardiff and Vale
NHS Trust, Cardiff
CF14 4XW
Antony Johansen
consultant
orthogeriatrician and
honorary senior
lecturer in public
health
Correspondence to:
M Parker
Martyn.Parker@
pbh-tr.nhs.uk
BMJ 2006;333:2730

Classification of hip fractures. Fractures in the blue area are

intracapsular and those in the red and orange areas are
extracapsular

than in those of the same age living in the

community.w9

How is the fracture diagnosed and

classified?
Most hip fractures are readily diagnosed by a history of
a fall that led to a painful hip, inability to walk, or an
externally rotated limb, and plain radiographs of the
hip that confirm the diagnosis. In about 15% of cases,
the hip fracture is undisplaced, and radiographic
changes may be minimalw10; in a further 1% of cases the
fracture will not be visible on plain radiographs, and
other investigations will be needed. Magnetic resonance imaging is currently the investigation of choice
in this situation.w11 w12
Fractures can be classified radiographically into
intracapsular and extracapsular fractures (figure).
These may be further subdivided, depending on the
level of the fracture and the presence or absence of
displacement and comminution.w13-w15
Extra references w1-w49 and figures A-D appear on bmj.com

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Clinical review
Healing of intracapsular fractures is complicated by
the tenuous blood supply to the femoral headthe
retinacular vessels that pass up the femoral capsule
may be damaged, especially if the fracture is displaced.
This problem does not occur in extracapsular
fractures, but up to one litre of blood may be lost from
fractures at this site, so fluid replacement and blood
transfusion may be needed.

Treatment
The first step is to decide between a surgical or
conservative approach. Conservative treatment is now
rarely used because of poor outcome and prolonged
hospital stay. Conservative treatment of a displaced
intracapsular fracture leads to a painful functionless hip.
An undisplaced intracapsular fracture can be managed
with analgesia, a few days rest, then gentle mobilisation,
but the risk of subsequent displacement of the fracture is
high, and internal fixation is preferable.w16-w19
Extracapsular fractures can be managed with
traction, but this must be maintained for one to two
months. The frail older people who typically sustain
this injury are poorly equipped to cope with prolonged
immobilisation, which may result in loss of mobility
and independence.w19 w20 This may precipitate placement into a long term care homean outcome that
some perceive as worse than death.w21 Thus, most hip
fractures are treated by surgery.
Intracapsular fractures may be treated by fixing the
fracture and preserving the femoral head.w22 Preservation of the femoral head is appropriate for undisplaced
fractures and for displaced fractures in younger
patients (under 70). In frail or older people, displaced
intracapsular fractures may be treated by reduction
and fixation, but the incidence of non-union and avascular necrosis is 30-50% for this procedure, so the
femoral head is replaced in most patients.w23 w24 The
approach may be hemiarthroplasty, where just the
femoral head is replaced, or a total hip replacement,
where both sides of the joint are replaced. Cementing
the prosthesis in place results in less pain and better
mobility (figs A and B on bmj.com).w25
Various types of plates, screws, and nails are
available for fixing extracapsular fractures. At present,
the sliding hip screw is the most effective device.w26
Subtrochanteric fractures may also be fixed with a sliding hip screw, but these are increasingly being treated
with an intramedullary nail (figs C and D on bmj.com).
With current implants and surgical techniques, most
patients with hip fracture can be allowed to bear weight
on the injured limb, and hip movements should not be
restricted after surgery.

Perioperative care
Traction to the limb before surgery seems to be of no
benefit.w27 Spinal anaesthesia may be marginally better
than general anaesthesia.w28 w29 Box 1 lists aspects of
good practice that have been recommended for the
care of patients with hip fracture.57
Thromboembolic prophylaxis is a contentious issue.
People who sustain a hip fracture are at high risk of
thromboembolic complications but are also at risk of the
adverse effects of prophylactic drugs. The incidence of
thromboembolic complications has fallen as a result of
28

Box 1 Recommended components of care for

patients with hip fracture
From admission
Adequate, appropriate analgesia
Supplementary nerve blocks for pain reliefw30
Intravenous fluid replacement
Monitoring of fluid balance
Assessment of associated injuries and medical
conditions
Fast tracking through the casualty departmentw31
Use of defined clinical pathwaysw32
Pressure area assessment and carew33 w34
On the ward
Help with eating in the early postoperative periodw35
Nutritional supportw36
Thromboembolic prophylaxisw37
At surgery
Surgery within 48 hours of admissionw38-w40
Perioperative antibiotic prophylaxisw41
Perioperative supplementary oxygen5
After surgery
Mobilisation the day after surgery
Early rehabilitation and planning for discharge

the measures listed in box 2, and the adverse effects of

prophylaxis may outweigh the benefits. A systematic
review of heparins and a large randomised trial of low
dose aspirin noted a reduction in thromboembolic
complications with prophylaxis, but at the expense of
increased bleeding complications.w37 w42
Cyclical leg compression or foot pump devices can
reduce thromboembolic complications but are time
consuming and costly, and the effectiveness of
graduated compression stockings is unclear in these
patients.5 w37 None of these approaches to thromboembolic prophylaxis have been shown to reduce overall mortality after hip fracture.

