Topic Overview

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. Activity and physical therapy can help you get your strength and mobility back. You are likely to need support from family or a caregiver as you recover.

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.

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

• Being female.
• Your family history—being thin or tall or having family members who had fractures later in life.
• Poor eating habits. Not getting enough calcium and vitamin D can weaken bones.
• Not being active. Weight-bearing exercise, such as walking, can help keep bones strong.
• Smoking.
• Medical conditions that cause dizziness or problems with balance, or conditions such as arthritis that can interfere with steady and safe movement.
• Taking certain medicines that may lead to bone loss.

What are the symptoms?

It is hard to miss the symptoms of a hip fracture. You will most likely 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 will probably 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, a metal plate, 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 may 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 you 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.
• Be sure you have good lighting where you are walking.
• Put grab bars in showers and bathtubs.
• Outside of your home, avoid icy or snowy sidewalks.
• Wear shoes with sturdy, flat soles.
• Get your eyes checked.
• Avoid too much alcohol.
• Exercise to help maintain strength and balance.
• Take medicines only as directed and periodically review your medicines with your primary care doctor, especially if you have more than one doctor. Some medicines, such as sleeping pills or pain relievers, can increase your risk of falling.

Frequently Asked Questions

Learning about fractured hips:	What is a hip fracture? What causes hip fractures? What are the symptoms of a hip fracture? What increases my risk for a hip fracture? Why do women have more hip fractures than men? What can I do to prevent a hip fracture?
Being diagnosed:	How is a hip fracture diagnosed?
Getting treatment:	How is a hip fracture treated? Will I need surgery? What can I do to treat my hip fracture after I am back home?

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	Aging well: Making your home fall-proof

Symptoms

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. But 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 typically 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.

Exams and Tests

Hip fractures usually are diagnosed with a physical exam and X-rays. Signs of hip fracture include pain in the groin, thigh, and knee, 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 first X-ray. But your doctor will still suspect a hip fracture because of your hip pain or recent fall. In these cases, your doctor may suggest other tests, such as:

• An MRI, which provides better images of bone and soft tissues.
• A CT scan, another way of getting more specific images than X-ray.
• A bone scan, which involves injecting a dye, then taking images that show hairline fractures (the bone is cracked, but all pieces are still in place).

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.

To prevent hip fractures, doctors 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 doctor will watch you stand up from a chair without using your arms, walk several paces, and return (called the "get up and go test"). If you have any trouble or unsteadiness, you need further assessment. This includes a detailed medical history, a review of your medicines, and an examination of vision, balance, and muscle strength.

Treatment Overview

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 make sure that the bones are lined up to heal correctly.

After your hip fracture is diagnosed, you may have a pillow placed under the knee of your injured leg. Or you may be placed in gentle skin traction to help keep you more comfortable until surgery. ¹ 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.

Surgery is done as soon as possible after a diagnosis of hip fracture, often within 24 hours. Having surgery right away can help shorten your stay in the hospital and may decrease pain and complications. ² But in some cases, surgery may be delayed for 1 to 2 days for treatment of other medical problems, such as heart or lung conditions, so surgery will be less risky.

There are different types of surgery for hip fractures, depending on the location of the break, the position of the bone fragments, 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, or plates. This type of surgery is usually for people who have fractures in which the bones can be properly aligned.
• Hip replacement surgery (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 working correctly. Arthroplasty is often done for femoral neck fractures when the blood supply to the top of the thighbone is damaged and there is a chance that the bone might die ( avascular necrosis ). And arthroplasty is often done 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. But there may be a greater chance of complications such as infection, nerve damage, and poor positioning of the hip replacement components. ³ The surgery looks promising, but it requires a very skilled and experienced surgeon. Research is still being done to see how well this surgery works in the long term. 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.

Reduction (getting the bone lined up correctly) and internal fixation (stabilizing broken bones) often are done on younger, active people. Hip replacement surgery often is done on older, less active adults. In deciding which of these methods 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 than internal fixation, but there is also more time in surgery, a greater chance of infection, and possibly a greater chance of death. ⁴

Surgery usually is the most effective treatment for a hip fracture, although in most cases you will 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, surgery is not done 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, your doctor will use medicine to manage your pain.

