High morbidity and mortality mean a sound understanding of all stages of management is important
Fractures of the hip in older people are a common and serious injury. Doctors from all specialties are likely to encounter patients with hip fractures at some point in their career—whether in primary care, the emergency department, or a hospital ward. With an ageing population, the incidence of hip fractures is rapidly increasing and represents a considerable financial cost. In the United Kingdom an estimated 70 000 hip fractures occur each year, with an annual cost of £2bn (€2.58bn; $3.1bn).
Patients presenting with hip fractures are often older with multiple comorbidities. The need for surgical intervention in the context of often complex medical and social problems means that the management of these patients is challenging. This challenge is best met through a multidisciplinary approach including surgeons, elderly care physicians, nurses, physiotherapists, occupational therapists, and social workers. The frailty of such patients is reflected in the one year death rate, which stands at about 30%. A sound understanding of the principles of diagnosis and treatment is therefore essential for all members of the team to improve outcomes and patient care.
Types of fracture and anatomy
Knowledge of hip anatomy and fracture patterns is key to understanding the principles of treatment. Broadly, fractures of the hip can be classified as intracapsular or extracapsular. Intracapsular fractures occur within the capsule and on radiographs are seen proximal to the intertrochanteric line. Extracapsular fractures can occur at the level of, or immediately below, the femoral trochanters (fig 1 1 ).
Central to decision making is whether the fracture is displaced or undisplaced. Perhaps the most widely known classification of intracapsular fractures is the Garden classification, which categorises fractures into four stages. Stages I and II are both undisplaced fractures, with stage I being an incomplete fracture and stage II being a complete fracture through the femoral neck. Stage III is a complete but moderately displaced fracture, and stage IV is a complete and severely displaced fracture. The Garden classification, although well known, is rarely used in clinical practice, however, because it has weak interobserver and intraobserver reliability.
The importance of displacement and fracture location is apparent when the blood supply to the femoral head is considered. The femoral head is principally perfused by vessels arising from the extracapsular arterial ring at the base of the femoral neck, with lesser contributions from the intraosseous metaphyseal vessels and the artery of the ligamentum teres. Blood from the intraosseous vessels and the extracapsular arterial ring travels from distal to proximal. The ligamentum teres supplies blood from proximal to distal, but makes up only a small proportion of the total blood supply. Therefore, displaced intracapsular fractures interrupt the blood supply from the ascending cervical branches of the extracapsular arterial ring, reducing the blood supply to the femoral head. This consequently increases the risk of avascular necrosis of the femoral head or fracture non-union, even if the fracture is reduced and stabilised.
Hip fractures are suspected when patients present with a history of a fall, pain in the proximal thigh, and the inability to bear weight. The absence of any these features, however, does not exclude a fracture and there should be a low threshold for requesting a pelvic radiograph. On examination, a shortened, externally rotated leg is classically seen if the fracture is displaced.
Radiological diagnosis of hip fractures is usually made on plain film. Ideally, both an anterior-posterior film and a lateral film should be obtained, although the necessity of a lateral film is debated.
Occasionally, plain film imaging does not show a fracture, particularly if it is undisplaced. A magnetic resonance image is the investigation of choice in patients in whom a fracture is still suspected clinically after a normal hip radiograph. Computed tomography is an alternative if a magnetic resonance image is not readily available.
The initial management of hip fractures follows that of any trauma patient using the advanced trauma life support protocol. This involves sequential assessment and management of airway, breathing, and circulatory compromise. When the patient has been resuscitated a focused history and thorough clinical examination are obtained, including a top to toe secondary survey to identify other injuries and assess limb neurovascular status. Neurovascular examination should include the assessment of distal pulses (popliteal, dorsalis pedis, and posterior tibial) and distal motor and sensory function (sciatic and femoral nerves, plus any evidence of “glove and stocking distribution” (ie, loss of sensation starting distally in a circumferential pattern) peripheral neuropathy). Pain levels should be appraised on arrival and reviewed regularly. Appropriate analgesia should be administered in the emergency department as a priority. Current guidelines from the National Institute for Health and Clinical Excellence (NICE) recommend the prescription of regular paracetamol every six hours with additional opioids and nerve blocks if required. Pain should be reviewed after 30 minutes and then hourly until the patient is settled on the ward. The prescription of intravenous fluids is usually needed, both to reverse losses occurring before presentation at hospital, and also to prevent dehydration while the patient is nil by mouth waiting for theatre.