Rehabilitation
Rehabilitation should start from the time of admission.
It is important for the patient and the family to outline
a proposed plan of treatment, along with provisional
dates for discharge. This helps them make necessary
arrangements, such as getting a bed downstairs.
Many patients who sustain a hip fracture fear that it
will result in death or disability, and it is important to
set reasonable expectations to restore their morale.
However, over optimistic reassurance about the success
of surgery may lead to disappointment if rehabilitation
is slow. Assessment must be comprehensive in order to

Box 2 Recommended measures to reduce the

risk of thromboembolic complications
Avoidance of dehydration
Early surgery
Avoidance of prolonged surgery
Avoidance of over transfusion
Early mobilisation

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Clinical review

Box 3 Approaches to rehabilitation

Traditional care on the orthopaedic ward, with variable
degrees of input from geriatricians
Initial treatment on the orthopaedic ward, with
subsequent transfer to a hospital based
geriatric-orthopaedic rehabilitation unitw43
Initial treatment on the orthopaedic ward, with
subsequent transfer to a skilled nursing facility in the
community for assessment and rehabilitationw44
Shared care on a ward that combines orthopaedic
surgical care with geriatric medical assessment and
rehabilitation until dischargew45
Care on an orthopaedic ward and early discharge home
with the support of a community rehabilitation teamw46

Box 4 Recommended plan for assessing and

preventing falls
Clinical assessment to determine the cause of any falls
Assessment of mental state
Medication review
Management of osteoporosis
Visual assessment and correction if possible
Assessment of continence
Assessment of gait and balance disorders
Mobility improvement and strength training for
inpatients
Provision of appropriate walking aids and footwear
Home assessment and modification of environmental
hazards
Access to strength and balance training after discharge

identify impediments to recovery, set realistic goals,

and coordinate appropriate rehabilitation.
Five broad categories of rehabilitation have been
described (box 3).8
The National Service Framework for Older People in
England recommends that each hospital should have at
least one orthogeriatric ward.9 The optimum model
of care is unknownrandomised trials have produced
conflicting results and no clear consensus.10

Can further fractures be prevented?

Multidisciplinary assessment of the reason for the fall
will reduce the risk of further fractures, and the components of such assessments are well described.11 12 Nearly
all patients with hip fracture meet the criteria for such an
assessment, which should be performed routinely as
part of inpatient rehabilitation care (box 4). A medical
cause for the fall should be sought; specifically, hypotension, postural hypotension, arrhythmia, vasovagal syncope, and carotid sinus hypersensitivity. Examination
should include lying and standing blood pressure and a
12 lead electrocardiogram.
About 3% of hip fractures are related to localised
bone weakness at the fracture site, secondary to tumour,
bone cysts, or Pagets disease. More than half of the
remaining patients have osteoporosis, and nearly all are
osteopenic. Over the age of 80, a woman with normal
bone mineral density for her age will have a T score of
around 2.5 (the diagnostic threshold for osteoporosis).
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sary in older age groups, and current UK guidelines only

recommend a dual energy x ray absorptiometry scan for
women under the age of 75.13
In men and younger women, routine preoperative
blood counts and basic biochemistry may need to be
accompanied by tests for causes of bone fragility. Malnutrition, low body weight, alcoholism, and deficiency of
calcium or vitamin D are common and important at all
ages. Treatment with steroids, renal failure, liver disease,
hyperthyroidism, hyperparathyroidism, and hypogonadism are other potential causes of bone fragility.
Pharmacological prevention of hip fracture is
controversial. An early study showed a benefit of calcium
and vitamin D supplementation in residents of care
homes. A similar regimen was therefore adopted among
people recovering from hip fracture, but this approach
has not been supported by later studies.14 15 w47, w48
Oral bisphosphonates are widely recommended
for secondary prevention of fragility fractures; UK
guidelines advocate them for all women over 75 and
for younger women with confirmed osteoporosis.16
The effectiveness of bisphosphonates in the very
elderly is not known, although no reason exists to
doubt their efficacy in this situation.17 Careful explanation and counselling are crucial to the effective use of
these drugs. Pre-existing gastrointestinal problems
raise concern over upper gastrointestinal intolerance,
and some frailer patients may have difficulty adhering
to the dosing regimen.
Strontium may be an effective and convenient
alternative in frailer patients.w49 Suggestions that strontium may predispose patients to thromboembolism
have not been confirmed, but prescription should be
delayed until the patient is mobile. Calcium and
vitamin D status should be optimised in patients taking
bisphosphonates or strontium.
Hormone replacement therapy and selective
oestrogen receptor antagonists should be avoided in
women recovering from hip fractures, as they greatly
increase the risk of thromboembolism.18 19 Early

