Hip fracture

Page last reviewed: 13/07/2011

Hip fractures, also called proximal femoral fractures, are cracks or breaks in the top of the thigh bone (femur) close to the hip joint.

Hip fractures are normally the result of a fall.

A fall can cause a hip fracture if the bones are weak due to osteoporosis (a condition that makes the bones fragile and more likely to break). Around 3 million people in the UK have osteoporosis.

How common are hip fractures?

Hip fractures are more common in older people. Most hip fractures occur in people who are around 80 years of age, and they are four times more common in women.

Analysis of hospital admission data in 2005 showed that 2274 people over 75 were admited to hospital in Ireland with a hip fracture.

Outlook

Hip fractures almost always need treatment with surgery. About half of all cases will require a partial or complete hip replacement (a surgical procedure to replace the hip joint with an artificial version). The rest will need surgery to fix the fracture with plates and screws or rods.

After surgery, a rehabilitation programme that includes physiotherapy will be used to help recovery.

Rehabilitation is very important for a successful recovery. There are dedicated rehabilitation units, called geriatric orthopaedic rehabilitation units (GORU), for older people with orthopaedic conditions. There will also be a number of different healthcare professionals involved in the programme, such as occupational therapists and physiotherapists

The right programme of rehabilitation may help older people get back on their feet after surgery. Despite this, after a hip fracture some older people may:

  • not regain complete mobility (the ability to move)
  • no longer be able to live independently in their own homes

 

The hip joints

Your hip joints are the joints that attach your thigh bones (femurs) to your pelvis.

Your hip joints are ball-and-socket joints:

  • The ball is the rounded top part of the femur.
  • The socket is the cup-shaped part of the pelvic bone that the rounded end of the femur sits inside.

A hip fracture is a fracture (crack or break) in the top end or 'neck' of the femur, nearest the hip joint. The fracture can either be:

  • intracapsular (in the part of the femur inside the socket of the hip joint)
  • extracapsular (in the part of the femur outside the socket of the hip joint)

Page last reviewed: 13/07/2011

If you have fractured your hip, you will need hospital treatment. Call 999 for an ambulance.

If you have a fractured hip:

  • your hip will be painful
  • you will not be able to lift, move or rotate (turn) your leg

Usually, you will be unable to stand or put weight on your leg, but occasionally this is possible. If the pain does not go away after a fall, do not ignore it.

If you have fallen, you may also have other injuries. For example, you may have hit your head. If you do not get help immediately, you may also experience:

  • hypothermia, when your body temperature drops below 35C (95F) as a result of being in a cold environment
  • dehydration, when the normal water content of your body is reduced because you have not been able to eat or drink  

If you have fallen

You may feel shaken or shocked after a fall, but do not panic. Try to get someone's attention by:

  • calling out for help
  • banging on the wall or the floor (if there is someone on the floor below you)
  • using your aid call button (if you have one)

When someone arrives, ask them to call 999 for an ambulance. If you are on you own, try to crawl to a telephone and dial 999 for an ambulance.

 

Page last reviewed: 13/07/2011

Most hip fractures in older people are the result of falls, often at home. Around 3 out of 10 people who are 65 years of age or over will have at least one fall a year. Half of all people who are 80 or over will have at least one fall a year.

Falls are more common in older people because they are more likely to have other health problems that increase their risk of falling, such as:

  • muscle weakness
  • problems with balance

A fall can lead to a hip fracture if the bones are weak due to a condition called osteoporosis.

Bones

Bone is made of:

  • a hard outer shell with an inner mesh of collagen (tough elastic fibres). This mesh looks a bit like a honeycomb, with spaces between the different parts
  • minerals (including calcium)
  • blood vessels
  • bone marrow (soft, spongy tissue in the centre of bones that produces blood cells)

Bone is a living tissue that is constantly repairing itself. This process is called bone turnover. There are cells that break down old bone (osteoclasts) and cells that build new bone (osteoblasts). This process requires a range of proteins and minerals, which are absorbed from the bloodstream.

Osteoporosis

From about 35 years of age, you gradually lose bone density (how solid the bone is). This is a normal part of ageing, but for some people it can lead to a condition called osteoporosis.

