Trauma & Orthopaedics

Neck of Femur Fracture

A hip fracture is an orthogeriatric emergency: image promptly, control pain, correct reversible physiology without avoidable delay, and operate on the day of or day after admission with the operation matched to the fracture pattern and pre-fracture function.

In a nutshell

Hip fracture is an orthogeriatric emergency. Give immediate analgesia, look for occult fracture if X-rays are negative, correct reversible problems without avoidable delay and operate on the day of or day after admission. For a displaced intracapsular fracture offer replacement arthroplasty; consider total hip replacement only in selected independently mobile, medically suitable patients expected to remain independent beyond 2 years. Mobilise early, prevent VTE and delirium, and arrange bone-health and falls prevention.

Classic presentation

An older patient after a fall has hip or groin pain and cannot weight-bear, often with a shortened and externally rotated leg; impacted or occult fractures may lack the classic deformity.

Key points

AP pelvis and lateral hip X-rays are first line. If fracture is still suspected despite negative adequate X-rays, offer MRI; if MRI is contraindicated or unavailable within 24 hours, consider CT.
Give immediate analgesia, including to patients with cognitive impairment; use regular paracetamol, add immediate-release opioids if needed and consider a trained-practitioner nerve block. NSAIDs are not recommended by NICE for hip-fracture analgesia.
Treat anaemia, anticoagulation, dehydration, electrolyte imbalance, uncontrolled diabetes, heart failure, arrhythmia/ischaemia and acute chest infection promptly, but do not delay surgery for non-essential optimisation.
NICE recommends surgery on the day of, or the day after, admission, on a planned trauma list with senior supervision.
Displaced intracapsular fracture = replacement arthroplasty, usually hemiarthroplasty. Consider total hip replacement if the patient walked independently outdoors with no more than a stick, has no unsuitable comorbidity and is expected to perform activities of daily living independently beyond 2 years; use cemented implants.
Trochanteric fractures above and including the lesser trochanter generally use an extramedullary implant such as a sliding hip screw, except reverse oblique patterns; subtrochanteric fractures use an intramedullary nail.
Aim for unrestricted weight bearing where appropriate, mobilise with physiotherapy on the day after surgery and continue at least daily; monitor for delirium, pressure injury, infection, VTE and acute kidney injury.
A low-trauma hip fracture is a sentinel fragility fracture: link the patient to fracture liaison, falls and bone-health pathways using current NOGG recommendations.

First-line investigation

AP pelvis and lateral hip radiographs; offer MRI for suspected occult fracture after negative adequate X-rays, or consider CT if MRI is contraindicated or unavailable within 24 hours.

Management

Analgesia and stabilisation

Give immediate analgesia, reassess it within 30 minutes and hourly until settled, correct reversible physiological problems and begin orthogeriatric assessment without creating avoidable theatre delay.^1,4,5,6

Confirm the fracture and plan safely

Use AP pelvis and lateral hip X-rays; if negative but suspicion remains, offer MRI or consider CT when MRI is contraindicated or unavailable within 24 hours. Check frailty, cognition, baseline mobility, comorbidity and goals of care.^1,2

Operate promptly and match the implant

Operate on the day of or day after admission. Offer replacement arthroplasty for displaced intracapsular fracture, consider THR only for selected independently mobile and medically suitable patients, and use the correct fixation strategy for trochanteric and subtrochanteric patterns.^1,4,7

Prevent peri-operative complications

Assess VTE and bleeding risk, provide appropriate prophylaxis, prevent and treat delirium, protect pressure areas, review medicines and monitor for infection, AKI, constipation and urinary retention.^1,8,9,2

Mobilise and prevent the next fracture

Aim for unrestricted weight bearing where appropriate, mobilise with physiotherapy the day after surgery and at least daily, then link the patient to rehabilitation, falls prevention, fracture liaison and NOGG-based bone protection.^1,3,7,2

Exam traps

A normal hip X-ray does not exclude a fracture when pain and inability to weight-bear persist; MRI is the next test, with CT if MRI is contraindicated or not available within 24 hours.
Displaced intracapsular fractures are treated with replacement arthroplasty, not routine internal fixation.
Total hip replacement is selective, not automatic: check outdoor mobility, medical suitability and expected independent activities of daily living beyond 2 years.
Do not wait days to optimise every abnormality. Correct reversible problems promptly while preserving the day-of or next-day surgical target.
Nerve blocks supplement analgesia and must be performed by trained staff; they do not substitute for early surgery.
Use current terminology and guidance for implant choice: cemented arthroplasty is recommended, and trochanteric versus subtrochanteric patterns have different fixation strategies.
The postoperative plan is part of the treatment: unrestricted weight bearing where appropriate, early mobilisation, delirium/VTE prevention and secondary fracture prevention.

Illustrations

Shortened and externally rotated leg after hip fractureClinical photograph showing the classic limb position of a displaced intracapsular neck of femur fracture.DocP at German Wikipedia, Wikimedia Commons · CC-BY-SA-3.0-DE

Blood supply of the femoral headDiagram of the medial femoral circumflex artery and retinacular vessels crossing the femoral neck within the capsule, explaining why displaced intracapsular fractures are treated with replacement arthroplasty.PassFinals · original

AP pelvis X-ray showing an intracapsular fractureRadiograph demonstrating a displaced subcapital fracture with disruption of the normal femoral-neck contour and Shenton's line.Booyabazooka, Wikimedia Commons · CC-BY-SA-3.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.