01OverviewDefinition, clinical context and the essential points that orientate the chapter.
Suspect hip fracture after any low-energy fall with groin, hip or referred knee pain, inability to weight bear or pain on passive rotation. Shortening and external rotation are helpful but can be absent in impacted fracture. Give analgesia before repeated movement. Obtain AP pelvis and lateral hip radiographs; when suspicion persists after adequate films, arrange MRI, or CT if MRI is contraindicated or cannot be obtained within 24 hours.
Admit directly into an integrated pathway. Orthopaedic and orthogeriatric teams should assess promptly, with anaesthetic input and nursing, physiotherapy, occupational therapy, pharmacy and nutrition. Record pre-fracture residence, cognition, mobility, aid, ADLs, advance decisions and goals using collateral. Baseline determines rehabilitation and operation discussions but should never justify inadequate analgesia or pressure care.
Assess pain immediately and repeatedly. NICE recommends immediate regular paracetamol, additional opioids if paracetamol is insufficient, and nerve block when it reduces opioid need or enables positioning. A commonly used adult paracetamol dose is 1 g every six hours, but reduce the daily maximum in low body weight, malnutrition or liver risk according to local and product guidance. Titrate short-acting opioid with renal, sedation and respiratory review and prescribe bowel care.
Prepare for surgery on the day of or day after admission. Perform FBC, renal and electrolytes, glucose, group and save, coagulation when indicated, ECG and chest or other tests according to disease. Correct anaemia, volume depletion, electrolyte imbalance, uncontrolled diabetes, uncontrolled heart failure, correctable arrhythmia, anticoagulation and acute chest infection promptly. These are treatment tasks, not reasons for open-ended delay.
Reconcile antithrombotic medicines exactly, including last dose, indication, renal function and thrombotic risk. Follow current anaesthetic and local reversal protocols for warfarin and direct oral anticoagulants. Do not guess from a drug list or stop antiplatelet treatment without indication review. Coordinate VTE prophylaxis timing with surgery, neuraxial anaesthesia, bleeding risk, renal function and mechanical options.
Operation choice follows fracture and person factors. For displaced intracapsular fracture, offer replacement arthroplasty. Consider total rather than hemiarthroplasty for people who could walk independently outdoors with no more than a stick, do not have comorbidity making total replacement unsuitable and are expected to remain independently able in ADLs beyond two years. Use cemented implants. Extracapsular fixation is chosen according to trochanteric or subtrochanteric pattern.
Bone cement implantation syndrome is an important anaesthetic and surgical risk during cemented arthroplasty, especially with frailty and cardiopulmonary disease; use team preparation and current safety procedures. Choice still follows evidence and guidance rather than avoiding cement reflexively. Document the operation, weight-bearing status and any precautions in language the rehabilitation team can act on.
Prevent delirium from arrival. Screen with 4AT when acute change is possible and obtain collateral. Provide glasses, hearing aids, clock, familiar contact, hydration, food, oxygen when indicated, pain relief, sleep opportunity, bowel and bladder care and early movement. Avoid unnecessary catheters, anticholinergics, benzodiazepines and prolonged fasting. Treat underlying causes; antipsychotic use is exceptional for immediate severe risk after de-escalation.
Mobilise on the day after surgery unless contraindicated and at least daily thereafter. Physiotherapy trains transfers, gait, strength and aid use; OT evaluates dressing, toileting, home access and equipment. Encourage normal clothing and meals in a chair. Weight-bearing instructions, analgesia and staffing must make mobility possible, not merely appear in a plan.
Provide adequate energy and protein, assess swallowing and dentition and minimise fasting. Monitor haemoglobin and symptoms rather than transfusing to a number without context. Prevent pressure injury, chest complications, constipation and urinary retention. Review wound, infection, delirium, orthostatic symptoms and pain during progress.
Begin secondary prevention before discharge. Assess fracture risk and usually start an appropriate osteoporosis pathway promptly, with calcium, vitamin D and renal safety. Perform multifactorial falls assessment and medication review. Communicate next bone dose, wound and thrombosis plan, mobility status, delirium course, cognition, equipment, carer training and rehabilitation goals to the next team.