Healthy bones are very dense, and the spaces inside the bones are small. In bone affected by osteoporosis, the spaces are larger. This makes the bones:

  • weaker
  • less elastic (flexible)
  • more likely to break

Other risk factors

As well as osteoporosis, older people who fracture their hip may also have other health problems linked to aging, such as:

  • reduced mobility (not being able to move as easily as a younger person)
  • dementia (an ongoing decline of the brain and its abilities)
  • poor vision
  • low blood pressure (hypotension), which can cause dizziness

These can make falls more likely, which may increase your risk of fracturing your hip.

Page last reviewed: 13/07/2011

Due to the way hip fractures occur, such as in a fall, diagnosis usually takes place at a hospital. It may be necessary to call 999 for an ambulance after someone has fallen or otherwise injured themselves.

Assessment in hospital

If you have been taken to hospital with a suspected hip fracture, the doctors treating you will assess your overall condition. For example, they may:

  • ask how you were injured and, if you fell, ask if this is the first time you have fallen
  • ask about any other medical conditions you have, such as a heart problem
  • ask if you are currently taking any medication
  • assess how much pain you are in
  • assess your mental state, for example if you also hit your head you may be confused or unconscious
  • take your temperature 
  • make sure you are not dehydrated (when the normal water content of your body is reduced)

Depending on your assessment, you may be given:

  • pain medication
  • a local anaesthetic injection near your hip
  • intravenous fluid (fluid through a needle into a vein in your arm)

The healthcare professionals treating you will make sure you are warm and comfortable. When possible, you may be moved from the emergency department to a ward, such as an orthopaedic ward (a ward for people with conditions that involve the skeleton).

Imaging tests

To confirm the hip fracture diagnosis, imaging tests are used to create a picture of the bones in your hip. Some imaging tests you may have are explained below.

X-ray

X-rays are a type of radiation (waves of energy) used to create an image of the inside of your body. X-rays are a very effective way of detecting problems with bones, such as fractures, and this is likely to be the first imaging test you have.

If an X-ray does not confirm the diagnosis, you may need additional tests such as a computerised (axial) tomography (CT) scan, a complex scanning X-ray or an MRI scan (see below).

Magnetic resonance imaging (MRI) scan

A magnetic resonance imaging (MRI) scan may be used if the diagnosis is uncertain.

MRI scans use strong magnetic fields and radio waves to produce a detailed image of the inside of the body. MRI scans are very effective at confirming even subtle hip fractures.

Page last reviewed: 13/07/2011

Hip fractures are usually treated in hospital with surgery. The alternative to surgery is called conservative treatment. This involves a long period of bed rest and is not often used as it can:

  • make people more unwell in the long term
  • involve a longer stay in hospital
  • slow down recovery

However, conservative treatment may be necessary if surgery is not possible, for example because someone is too fragile to cope with surgery.

Types of surgery

There are a number of different surgical techniques, which are explained in more detail below.

The type of surgery you have will depend on:

  • the type of fracture you have (where in the femur the fracture is)
  • your age
  • how physically mobile you were before the hip fracture
  • your mental ability before the hip fracture, for example if you have dementia (an ongoing decline of the brain and its abilities)
  • the condition of the bone and joint, for example if you have arthritis (a condition that causes pain and swelling of the joints and bones)

In general, people under 65 years of age with intracapsular hip fractures may have internal fixation, while older people or those who are less fit may have hemiarthroplasty. In the latter group, the broken hip fragment is removed and replaced.

A complete hip replacement may be considered if you:

  • already have a condition affecting your joints, such as arthritis
  • are very active
  • have a reasonable life expectancy

For people with an extracapsular fracture, some form of very strong plate and screw or locked rod internal fixation device will be necessary. This usually allows you to walk on the leg while the fracture heals over the following three to four months.

Internal fixation

Internal fixation means fixing the fracture (break in the bone) using devices to hold the bone in place while it heals. Such devices include:

  • pins
  • screws
  • rods
  • plates

If internal fixation is used for an intracapsular fracture, you will need to be followed up over several months with X-rays (when radiation is used to create an image of your bones). This is to check that you are healing.

You can have problems healing and sometimes further surgery is necessary. This is why hemiarthroplasty is preferred in older people as a one-off operation. 

