Hip Fracture

What is a hip fracture?

A hip fracture is more than a broken bone. If you are older, breaking your hip can mean a major change in your life. You will likely need surgery, and it can take as long as a year to recover. But you can get back to normal with activity, physical therapy, and support.

Most hip fractures happen to people who are 65 or older. If you are in this age group, you need to be extra careful to avoid falls. Most people break their hip near the upper part of the thighbone (femur) . It usually happens near where the thighbone fits into the hip joint.

What causes hip fractures?

Falls cause most hip fractures in older adults. As you get older, your bones naturally lose some strength and are more likely to break, even from a minor fall. Children and young adults are more likely to break a hip because of a bike or car accident or a sports injury.

Hip fractures are most common in older women.¹ This is true for several reasons. Men naturally have stronger bones than women. And when women go through menopause, they lose estrogen. This makes it more likely that they will develop osteoporosis, a disease that causes bones to thin. Osteoporosis greatly increases the risk of a hip fracture.

Other things that increase your risk of breaking your hip include:

• Your family history. Being thin or tall or having family members who had fractures later in life increases your risk.
• Poor eating habits. Not getting enough calcium and vitamin D can weaken bones.²
• Not being active. Weight-bearing exercise, such as walking, can help keep bones strong.³
• Smoking.
• Having certain medical problems, such as Ménière's disease or arthritis.

What are the symptoms?

It is hard to miss the symptoms of a hip fracture. You will have severe pain in your hip or lower groin area. You probably will not be able to walk or put any weight on your leg.

These symptoms would be most likely after a fall. But if you have very thin bones from osteoporosis or another problem, you could break your hip without falling. In rare cases, people have only thigh or knee pain. They may be able to walk.

How is a hip fracture diagnosed?

Doctors use X-rays to diagnose a broken hip. If your doctor thinks that you have a fracture but cannot see it on an X-ray, you may need an MRI, a CT scan, or a bone scan.

How is it treated?

You will probably need surgery to fix your hip. Surgery usually works well, but you will need to be patient. Getting better can take a long time, and you may never be able to get around as well as you could before.

The type of surgery you have will depend on where the break is and how bad it is. Your doctor may put metal screws, pins, or a rod in your hip to fix the break. Or you may need to have all or part of your hip replaced.

Your doctor will want you to start moving as soon after surgery as you can. This will help prevent problems such as pneumonia, blood clots, and bed sores. These things may happen because you have to stay in bed so long.

After your surgery, it will be hard for you to do things yourself. You will need to go to a nursing home or rehabilitation center for a while after your surgery. But the more active you can be in your care, the faster you will get better.

How can I prevent a hip fracture?

There are many things you can do to prevent a hip fracture. One of the most important is to prevent osteoporosis. This disease can happen to men or women, but it is more common in women.

To slow or prevent osteoporosis:

• Get plenty of calcium and vitamin D. Some women may want to take estrogen after menopause.
• Eat foods high in calcium. Milk, cheese, yogurt, and other dairy foods have lots of calcium. Dark green vegetables, some seafood, and almonds are also good. If you want to take calcium pills, talk to your doctor about how much you need to take.
• Avoid alcohol, and do not smoke.
• Do weight-bearing exercise that puts pressure on bones and muscles. Walking is a good choice.

Preventing falls is also very important.

• Arrange furniture so that you will not trip on it.
• Get rid of throw rugs, and move electrical cords out of the way.
• Put grab bars in showers and bathtubs.
• Outside of your home, avoid icy or snowy sidewalks.
• Wear shoes with sturdy, flat soles.

Frequently Asked Questions

The most common symptom of hip fracture is severe pain in the hip or lower groin. Your leg may be rotated to the outside, feel more comfortable when moved away from your other leg, and be a little shorter than the other leg. You usually can't walk or even put weight on the injured leg. However, in rare cases, there may be only thigh or knee pain. Walking may still be possible, although painful, with impacted fractures, where the ball at the top of the thighbone is pushed down onto the rest of the thighbone.

You usually notice symptoms after a fall, but a fracture can also occur without a fall, especially if the bone has been thinned through osteoporosis or other health conditions.

Hip fractures usually are diagnosed with a physical exam and X-rays. Signs of hip fracture include extreme pain, being unable to move the leg, and the leg being shorter than the other and rotated to the outside.

