Hip Fracture Management in Elderly
Definition
- Hip fracture = fracture through the proximal femur (femoral neck, intertrochanteric, or subtrochanteric region) occurring after a low‑energy fall in an elderly individual (≥65 years).
- Classified radiologically as:
- Femoral neck (intracapsular) – Garden I‑IV, Pauwels angle.
- Intertrochanteric (extracapsular) – AO/OTA 31‑A1 to A3.
- Subtrochanteric – AO/OTA 31‑A4.
Epidemiology
- 1.5–2 million hip fractures worldwide per year; > 90 % occur in people > 65 y.
- In India, incidence ≈ 300 / 100 000 in women > 70 y; projected to rise 2‑fold by 2030 due to ageing population.
- Female : male ratio ≈ 3 : 1 (post‑menopausal osteoporosis).
- 30‑day mortality 5‑10 %; 1‑year mortality 20‑30 %.
Aetiology / Risk Factors
- Intrinsic: osteoporosis, osteomalacia, Paget’s disease, chronic steroid use, rheumatoid arthritis, secondary causes (hyperparathyroidism, CKD‑MBD).
- Extrinsic: low‑energy fall from standing height, environmental hazards (poor lighting, slippery floors).
- Systemic: frailty, sarcopenia, cognitive impairment, visual deficits, polypharmacy (especially sedatives).
Pathophysiology
- Osteoporotic bone has reduced trabecular mass and cortical thinning → decreased load‑bearing capacity.
- A fall transmits axial load and shear forces; in the femoral neck the impact exceeds bone strength → intracapsular fracture; in intertrochanteric region the tensile/compressive forces cause extracapsular fracture.
- Intracapsular fractures disrupt blood supply from medial femoral circumflex artery → risk of avascular necrosis (AVN).
- Fracture leads to pain, loss of weight‑bearing, immobilisation → cascade of complications (pulmonary embolism, pressure sores, delirium).
Clinical Features
- Sudden hip or groin pain after fall; inability to bear weight.
- Limb appears shortened and externally rotated (femoral neck) or shortened and internally rotated (intertrochanteric).
- Swelling, bruising over greater trochanter.
- In frail elders, may present with “silent” fracture – minimal pain, confusion, or delirium.
Investigations
| Modality | Purpose |
|---|---|
| Plain AP pelvis & lateral hip X‑ray | First‑line; identifies fracture type, displacement, and allows Garden/AO classification. |
| CT scan | Clarifies fracture pattern, especially in occult or minimally displaced fractures; guides surgical planning. |
| MRI (STIR) | Detects occult fractures when X‑ray negative; also assesses AVN risk. |
| DXA (Dual‑energy X‑ray absorptiometry) | Baseline osteoporosis assessment (usually after acute phase). |
| Laboratory panel | CBC, electrolytes, renal & liver function, calcium, phosphate, vitamin D, thyroid, PTH (to rule out secondary causes). |
| Pre‑operative assessment | ECG, chest X‑ray, ASA grading, frailty score (e.g., Clinical Frailty Scale). |
Management
General Principles (NICE Guideline NG38, 2023; AAOS Clinical Practice Guideline, 2022)
- Early surgery – within 24–48 h of admission (unless medically unstable) to reduce mortality and complications.
- Multidisciplinary care – orthopaedics, geriatrics, anaesthesia, physiotherapy, nutrition, and social services.
- Optimise medical comorbidities – correct anemia, electrolyte imbalance, manage anticoagulation, treat delirium.
Surgical Options
| Fracture Type | Preferred Fixation (2024) | Rationale |
|---|---|---|
| Femoral neck (non‑displaced, Garden I‑II) | Internal fixation – 3‑hole cannulated screws or dynamic hip screw (DHS) in selected young‑elderly (< 70 y). | Preserves native hip; lower morbidity. |
| Femoral neck (displaced, Garden III‑IV) | Arthroplasty – Hemiarthroplasty (HA) for low‑functioning; Total hip arthroplasty (THA) for active, cognitively intact patients. | Reduces re‑operation for AVN/non‑union; better functional outcome with THA in fit elders. |
| Intertrochanteric | Dynamic hip screw (DHS) for stable (A1) fractures; Intramedullary nail (PFN/IMN) for unstable (A2‑A3) fractures. | Provides stable fixation; nail offers shorter operative time and less blood loss in unstable patterns. |
| Subtrochanteric | Long intramedullary nail (proximal femoral nail) ± supplementary cerclage. | Allows load sharing across long lever arm; reduces implant failure. |
Peri‑operative care
- Antibiotic prophylaxis – cefazolin 2 g IV within 60 min of incision; repeat if surgery > 4 h.
