Hip Fracture (Proximal Femur Fracture)

Also known as: Hip fracture, Proximal femur fracture, Proximal femoral fracture, Femoral neck fracture, Intracapsular hip fracture, Intertrochanteric fracture, Trochanteric hip fracture, Broken hip

Last updated: December 18, 2024

Hip fracture (proximal femur fracture) is a break in the upper thigh bone near the hip joint, often in the femoral neck or intertrochanteric area. It can reduce hip stability and limit walking or weight-bearing. Symptoms may include sudden hip or groin pain and inability to bear weight. Treatment may include pain control such as multimodal analgesia or nerve blocks. Recovery varies with fracture features and baseline function.

Key Facts

•A hip fracture refers to a break in the proximal femur near the hip joint, most involving the femoral neck or intertrochanteric region
•Sudden hip or groin pain that be severe and worsens with attempted standing or walking
•Diagnosed through history, physical exam, and imaging
•First-line treatment includes exercise, weight management, and activity modification

What It Is

A hip fracture typically refers to a break in the proximal femur near the hip joint, most often involving the femoral neck or intertrochanteric region. The injury can disrupt the structural stability of the hip and may impair weight-bearing and mobility. In older adults, hip fractures often occur after low-energy falls and can be associated with reduced bone strength from osteoporosis. In some cases, fracture patterns can affect local blood supply, which may influence healing potential and surgical planning.

Affected Anatomy

This condition affects several structures in and around the joint:

•Femoral neck (intracapsular proximal femur)
•Intertrochanteric region (between greater and lesser trochanters)
•Subtrochanteric region (proximal femoral shaft just below the lesser trochanter)
•Femoral head articular cartilage (hip joint surface)
•Hip joint capsule (fibrous capsule surrounding the femoral head and acetabulum)
•Retinacular vessels supplying the femoral head (branches associated with the medial femoral circumflex artery)
•Acetabulum (pelvic socket articulating with the femoral head)
•Gluteus medius and minimus tendon insertions on the greater trochanter (abductor mechanism)

Common Symptoms

Symptoms can vary in intensity and may change over time. Common experiences include:

•Sudden hip or groin pain that can be severe and may worsen with attempted standing or walking
•Inability to bear weight on the affected leg, often with marked functional limitation
•Pain that can radiate to the thigh or knee, which may contribute to diagnostic uncertainty
•Visible leg shortening and external rotation of the affected limb, which can occur with displaced fractures
•Tenderness around the lateral hip or groin with pain on gentle passive range of motion
•Swelling or bruising around the hip or upper thigh, which may be more apparent with extracapsular fractures
•Reduced hip range of motion due to pain and mechanical instability
•In some older adults, confusion or delirium can occur after injury, particularly when pain, dehydration, or acute illness is present

Causes and Risk Factors

Multiple factors can contribute to the development of this condition:

Causes

•Low-energy fall from standing height in the setting of reduced bone mineral density, often associated with osteoporosis
•High-energy trauma (such as motor vehicle collisions) that can cause complex fracture patterns, more common in younger individuals
•Pathologic fracture through weakened bone due to metastatic cancer or other bone lesions, which can occur with minimal trauma
•Stress or insufficiency fracture of the femoral neck related to repetitive loading or impaired bone quality, which can present with gradually increasing pain
•Direct impact to the lateral hip (greater trochanter region) during a fall, which can transmit force to the proximal femur

Risk Factors

•Older age, which can be associated with lower bone density, sarcopenia, and higher fall risk
•Osteoporosis or osteopenia, including prior fragility fractures
•History of falls, gait instability, or balance impairment, often related to neuromuscular conditions
•Use of medications that can increase fall risk (such as sedatives) or reduce bone density (such as long-term systemic corticosteroids)
•Vitamin D deficiency or low calcium consumption patterns, which can be associated with reduced bone health
•Visual impairment, which can contribute to environmental missteps and falls
•Chronic conditions such as dementia, Parkinson disease, or stroke, which can affect mobility and protective reflexes
•Low body weight or frailty, which can be associated with reduced muscle mass and bone strength

How It's Diagnosed

Diagnosis typically involves a combination of clinical assessment and imaging studies:

•Clinical assessment including history of mechanism of injury, baseline mobility, pain characteristics, and review of comorbidities that can influence management planning
•Physical examination including inspection for limb shortening and external rotation, palpation for focal tenderness, and gentle assessment of hip range of motion limited by pain
•Plain radiographs (X-rays) of the pelvis and affected hip, typically including anteroposterior pelvis and lateral hip views to identify fracture location and displacement
•Additional femur imaging when indicated (such as full-length femur radiographs) to evaluate for extension into subtrochanteric regions or associated injuries
•Magnetic resonance imaging (MRI) when X-rays can appear normal but clinical suspicion remains high, particularly for occult femoral neck fractures
•Computed tomography (CT) to further characterize complex fracture patterns, assess comminution, or support surgical planning when radiographs are limited
•Laboratory evaluation that can include complete blood count and metabolic panels to assess anemia, electrolyte abnormalities, and perioperative risk factors, often used in hospital-based evaluation

Treatment Options

Treatment approaches range from conservative measures to surgical interventions, often starting with the least invasive options:

Self-Care and Activity Modification

•Pain management strategies that can include multimodal analgesia and regional anesthesia techniques (such as nerve blocks) in acute care settings
•Internal fixation for certain femoral neck fractures, which can use screws or a sliding hip screw depending on fracture characteristics
•Cephalomedullary nailing for many intertrochanteric or subtrochanteric fractures, particularly when stability is a concern
•Venous thromboembolism prophylaxis approaches during hospitalization and recovery, which can include mechanical methods and medications depending on bleeding risk
•Evaluation and management of underlying bone health (such as osteoporosis assessment and secondary causes), which can be integrated into post-fracture care pathways

Physical Therapy and Exercise

•Multidisciplinary geriatric co-management models, which can address delirium risk, nutrition, fall risk factors, and rehabilitation planning

Surgery

•Early mobilization and physical therapy planning, often coordinated with surgical timing and weight-bearing status
•Nonoperative management in selected cases (such as some nondisplaced fractures or individuals with very high surgical risk), typically involving activity modification and close monitoring
•Hemiarthroplasty for displaced femoral neck fractures in many older adults, which can reduce risks related to femoral head blood supply compromise
•Total hip arthroplasty in selected individuals, which can be considered based on pre-injury function, arthritis status, and fracture pattern

Prognosis and Recovery

The course of this condition varies between individuals:

•Functional recovery can vary widely and may depend on fracture type, displacement, baseline mobility, cognitive status, and timeliness of definitive management.
•Many individuals can experience reduced independence after a hip fracture, and some may require extended rehabilitation or supportive living arrangements.
•Complications can include infection, blood clots, pneumonia, pressure injuries, and delirium, particularly in older adults with multiple comorbidities.
•Healing and long-term outcomes can be influenced by fracture location; intracapsular femoral neck fractures can have higher risks related to femoral head blood supply compromise.
•Mortality risk can be increased in the months following hip fracture in older adults, often reflecting frailty and underlying health status rather than the fracture alone.

Open Reduction and Internal Fixation (ORIF)(Procedure)
Total Hip Arthroplasty (Total Hip Replacement)(Procedure)
Osteoporosis(Condition)

Frequently Asked Questions

Common symptoms include: Sudden hip or groin pain that can be severe and may worsen with attempted standing or walking; Inability to bear weight on the affected leg, often with marked functional limitation; Pain that can radiate to the thigh or knee, which may contribute to diagnostic uncertainty; Visible leg shortening and external rotation of the affected limb, which can occur with displaced fractures; Tenderness around the lateral hip or groin with pain on gentle passive range of motion.

Diagnosis typically involves: Clinical assessment including history of mechanism of injury, baseline mobility, pain characteristics, and review of comorbidities that can influence management planning; Physical examination including inspection for limb shortening and external rotation, palpation for focal tenderness, and gentle assessment of hip range of motion limited by pain; Plain radiographs (X-rays) of the pelvis and affected hip, typically including anteroposterior pelvis and lateral hip views to identify fracture location and displacement; Additional femur imaging when indicated (such as full-length femur radiographs) to evaluate for extension into subtrochanteric regions or associated injuries.

Treatment options range from conservative measures to surgical interventions, including: Pain management strategies that can include multimodal analgesia and regional anesthesia techniques (such as nerve blocks) in acute care settings; Early mobilization and physical therapy planning, often coordinated with surgical timing and weight-bearing status; Nonoperative management in selected cases (such as some nondisplaced fractures or individuals with very high surgical risk), typically involving activity modification and close monitoring; Internal fixation for certain femoral neck fractures, which can use screws or a sliding hip screw depending on fracture characteristics; Cephalomedullary nailing for many intertrochanteric or subtrochanteric fractures, particularly when stability is a concern.