In some cases a fracture is not visible on the initial X-ray (an occult fracture), but your doctor will still suspect a hip fracture because of your hip pain or recent fall. In these cases, an MRI scan (magnetic resonance imaging scan, which provides better images of bone and soft tissues), a CT scan (another way of providing more specific images than X-ray), or a bone scan (which involves injecting a dye, then taking images that show slight fractures) may be done. Fractures that were not clearly visible on an X-ray may show up on an MRI, a CT scan, or a bone scan.

Women who have been through menopause and have a hip fracture also may have osteoporosis or be at a higher risk for it. A bone mineral density test for osteoporosis may provide early detection and lead to treatment that can help prevent future fractures.

The level of a chemical in the blood called homocysteine has been shown to predict the risk of fractures associated with osteoporosis. This can be evaluated through a blood test and is treated by getting adequate folic acid.^{4, 5}

To prevent hip fractures, health professionals should ask older people at least once a year whether they have fallen. If a single fall has occurred, a simple test should be done to assess the risk of more falls. Your health professional will watch you stand up from a chair without using your arms, walk several paces, and return. If you have any difficulty or unsteadiness, you need further assessment. This includes a detailed medical history, a review of your medications, and an examination of vision, balance, and muscle strength.⁶

The goal of treatment for hip fractures is to allow you to do, without pain, most of the things you did before your fracture. The most common and almost always the best treatment for a hip fracture is surgery. Surgery helps ensure that the bones are lined up to heal correctly.

Once your hip fracture is diagnosed, you may be placed in gentle skin traction until surgery.⁷ Skin traction attaches a light weight to your leg using tape, straps, or a special boot, and this weight provides a constant pull on your leg. The idea is to gently separate the fracture site to decrease pain and muscle spasm. It may also help keep your fractured bone in place until surgery.

Surgery is done as soon as possible after a diagnosis of hip fracture, usually within 24 hours. However, in some cases, surgery may be delayed for 1 to 2 days for treatment of other medical problems (such as dehydration) to help reduce complications from surgery.^{8, 9}

There are different types of surgery for hip fractures, depending on the location of the break, the position of the bone fragments (degree of displacement), and your age. Surgery for a hip fracture may include one of the following:

• Internal fixation. Internal fixation involves stabilizing broken bones with surgical screws, rods, pins, or plates. This type of surgery is usually used in people who have fractures in which the bones can be properly aligned.
• Arthroplasty. Arthroplasty involves replacing part or all of the joint with artificial (usually metal) parts. A partial hip replacement may be done to replace the broken upper part of the thighbone (femur) with artificial parts. In some cases a total hip replacement can be done if the hip joint area was already damaged before the fracture by arthritis or an injury and the joint was not functioning correctly. Additionally, arthroplasty is often done for femoral neck fractures when the fractured bones cannot be properly aligned.

Some surgeons are now performing minimally invasive hip replacement surgery. This means they use a smaller incision in order to minimize bleeding, healing time and scar formation. However, there may be a greater chance of complications such as infection, nerve damage, and poor positioning of the hip replacement components.¹⁰ The surgery looks promising, but it requires a very skilled and experienced surgeon, and there are few studies comparing it to standard procedures at this time. Until risks and long-term benefits are studied, there may be a risk in choosing a less experienced surgeon to do minimally invasive surgery and leave a smaller scar, instead of an experienced surgeon who will do a standard procedure.^{11, 12}

Reduction (getting the bone lined up correctly) and internal fixation (stabilizing broken bones) often are done on younger, active people, while arthroplasty—hip replacement surgery—often is done on older, less active adults. In deciding what method to use for repairing a hip fracture, your surgeon will consider the type of fracture, your age and activity level, and also the possible trade-offs. Research on displaced hip fractures (where the bones are not aligned) shows that, in the long term, total hip replacements may need to be redone less often, but there is also more time in surgery, a greater chance of infection, and possibly a greater chance of death.¹³

Surgery usually is the most effective treatment for a hip fracture, although in most cases you may not regain all of the mobility that you had before the hip fracture. In general, if you were healthy and active before the fracture, then you will recover faster after surgery than a person who was not. If you have other health problems and have not stayed active, there is a greater chance of complications after surgery.

