Hip fracture
A fracture of the proximal femur - a major injury most commonly affecting elderly patients with osteoporosis. Prompt surgical treatment within 36 hours and comprehensive geriatric care significantly reduce mortality and complications.
📊 Approximately 76,000 hip fractures occur annually in the UK. The 30-day mortality is approximately 7-8% and the 1-year mortality approximately 30%. Hip fracture is a major public health problem.
What is a hip fracture?
Hip fractures are classified by location into intracapsular fractures (within the hip joint capsule, involving the femoral neck) and extracapsular fractures (outside the capsule, involving the trochanteric region). This distinction is critical as it determines the surgical treatment. Intracapsular fractures disrupt the blood supply to the femoral head, risking avascular necrosis, and are therefore typically treated by replacement (hemiarthroplasty or total hip replacement) rather than fixation in elderly patients.
Extracapsular fractures are further classified as intertrochanteric or subtrochanteric. These fractures occur in the well-vascularised metaphysis and can be reliably fixed with internal fixation devices (dynamic hip screw or intramedullary nail). The AO/OTA classification system further categorises fracture patterns to guide implant selection.
Hip fractures in younger patients (under 60) are almost always caused by high-energy trauma and are managed differently - fixation is preferred over replacement in this age group to preserve the native joint. The NICE hip fracture guideline (NG124) mandates surgery within 36 hours of admission, involvement of a consultant orthopaedic surgeon and orthogeriatrician, and a comprehensive, multi-disciplinary rehabilitation programme.
Common causes
- Low-energy fall in elderly osteoporotic patients (most common)
- High-energy trauma in younger adults
- Pathological fracture through metastatic bone disease
- Periprosthetic fracture around a hip replacement (rare)
Who is at risk? Osteoporosis and falls risk are the two modifiable risk factors. Female sex, age over 75, white ethnicity, previous fragility fracture, low body weight, smoking, excess alcohol, and corticosteroid use all increase the risk of hip fracture. All patients should be assessed and treated for osteoporosis after a hip fracture.
Symptoms
Symptoms vary depending on the severity and duration of the condition. Common symptoms include:
- Sudden severe pain in the hip or groin after a fall
- Inability to stand or bear weight
- The leg lies shortened and externally rotated (classic position)
- Tenderness over the hip and upper thigh
- In impacted fractures, the patient may retain some ability to walk - any post-fall hip pain warrants X-ray
When to seek help: Any elderly patient who falls and cannot stand, or who has persistent hip pain after a fall, requires emergency assessment. Call 999. Do not attempt to help the patient stand without assessment.
How is it diagnosed?
Your surgeon will take a detailed history and examine the joint. The following investigations may be arranged to confirm the diagnosis:
- X-ray - AP pelvis and lateral hip views in A&E (diagnoses the majority of fractures)
- MRI - gold standard for occult fractures not visible on X-ray (same-day MRI is recommended by NICE when X-ray is normal but clinical suspicion is high)
- CT scan - alternative to MRI if unavailable, or for fracture classification before surgery
Up to 10% of hip fractures are not visible on plain X-ray. If clinical suspicion is high and X-rays are normal, MRI should be arranged on the same day as per NICE NG124. Untreated occult fractures may displace, converting a manageable situation into a surgical emergency.
Treatment pathway
Treatment is tailored to the severity of the condition, your age, activity level, and overall health. Most conditions are treated in a stepwise fashion, starting with the least invasive options.
Hemiarthroplasty or total hip replacement
Replacement of the femoral head. Hemiarthroplasty (replacing the femoral head only) or total hip replacement (replacing both ball and socket). THR is preferred for medically fit, independently mobile patients with pre-existing hip arthritis. Both allow immediate full weight-bearing after surgery.
Dynamic hip screw (DHS) or intramedullary nail
Internal fixation using a large lag screw and plate (DHS) or an intramedullary nail. The choice depends on fracture pattern. Both allow immediate weight-bearing. Intramedullary nail is preferred for subtrochanteric and unstable intertrochanteric fractures.
Internal fixation (cannulated screws)
For younger patients (under 60-65) or those with Garden I/II undisplaced fractures, preserving the femoral head with cannulated screw fixation is preferred. The risk of avascular necrosis necessitates careful monitoring.
Recovery
Hip fracture recovery requires a comprehensive multi-disciplinary approach involving orthopaedics, orthogeriatrics, physiotherapy, occupational therapy, and social services. Osteoporosis treatment must be commenced before discharge. Falls prevention assessment is an essential component of post-fracture care.
- Surgery: Within 36 hours of admission (NICE guideline)
- Mobilisation: Day 1 after surgery
- Discharge from acute ward: 5-7 days
- Rehabilitation: Weeks to months
- Return to independent living: 3-6 months
What results can I expect?