- Thromboprophylaxis – LMWH (enoxaparin 40 mg SC daily) started 12 h post‑op, continued 35 days (or until full ambulation).
- Pain control – multimodal: acetaminophen, NSAIDs (if renal function permits), regional nerve block (fascia‑iliaca or lumbar plexus).
- Early mobilisation – weight‑bearing as tolerated (usually day 1–2) with physiotherapy; assistive device (walker/crutch).
Non‑Surgical Management (rare)
- Reserved for non‑operative candidates (severe comorbidity, end‑stage dementia) – pain control, traction, and early mobilisation as tolerated; high mortality, thus surgery is preferred whenever feasible.
Complications
| Early (≤ 30 days) | Late (> 30 days) |
|---|---|
| Surgical site infection, wound dehiscence | Avascular necrosis (intracapsular), non‑union, malunion |
| Deep vein thrombosis / pulmonary embolism | Implant failure, periprosthetic fracture (arthroplasty) |
| Delirium, urinary tract infection, pneumonia | Post‑operative hip osteoarthritis (if fixation) |
| Pressure ulcers, prolonged immobilisation | Chronic pain, reduced gait speed, loss of independence |
High‑Yield Exam Points
- Timing: Surgery within 24–48 h reduces 30‑day mortality (NICE 2023).
- Choice of arthroplasty: HA for low‑activity, THA for ambulatory, cognitively intact elders (AAOS 2022).
- Garden classification: Determines displacement; Garden III‑IV → arthroplasty.
- AO/OTA classification: Guides implant – stable intertrochanteric (31‑A1) → DHS; unstable (31‑A2/A3) → intramedullary nail.
- Blood loss: Intramedullary nails generally cause less intra‑operative blood loss than DHS in unstable fractures.
- Thromboprophylaxis duration: Minimum 35 days (NICE) or until full ambulation.
- Post‑op mobilisation: Early weight‑bearing improves functional outcome; delayed mobilisation ↑ mortality.
- Osteoporosis work‑up: DXA after fracture; start bisphosphonate/denosumab + calcium + vit D.
- Mortality predictors: Age > 80, male sex, ASA ≥ III, delayed surgery, pre‑op delirium.
Practice questions
1. An 78‑year‑old woman with a displaced Garden IV femoral neck fracture is cognitively intact and ambulates independently before the fall. According to the 2022 AAOS guideline, the most appropriate surgical option is:
- A) Closed reduction and internal fixation with three cannulated screws
- B) Hemiarthroplasty
- C) Total hip arthroplasty
- D) Dynamic hip screw
Answer: C — THA provides better functional outcome in active, cognitively intact elders with displaced intracapsular fractures.
2. Which of the following statements regarding timing of surgery for hip fracture in the elderly is correct?
- A) Surgery after 72 h reduces the risk of deep vein thrombosis.
- B) Delay beyond 48 h is associated with increased 30‑day mortality.
- C) Immediate surgery (< 6 h) is mandatory regardless of medical status.
- D) Surgery should be postponed until the patient is fully weight‑bearing.
Answer: B — Evidence (NICE 2023) shows mortality rises when surgery is delayed beyond 48 h.
3. A 70‑year‑old man sustains an intertrochanteric fracture classified as AO/OTA 31‑A2. The recommended implant according to current guidelines is:
- A) Sliding hip screw (DHS) only
- B) Long intramedullary nail
- C) Short intramedullary nail (proximal femoral nail)
- D) Cannulated screw fixation
Answer: C — Unstable intertrochanteric (A2) fractures are best managed with a short intramedullary nail for stable fixation and early mobilisation.
Want to master Hip Fracture Management in Elderly?
Ask MEDOST anything about it, take a quiz, or practise ECG strips — free.
Study Hip Fracture Management in Elderly on MEDOSTMore in Orthopaedics
AI-assisted study material for exam revision. Always confirm with standard textbooks and current guidelines; not medical advice.