Hemiarthroplasty

Hemiarthroplasty means replacing the femoral head with a prosthesis (false part). The femoral head is the rounded top part of the femur (upper thigh bone) that sits in the hip socket. 

Complete hip replacement

A complete hip replacement (arthroplasty) is when both the natural socket in the hip and the femoral head are replaced with prostheses (false parts). This is a more major operation than hemiarthroplasty and is not necessary in most patients.

 

Pre-operative assessment

Ideally, you will have surgery within 36 hours of your arrival at hospital, provided you are in a stable condition. You will first have a pre-operative assessment.

A pre-operative assessment will check your overall health to make sure you are ready for surgery. During your assessment:

  • You will be asked about any medications you are currently taking, such as low-dose aspirin (to prevent a stroke or heart attack).
  • Any necessary tests and investigations will be carried out, such as an echocardiography (when sound waves are used to take an image of your heart).

You will also have an anaesthetic assessment. Anaesthesia is medication to relieve pain that will be used during your operation. Several different types of anaesthesia may be used:

  • Spinal or epidural anaesthesia is used to numb the nerves in the lower half of your body so you cannot feel anything from this area.
  • General anaesthetic makes you unconscious and prevents your brain from recognising any signals from your nerves, so you cannot feel anything.

Before surgery

You may be given antibiotics (medicines that treat infections caused by bacteria) before your operation. This has been found to reduce the risk of your wound becoming infected after surgery.

Surgery carries the risk of venous thromboembolism (a blood clot forming in a vein). Because of this, steps will be taken to reduce your risk. For example, you may be given injections, such as heparin (an anticoagulant, which reduces the ability of the blood to clot).

You will continue to be monitored for venous thromboembolism throughout your stay in hospital. You may still need to take medication after you are discharged. 

Your operation

Depending on which type of surgery you are having (see above), the operation lasts around two hours.

Surgery will be performed by a team of healthcare professionals, including an orthopaedic surgeon (a surgeon who specialises in operating on conditions that involve the skeleton). If you have any questions about your operation, your surgeon or another member of the team should be able to help you.

After the operation, you will begin your rehabilitation programme. This may take place in a different ward to the one where you had surgery.

Hip fractures often occur in people with osteoporosis (weak and fragile bones).

  If you have osteoporosis or are at high risk, this will be treated as well as your hip fracture. For example, you may:

  • be given calcium or vitamin D supplements (minerals that your bones need to be strong)
  • have your bone density measured (how solid your bones are)
  • be given bisphosphonates (medication to slow the breakdown of bone)

 

Pain relief

A hip fracture can be very painful. Throughout your diagnosis and treatment, you should be given medication to relieve your pain. This is initially usually given intravenously (through a needle into a vein in your arm), with a local anaesthetic injection near the hip or with tablets.

If you are still in pain, tell the healthcare professionals treating you.

The hip joints

Your hip joints are ball-and-socket joints:

  • The ball is the rounded top part of the femur.
  • The socket is the cup-shaped part of the pelvic bone that the rounded end of the femur sits inside.

A hip fracture is a fracture (crack or break) in the top end or neck of the femur, nearest the hip joint. The fracture can either be:

  • intracapsular (in the part of the femur inside the socket of the hip joint)
  • extracapsular (in the part of the femur outside the socket of the hip joint)

Page last reviewed: 13/07/2011

After a hip fracture, you will be given a rehabilitation programme. This is a programme of treatment to help you recover from your injury and any surgery you have had. The aims of rehabilitation may include:

  • increasing your mobility (ability to move), particularly walking
  • increasing your independence so you can wash and dress yourself and use the toilet without help

Your multidisciplinary team

Rehabilitation will usually involve a multidisciplinary team (a team of different healthcare professionals working together), such as:

  • physiotherapists: healthcare professionals trained in using physical methods, such as massage and manipulation, to promote healing and wellbeing
  • occupational therapists: therapists who will help identify problem areas in your everyday life, such as dressing yourself or getting to your local shops, and will help you work out practical solutions
  • social workers: people involved in providing social services, who can advise you on a variety of practical issues, such as benefits, housing and day care
  • orthopaedic surgeon: a surgeon who specialises in operating on conditions that involve the skeleton, particularly the spine and the surrounding joints
  • geriatrician: a doctor who specialises in the healthcare of older people (if you are an older person)
  • liaison nurse: a healthcare professional who may be involved in planning your discharge and keeping you and your family informed about the care you are receiving 

