• Hip fractures, which occur most frequently among older people, can be caused by minor falls, particularly among people with osteoporosis.
• Most people with a hip fracture cannot move the leg, stand, or walk.
• Hip fractures are diagnosed with x-rays or sometimes other imaging tests.
• Surgery is usually done, and sometimes the joint is replaced.

More than 270,000 hip fractures occur in the United States each year, with about 90% of them occurring in people older than 60. Hip fractures are more common in older people because of osteoporosis and because older people are more likely to fall. Use of some drugs increases the risk of hip fractures in older people (see Aging and Drugs). One in 3 women and 1 in 6 men who reach age 90 will fracture a hip. Hip fractures in older people can lead to life-threatening complications, such as blood clots and pneumonia. Hip fractures sometimes change how people live. For example, people who have a hip fracture may need supervised care or have to move to a nursing home.

The upper end of the thighbone (femur) has large bony bumps (trochanters) where powerful muscles attach, then a short neck, and finally a spherical head that forms the outer half of the hip joint. Most hip fractures occur just below the spherical head (femoral neck or subcapital hip fractures) or through the trochanters (intertrochanteric hip fractures).

Femoral neck hip fractures are particularly problematic because the fracture often disrupts the blood supply to the femoral head, which forms the hip joint. Without a good blood supply, the bone cannot heal and eventually collapses and dies. These fractures can be caused by minimal force, such as walking, in people with osteoporosis and may be stress fractures.

Intertrochanteric hip fractures tend to create large broken bone surfaces that cause internal bleeding. These fractures usually result from a fall or direct blow.

Symptoms and Diagnosis

Most older people with fractured hips cannot move their leg, much less stand or walk. When a doctor examines the person, the leg may appear shortened and turned outward because of the unbalanced pull of muscles. Swelling and a purplish bruise may develop because of blood leaking from the fracture. Hip fractures can cause pain in the knee, called referred pain.

An x-ray usually shows an obvious fracture and can help a doctor confirm the diagnosis. However, faint fracture lines may not be seen initially on an x-ray. Thus, when a doctor still suspects a hip fracture or the person continues to have pain and is unable to stand a day or more after a fall, magnetic resonance imaging (MRI) or computed tomography (CT) may be done.

Did You Know... Surgery is the preferred treatment for hip fractures in older people because it allows people to walk sooner and avoid serious problems that can result from staying in bed too long.

Treatment

Most people with a hip fracture are treated with surgery. If people with hip fractures are forced by their injury to stay in bed, they are at increased risk for developing serious complications, such as pressure sores, blood clots leading to pulmonary embolism, mental confusion, and pneumonia. A great benefit of surgery is that it allows the person to get out of bed and begin walking as soon as possible. Usually, the person can take a few steps with a walker 1 to 2 days after the operation. Physical rehabilitation is started as soon as possible (see Rehabilitation: Hip Fracture).

The type of surgery depends on the type of fracture.

Repairing a Fractured Hip There are two common types of hip fractures. Femoral neck or subcapital hip fractures occur in the neck of the thighbone (femur). Intertrochanteric fractures occur in the large bony bumps (trochanters) where the powerful muscles of the buttocks and legs attach. When the fracture is not too severe, metal pins can be inserted surgically to support the femoral head. This surgical procedure preserves the person's own hip joint.

Femoral neck hip fractures may be repaired with metal pins or by removing the broken pieces and replacing the head of the femur with a metal implant (partial hip replacement). An implant may be needed when the blood supply to the femoral head has been damaged.

Intertrochanteric hip fractures are treated with a sliding compression screw and side plate, which holds the bone fragments in their proper position while the fracture heals. The fixation is usually strong enough to permit people to bear weight shortly after surgery. Although the bone fragments usually heal in a couple of months, most people need at least 6 months to fully regain their original level of comfort, strength, and walking ability.

Partial Hip Replacement: If partial hip replacement is needed, doctors use special metallic implants. These implants have a polished spherical surface to match the joint socket and a strong stem to fit within the central marrow canal of the thighbone. Some prosthetic implants are secured to the bone with a rapid-setting plastic cement. Others have special porous or ceramic coatings into which the surrounding living bone can grow and bond directly.

Replacing a Hip When the topmost part (head) of the thighbone (femur) is badly damaged, it may be replaced with an artificial part (prosthesis), made of metal (usually a Moore prosthesis). This procedure is called partial hip replacement. Very rarely, the socket into which the femoral head fits (forming the hip joint) must also be replaced. The part used is a metal shell lined with durable plastic. This procedure is called total hip replacement.

After joint replacement surgery, the person usually begins walking with crutches or a walker immediately and switches to a cane in 6 weeks. However, artificial joints do not last forever. The person, especially someone who is active or heavy, may need to undergo another operation 10 to 20 years later. Joint replacement is often advantageous for older people, because the likelihood that additional surgery will be needed is very low. In addition, older people benefit greatly from being able to walk almost immediately after surgery.

Sometimes the whole joint needs to be replaced. This procedure is commonly done to treat osteoarthritis. Whole-joint replacement is rarely used to treat fractures.

Last full review/revision December 2008 by James R. Roberts, MD