Hip fracture

A hip fracture is a break or crack in the upper part of your thigh bone (the femur). It can occur along any part of the femur: 

• The femoral neck — this area is just below the femoral head (the ball part of the ball-and-socket of the hip joint) 
• The intracapsular region — this area comprises the ball and socket parts of your hip joint; a fracture here can tear the blood vessels that supply the femoral head
• The intertrochanteric region — this area is in the upper part of the femur but further down from the femoral neck; it is in the part of your femur that juts out

Hip fractures most commonly occur due to a fall or impact to the side of the hip eg from a car accident.

Your risk of a hip fracture increases as you age and most often occurs in people aged 80 or over. This is because:

• You are more likely to fall as you get older
• Your bones become weaker as you age

There are various reasons you're more likely to fall:

• Certain medications and medical conditions that affect balance
• Medical conditions affecting the brain and nervous system eg cognitive impairment, dementia, Parkinson's disease, peripheral neuropathy and stroke
• Poor vision and balance problems
• Physical inactivity reducing bone and muscle strength

You're also more susceptible to fractures if you suffer from a condition that weakens the bones. The most common one is osteoporosis — a condition that results in loss of bone density and is most likely to affect women after the menopause and people of Asian or Caucasian heritage. For this reason, women are more likely than men to suffer from a broken hip, as well as people who are Asian or Caucasian.

You can also have weakened bones due to:

• Cancer
• Endocrine disorders eg an overactive thyroid
• Intestinal disorders that reduce your ability to absorb calcium and vitamin D from your diet
• Low blood sugar levels and low blood pressure 
• Malnutrition — this can cause calcium and vitamin D deficiencies
• Physical inactivity and previous stress injuries (due to overuse)

Smoking tobacco and drinking alcohol also increase your risk of hip fractures. 

In cases of extreme bone weakness, you can even suffer a fracture simply by twisting or standing awkwardly.

About half of people who have a hip fracture lose the ability to live independently. In some cases, having a hip fracture can also shorten your lifespan. 

If you are immobile due to a hip fracture for a long time, you can develop: 

• Bedsores
• Blood clots in your legs or lungs
• Further loss of muscle — this increases your risk of having another fall or injury
• Pneumonia
• Urinary tract infections

If you suspect you have a broken hip or hip fracture, you need to go to A&E immediately. Try to stay still and warm. If you are alone, try to get someone's attention by banging on the floor or wall, calling out or pressing your aid button. 

Symptoms of a hip fracture include:

• A shorter leg that may be turned outwards on your injured side
• Being unable to put weight on your leg
• Bruising, stiffness and swelling
• Inability to move your leg
• Severe pain in your groin or hip area

You may still be able to stand up and walk if you have a hip fracture and there may not be any bruising. 

Once you've arrived at hospital, you can usually get a diagnosis of a hip fracture based on your symptoms and the position of your hip or leg. However, you will still have an X-ray to confirm the diagnosis. If your fracture does not show up on an X-ray, you may have a CT scan or MRI scan.

When you are seen by a doctor, they will usually ask how you were injured and if you had a fall. They may also ask:

• If you have any health conditions
• If you have fallen before (if this is the cause of your current injury)
• If you're taking any medications

Your doctor will also assess how much pain you are in and, if you hit your head during your fall, whether you have a concussion. They may take your temperature and check if you're dehydrated. 

To relieve your pain, they may give you: 

• Intravenous fluid
• Local anaesthetic around your hip 
• Painkillers

The most common treatment for a hip fracture is surgery and will be carried out as soon as possible for a better outcome. The type of surgery you require depends on:

• Where the fracture is on your thigh bone
• Your age
• How physically fit you are
• Your ability to take part in the physiotherapy following the operation
• The overall health of your joint

There are three main types of surgery:

Total hip replacement

Both the top of your thigh bone and socket are replaced. It's required in around half of cases and recommended if you have arthritis.

Partial hip replacement

Only the top of your thigh bone is replaced with a prosthesis. This is recommended when the fracture has occurred inside the socket of the hip joint (an intracapsular or femoral neck fracture).

