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Physical Examination

Most of the time, a patient with a hip fracture will be taken by ambulance to a hospital emergency room.

At the hospital, you will be examined by either an emergency room physician or an orthopaedic surgeon. They will take a history of your injury and check to make sure you do not have injuries to other parts of your body. The doctor will also check the sensation, movement, and circulation in your lower leg.

Imaging Tests

Imaging tests will help confirm the diagnosis and provide more information about the fracture.

X-rays. X-rays provided images of dense structures, such as bone. Most hip fractures can be diagnosed with an X-ray.

Most hip fractures are visible on an X-ray.

Image courtesy of Stuart J. Fischer, MD, FAAOS

Computerized tomography (CT) scans. A CT scan will provide a detailed cross-sectional image of your hip. Your doctor may order a CT scan if X-rays do not show a fracture or to learn more about your fracture to aid in surgical planning.

Magnetic resonance imaging (MRI) scans. MRI scans are rarely needed. An MRI scan provides detailed images of both soft tissues and bone. Because it is very sensitive, an MRI can sometimes detect a small or incomplete fracture that cannot be seen on an X-ray. MRI is more commonly ordered if both X-rays and CT scans are negative and if your doctor suspects a stress fracture.

This MRI scan shows a hip fracture that was not visible on an X-ray.

Most hip fractures require surgical treatment. Only a very small group of nondisplaced fractures in healthy patients can be treated without surgery, while a separate small group of patients may be too sick to safely have surgery.

Surgical treatment is required to relieve the acute pain of the fracture and to allow the patient to get out of bed. Having surgery as soon as possible, within 24 to 48 hours (1 to 2 days) may reduce the risk of complications.

• If you are admitted to the hospital with a hip fracture, you will have preoperative testing and will most likely be seen by an internist. They will make sure that you are medically ready to have surgery.
• In some cases, you may need to be seen by a specialist, such as a heart doctor (cardiologist) or lung doctor (pulmonologist), to treat specific medical problems.
• If you have been on a blood thinner, you may need to wait for your clotting times to improve before you go to the operating room.

This process of getting a patient medically ready for surgery is called optimization. Ideally, it should be done within 48 hours, but sometimes it may take longer. Even if it does takes longer, it is better to be optimized than to rush to surgery.

Treatment for a hip fracture depends on the type and location of the fracture, as well as the age and condition of the patient.

Femoral Neck Fracture

This type of fracture is also sometimes called a subcapital or intracapsular fracture.

If a femoral neck fracture is not displaced (meaning the pieces of bone are properly aligned), the most common treatment is in-situ fixation.

In this procedure, surgical pins/screws or a plate and screw device are passed across the fracture site to hold the ball of the femur in place while the fracture heals. This procedure prevents the femoral head from dislodging or slipping off of the femoral neck, a situation that would require partial or total hip replacement. Both options provide stability to allow for immediate mobilization (getting out of bed and moving around)

Nondisplaced femoral neck fracture

In-situ pinning with three screws has been used to treat a nondisplaced femoral neck fracture.

X-ray courtesy of Stuart J. Fischer, MD, FAAOS

X-ray showing treatment of a nondisplaced femoral neck fracture using a plate and screw device.

A small number of femoral neck fractures may be treated without surgery. These are typically nondisplaced fractures in younger, healthy patients. Because there is a risk of displacement, these patients need to be monitored carefully. Non-operative treatment consists of limited or protected weightbearing with crutches for several weeks.

Patients who did not walk before surgery or have severe medical problems may also be considered for nonsurgical treatment.

Displaced fractures of the femoral neck present a more difficult problem than nondisplaced fractures. The blood supply to the head of the femur comes through a structure called the posterior capsule. The posterior capsule is often injured with a displaced femoral neck fracture, so the fracture has less chance of healing.

Displaced femoral neck fracture

Even if the fracture does heal, a condition called avascular necrosis may develop in the head of the femur. This causes damage to the bone cells, collapse of part of the femoral head, and subsequent arthritis.

For this reason, displaced fractures of the femoral neck are often treated with hip replacement.

• For elderly patients, a hemi-arthroplasty, or partial hip replacement, is typically the treatment of choice.
• In properly selected patients, there may be a benefit to total hip replacement (at the risk of increasing complications). Total hip replacement may also be considered in younger, more active patients.

Treatment of a displaced femoral neck fracture with a partial hip replacement.

X-ray courtesy of Stuart J. Fischer, MD, FAAOS

In some younger patients, it is desirable to preserve the natural femoral head rather than do a replacement. In these patients an open reduction is performed. This involves making an incision over the hip joint, putting the bone back into place, and then holding the bone with pins, screws, or another type of metal fixation.

While this procedure does carry the risks of avascular necrosis and failure to heal (nonunion), it is generally agreed that the goal is to preserve a younger person’s normal hip.

