A hip fracture is a break of the upper end of the femur. In older people it usually follows a simple fall onto the side and occurs on a background of osteoporosis; in younger patients it takes high-energy trauma. It is one of the few orthopaedic injuries in which the timing of surgery has a direct effect on survival.
Intracapsular (femoral neck) fractures occur within the hip capsule and may disrupt the blood supply to the femoral head, risking non-union and avascular necrosis. Extracapsular fractures — intertrochanteric and subtrochanteric — occur below the capsule, where the blood supply is good and healing is reliable but bleeding is greater. The distinction determines the operation.
Severe groin or hip pain after a fall, inability to bear weight or lift the leg, and a leg that lies shortened and externally rotated. Impacted or undisplaced fractures can be deceptive: the patient may still walk with pain. Where clinical suspicion is high and radiographs look normal, MRI or CT is required, because a missed fracture will displace.
Non-operative treatment means prolonged immobility, with a high risk of pneumonia, pressure sores, thromboembolism, delirium and loss of independence. Surgery within twenty-four to forty-eight hours, once the patient is medically optimised, is associated with lower complication rates, shorter hospital stay and better one-year survival. Delay is justified only to correct a reversible medical problem such as anticoagulation or severe anaemia.
Undisplaced femoral neck fractures are fixed with cannulated screws or a sliding hip screw. Displaced femoral neck fractures in older patients are treated by replacement: hemiarthroplasty for lower-demand patients, and total hip replacement for active, independent patients or those with pre-existing arthritis, which gives better function and less residual pain. Intertrochanteric and subtrochanteric fractures are stabilised with an intramedullary nail or a sliding hip screw. Where replacement is performed, the ASI approach preserves the abductor muscles and supports early mobilisation.
Mobilisation begins on the first post-operative day. Hospital stay is typically four to seven days, followed by rehabilitation at home or in a facility. Walking aids are needed for six to twelve weeks after fixation and for a shorter period after replacement. Recovery of pre-injury function takes three to six months and is not achieved by every patient, which is why rehabilitation, nutrition and fall prevention matter as much as the operation.
A hip fracture is a sentinel event for osteoporosis. Bone density assessment, vitamin D and calcium, bone-protective medication where indicated, a review of medicines that cause dizziness, correction of vision and a home hazard assessment substantially reduce the risk of a second fracture.
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