Internal fixation

Pins, screws and rods are inserted into the bone to keep it together while it heals. It can be used when the break is outside the socket or inside, but the bones haven't been displaced.

After surgery, a physiotherapist will help promote healing using massage, manipulation and gentle exercise.

Very rarely, surgery isn't an option. This may be because you’re too frail or the break happened earlier and has already started to heal. If so, healing can take longer and usually requires bed rest.

Before your surgery is confirmed, you will have a pre-operative assessment to check your health and if you are ready for surgery. This may involve tests and investigations. Your doctor will ask you about any medications you are taking and you will have an assessment to decide what type of anaesthetic will be used (ie epidural or general anaesthetic).

Before surgery you will be given pain relief (eg intravenous fluid or local anaesthetic) and an anticoagulant to reduce the risk of blood clots during your surgery. While you are in hospital, you will be monitored for the development of blood clots. 

Your surgeon or a member of your healthcare team can answer any questions you have about your surgery. The procedure will take a couple of hours. 

After surgery, the goal is to recover as quickly as possible and regain your mobility. The day after your surgery, a physiotherapist will assess you and put together a rehabilitation programme. This programme will set realistic goals for your recovery so you can regain your independence and mobility. 

How long you stay in hospital will depend on your condition and mobility. Most people spend around two weeks in hospital but some stay for shorter or longer periods of time. 

Prompt surgery and a personal rehabilitation programme are proven to improve recovery times as well as mobility and quality of life. 

Your multidisciplinary team

A team of different healthcare professionals (a multidisciplinary team) will be involved in your rehabilitation. This may include: 

• A geriatrician — a doctor specialising in the care and treatment of older people
• A liaison nurse
• A physiotherapist
• An orthopaedic surgeon
• Occupational therapists
• Social workers

Rehabilitation in hospital

During your stay in hospital after surgery, a physiotherapist will recommend exercises eg weight-bearing exercises to help you become mobile. A member of your rehabilitation team will help you carry out these exercises, starting from the day after your surgery. 

You may engage in rehabilitation in:  

• A geriatric orthopaedic rehabilitation unit — a ward for older people with bone and joint conditions 
• An orthopaedic ward — a ward for people with bone and joint conditions
• A rehabilitation ward — a ward for people taking part in rehabilitation programmes

Being discharged

An occupational therapist may assess your home to check if you need any mobility aids to be installed. Your GP and/or carer may also be informed so they can support your recovery. 

After you're discharged you may need:

• A rehabilitation appointment at hospital
• To have visits or telephone calls at home from healthcare professionals 
• To see your GP for a follow-up appointment

After hip surgery, you may develop: 

• An infection — this needs treatment and often further surgery
• Bedsores (pressure ulcers) — caused by reduced mobility, which puts constant pressure on certain parts of your skin eg when sitting or lying down for a long time
• Blood clots — reduced mobility after surgery can cause blood clots to form in the deep veins of your leg (deep vein thrombosis (DVT); to reduce your risk of DVT: 
• Do exercises
• Take medications prescribed by your doctor
• Wear special medical stockings

You can help prevent future hip fractures by reducing your risk of falling and if you have osteoporosis, getting treatment. 

To reduce your risk of falling: 

• Assess your home for trip hazards (eg loose carpet and stray wires) and make changes to resolve these hazards
• Be aware of the medications you are taking and whether you are having any side effects eg balance problems or dizziness
• Do exercises to improve your balance and strengthen your bones and muscles
• Have your vision regularly tested at the opticians
• Take calcium and vitamin D supplements if you are deficient in these 
• Use walking aids eg a walking stick

It is also recommended to avoid excessive drinking and if your smoke, to quit.

These can help prevent hip fractures in older people by reducing the impact of a fall. Modern hip protectors are more comfortable than older versions. They comprise padded material and a plastic shield attached to specially designed underwear.

They are most suited to people who spend a lot of time at home, rather than those who are still active and independent.