The prognosis after hip fracture is significantly influenced by pre-existing health status. Approximately 50% of patients do not regain their pre-fracture level of mobility. Early surgery, comprehensive orthogeriatric care, and prompt rehabilitation improve outcomes. All patients should be offered osteoporosis treatment to reduce the risk of future fractures.
Hip fracture - surgery and recovery
In numbers
Typical activity timelines for this condition. These are approximate and vary considerably between patients. Always follow the specific guidance given by your surgeon and physiotherapist.
| Activity | Typical timeline | Notes |
|---|---|---|
| Get to A&E | Immediately | A suspected hip fracture is always an emergency. Do not try to walk on it. Call an ambulance.[2] |
| Have surgery | Within 36 hours if fit | NICE recommends surgery within 36 hours of admission to reduce complications and improve outcomes.[1] |
| Stand and walk | Day 1 after surgery | Early mobilisation the day after surgery is standard and reduces chest infection, blood clots, and pressure sores.[1] |
| Use walking aids | For several weeks | Crutches or a frame are usually required for several weeks; transition to a stick and then unaided walking under physiotherapy guidance.[1] |
| Bone health review | Within weeks | A bone health and falls assessment should follow every hip fracture to reduce the risk of a second fracture.[1] |
| Drive | 6-12 weeks | Depends on the type of surgery, your strength, and your ability to react safely. Confirm with surgeon and insurer.[3] |
| Return to previous activity | 3-6 months | Many patients return to their previous level of activity but it can take months and around 1 in 3 does not fully regain previous independence.[1] |
Common concerns from patients with this condition or recovering from treatment, and whether they are expected or worth mentioning to your team.
Your questions, answered
Plain-English answers to the things people most often ask, grounded in UK clinical guidance. Tap a question to open it.
About thisWhat is a hip fracture?
A hip fracture is a break in the upper part of the thigh bone, just below the ball of the hip joint. It most often happens in older people after a fall, particularly where the bone is thinned by osteoporosis. It is a serious injury but one that is treated every day.
TreatmentWill I need an operation?
Almost always, yes. Surgery lets you start moving and bearing weight quickly, which is far safer than long periods in bed. UK guidance recommends operating without unnecessary delay, usually within a day or so of admission once you are safe for surgery.
The operationWhat kind of surgery is used?
It depends on where the break is. Some fractures are fixed with screws, a plate or a rod, while others are treated by replacing part or all of the hip. Your surgeon will choose the method most likely to get you walking and to last well.
AnaestheticWill I be asleep for the operation?
You will have either a spinal anaesthetic, which numbs you from the waist down, or a general anaesthetic where you are fully asleep. The anaesthetist will discuss which is safest for you, taking your other health conditions into account.
RecoveryHow soon will I be up and about?
The aim is to get you standing and walking, with help, on the day after surgery. Recovery then continues over weeks to months with physiotherapy. How far you regain depends partly on how mobile and well you were beforehand.
After a fractureHow do I avoid breaking another bone?
A hip fracture is a strong signal to look after your bone health. You will usually be assessed for osteoporosis and may be offered bone-strengthening treatment, vitamin D and calcium. Reducing falls risk at home, keeping active and reviewing medicines all help.
When to worryWhat warns of a problem after surgery?
Tell your team about increasing pain, redness or discharge from the wound, fever, or a calf that becomes swollen, hot or painful. Sudden breathlessness or chest pain needs emergency help, as these can signal a clot.
- 1.NICE CG124: Hip fracture, management
- 2.NHS: Broken hip
- 3.Royal College of Surgeons of England: Recovering from surgery, driving guidance
- 4.British Hip Society: Patient information
- 5.National Joint Registry annual report (NJR), hip and knee implant data
References are to UK clinical guidance and patient information from recognised organisations. This page is for general information and does not replace personalised advice from your own clinical team.
Preparing for surgery?
Read our step-by-step guide - what to expect before, during, and after your procedure.
How is it diagnosed?
- ✓X-ray - AP pelvis and lateral hip views in A&E (diagnoses the majority of fractures)
- ✓MRI - gold standard for occult fractures not visible on X-ray (same-day MRI is recommended by NICE when X-ray is normal but clinical suspicion is high)
- ✓CT scan - alternative to MRI if unavailable, or for fracture classification before surgery
Recovery milestones
- ●Surgery: Within 36 hours of admission (NICE guideline)
- ●Mobilisation: Day 1 after surgery
- ●Discharge from acute ward: 5-7 days
- ●Rehabilitation: Weeks to months
- ●Return to independent living: 3-6 months