Hip Fractures: A Major Challenge in Ageing Populations 🦴

Let’s talk about hip fractures—a serious and often life-altering injury, especially for our elderly patients. In Australia, hip fractures are one of the leading causes of hospital admissions in people over 65. They’re not just painful—they’re a sentinel event, often marking a turning point in a patient’s independence, mobility, and overall health.

But what exactly is a “hip fracture”? And why does it carry such weight in clinical practice?

Let’s break it down and see how we can make a difference.

🔬 Anatomy of the Hip Joint: Why Location Matters

The hip is a ball-and-socket joint, where the femoral head (the ball) articulates with the acetabulum (the socket) of the pelvis. The femoral neck connects the head to the shaft and is a structurally vulnerable zone—especially in older adults with osteoporosis.

Critically, the blood supply to the femoral head comes primarily from the medial and lateral circumflex femoral arteries, which travel through the femoral neck. When this area fractures, these vessels can be torn, leading to avascular necrosis (AVN)—death of bone tissue due to lack of blood.

🧠 Clinical insight:

This is why intracapsular fractures often require joint replacement rather than fixation—the bone may not heal due to compromised perfusion.

🦴 Types of Hip Fractures

Hip fractures are classified based on their anatomical location:

🔹 Intracapsular Fractures – Occur within the joint capsule.

Hip fractures are classified by location:

🔹 Intracapsular Fractures

Occur within the joint capsule and include:

• Femoral head fractures – Rare, usually from high-energy trauma

• Femoral neck fractures – Common in older adults with osteoporosis

⚠️ Complication: High risk of AVN due to disrupted blood supply. Healing is unpredictable, and surgical replacement is often preferred.

🔹 Extracapsular Fractures

Occur outside the capsule and include:

• Intertrochanteric fractures – Between the greater and lesser trochanters

• Subtrochanteric fractures – Below the lesser trochanter

⚠️ Complication: Lower risk of AVN, but these fractures can be mechanically unstable and challenging to fix.

🧠 Think like a clinician:

Why might a younger patient with an intertrochanteric fracture be treated differently than an older patient with a displaced NOF fracture?

📊 Epidemiology and Risk Factors

Hip fractures are a major public health issue:

• 📈 ~30,000 hip fractures occur annually in Australia

• 📆 Most occur in people over 75

• 🚺 Women are at higher risk due to postmenopausal bone loss

Key risk factors include:

• Osteoporosis – The #1 risk factor

• Falls – Often from standing height

• Poor balance, muscle weakness, medications (e.g., sedatives, antihypertensives)

• Environmental hazards – Loose rugs, poor lighting

• Low BMI, smoking, alcohol, vitamin D deficiency

🧠 Clinical reasoning:

If your patient has a hip fracture, what modifiable risk factors could you address to prevent the next one?

🚑 Sequelae of Hip Fractures

Hip fractures often mark a decline in health and independence:

• ⚠️ Mortality: Up to 30% die within 1 year

• ⚠️ Morbidity: Many lose mobility, require long-term care, or experience chronic pain

• 🧠 Psychological impact: Depression and anxiety are common

• 🩺 Future fracture risk: One fracture often predicts another

🧠 Patient-centred care:

How might you support a patient emotionally and socially after a hip fracture?

🏥 Management: From Emergency to Rehabilitation

Managing a hip fracture isn’t just about fixing the bone—it’s about restoring function, preventing complications, and supporting the patient through a vulnerable period. The approach is multidisciplinary and spans several phases:

🔹 Acute Management

💊 Pain Control

Pain from a hip fracture can be severe and immobilising. Initial management includes:

• Opioids for systemic relief

• Regional nerve blocks (e.g., fascia iliaca block) to reduce opioid requirements and improve comfort

• Paracetamol and NSAIDs may be used cautiously depending on renal function and bleeding risk

🔪 Surgical Intervention

Most hip fractures require surgery, ideally within 48 hours to reduce mortality and improve outcomes. The choice of procedure depends on fracture type and patient factors:

• Internal fixation (e.g., screws, plates, nails) is used for stable extracapsular fractures

