Hip Fractures: Symptoms, Surgery, and Recovery

What is a hip fracture?

A hip fracture is a break in the upper part of the thighbone (femur), close to the hip joint. It is a serious injury that requires urgent hospital assessment and, in most cases, surgical treatment.

Hip fractures are particularly common among older adults, where even a simple fall may cause a fracture because of osteoporosis or reduced bone strength. In younger adults, hip fractures are more commonly associated with high-energy injuries, such as road traffic accidents or falls from height.

The appropriate treatment depends on the fracture pattern, displacement, bone quality, general health, and mobility before the injury.

Although some hip fractures can be repaired using screws, plates, or intramedullary nails, others—particularly displaced femoral neck fractures in older adults—may require partial or total hip replacement.

Symptoms of a hip fracture

Common symptoms include:

• Severe pain in the hip, groin, or upper thigh following a fall or injury.
• Difficulty standing, walking, or bearing weight on the affected leg.
• Pain that increases when attempting to move the hip.
• A leg that appears shortened or rotated outward.
• Occasionally, swelling or bruising around the hip.

Not all patients experience these typical findings. Some patients with undisplaced or impacted fractures may still be able to stand or walk a short distance.

Being able to walk does not exclude a hip fracture.

When should you seek emergency care?

A suspected hip fracture requires immediate assessment at a hospital emergency department. Patients should avoid bearing weight on the injured leg and should not attempt to drive themselves to hospital. A routine outpatient appointment should not delay emergency evaluation.

Types of hip fractures

Hip fractures are classified according to their anatomical location and fracture characteristics.

1. Femoral neck fractures

These fractures occur through the neck of the femur, between the femoral head and the trochanteric region. Most are intracapsular fractures, meaning they occur within the hip joint capsule.

They are particularly important because displacement may compromise blood supply to the femoral head, increasing the risk of avascular necrosis and nonunion.

Femoral neck fractures may be classified as undisplaced or minimally displaced (the fragments remain relatively aligned), or displaced (the fragments have shifted from their normal anatomical position). This distinction is especially important when deciding between internal fixation and hip replacement.

2. Intertrochanteric fractures

These fractures occur between the greater and lesser trochanters of the proximal femur. They are extracapsular fractures and are commonly seen in older adults following low-energy falls. Most are treated with internal fixation, typically using a sliding hip screw or a cephalomedullary nail, depending on fracture stability and morphology.

3. Subtrochanteric fractures

These occur immediately below the lesser trochanter, typically within approximately 5 cm of it. They may occur following high-energy trauma or in patients with weakened bone. Surgical fixation, commonly using a long cephalomedullary intramedullary nail, is frequently required.

Hip fractures should also be distinguished from pelvic and acetabular fractures, which involve different anatomical structures and require separate treatment strategies.

How is a hip fracture diagnosed?

Diagnosis begins with clinical assessment and imaging. The treating team evaluates the mechanism of injury, pain, limb position, ability to bear weight, associated injuries, medical conditions, and current medications.

Standard X-rays of the pelvis and affected hip are usually the initial imaging studies. If X-rays appear normal but clinical suspicion remains high, additional imaging may be necessary.

According to the NICE guidelines, MRI should be offered when a hip fracture remains suspected despite adequate negative X-rays. CT may be considered if MRI is unavailable within 24 hours or contraindicated.

Blood tests and appropriate medical investigations are also performed to assess the patient's condition and prepare for treatment.

How are hip fractures treated?

The majority of hip fractures in older adults require surgery. The principal goals are to relieve pain, restore stability, enable early mobilization, reduce complications associated with prolonged immobility, and help the patient regain as much independence as possible.

The choice of operation depends on fracture location, displacement, and stability; age and physiological condition; bone quality; pre-injury mobility and independence; cognitive function and medical comorbidities; pre-existing hip arthritis; rehabilitation potential and patient preferences.

When is internal fixation appropriate?

Internal fixation stabilizes the broken bone using metal implants while preserving the natural hip joint. Depending on the fracture pattern, fixation may involve cannulated screws, a sliding hip screw, a plate, or an intramedullary nail.

It is commonly used for intertrochanteric and subtrochanteric fractures and may be appropriate for undisplaced femoral neck fractures.

In younger patients with femoral neck fractures, preserving the natural femoral head is generally a major treatment priority when feasible, including in some displaced fractures after appropriate reduction.

However, fixation carries potential risks, including nonunion, fixation failure, and avascular necrosis, particularly following displaced intracapsular fractures.

When is hip replacement needed after a hip fracture?

Hip replacement is commonly considered for displaced intracapsular femoral neck fractures in older adults. In these fractures, internal fixation may carry a greater risk of nonunion, femoral head avascular necrosis, and subsequent reoperation. Replacing the damaged femoral head can provide a more reliable means of restoring mobility in appropriately selected patients.

