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Orthopedics›Condition·Updated Jul 11, 2026·v1

Hip Fracture

Hip fracture is a common, life-threatening injury in the elderly requiring prompt surgical intervention. Key principles: surgery within 24 hours, cemented arthroplasty for displaced femoral neck fractures, cephalomedullary nailing for unstable intertrochanteric fractures, early unrestricted weight-bearing, and orthogeriatric comanagement. Perioperative care includes PENG block for analgesia, tranexamic acid to reduce transfusion, and nutritional supplementation. Osteoporosis treatment must be initiated during the index admission to prevent secondary fractures.

High Evidence364 references·10,270 words·42 min read·v1
orthopedicship fracturefemoral neck fractureintertrochanteric fractureosteoporosisgeriatric traumaarthroplastyinternal fixation

Quick Reference

RxDrug of choiceTranexamic acid 1 g IV at induction and 1 g at closure to reduce transfusion.
AltAlternativesFor VTE prophylaxis: rivaroxaban 10 mg PO daily or apixaban 2.5 mg PO BID for 28 days.
⊘AvoidNonoperative management except in palliative cases; avoid non-dihydropyridine CCBs and NSAIDs in renal impairment or myocardial injury.
DxTest of choiceAP pelvis + cross-table lateral hip radiograph; if negative, MRI hip.
ScKey scoreNottingham Hip Fracture Score (NHFS) for 30-day mortality; ASA class for perioperative risk.
→When to referOrthogeriatric comanagement for all patients; cardiology for troponin elevation; osteoporosis specialist for bone health.
Surgery within 24 hours, cemented arthroplasty for displaced femoral neck, unrestricted weight-bearing, and orthogeriatric care are the pillars that reduce mortality and improve outcomes.
Bottom line: Hip fracture is a life-threatening injury in the elderly, with 1-year mortality of 20-36% despite optimal care. The goal is surgery within 24 hours, with cemented arthroplasty for displaced femoral neck fractures and cephalomedullary nailing for unstable intertrochanteric fractures. Perioperative optimization includes pain control with PENG block, reversal of anticoagulation, tranexamic acid, and orthogeriatric comanagement. Every patient should be evaluated for osteoporosis and started on treatment during the index admission.

Overview and Recommendations

Background

  • •Hip fracture refers to fractures of the proximal femur, including femoral neck (intracapsular), intertrochanteric, and subtrochanteric subtypes, each with distinct blood supply, healing potential, and treatment implications. The global burden is 1.5 million cases annually, with 340,000 in the United States, predominantly in women over 65 with osteoporosis.
  • •The critical distinction is between intracapsular (femoral neck) and extracapsular fractures. Intracapsular fractures disrupt the retinacular blood supply, causing avascular necrosis in 10-11% of displaced fractures; extracapsular fractures have robust blood supply but risk medialization and collapse.
  • •Mortality is substantial: 1-year mortality is 20-36% with surgery, rising to 84% without operative treatment. The paradigm has shifted from nonoperative management to early operative fixation, and from uncemented to cemented arthroplasty based on level I evidence.
  • •The four pillars of modern care are: early surgery (<24 hours), cemented arthroplasty for displaced femoral neck, cephalomedullary nailing for unstable intertrochanteric, and orthogeriatric comanagement. This bundle reduces mortality and complications.
  • •Risk factors include age, female sex, low BMD (T-score < -2.5), prior fragility fracture, dementia, and glucocorticoid use. The FRAX tool integrates these factors; a 10-year hip fracture risk ≥3% triggers pharmacotherapy.
  • •The single most important secondary prevention is anti-osteoporotic therapy after a hip fracture, yet only 6% of patients receive it, and adherence is low.

Evaluation

  • •Suspect a hip fracture in any elderly patient who presents after a fall with inability to bear weight, hip or groin pain, and a shortened, externally rotated leg. However, up to 21% of patients present with delirium as the sole feature, and 23% have silent myocardial injury with elevated troponin.
  • •Ask about the mechanism of fall, prior fragility fractures, osteoporosis treatment, anticoagulant use, and baseline functional status. A history of dementia or frailty increases risk of poor outcomes.
  • •Examine for tenderness over the hip or greater trochanter, painful passive internal rotation, and inability to straight leg raise. Always perform a neurovascular exam of the distal limb; a hip fracture alone does not cause neurovascular deficit.
  • •Order an anteroposterior (AP) pelvis radiograph and a cross-table lateral view of the affected hip. Most fractures are visible on plain films. If radiographs are negative but clinical suspicion remains high (pain, inability to weight bear), obtain an MRI of the hip, the gold standard for occult fractures with near 100% sensitivity.
  • •Classify the fracture using the Garden system (I-IV) for femoral neck fractures and AO/OTA classification (31A, B, C) for all proximal femur fractures. Garden I-II are nondisplaced, amenable to internal fixation; Garden III-IV are displaced, typically requiring arthroplasty in the elderly.
  • •Also assess for red flags: delirium on arrival (assess with 4AT score) doubles inpatient mortality; check troponin on all patients because myocardial injury is common and accelerated surgery reduces mortality.
  • •Consider additional workup: complete blood count, renal function, coagulation studies, and type and screen. Assess nutritional status (MUST score) and vitamin D level.
  • •The diagnostic algorithm: Step 1, AP pelvis + lateral hip. If positive, classify and proceed. Step 2, if negative but high suspicion, MRI. Step 3, if MRI negative, fracture excluded.
  • •Differential diagnoses include hip dislocation, pelvic fracture, pathologic fracture (cancer, infection), and referred pain from lumbar spine or knee.