Key points
- First-line suspected hip-fracture care is analgesia, safe positioning, pressure care, radiographs and admission to a coordinated orthopaedic–orthogeriatric pathway.
- MRI is the reference test when hip fracture remains suspected after adequate negative radiographs; use CT if MRI is contraindicated or unavailable within 24 hours.
- Offer immediate regular paracetamol unless contraindicated, add opioids when needed and use nerve block to limit opioid dose; NICE advises against NSAIDs in hip-fracture care.
- Surgery should occur on the day of or day after admission, with correctable anaemia, anticoagulation, volume depletion, electrolytes, diabetes, heart failure, arrhythmia and chest infection addressed without avoidable delay.
- Use replacement arthroplasty for displaced intracapsular fracture and consider total hip replacement using pre-fracture mobility, comorbidity and expected independent function criteria.
- Use cemented implants for arthroplasty and fixation selected to fracture pattern and current guidance.
- Provide venous-thromboembolism prophylaxis using current NICE risk, bleeding and renal criteria and the selected anaesthetic and operative timing.
- Screen for delirium and provide orientation, sensory aids, hydration, nutrition, pain, sleep, bowel and bladder care rather than relying on sedation.
- Mobilise on the day after surgery unless medically or surgically contraindicated and offer mobilisation at least daily with regular physiotherapy review.
- Before transition, address osteoporosis treatment, multifactorial falls prevention, cognition, mood, continence, wound, medication, carers and realistic rehabilitation goals.
02AetiologyUnderlying causes, associations and risk factors, with why each one matters.
Low-energy fragility fracture
Most hip fractures follow a standing-height fall onto osteoporotic bone, combining skeletal weakness with impaired balance and protective response.
Intracapsular fracture
Fracture through the femoral neck threatens femoral-head blood supply and may be undisplaced or displaced, determining fixation or replacement options.
Extracapsular fracture
Trochanteric and subtrochanteric patterns occur outside the capsule and are usually stabilised with pattern-specific fixation. Stable fixation supports pain control and early rehabilitation according to the operative plan.
Pathological or atypical fracture
Malignancy, metabolic bone disease or atypical femoral stress injury should be considered when trauma, imaging or preceding pain is unusual.
03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.
- 1Pain and immobility response
Fracture pain and inflammatory stress cause delirium, catabolism, atelectasis and loss of muscle while immobility raises thrombotic and pressure risk.
- 2Blood and fluid loss
Hidden bleeding into tissues, poor intake and vasodilation can produce anaemia, hypotension and renal injury. Repeated physiological assessment guides safe resuscitation and anaesthesia.
- 3Femoral-head ischaemia
Displaced intracapsular fracture disrupts retinacular vessels, increasing non-union and avascular necrosis and supporting replacement in many older adults.
- 4Delirium cascade
Pain, unfamiliar environment, sleep loss, fasting, drugs, constipation and infection interact with reduced cognitive reserve. Multicomponent prevention interrupts several of these precipitating pathways at once.
- 5Post-fracture imminent risk
The index fall, osteoporosis and new weakness make another fall and fracture particularly likely during recovery.
04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.
Groin pain, inability to weight bear and a shortened externally rotated limb after a fall is highly concerning.
Persistent pain on hip movement or weight bearing despite normal radiographs requires cross-sectional imaging.
Femoral-neck fracture may threaten head blood supply and displaced injury commonly requires replacement.
Trochanteric or subtrochanteric imaging determines the fixation construct.
Inattention, fluctuating alertness or acute functional loss may be the dominant perioperative complication.
Minimal trauma with a destructive lesion or preceding night pain requires malignancy or metabolic assessment.
05InvestigationsWhat to request, why it matters and how to interpret it.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Hip radiographsFirst stepFirst line - Why
- Confirm and classify suspected fracture first line.
- Interpretation and limitations
- Use AP pelvis and lateral hip views; normal films do not exclude an occult fracture when clinical suspicion persists.
- 02
MRI or CT for occult fracture - Why
- Identify radiographically occult hip injury.
- Interpretation and limitations
- MRI is preferred; use CT when MRI is contraindicated or unavailable within 24 hours and reconsider MRI if concern persists.
- 03
Preoperative blood tests - Why
- Identify correctable physiological risk and prepare surgery.