In rare cases, surgery is not done—for example, in people who are at high risk for complications during or after surgery and who may not benefit significantly from surgery, such as those who were unable to walk before the hip fracture and who have minimal pain. In these cases, pain relievers are given.¹⁴

What to expect after surgery

Right after surgery for a hip fracture, you will have medicine to control pain and perhaps medicine to prevent blood clots (anticoagulants). You may have a catheter so you don't have to get out of bed to urinate. You may also have a compression pump or compression stocking on your leg, which squeezes your leg to keep the blood circulating and to help prevent blood clots, and a cushion between your legs to keep your hip in the correct position. It is not unusual to have an upset stomach or feel constipated, so talk with your doctor or nurse if you don't feel well.

Your health professional may teach you to do simple breathing exercises to help prevent congestion in your lungs while your activity level is decreased. You may also learn to move your feet up and down to flex your muscles and keep your blood circulating, and begin to learn about how to keep your hip in the right position while you move in bed and get out of bed.

It is very important to start moving around soon after surgery. This will speed recovery and reduce complications. On the first day after surgery, you will usually be moved out of bed into a chair for a short time, and you will probably begin light exercises on the second day after surgery.

You usually will stay in the hospital for about a week after surgery. Often, you may be transferred to an extended-care facility for additional rehabilitation before going home and so that help is available for daily activities, such as showering. You will probably need a walking aid—a walker, cane, or crutches—for several months, and full recovery may take up to a year. For more information on using walking aids, see:

• Using a walker.
• Using crutches.
• Using a cane.

There are many issues to consider after hip surgery. Older adults often need extensive care, including physical therapy and help with cooking, taking medicine, and personal care. Anticoagulant medications are prescribed to reduce the risk of blood clots and associated stroke, pulmonary embolism, or thrombophlebitis. You will probably keep taking this medicine until you are walking frequently and well, often at least 3 weeks.

After hip fracture surgery, your doctor will encourage you to participate in a rehabilitation program. Recent research shows that 6 months of outpatient rehabilitation that includes strength training can improve quality of life and decrease disability.¹⁵ Following a rehabilitation program is very important; it will speed recovery and allow you to return to daily activities sooner.

Prevention

There are steps you can take to help prevent a hip fracture.

Keep your bones strong:

Eating a nutritious diet with adequate calcium and vitamin D, which helps your body absorb calcium, can help strengthen your bones.

• The recommended daily calcium intake for adult men and women is between 1,000 and 1,200 mg per day.² All women older than 65, as well as women older than 51 who are not taking estrogen replacement therapy, need 1,500 mg of calcium each day.¹⁶ Women who do not get this amount of calcium from food each day may take calcium supplements. Calcium is found in dairy products such as milk, cheese, and yogurt; dark green, leafy vegetables such as broccoli; and other foods.
• The National Osteoporosis Foundation recommends 400 to 800 IU of Vitamin D per day. Do not take more than 800 IU per day unless your doctor prescribes it, since large doses of vitamin D may be harmful.² You can get the amount of vitamin D you need each day if you drink at least one glass of milk or eat other dairy products that have vitamin D added (fortified). You also will get the amount of vitamin D you need if you are outside in sunlight for at least 15 minutes each day.

Recent studies show that calcium and vitamin D supplements will not prevent fractures in people who already have risks of fracture such as low body weight or previous fractures.^{17, 18} However, getting enough calcium and vitamin D over your lifetime will help you have stronger bones as you age.

Exercising and staying active help maintain bone strength. Weight-bearing exercises such as walking, jogging, and light weight training help to minimize bone loss. Talk to your doctor about an exercise program that is right for you. Begin slowly, especially if you have been inactive.

• A recent study revealed that moderate physical activity, such as walking, was associated with a substantially lowered number of hip fractures in postmenopausal women.³

Talk to your doctor about taking hormone replacement therapy or other medicines if you are at risk for osteoporosis. Some doctors recommend hormone therapy for osteoporosis, although its risks and benefits should be considered. Other medications such as bisphosphonates, including alendronate (Fosamax) and risedronate (Actonel); raloxifene (Evista); and calcitonin (Calcimar or Miacalcin) are also used to prevent or treat osteoporosis. Studies show that these medicines, the bisphosphonates in particular, significantly reduced the risk of hip fracture in older women with osteoporosis.¹⁹ For more information, see the topic Osteoporosis.