Current and future directions for research

New designs and developments in surgical implants
Assessment of many aspects of perioperative care
Definition of the optimum method of rehabilitation
Evaluation of proposed methods for reducing the risk
of further fractures

Additional educational resources

Further reading
Parker MJ, Handoll HHG. Hip fracture. Clinical
evidence. BMJ Publishing, 20054
Scottish Intercollegiate Guidelines Network (SIGN).
Prevention and management of hip fractures in older people.
SIGN Publication No 56. (www.sign.ac.uk/guidelines/
fulltext/56/index.html)5
Cochrane Database of Systematic Reviews
(www.cochrane.org/reviews/clibaccess.htm)
Patient resources
National Osteoporosis Society, PO Box 10, Bath BA3
3YB ( www.nos.org.uk)

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Clinical review

Summary points
Hip fracture is the most common cause of acute orthopaedic
admission in older people
Treatment is generally surgical to replace or repair the broken bone
Mortality is 5-10% after one month and about 30% after one year
Some loss of function is to be expected in most patients
Multidisciplinary rehabilitation is needed for the patient to return
home
Ways to reduce the risk of further fracture should be considered

reports of hip protectors, which absorb or spread the

energy of a fall, were promising, but recent studies have
questioned their effectiveness.20 21

Conclusions
Hip fracture is the most common disabling injury and
cause of accidental death in older people. The
incidence and the public health and economic
consequences of this injury have risen as the
population has aged, and this is expected to continue
for the foreseeable future.
The prevention and management of hip fractures
involves a wide range of disciplines, and most people
who sustain the injury require surgery followed by a
period of rehabilitation. The complexity of care
needed for hip fractures makes the condition a real test
and a useful marker of the integration and effectiveness of modern health care.
Competing interests: None declared by MP. AJ received
reimbursement of conference expenses and fees for nonpromotional lecturing from the manufacturers of various oral
bisphosphonates.
1

Gullberg B, Johnell O, Kanis JA. World-wide projections for hip fracture.

Osteoporosis Int 1997;7:407-13.
2 Keene GS, Parker MJ, Pryor GA. Mortality and morbidity after hip
fracture. BMJ 1993;307:1248-50.
3 Roche JJW, Wenn RT, Sahota O, Moran CG. Effect of comorbidities and
postoperative complications on mortality after hip fracture in elderly
people: prospective observational cohort study. BMJ 2006;331:1374-6.
4 Parker MJ, Handoll HHG. Hip fracture. Clinical evidence. BMJ Publishing,
2005.
5 Scottish Intercollegiate Guidelines Network (SIGN). Prevention and management of hip fractures in older people. SIGN Publication No 56. Edinburgh:
SIGN. 2002. www.sign.ac.uk/guidelines/fulltext/56/index.html (last
accessed 6 Jun 2006).
6 New Zealand Guidelines Group. Acute management and immediate rehabilitation after hip fracture amongst people aged 65 years and over. 2003.
www.nzgg.org.nz/guidelines/
dsp_guideline_popup.cfm?guidelineCatID = 32&guidelineID = 7
(last
accessed 6 Jun 2006).
7 March LM, Chamberlain AC, Cameron ID, Cumming RG, Brnabic AJM,
Finnegan TP, et al. How best to fix the broken hip. Med J Aust
1999;170:489-94.
8 Cameron I, Crotty M, Curry C, Finnegan T, Gillespie L, Gillespie W, et al.
Geriatric rehabilitation following fractures in older people: a systematic
review. Health Technol Assess 2000;4(2):i-iv, 1-111.
9 Department of Health. National service framework for older people. London:
DoH, 2001 www.dh.gov.uk/PublicationsAndStatistics/Publications/
PublicationsPolicyAndGuidance/
PublicationsPolicyAndGuidanceArticle/fs/
en?CONTENT_ID = 4003066&chk = wg3bg0 (last accessed 8 Jun 2006).
10 Cameron ID, Handoll HHG, Finnegan TP, Madhok R, Langhorne P.
Co-ordinated multidisciplinary approaches for inpatient rehabilitation of
older patients with proximal femoral fractures. Cochrane Database Syst Rev
2001;(3):CD000106.
11 Gillespie LD, Gillespie WJ, Cumming R, Lamb SE, Rowe BH.
Interventions for preventing falls in the elderly. Cochrane Database Syst Rev
2003;(4):CD000340.

