Hip fracture

A hip fracture is a break of the upper end of the femur, right where it articulates with the pelvis. In the older adult a fall from standing height is enough to cause it, because the bone is already weakened by osteoporosis. In the young, by contrast, it takes high-energy trauma.

It is worth saying plainly: this is not “just another broken bone”. It is an event that changes the health trajectory of an older person, and the goal of treatment is to get them walking again as soon as possible, because every day in bed brings its own complications — pneumonia, thrombosis, pressure sores, cognitive decline, loss of muscle mass.

How it is recognised

Severe pain in the hip or groin after the fall, inability to bear weight and, frequently, the leg shortened and externally rotated. In undisplaced fractures the picture can be subtler: the person walks with pain and the initial radiograph looks normal. When clinical suspicion is high and the radiograph is inconclusive, CT or MRI is added — missing an occult fracture and letting it displace worsens the prognosis considerably.

Where the fracture is decides the treatment

The key distinction is not the name but the blood supply to the femoral head. The vessels that feed it run up the neck, so a fracture there can leave it without circulation.

In fractures of the femoral neck that are displaced in an older patient, the risk of the head becoming necrotic is high, and so the usual approach is to replace it: hemiarthroplasty or total hip replacement, depending on previous function and the state of the acetabulum. Undisplaced fractures can be fixed, preserving the head.

Fractures that are Intertrochanteric and subtrochanteric fractures occur lower down, in well-vascularised bone, and unite well: they are fixed with an intramedullary nail or a sliding hip screw. Nothing is replaced here; the fracture is stabilised to allow early weight-bearing.

How long can surgery wait

Surgery should be early, but it is worth knowing what the evidence showed. The international HIP ATTACK trial randomised 2,970 patients to accelerated surgery — aiming to operate within six hours — or to standard care. The median time to surgery was 6 hours versus 24. At 90 days there was no significant difference in mortality or in major complications.

The practical conclusion is not that waiting makes no difference. It is that the priority is to optimise the patient and operate without avoidable delay, not to race a six-hour clock. Time spent correcting anaemia, adjusting anticoagulation or stabilising cardiac decompensation is time well spent.

The part that gets forgotten: the second fracture

A fragility fracture is a warning. Anyone who has had one is at high risk of another, and yet most of these patients leave hospital without anyone investigating their osteoporosis.

Complete treatment includes assessing bone density, correcting vitamin D and calcium, starting antiresorptive treatment where indicated, and reviewing the risk of falls at home: loose rugs, lighting, footwear, medications that cause dizziness. That part prevents the next fracture, which is usually worse than the first.