Partial hip replacement (hemiarthroplasty) replaces the femoral head while preserving the patient's natural acetabulum. It is commonly used for displaced femoral neck fractures in older adults, particularly when total hip replacement is unlikely to provide a meaningful additional functional benefit.

Total hip replacement (THA) replaces both the femoral head and the acetabular joint surface. It may be appropriate for selected patients who were independently mobile before the fracture, are medically suitable for the procedure, and are expected to benefit from the additional function it may offer.

Pre-existing symptomatic hip arthritis may also influence the decision. Total hip replacement is not automatically the best option for every older patient. It involves different risks, including dislocation, and the decision must be individualized.

Comparison of common surgical treatments

These are general treatment patterns, not fixed rules. The final surgical plan depends on the patient's clinical condition and fracture characteristics.

Can a hip fracture be treated without surgery?

Nonoperative treatment may be considered in selected circumstances, such as when the risks of surgery substantially outweigh the potential benefits or when care goals favor a nonoperative approach.

However, prolonged immobility can lead to serious complications, including blood clots, pneumonia, pressure injuries, muscle weakness, and loss of independence. The decision should be made through careful discussion between the treating team, the patient, and family or caregivers when appropriate.

How soon should hip fracture surgery be performed?

Early surgery is generally recommended when the patient's medical condition permits. The NICE guidelines recommend performing hip fracture surgery on the day of admission or the following day. The AAOS guidelines support surgery within 24–48 hours of admission in older adults when appropriate.

Some patients require urgent medical optimization before surgery, including management of significant dehydration, electrolyte abnormalities, acute medical illness, or other unstable conditions. The objective is to avoid unnecessary delay while ensuring that surgery and anesthesia can be performed as safely as possible.

Recovery and rehabilitation after hip fracture surgery

Recovery depends on the fracture type, surgical procedure, general health, and level of mobility before injury. For most older patients undergoing hip fracture surgery, early mobilization is an important part of recovery.

Physiotherapy assessment and assisted mobilization are generally encouraged by the day after surgery when medically and surgically appropriate. Whenever fixation stability and the procedure permit, the goal is early weight bearing as tolerated. Some fracture patterns or reconstructions require individualized restrictions.

Rehabilitation may involve walking practice, muscle strengthening, balance training, transfer training, and support with daily activities. Some patients recover substantial independence within weeks or months, while others require prolonged rehabilitation or additional assistance.

Possible complications

Hip fractures and their treatment may be associated with complications such as:

• Deep vein thrombosis or pulmonary embolism.
• Chest infections and complications of immobility.
• Surgical-site infection.
• Delirium, particularly in vulnerable older adults.
• Implant failure, fracture nonunion, or malunion.
• Avascular necrosis following certain femoral neck fractures.
• Hip dislocation or other complications following joint replacement.
• Persistent weakness or reduced mobility.

The treating team uses individualized measures to reduce these risks, including appropriate pain control, early mobilization, thromboprophylaxis when indicated, and coordinated medical and rehabilitation care. Not every patient experiences these complications.

Hip fractures in older adults

Hip fractures in older adults deserve particular attention because the injury can affect mobility, independence, and overall health. Treatment often requires collaboration between orthopedic surgeons, anesthesiologists, physicians or geriatric specialists, physiotherapists, and rehabilitation teams.

In addition to repairing the fracture, the care plan should address pain, hydration, nutrition, cognition, fall risk, and medical conditions that may affect recovery. The goal is not simply fracture healing, but helping the patient regain mobility and maintain the greatest achievable level of independence.

Osteoporosis and prevention of another fracture

A hip fracture after a fall from standing height may indicate underlying osteoporosis or increased skeletal fragility. Following acute treatment, patients should be considered for bone-health assessment and secondary fracture prevention.

Depending on the circumstances, this may include osteoporosis investigation and treatment, adequate nutrition, vitamin D and calcium assessment, balance and strengthening exercises, medication review, and measures to reduce falls at home. Preventing another fracture is an important part of long-term care.

Frequently asked questions

Important medical information

This article provides general medical information and does not replace an individual clinical assessment. A suspected hip fracture requires urgent hospital evaluation. Treatment decisions must be based on examination, imaging, medical condition, and discussion with the treating orthopedic team.

Medical references

1. National Institute for Health and Care Excellence (NICE). Hip fracture: management. Clinical Guideline CG124. https://www.nice.org.uk/guidance/cg124

1. American Academy of Orthopaedic Surgeons (AAOS). Management of Hip Fractures in Older Adults. Clinical Practice Guideline, 2021. https://www.aaos.org/quality/quality-programs/hip-fractures-in-older-adults/