Your orthopedic surgeon will review the treatment options with you and your family.

Intertrochanteric Fracture

Intertrochanteric fractures occur below the femoral neck in a broader region between the greater and lesser trochanters. The greater trochanter is the bump you feel on the side of your hip. There may be two, three, or even more fracture fragments.

Two-part (left) and three-part (right) intertrochanteric fractures

Intertrochanteric fractures are treated surgically with either a sliding compression hip screw and side plate or an intramedullary nail.

The compression hip screw is fixed to the outer side of the bone with bone screws. A large secondary screw (lag screw) is placed through the plate into the femoral head and neck. This design allows for compression at the fracture site, increasing stability and promoting healing.

Two-part intertrochanteric fracture treated with a compression screw and side plate.

X-ray courtesy of Stuart J. Fischer, MD, FAAOS

The intramedullary nail is placed directly into the marrow canal of the bone through an opening made at the top of the greater trochanter. One or multiple screws are then placed through the nail and into the femoral head. An additional screw is placed into the bone to control rotation.

Two-part intertrochanteric fracture treated with an intramedullary nail.

X-ray courtesy of Stuart J. Fischer, MD, FAAOS

Fracture of the Greater Trochanter

Isolated fractures of the greater trochanter usually come from a low-energy household fall. While they are often painful, they usually heal without surgery. These fractures are stable and can be treated with protected weightbearing using either crutches or a walker.

An isolated fracture of the greater trochanter

If an X-ray shows an isolated fracture of the greater trochanter, it is often helpful to get a CT scan to make sure that the fracture does not extend to the intertrochanteric area.

Subtrochanteric Fracture

Subtrochanteric fractures involve the upper part of the shaft of the femur, just below the hip joint.

Subtrochanteric fracture

They are treated surgically with an intramedullary nail into the shaft of the femur and a screw placed through the nail into the femoral head.

To keep the bones from rotating around the nail or from shortening (telescoping) on the nail, additional screws may be placed at the lower end of the nail near the knee. These are called interlocking screws.

In some cases, your surgeon may choose to use a compression screw with a long side plate instead of a nail.

X-rays show treatment options for a subtrochanteric fracture: (Left) Intramedullary nail and screw, (Center) An interlocking screw has been placed at the lower end of the femur to prevent the bone from shortening. (Right) Side plate and compression screws.

Femoral Head Fracture

Femoral head fractures are rare; they account for less than 1% of all hip fractures. They usually result from a high-velocity event. Sometimes there may be an associated fracture of the hip joint socket.

• If the fracture is not displaced, it may be treated nonsurgically with limited weightbearing.
• If there is a small displaced fragment that does not involve a large part of the joint surface, the fragment may be simply removed.
• If there is a large fragment in a young active person, open reduction and fixation with screws is often done.
• In an older person, the treatment of choice is hip replacement — either partial or total — to replace the damaged femoral head.

Femoral head fracture

Pain Management

Your doctor and nurses will work with you to help reduce your pain. Typically, you will be given medicine through an IV in the first few hours after surgery. Then you will be switched to oral pain medicine. This may take the form of opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), or over-the-counter pain medication such as acetaminophen. Your doctor may also use a combination of these medications to manage pain.

Be aware that while opioids can relieve pain after surgery, their use has risks and complications. These medications can be addictive and potentially dangerous. It is therefore important to use opioids only as directed by your doctor, to use as little as possible for as short a time as possible, and to stop taking them as soon as your pain starts to improve. Your surgeon will help you with pain management during your recovery.

Rehabilitation

Many patients go home after hip fracture surgery, but some will need short-term care in a rehabilitation facility. Usually, these patients are elderly or have no caregivers at home.

• If you go to a rehabilitation facility, you will need to stay there until you can walk independently and manage your daily activities. 
• If you go directly home, you will have in-home physical therapy until you are strong enough to go to therapy at an outside facility. 
• It is important to recognize that these types of fractures often occur in elderly people, emphasizing how frail the elderly tend to be. Hip fractures may therefore be challenging for elderly patients to recover from; they often need more assistance in their daily lives and experience a stepwise decrease in their level of function after their hip fracture.

Your doctor will manage your care in the post-operative period. They will check the wound, prescribe physical therapy, and take X-rays to monitor healing.

• If you have had a procedure that includes internal fixation, your doctor will let you know whether you can bear weight immediately or have any limitations or restrictions.
• If you have a hip replacement, you can bear weight fully right away unless you are experiencing complications from surgery.

To assist doctors in the management of hip fractures in the elderly, the American Academy of Orthopaedic Surgeons has conducted research to provide some useful guidelines. These are recommendations only and may not apply to every case. For more information: Plain Language Summary - Clinical Practice Guideline - Hip Fractures - AAOS