• Don't drink more than 1 alcoholic drink per day. People who drink more than this may be at higher risk for osteoporosis. Alcohol use also increases your risk of falling and breaking a bone.
• Don't smoke. Smoking puts you at a higher risk for developing osteoporosis and increases the rate of bone thinning once it starts.

For more information, see the topics Fitness and Healthy Eating.

Avoid falls:

Almost all hip fractures happen because of a fall. Things that increase your chance of falling include:

• Having poor balance and coordination.
• Having weakness in one or both legs.
• Using certain medications that may cause sleepiness, weakness, or dizziness.
• Having vision problems.
• Drinking too much alcohol.
• Feeling confused or having impaired reasoning (caused by age or conditions such as dementia).

You can reduce your risk for falls by:

• Removing anything in your house that may cause you to fall. Household hazards that can cause falls include slippery floors, cords, poor lighting, cluttered walkways, furniture placement that does not allow a clear pathway for walking, and throw rugs.
• Using nonslip mats and grab bars in the bathtub and shower.
• Making sure stairways have handrails; having rails on both sides of the stairs is best.
• Making sure you have enough light to see obstacles or pets as you move around your home.
• Exercising to help maintain strength and balance.
• Taking medications only as directed and periodically reviewing medications with your primary care doctor, especially if you have more than one health professional. Some medications, such as sleeping pills or pain relievers, can increase your risk of falling.
• Wearing low-heeled shoes that fit well.
• Using walking aids correctly.

For more information, see the topic Preventing Falls.

Hip protectors:

Hip protectors look like a girdle or underwear with pads on both hips to help reduce the force of a fall. Recent studies show that external hip protectors reduced hip fractures by 54% when used by people age 70 or older who had one or more risk factors for hip fracture. While hip protectors were effective in reducing the number of hip fractures, many people in the study refused to wear them.²⁰ Another study concluded that hip protectors did not prevent hip fractures in a fall.²¹ Hip protectors may be most useful for people in nursing homes or other institutions.

To help you recover from hip fracture surgery, your doctor will recommend a rehabilitation (rehab) program based on what part of your hip was fractured and the type of surgery done to repair it. A rehab program will include exercises to help you regain your strength and your ability to move around, retraining in simple daily activities, and ideas for staying active. Your doctor may recommend that you:

• Begin balance training (with a physical therapist from your hospital or local community center).
• Avoid movements that may strain your hip (or your new artificial hip parts).

After hip fracture surgery, you may need to learn new ways to do simple daily activities.

• You will probably need to use a walking aid (such as a walker, cane, or crutches) for several months. For more information on how to use walking aids, see:
  • Using a walker.
  • Using crutches.
  • Using a cane.
• Cooking and other simple daily activities, such as bathing, may be difficult for you to do alone. There are devices such as dressing aids, raised toilet seats, and handrails that may be helpful for you. Your local chapter of the Arthritis Foundation or a medical supply company may be able to help you find assistive devices in your area.
• You may need to make changes to your home to reduce your risk for falls. Household hazards that can cause falls include slippery floors, cords, poor lighting, cluttered walkways, furniture placement that does not allow a clear pathway for walking, and throw rugs.

Take care of yourself:

• Stay active, and exercise a little every day.
• Eat a nutritious diet.
• Limit alcohol use.
• Don't smoke.
• Take the correct medication at the correct time.
• Get your eyes checked on a regular basis.

Online Resource

Organizations

• Hip Problems and Injuries, Age 11 and Younger
• Hip Problems and Injuries, Age 12 and Older
• Osteoporosis

Citations

1. Cummings SR, Melton LJ III (2002). Epidemiology and outcomes of osteoporotic fractures. Lancet, 359(9319): 1761–1767.

2. National Osteoporosis Foundation. Prevention: Calcium and Vitamin D. Available online: http://www.nof.org/prevention/calcium.htm.

3. Feskanich D, et al. (2002). Walking and leisure-time activity and risk of hip fracture in postmenopausal women. JAMA, 288(18): 2300–2306.

4. Van Meurs JBJ, et al. (2004). Homocysteine levels and the risk of osteoporotic fracture. New England Journal of Medicine, 350(20): 2033–2041.

5. McLean RR, et al. (2004). Homocysteine as a predictive factor for hip fracture in older persons. New England Journal of Medicine, 350(20): 2042–2049.

6. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (2005). Falls and Hip Fractures Among Older Adults. Available online: http://www.cdc.gov/ncipc/factsheets/falls.htm.

7. Smith WR, et al. (2003). Musculoskeletal trauma surgery. In HB Skinner, ed., Current Diagnosis and Treatment in Orthopedics, 3rd ed., 145–154. New York: Lange Medical Books/McGraw-Hill.

8. Huddleston JM, Whitford KJ (2001). Medical care of elderly patients with hip fractures. Mayo Clinical Proceedings, 76(3): 295–298.

9. Orosz GM, et al. (2004). Association of timing of surgery for hip fracture and patient outcomes. JAMA, 291(14): 1738–1743.

10. Howell JR, et al. (2004). Minimally invasive hip replacement: Rationale, applied anatomy, and instrumentation. Orthopedic Clinics of North America, 35(2): 107–118.

11. Goldstein WM, Branson JJ (2004). Posterior-lateral approach to minimal incision total hip arthroplasty. Orthopedic Clinics of North America, 35(2): 131–136.

12. American Academy of Orthopedic Surgeons (2004). Minimally Invasive Hip Replacement. Available online: http://orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=471&topcategory=Hip.

13. Bhandari M, et al. (2003). Internal fixation compared with arthroplasty for displaced fractures of the femoral neck. Journal of Bone and Joint Surgery, 85-A(9):1673–1681.

14. Greene WB, et al. (2001). Fracture of the proximal femur. In Essentials of Musculoskeletal Care, 2nd ed., pp. 312–314. Rosemont, IL: American Academy of Orthopaedic Surgeons and American Academy of Pediatrics.

15. Binder EF, et al. (2004). Effects of extended outpatient rehabilitation after hip fracture: A randomized controlled trial. JAMA, 492(7): 837–846.

16. National Institutes of Health, Osteoporosis and Related Bone Diseases National Resource Center (2000). Osteoporosis overview. Available online: http://www.osteo.org/osteo.html.

17. Porthouse J, et al. (2005). Randomised controlled trial of calcium and supplementation with cholecalciferol (vitamin D₃) for prevention of fractures in primary care. BMJ, 330(7498): 1003.

18. Grant AM, et al. (2005). Oral vitamin D₃ and calcium for secondary prevention of low-trauma fractures in elderly people (Randomised evaluation of calcium or vitamin D, RECORD): A randomised placebo-controlled trial. Lancet, 365(9471): 1621–1628.

19. Ettinger MP (2003). Aging bone and osteoporosis: Strategies for preventing fractures in the elderly. Archives of Internal Medicine, 163(18): 2237–2246.

20. Kannus P, et al. (2000). Prevention of hip fracture in elderly people with use of a hip protector. New England Journal of Medicine, 343(21): 1506–1513.

21. Van Schoor NM, et al. (2003). Prevention of hip fractures by external hip protectors: A randomized controlled trial. JAMA, 289(15): 1957–1962.

Other Works Consulted

• Fiechtner JJ (2003). Hip fracture prevention. Postgraduate Medicine, 114(3): 22–32.

• Gillespie W (2001). Hip fracture. Clinical Evidence (7): 992–1013.

• Mercier LR (2000). Fractures of the hip. In Practical Orthopedics, 5th ed., pp. 172–176. St. Louis: Mosby.

• Morris AH, Zuckerman JD (2002). National consensus conference on improving the continuum of care for patients with hip fracture. Journal of Bone and Joint Surgery, 84-A(4): 670–674.

• Osteoporosis Prevention, Diagnosis, and Therapy. NIH Consensus Development Conference Statement, vol. 17, no. 1 (2000 March 27–29).

• Rudman N, McIlmail D (2000). Emergency department evaluation and treatment of hip and thigh injuries. Emergency Medicine Clinics of North America, 18(1): 29–66.

• Youm T, et al. (1999). Do all hip fractures result from a fall? American Journal of Orthopedics, 28(3): 190–194.

Author:	Shannon Erstad, MBA/MPH Ellie Rodgers	Last Updated May 26, 2005
Medical Review:	Patrice Burgess, MD - Family Medicine Kathleen Romito, MD - Family Medicine David Bardana, MD, FRCSC - Orthopedic Surgery/Sports Medicine
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