• Hemiarthroplasty replaces the femoral head in displaced intracapsular fractures

• Total hip replacement may be considered in active, cognitively intact patients with good pre-fracture mobility

🚨 Preventing Complications

Hip fracture patients are at high risk for hospital-acquired complications. Key strategies include:

• VTE prophylaxis

• Low molecular weight heparin (LMWH) or mechanical compression devices

• Continued for several weeks post-op depending on mobility and bleeding risk

• Delirium prevention

• Avoid unnecessary medications (especially anticholinergics and sedatives)

• Maintain hydration, nutrition, and orientation

• Minimise sleep disruption and support sensory aids (glasses, hearing aids)

🔹Post-operative care

🏃 Early Mobilisation

Getting patients out of bed within 24–48 hours is critical. It reduces the risk of:

• Pneumonia

• Pressure injuries

• Venous thromboembolism

• Muscle wasting and deconditioning

Mobilisation is guided by physiotherapists and tailored to the patient’s surgical procedure and baseline function.

🧑‍🤝‍🧑 Multidisciplinary Rehabilitation

Recovery doesn’t end at discharge. It involves:

• Physiotherapy to rebuild strength and gait stability

• Occupational therapy to assess home safety and support activities of daily living

• Social work to coordinate community services, equipment, and carer support

• Geriatric review to optimise medical management and prevent readmission

🔹Secondary prevention

🦴 Osteoporosis Management

A hip fracture is often the first sign of underlying bone fragility. Secondary prevention includes:

• Bisphosphonates (e.g., alendronate) to reduce future fracture risk

• Calcium and vitamin D supplementation

• Endocrine review if secondary causes (e.g., hyperparathyroidism) are suspected

• Monitoring adherence and side effect

🚶 Falls Prevention

Preventing the next fall is just as important as treating the fracture. Strategies include:

• Medication review to reduce sedatives and hypotensives

• Strength and balance training

• Vision and hearing checks

• Home safety assessments to remove hazards like loose rugs or poor lighting

• Referral to falls clinics or community programs

🩻 Screening and Prevention BEFORE the fracture

Preventing hip fractures means thinking upstream—spotting risk factors early and intervening before the fall happens. This is where medicine meets public health.

🔍 Bone Health Screening

📉 DEXA Scans (Dual-energy X-ray Absorptiometry)

Used to measure bone mineral density (BMD), especially in:

• Women ≥65 and men ≥70

• Postmenopausal women and men >50 with risk factors (e.g., prior fracture, corticosteroid use, low BMI)

• Patients with diseases or medications affecting bone metabolism

📊 FRAX Tool

A validated calculator that estimates 10-year probability of hip and major osteoporotic fractures. It integrates:

• Age, sex, BMI

• Prior fractures

• Parental hip fracture

• Smoking, alcohol use

• Secondary osteoporosis and glucocorticoid use

🚶‍♂️ Falls Risk Assessment

Falls are the leading cause of hip fractures in older adults. Screening should be routine in primary care and hospital settings:

• Timed Up and Go (TUG) test

• Gait and balance assessments

• Medication review (especially sedatives, antihypertensives)

• Vision and hearing checks

• Environmental hazards (e.g., stairs, rugs, poor lighting)

❗ Why This Matters: Beyond the Bone

Hip fractures are sentinel events. They often mark a turning point in an older person’s life—loss of independence, increased mortality, and strain on families and health systems.

You’re not just treating fractures—you’re preventing them. 

Your impact spans:

✅ Prevention

• Educating patients on bone health and fall safety

• Advocating for screening and early intervention

• Supporting public health initiatives targeting frailty and ageing

✅ Early Diagnosis

• Recognising subtle signs of osteoporosis or frailty

• Using tools like FRAX and DEXA proactively

• Identifying high-risk medications and comorbidities

✅ Management & Rehabilitation

• Coordinating multidisciplinary care

• Supporting recovery and return to function

• Preventing recurrence through secondary prevention

By understanding hip fractures through the lens of prevention, acute care, and rehabilitation, you’re not just learning to treat a broken bone—you’re preparing to restore dignity, independence, and quality of life for some of your most vulnerable patients.