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 urinary 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 doctor may teach you to do simple breathing exercises to help prevent congestion in your lungs while your activity level is low. You may also learn to move your feet up and down to flex your muscles and keep your blood circulating. And you may begin to learn 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 most likely 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 will probably stay in the hospital for about 2 to 4 days after surgery. You may be moved to an extended-care facility for rehabilitation before going home and so that you can get help with daily activities, such as bathing on a bath stool. 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 medicines 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. This often takes at least 3 weeks.

After hip fracture surgery, your doctor will encourage you to participate in a rehabilitation (rehab) program. Research shows that 6 months of outpatient rehab that includes strength training can improve quality of life and reduce disability. ⁵ Following a rehab program is very important because it will speed up your recovery and allow you to return to daily activities sooner.

If your hip fracture was from bone thinning of osteoporosis or another cause, your doctor may suggest that you take medicines such as bisphosphonates to help prevent another fracture. ⁶

After a hip fracture, some people can never again be as independent as they were before the fracture. They may need to use a walker or cane to walk. They may need help with daily activities such as dressing and bathing. And many can no longer live on their own. It is hard to recover from a hip fracture. So be sure to do all you can to keep your bones strong and to avoid falls that can lead to a fracture. And if you do break your hip, work hard to get your strength and mobility back so you can be as independent as possible.

Prevention

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

Keep your bones strong:

Eat a nutritious diet that includes adequate amounts of calcium and vitamin D. Both are needed for building healthy, strong bones. The recommended daily calcium intake for adults up to age 50 is 1,000 mg a day. Men and women age 50 and older need 1,200 mg of calcium each day. The recommended daily intake for vitamin D is 400 to 800 IU a day for adults up to age 50. If you are age 50 or older, the recommended amount is 800 to 1,000 IU of vitamin D a day. ⁷ The best source of vitamin D is exposure to sunlight. Vitamin D is vital for calcium absorption in bones and to improve muscle strength. One study showed that vitamin D may reduce an older person's risk of falling by 22%. ⁸

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. ^{9, 10} But 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.

• One study revealed that moderate physical activity, such as walking, was linked to a substantially lowered number of hip fractures in postmenopausal women. ¹¹

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 medicines such as bisphosphonates, including alendronate (Fosamax) and zoledronic acid (Reclast); raloxifene (Evista); and calcitonin (Calcimar or Miacalcin) are also used to prevent or treat osteoporosis. Studies show that the bisphosphonates, in particular, significantly reduced the risk of hip fracture in older women with osteoporosis. ¹² For more information, see the topic Osteoporosis.

• Don't drink more than 2 alcohol drinks a day if you are a man, or 1 alcohol drink a day if you are a woman. Drinking more than this puts you at higher risk for osteoporosis. Alcohol use also raises your risk of falling and breaking a bone.
• Don't smoke. Smoking puts you at a higher risk for osteoporosis and increases the rate of bone thinning after it starts.

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

Avoid falls:

Almost all hip fractures in older adults 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 medicines 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. Also be sure to turn on the lights when you use the stairs.
• 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 medicines only as directed and periodically reviewing your medicines with your primary care doctor, especially if you have more than one doctor. Some medicines, 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.

Home Treatment

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 bath benches, 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. For more information, see:

  Aging well: Making your home fall-proof.

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 medicine at the correct time.
• Get your eyes checked on a regular basis.