Management

  • •Initiate pain control immediately with a pericapsular nerve group (PENG) block under ultrasound guidance; this reduces pain by a median of 6 points on VNRS at 30 minutes, superior to IV morphine. Multimodal analgesia with scheduled acetaminophen and low-dose opioids as needed.
  • •Reverse anticoagulation selectively: for vitamin K antagonists, give vitamin K 5-10 mg IV and/or prothrombin complex concentrate; for DOACs, hold for 24-48 hours depending on renal function. Do not routinely delay surgery for 5 days.
  • •Aim for surgery within 24 hours of injury. Surgery within 24 hours reduces 30-day mortality (RR 0.86) and complications. For patients with troponin elevation, accelerated surgery (median 6 hours) reduces 90-day mortality from 23% to 10% (NNT=8).
  • •Administer tranexamic acid (TXA) 1 g IV at induction and 1 g at closure. This reduces transfusion requirements by 50% without increasing thromboembolic events.
  • •Choose the operative procedure based on fracture type: for displaced femoral neck fractures in elderly patients, perform cemented hemiarthroplasty or total hip arthroplasty; for undisplaced femoral neck fractures, internal fixation with cannulated screws (non-parallel configuration reduces osteonecrosis); for stable intertrochanteric fractures (AO/OTA 31A1), sliding hip screw; for unstable intertrochanteric fractures (31A2, A3, reverse obliquity), cephalomedullary nail; for subtrochanteric fractures, cephalomedullary nail.
  • •Use spinal anesthesia when possible; it is preferred over general anesthesia.
  • •Start oral nutritional supplementation (ONS) as soon as oral intake is safe. ONS reduces total complications (OR 0.57), infective complications (OR 0.54), and pressure ulcers (OR 0.54), and shortens length of stay by 2.4 days.
  • •Mobilize the patient on the day of or day after surgery with full weight-bearing. Weight-bearing restrictions are not needed and are associated with higher mortality (RR 0.67 for unrestricted vs restricted). Elderly patients cannot comply with partial weight-bearing.
  • •For postoperative pain, consider IV acetaminophen for the first 24 hours to reduce delirium (from 32.8% to 15.4%, NNT=6). Preoperative dexamethasone or methylprednisolone also reduces delirium (RR 0.84, NNT=7).
  • •Provide VTE prophylaxis with factor Xa inhibitors (rivaroxaban or apixaban) for 28 days postoperatively. They reduce DVT compared with conventional prophylaxis (OR 0.59, NNT=33).
  • •Monitor for complications: pneumonia (6% at 30 days), surgical site infection (1.7%), reoperation (2.3%), and myocardial injury. Check troponin and ECG postoperatively.
  • •Refer to orthogeriatric service for comanagement; this reduces in-hospital mortality (RR 0.60) and long-term mortality (RR 0.83).
  • •Initiate osteoporosis treatment during the index admission: start bisphosphonate (e.g., zoledronic acid 5 mg IV once yearly) or anabolic agent (teriparatide) if indicated. Ensure calcium and vitamin D supplementation.
  • •Discharge criteria: pain controlled, mobilized with assistive device, no acute medical issues, cognitive status acceptable for safe discharge, and a plan for outpatient follow-up including bone health and fall prevention.
  • •Do not use nonoperative management except in patients who are non-ambulatory, severely cognitively impaired, or at extremely high anesthetic risk with a palliative goal. Document shared decision-making.
  • •Avoid non-dihydropyridine calcium channel blockers and NSAIDs in patients with perioperative myocardial injury or renal impairment.

Board Review — High Yield

  • •Garden classification, Garden I-II (nondisplaced) amenable to internal fixation; Garden III-IV (displaced) require arthroplasty in elderly.
  • •Avascular necrosis risk, Displaced femoral neck fractures have AVN risk of 10-11%; undisplaced risk 4.5%.
  • •Tip-apex distance (TAD), TAD <25 mm reduces lag screw cutout in intertrochanteric fractures; low-center screw position can compensate.
  • •PENG block, First-line analgesia in ED; reduces pain by 6 points on VNRS at 30 min, superior to IV morphine.
  • •Surgery within 24 hours, Reduces 30-day mortality (RR 0.86) and improves mobility; for troponin-positive patients, accelerated surgery (median 6h) reduces 90-day mortality from 23% to 10%.
  • •Cemented vs uncemented hemiarthroplasty, Cemented stems reduce periprosthetic fracture and reoperation without increasing cardiopulmonary complications.
  • •Unrestricted weight-bearing, Elderly cannot comply with partial weight-bearing; unrestricted weight-bearing lowers long-term mortality (RR 0.67).
  • •Orthogeriatric comanagement, Reduces in-hospital mortality by 40% (RR 0.60) and long-term mortality by 17% (RR 0.83).
  • •Osteoporosis treatment gap, Only 6% of patients receive anti-osteoporotic therapy after hip fracture; start during admission.
  • •Delirium and myocardial injury, 21% present with delirium, 23% with elevated troponin; both independently increase mortality, and accelerated surgery benefits the latter.

Deep Dive — Evidence Details

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