30

12 American Geriatrics Society, British Geriatrics Society, American

Academy of Orthopaedic Surgeons. National guidelines for the prevention of
falls in older persons. 2001. http://www.americangeriatrics.org/products/
positionpapers/Falls.pdf (last accessed 6 Jun 2006).
13 National Institute for Health and Clinical Assessment. Clinical practice
guideline for the assessment and prevention of falls in older people. London:
NICE, 2004. www.nice.org.uk/page.aspx?o = cg021fullguideline (last
accessed 6 Jun 2006).
14 Chapuy MC, Arlot ME, Delmas PD, Meunier PJ. Effect of calcium and
cholecalciferol treatment for 3 years on hip fractures in elderly women.
BMJ 1994;308:1081-2.
15 Avenell A, Gillespie WJ, Gillespie LD, OConnell DL. Vitamin D and vitamin D analogues for preventing fractures associated with involutional
and post-menopausal osteoporosis. Cochrane Database Syst Rev
2005;(3):CD000227.
16 National Institute for Health and Clinical Excellence. Bisphosphonates
(alendronate, etidronate, risedronate), selective oestrogen receptor modulators
(raloxifene) and parathyroid hormone (teriparatide) for the secondary prevention
of osteoporotic fragility fractures in postmenopausal women. London: NICE,
2005. www.nice.org.uk/pdf/TA087guidance.pdf (last accessed 6 Jun
2006).
17 Boonen S, McClung MR, Eastell R, Fuleihan GE-H, Barton IP, Delmas P.
Safety and efficacy of risedronate in reducing fracture risk in
osteoporotic women aged 80 and older: implications for use of
antiresorptive agents in the old and oldest old. J Am Geriatr Soc
2004;52:1836-9.
18 Writing Group for the Womens Health Initiative Investigators. Risks and
benefits of estrogen plus progestin in healthy postmenopausal women.
Principal results for the Womens health initiative randomized controlled
trial. JAMA 2002;288:321-33.
19 Cummings SR, Eckert S, Krueger KA, Grady D, Powles TJ, Cauley JA, et
al. The effect of raloxifene on risk of breast cancer in postmenopausal
women: results from the MORE randomized trial. Multiple outcomes of
raloxifene evaluation. JAMA 1999;281:2189-97.
20 Parker MJ, Gillespie LD, Gillespie WJ. Hip protectors for preventing hip
fractures in older people. Cochrane Database Syst Rev 2005;(3):CD001255.
21 Parker MJ, Gillespie L, Gillespie W. Hip protectors for preventing hip
fractures in the elderly: the evolution of a systematic review of
randomised controlled trials. BMJ 2006;332:571-3.

Corrections and clarifications

Minerva
Minerva apologises for nearly launching a health
scare. As many readers have pointed out, she
slipped up somehow in her assertion that long
term use of antiepileptic drugs is associated with an
increased risk of cancers, particularly in women
(BMJ 2006;332:1282, 27 May). The source article
(Neurology 2006;66:1318-24) quite clearly refers to
a risk of fractures, not cancer.
Selective serotonin reuptake inhibitors (SSRIs) and
suicide in adults: meta-analysis of drug company data
from placebo controlled, randomised controlled trials
submitted to the MHRAs safety review
The authors of this article published last year,
David Gunnell and colleagues, have alerted us to
an error in the abridged version of their paper
(BMJ 2005;330:385-8). In the table, the correct
estimate for the pooled odds ratio for self harm
from the bayesian random effects meta-analysis for
non-fatal self harm in relation to use of selective
serotonin reuptake inhibitors (excluding
paroxetine) is 1.57 (credible interval 0.99 to
2.55)not 1.51 (0.95 to 2.49). This matches the
values given in the abstract and in the results
section of the paper.
Randomised, controlled trial of alternating pressure
mattresses compared with alternating pressure overlays
for the prevention of pressure ulcers: PRESSURE
(pressure relieving support surfaces) trial
An editorial misunderstanding during the proof
stage led us to inflate some values in this paper by
Jane Nixon and colleagues (BMJ 2006;332:1413-5,
17 Jun). In table 4 of the full version on bmj.com
(table 2 of the abridged version), the haemoglobin
levels on admission or preoperatively should be
0.89 (0.82 to 0.97) [not 8.9, 8.2 to 9.7], and the
corresponding P value should be 0.01 [not 0.1].

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