Other Places To Get Help

Organizations

American Academy of Orthopaedic Surgeons (AAOS)
6300 North River Road
Rosemont, IL  60018-4262
Phone:	1-800-346-AAOS (1-800-346-2267) (847) 823-7186
Fax:	(847) 823-8125
E-mail:	pemr@aaos.org
Web Address:	www.aaos.org
The American Academy of Orthopaedic Surgeons (AAOS) provides information and education to raise the public's awareness of musculoskeletal conditions, with an emphasis on preventive measures. The AAOS Web site contains information on orthopedic conditions and treatments, injury prevention, and wellness and exercise.
Centers for Disease Control and Prevention (CDC): National Center for Injury Prevention and Control
1600 Clifton Road
Atlanta, GA  30333
Phone:	1-800-CDC-INFO (1-800-232-4636)
TDD:	1-888- 232-6348
E-mail:	cdcinfo@cdc.gov
Web Address:	www.cdc.gov/injury
This department of the CDC focuses on preventing injuries and violence and reducing the consequences of injuries and violence. The Web site has information about injuries, accidents, and situations that can lead to injuries. It also has prevention ideas and links to other Web sites with specific information. You can download or order a lot of information from this Web site.
National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health
1 AMS Circle
Bethesda, MD  20892-3675
Phone:	1-877-22-NIAMS (1-877-226-4267) toll-free (301) 495-4484
Fax:	(301) 718-6366
TDD:	(301) 565-2966
E-mail:	niamsinfo@mail.nih.gov
Web Address:	www.niams.nih.gov
The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) is a governmental institute that serves the public and health professionals by providing information, locating other information sources, and participating in a national federal database of health information. NIAMS supports research into the causes, treatment, and prevention of arthritis and musculoskeletal and skin diseases and supports the training of scientists to carry out this research. The NIAMS Web site provides health information referrals to the NIAMS Clearinghouse, which has information packages about diseases.
National Osteoporosis Foundation (NOF)
1232 22nd Street NW
Washington, DC  20037-1292
Phone:	(202) 223-2226
Web Address:	www.nof.org
The National Osteoporosis Foundation (NOF) funds research and publishes educational material about osteoporosis for consumers and health professionals. The NOF also provides information about bone density testing sites, new treatment, and local groups interested in osteoporosis. The foundation's mission is to prevent osteoporosis, to promote lifelong bone health, to help improve the lives of those affected by osteoporosis and related fractures, and to find a cure.

Related Information

• Healthy Eating
• Hip Problems, Age 11 and Younger
• Hip Problems, Age 12 and Older
• Osteoporosis
• Physical Therapy

References

Citations

1. Smith WR, et al. (2006). Musculoskeletal trauma surgery. In HB Skinner, ed., Current Diagnosis and Treatment in Orthopedics, 4th ed., pp. 81–162. New York: Lange Medical Books/McGraw-Hill.
2. Orosz GM, et al. (2004). Association of timing of surgery for hip fracture and patient outcomes. JAMA, 291(14): 1738–1743.
3. Howell JR, et al. (2004). Minimally invasive hip replacement: Rationale, applied anatomy, and instrumentation. Orthopedic Clinics of North America, 35(2): 107–118.
4. 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.
5. Binder EF, et al. (2004). Effects of extended outpatient rehabilitation after hip fracture: A randomized controlled trial. JAMA, 492(7): 837–846.
6. Qaseem A, et al. (2008). Pharmacologic treatment of low bone density or osteoporosis to prevent fractures: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 149(6): 404–415.
7. National Osteoporosis Foundation (2008). Prevention. Available online: www.nof.org/prevention/index.htm.
8. Bischoff-Ferrari HA, et al. (2004). Effect of vitamin D on falls: A meta-analysis. JAMA, 291(16): 1999–2006.
9. 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.
10. 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.
11. Feskanich D, et al. (2002). Walking and leisure-time activity and risk of hip fracture in postmenopausal women. JAMA, 288(18): 2300–2306.
12. Ettinger MP (2003). Aging bone and osteoporosis: Strategies for preventing fractures in the elderly. Archives of Internal Medicine, 163(18): 2237–2246.

Other Works Consulted

• American Academy of Orthopaedic Surgeons and American Academy of Pediatrics (2005). Fracture of the proximal femur. In LY Griffin, ed., Essentials of Musculoskeletal Care, 3rd ed., pp. 423–427. Rosemont, IL: American Academy of Orthopaedic Surgeons.
• American Academy of Orthopedic Surgeons (2007). Minimally Invasive Hip Replacement. Available online: http://orthoinfo.aaos.org/topic.cfm?topic=A00404&return_link=0.
• Fiechtner JJ (2003). Hip fracture prevention. Postgraduate Medicine, 114(3): 22–32.
• Goldstein WM, Branson JJ (2004). Posterior-lateral approach to minimal incision total hip arthroplasty. Orthopedic Clinics of North America, 35(2): 131–136.
• 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.
• Oliver D, et al. (2007). Hip fracture, search date January 2007. Online version of Clinical Evidence (10): 1110.

Credits

Author	Shannon Erstad, MBA/MPH
Editor	Kathleen M. Ariss, MS
Associate Editor	Pat Truman, MATC
Primary Medical Reviewer	William M. Green, MD - Emergency Medicine
Specialist Medical Reviewer	Kenneth J. Koval, MD - Orthopedic Surgery, Orthopedic Trauma
Last Updated	May 27, 2009