The mechanism of injury should be determined in the history. In most cases this will be a fall from standing height. Attention should be given to identifying any cardiac causes of collapse that might have implications for anaesthesia. The possibility of underlying malignancy should also be considered, particularly in patients who present after no trauma or minimal trauma. A detailed social history considering pre-fracture mobility, housing type, and current domestic care arrangements is important in deciding the most appropriate surgical intervention, the goals for rehabilitation, and anticipating whether the patient will be able to return home without adaptation of their accommodation or additional domestic care.
It is important to ascertain a good history, especially about anticoagulants or antiplatelet agents. Many hospitals have their own protocols for the reversal of anticoagulation. It is now common to see older patients who are on dual antiplatelet therapy with agents such as clopidogrel in combination with aspirin. These drugs can cause considerable bleeding, leading to anaemia or haematoma formation, which can predispose to infection. Local policies should be followed with regard to the reversal of anticoagulants such as warfarin or the requirement for platelet cover for patients on clopidogrel or aspirin. 
Aside from pelvis and hip radiographs, other investigations required include an electrocardiogram, a chest radiograph, and blood tests (full blood count, electrolytes, group and save). A bone profile is often useful not only as a baseline but to identify hypocalcaemia, metabolic bone disease, or potential malignancy. Occasionally it is necessary to obtain further investigations, such as full length femoral views in patients with suspected malignancy or echocardiograms in patients with heart failure. Increasingly in the UK, orthogeriatricians are involved in the assessment of patients before surgery and will guide appropriate investigations and treatment with the aim of optimising patients quickly for surgery.
Ideally, surgery should be carried out within 48 hours of admission on a planned trauma list. The nature of the operation will be influenced by fracture site, displacement, and the patient’s functional status. NICE guidelines have been published offering recommendations on the choice of fixation method or implant to be used in particular situations (table): extracapsular fractures at or above the level of the lesser trochanter should be managed with a dynamic hip screw (fig 2 2 ). Fractures within the subtrochanteric region should receive an intramedullary nail. Displaced intracapsular fractures should be treated with a cemented arthroplasty procedure, either total hip replacement (femoral head and acetabulum replaced) or hemiarthroplasty (femoral head alone replaced). Patients who were independently mobile before their fracture, who are not cognitively impaired, and who are medically fit for anaesthesia should be offered a total hip replacement. Patients who do not fulfil these mobility and cognitive requirements should be offered a hemiarthroplasty based on a recognised total hip stem—for example, Exeter, Stanmore—and not one of the older hemiarthroplasty devices such as the Austin-Moore or Thompson (fig 3 3 ). NICE does not mention undisplaced intracapsular fractures in its guidance. Internal fixation with either cannulated screws (fig 4 4 ) or a dynamic hip screw is preferred to non-operative management of these fractures, however, which is associated with a 20% risk of non-union or fracture displacement. 
|Extracapsular, at or above the level of the lesser trochanter||Dynamic hip screw (fig 2[f2])|
|Extracapsular, subtrochanteric||Intramedullary nail|
|Displaced intracapsular||Cemented arthroplasty procedure|
|Undisplaced intracapsular||Fixation with cannulated screws (fig4[f4]) or a dynamic hip screw|
There are very few indications for non-operative management of hip fractures, because even in the immobile and palliative patient, surgery can substantially relieve pain and discomfort. Life threatening comorbidities that preclude safe anaesthesia and patient choice are the main contraindications to operative management.
Postoperatively, further consideration should be made about the aetiology of the fracture and secondary prevention of fragility fractures. Patients should therefore undergo a falls assessment and be started on an antiresorptive treatment, such as a bisphosphonate or strontium ranelate. Common risk factors for falls, including hypotension, polypharmacy, diabetes, and Parkinson’s disease, should be sought and modified if possible. Consideration should be made about possible pathological causes of hip fracture, such as multiple myeloma or metastatic disease arising from lung, breast, kidney, thyroid, or prostate primaries.
Ideally, patients should undergo early mobilisation (<24 hours) with full weight bearing to reduce the risk of pressure ulcers, thromboembolism, and other medical complications.
Given the high levels of morbidity and mortality associated with hip fractures a sound understanding of all stages of management is important. Greater knowledge and adherence to local and national guidelines will continue to improve outcomes for patients.
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1Ealing Hospital, Uxbridge Road, Southall, Middlesex UB1 3HW, UK , 2St Mary’s Hospital, Praed Street, London W2 1NY, UK
Correspondence to: firstname.lastname@example.org
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
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Cite this as: Student BMJ 2012;20:e4838