- Interpretation and limitations
- Use FBC, renal, electrolytes, glucose, group and save and coagulation or other tests according to treatment and disease.
- 04
ECG and targeted cardiopulmonary tests - Why
- Guide anaesthesia without indiscriminate delay.
- Interpretation and limitations
- Use ECG routinely in the relevant older population and add imaging or biomarkers only for findings likely to change immediate management.
- 05
Delirium and cognition assessment - Why
- Detect acute brain dysfunction and baseline vulnerability.
- Interpretation and limitations
- Use 4AT for possible delirium, collateral for baseline and repeated assessment when cognition fluctuates.
- 06
Fracture and falls assessment - Why
- Prevent the next fall-related injury.
- Interpretation and limitations
- Review previous fractures, height loss, bone risk, gait, posture, vision, medicines, cognition and home hazards before transition.
- 07
Functional and social assessment - Why
- Set a realistic recovery pathway.
- Interpretation and limitations
- Document pre-fracture walking, aid, ADLs, residence, carers, home access and goals and compare post-operative progress.
06Differential diagnosisRealistic alternatives and the features that help distinguish them.
Occult hip fracture
Persistent groin pain or inability to weight bear after normal radiographs requires MRI or CT rather than reassurance.
Pelvic or acetabular fracture
Pelvic compression pain and imaging can reveal an alternative low-trauma fracture with different weight-bearing plan. CT or MRI is selected when plain imaging and examination remain discordant.
Soft-tissue or arthritic pain
Contusion, tendon injury and osteoarthritis can mimic fracture but are diagnoses after adequate injury assessment. Persistent inability to mobilise should therefore reopen imaging and diagnosis.
Pathological fracture
Preceding night pain, constitutional change or lytic imaging requires malignancy and metabolic investigation. Biopsy planning may be required before definitive fixation when malignancy is suspected.
Acute neurological or medical fall
Stroke, syncope, seizure, hypoglycaemia and infection can cause the fall and require parallel treatment. Treating only the fracture would leave the precipitating danger unaddressed.
07ManagementImmediate care, first-line treatment, alternatives and escalation.
01First-line admission sequenceRelieve pain and reach surgery quicklyFirst stepFirst lineHip fracture is suspected or confirmed.+
- 1Give analgesia, protect pressure areas, obtain radiographs and use MRI or CT promptly for occult fracture.
- 2Admit to coordinated hip-fracture care and document baseline, comorbidity, cognition, medicines and goals.
- 3Optimise correctable problems in parallel and operate on the day of or day after admission where possible.
02Perioperative optimisationCorrect without open-ended delayAnaemia, anticoagulation, volume, metabolic or cardiopulmonary problems may increase risk.+
- 1Identify the exact abnormality, severity and treatment or last antithrombotic dose.
- 2Use senior orthogeriatric, anaesthetic and surgical decisions and current reversal or optimisation protocols.
- 3Record a time-bound action and proceed once the modifiable immediate risk is adequately addressed.
03Delirium-prevention routeProtect cognition and participationFrailty, dementia, pain or acute change creates high delirium risk.+
- 1Screen with 4AT, obtain baseline collateral and identify pain, infection, hypoxia, retention, constipation and medicine causes.
- 2Provide orientation, sensory aids, hydration, nutrition, sleep and repeated safe mobilisation and minimise catheters and sedatives.
- 3EscalationUse de-escalation and familiar support; reserve emergency antipsychotic treatment for exceptional immediate severe risk.
04Post-operative recoveryMobilise and prevent refractureSurgery is complete and no medical or surgical contraindication prevents movement.+
- 1Mobilise the next day and daily with appropriate analgesia, aid, weight-bearing instruction and physiotherapy.
- 2Manage nutrition, pressure, VTE, bowel, bladder, wound, posture and cardiopulmonary recovery.
- 3Start bone and falls secondary prevention and transfer with named rehabilitation, medication and carer actions.
Key medicines and prescribing safety4 treatments · regimens, roles and cautions+
Paracetamol
A common adult regimen is 1 g orally or intravenously every six hours, maximum 4 g in 24 hours; use a lower maximum or longer interval for body weight under 50 kg, malnutrition, liver risk or other product-specific factors.Count all combination products, review liver and nutrition risk and reassess pain rather than leaving an automatic high dose in a frail low-weight patient.
