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    Hip Fracture

    Orthopedic, Trauma

    Last Updated Dec 21, 2023
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    By Julian Marsden, Jonathan Bulger

    First 5 Minutes

    • Perform and document neurovascular assessment of lower limbs.
    • Determine mechanism of injury and assess for any other injuries.


    • High morbidity and mortality even with effective treatment
      • Nearly 10% mortality within 30 days post-op.
      • 80% use gait at one year post injury.
    • 3 different fracture patterns
      • Femoral neck fracture

    License: CC BY-NC-SA 3.0 DEED

        • Intracapsular fracture.
        • Higher risk of avascular necrosis, non-union than other hip fracture types.
        • Common hip fracture pattern.
      • Intertrochanteric fracture

    License: CC BY-NC-SA 3.0 DEED

        • Extracapsular fracture.
        • Common hip fracture pattern.
      • Subtrochanteric fracture

    License: CC BY-NC 3.0 DEED

        • Extracapsular fracture.
        • Less common hip fracture pattern.
        • Consider possible pathological femoral fracture secondary to bisphosphonates, denosumab or cancer.

    Diagnostic Process

    • Older patients typically present with a low energy mechanism, such as a history of fall, and sudden onset hip pain.
      • Consider a pathological fracture if pain preceded fall.
    • Younger patients typically high energy trauma.
    • Physical exam findings may include:
      • Inability to ambulate and pain on palpation.
      • Affected limb shortened, abducted, externally rotated (if fracture is displaced).
      • NB: If impacted femoral neck or incomplete fracture may present with mild discomfort with active and passive hip ROM.
        • Patients have been known to walk on fractured hips.
    • Imaging
      • Plain x-ray
        • AP hip (maximum possible internal rotation is ideal), AP pelvis, cross table lateral, full length femur if significant mechanism.
      • If high clinical suspicion, no fracture on x-ray – CT or MRI may be used to rule out occult fracture
        • MRI is preferred, but usually CT ordered initially.

    Recommended Treatment

    • Early referral to orthopedic surgery is indicated.
    • Analgesia
      • IV opioids appropriate for management.
    • Ex: Hydromorphone 0.1- 0.5 mg IV Q 1 -2 hours prn (in ED). Rarely are cases managed non-surgically;
      • Patient high risk for surgery/cannot tolerate surgery (i.e., highly comorbid).
      • Non-ambulatory at baseline.

    Criteria For Hospital Admission

    • All patients require admission.

    Criteria For Transfer To Another Facility

    • Patients require transport to a facility with an orthopedic surgery service.

    Criteria For Close Observation And/or Consult

    • Orthopedic surgery consult is required.

    Quality Of Evidence?


    Hip fractures are well studied, resources cited trials, and systematic reviews for assessment and management, though the specific surgical techniques are still debatable.


    Related Information


    Reference List

    1. Bhandari M, Swiontkowski M. Management of Acute Hip Fracture. Solomon CG, editor. N Engl J Med. 2017 Nov 23;377(21):2053–62.

    2. Blomberg J. Femoral Neck Fractures – Trauma – Orthobullets [Internet]. [cited 2023 Sep 23]. Available from: https://www.orthobullets.com/trauma/1037/femoral-neck-fractures

    3. Foster KW. Overview of common hip fractures in adults – UpToDate [Internet]. [cited 2023 Aug 6]. Available from: https://www.uptodate.com/contents/overview-of-common-hip-fractures-in-adults?search=hip%20fracture&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

    4. Karadesh M, Tarazona D. Intertrochanteric Fractures – Trauma – Orthobullets [Internet]. [cited 2023 Sep 23]. Available from: https://www.orthobullets.com/trauma/1038/intertrochanteric-fractures

    5. Weatherford B. Subtrochanteric Fractures – Trauma – Orthobullets [Internet]. [cited 2023 Sep 23]. Available from: https://www.orthobullets.com/trauma/1039/subtrochanteric-fractures


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