Rehabilitation in hospital

If you are well enough, rehabilitation can be started as soon as 24 hours after surgery. While you are in hospital, your rehabilitation may take place in:

  • an orthopaedic ward: a ward for people with conditions that involve the skeleton
  • a rehabilitation ward: a ward for people undergoing rehabilitation programmes
  • a geriatric orthopaedic rehabilitation unit (GORU): a rehabilitation unit specifically for older people with orthopaedic conditions

Being discharged

How long you need to stay in hospital will depend on how fit you are. If you are otherwise healthy, you may be discharged from hospital after a hip replacement in three to five days.

An occupational therapist may assess your home to see if you will need any mobility aids fitted before you are discharged, such as hand rails. These will make it easier for you to regain your independence. You may also be provided with walking aids, such as a cane or crutch.

Your GP and carer (if you have one) may also be told when you are being discharged so that plans can be made to support you. After you have been discharged, you may need to:

  • return to hospital for a rehabilitation appointment
  • see your GP for a follow-up appointment
  • have visits or telephone calls at home from the healthcare professionals involved in your care

This will be discussed with you before you are discharged.

Your rehabilitation programme

Your individual rehabilitation programme may involve some of the following:

  • weight-bearing exercises, where your feet and legs support your weight, such as brisk walking, keep-fit classes or a game of tennis
  • non-weight-bearing exercises, where your feet and legs are not supporting your weight, such as swimming or cycling
  • treadmill exercises, such as walking on a treadmill (a piece of exercise equipment with a moving conveyor belt that allows you to walk in one place)
  • intensive physical training, such as meeting with an exercise instructor three or more times a week to exercise
  • strength and balance training, such as weight lifting, to build and strengthen muscles and joints, improving your balance, stability and posture

There is currently not enough evidence to suggest that one type of exercise programme is better than another. However, it is thought that these types of programme will improve your mobility.

Page last reviewed: 13/07/2011

Some people may have a slow or incomplete recovery after a hip fracture. Complications can also arise from surgery. 

Slow recovery

Not everyone will completely recover after a hip fracture. This may depend on how healthy you were before your hip fracture. Some people may:

  • not regain their previous level of mobility (ability to move)
  • no longer be able to live at home

Around 3 people in every 10 die within one year o a hip fracture. Around one-third of these deaths are directly related to the hip fracture. 

Complications from surgery f

All types of surgery carry risks. Complications that can arise after a hip operation include:

  • Infection. The risk is reduced by using antibiotics at the time of the surgery and careful sterile techniques. Infection occurs in about 1-3% of cases and requires further treatment and often surgery.
  • Blood clots. These can form in the deep veins of the leg due to reduced movement, but can be prevented using special stockings, exercise and medication.

Your surgeon can discuss these and any other risks with you.

Useful Links

Page last reviewed: 13/07/2011

It may be possible to prevent hip fractures by taking steps to prevent falls and by treating osteoporosis (weak and fragile bones).

Preventing falls

People over 65 years of age have an increased risk of falling. You can reduce your risk of falling by:

  • using walking aids, such as a crutch
  • assessing your home for hazards and making it safer
  • using exercises to improve your balance

 

Osteoporosis

If you are diagnosed with osteoporosis, follow your treatment plan. If you can improve the health of your bones, you may have a lower risk of fractures.

Hip protectors

Hip protectors are padding made of plastic shields or foam pads that are attached to specially designed underwear. These have been used to prevent hip fractures in older people, as they should reduce the impact of a fall.

It was thought that hip protectors could reduce the number of hip fractures. However, more recent research has questioned their effectiveness. It is difficult to judge their true effect, as people may avoid wearing the hip protectors if they are uncomfortable.

Research suggests that hip protectors may be useful for older people who are in nursing homes or residential care homes (homes that provide various levels of care and support). However, they are less effective for older people who remain active in their own communities.

Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.

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