Immediate-release opioid
Use a small titrated oral or intravenous dose according to local protocol and prior exposure; reduce and lengthen dosing in frailty or renal impairment and reassess after each dose.Monitor respiratory rate, sedation, delirium, nausea, constipation and renal accumulation; prescribe bowel care and avoid a fixed one-size regimen.
Enoxaparin
For high-risk orthopaedic prophylaxis use 4,000 IU (40 mg) subcutaneously once daily; after hip-fracture surgery begin 6 to 12 hours postoperatively when haemostasis is secure and continue for one month. For creatinine clearance 15 to 30 mL/min, use 2,000 IU (20 mg) once daily.Not recommended below creatinine clearance 15 mL/min outside haemodialysis; check bleeding, platelets, low weight, last anticoagulant dose and exact neuraxial timing and do not interchange LMWH doses.
Alendronic acid
70 mg orally once weekly when selected, with fasting, plain-water and upright administration requirements.Hip-fracture patients often cannot initially follow administration; consider IV zoledronate or another pathway rather than unsafe oral dosing.
08ComplicationsImportant consequences, why they occur and why they matter clinically.
Delirium and cognitive decline
Acute confusion increases distress, immobility, aspiration and institutionalisation and can persist after discharge. Early recognition enables cause treatment, communication support and safer mobilisation.
Venous thromboembolism and chest disease
Fracture, surgery and immobility raise DVT, pulmonary embolism, atelectasis and pneumonia risk. Prophylaxis and early mobilisation reduce these potentially fatal complications.
Pressure, urinary and bowel harm
Pressure injury, retention, catheter infection and opioid constipation arise without anticipatory care. Daily anticipatory assessment prevents these problems from blocking rehabilitation.
Surgical complications
Infection, dislocation, fixation failure, non-union, bleeding and periprosthetic fracture require early recognition. New pain, fever or lost function should trigger prompt reassessment.
Persistent disability and death
Many people do not regain pre-fracture mobility; complications and frailty increase short- and long-term mortality. Coordinated orthogeriatric rehabilitation aims to reduce these outcomes and restore participation.
09Monitoring and follow-upTreatment response, safety checks and longer-term review.
- Reassess pain after every analgesic escalation and before movement, imaging and physiotherapy.
- Track time to surgery and document a specific active reason and review time for any delay.
- Monitor delirium, hydration, oxygenation, haemoglobin, renal function, bowel, bladder, skin and nutrition.
- Record mobilisation from the day after surgery, assistance, distance, aid, pain and barriers relative to baseline.
- Review wound, VTE prophylaxis, weight-bearing status and medicine changes at every transition.
- Confirm bone treatment, falls plan, next dose, rehabilitation owner and carer training before discharge.
10Special situationsVariants, exceptions and circumstances that change the usual approach.
Normal X-ray is not clearance
Clinical inability to weight bear keeps occult fracture in the pathway until adequately imaged.
Analgesia enables diagnosis
Treating pain improves positioning, breathing and cognition and does not erase useful examination findings.
Optimisation runs in parallel
Correcting reversible physiology should accelerate safe surgery, not create indefinite medical waiting.
Baseline shapes the goal
Pre-fracture mobility and ADLs guide operation and rehabilitation discussions more accurately than age alone.
Delirium prevention is ordinary care
Glasses, hydration, pain control, sleep, bowel care and movement are core clinical interventions.
Discharge is another handover risk
A bone recommendation without dose timing and ownership is likely to be lost.
11Common pitfallsFrequent interpretation and management errors.
- 01
Forcing weight bearing after normal radiographs despite persistent clinical suspicion.
- 02
Withholding adequate opioid or nerve block because delirium is feared while leaving severe pain untreated.
- 03
Delaying surgery for minor abnormalities without a time-bound treatment plan.
- 04
Applying a rigid operation choice based on chronological age rather than fracture and baseline criteria.
- 05
Failing to reconcile the exact anticoagulant, indication, last dose and renal function.
- 06
Using sedatives instead of treating delirium precipitants and communication needs.
- 07
Writing mobilise without analgesia, staffing, aid and weight-bearing instructions.
- 08
Discharging without osteoporosis, falls and next-dose ownership.