Definition

A neck of femur or hip fracture is a fracture of the proximal femur, commonly described as intracapsular, intertrochanteric or subtrochanteric. It is a major orthopaedic and geriatric emergency because pain and immobility destabilise a frequently frail patient and the fracture may require arthroplasty or fixation.

Epidemiology

Hip fractures occur predominantly in older adults after a low-energy fall and are strongly associated with frailty, osteoporosis, falls, loss of independence and increased mortality. High-energy trauma, pathological fracture and occult fracture are important presentations in younger or atypical patients.

Pathophysiology

A fall or other force exceeds the strength of the proximal femur. Within the capsule, displacement can disrupt the retinacular blood supply and lead to non-union or femoral-head avascular necrosis, which is why displaced intracapsular fractures are replaced. Extracapsular fracture patterns are generally fixed. Pain, blood loss, immobility, inflammation, dehydration and comorbidity create risks of delirium, pressure injury, VTE, chest infection, AKI and functional decline.

First principles

Fracture location changes the operation

Intracapsular fractures lie within the hip capsule and can disrupt the retinacular blood supply to the femoral head. Extracapsular fractures are outside the capsule and are generally treated with fixation that preserves the patient's own femoral head. The practical surgical distinction is displaced intracapsular fracture versus the other common hip-fracture patterns.¹

Displaced intracapsular fractures need replacement arthroplasty

NICE recommends replacement arthroplasty for a displaced intracapsular hip fracture. Hemiarthroplasty is used for most patients; total hip replacement can be considered when pre-fracture outdoor mobility, medical fitness and expected independent activities of daily living make the larger operation worthwhile. NICE recommends cemented implants for arthroplasty.¹

The fracture is also a frailty and systems emergency

Hip fracture commonly occurs in older or frail adults with multimorbidity, polypharmacy and high delirium risk. Pain, immobility, dehydration and the inflammatory response can destabilise the patient quickly, so orthogeriatric assessment and targeted correction of reversible comorbidity must begin on admission while theatre is arranged.^1,2

Recovery depends on getting the patient moving again

The operative plan should aim for unrestricted weight bearing where clinically appropriate, followed by physiotherapy-led mobilisation on the day after surgery and at least daily thereafter. The admission is also an opportunity to prevent delirium, falls and another fragility fracture through coordinated rehabilitation and bone-health care.^1,3,2

Presentation

Usually an older person after a fall has acute hip or groin pain and cannot weight-bear; a displaced fracture may cause a shortened, externally rotated leg. Impacted, undisplaced or atypical fractures can be subtler, so persistent inability to weight-bear matters even when the first X-ray is normal.^1,2

Cardinal features

Acute hip or groin pain after a fall or other trauma
Inability or marked difficulty weight-bearing
Pain with movement of the hip or gentle leg rotation
Shortening and external rotation of the leg in a displaced fracture
Bruising or local tenderness around the hip
Persistent clinical suspicion despite a normal initial radiograph suggests an occult fracture

Red flags

Shock, significant anaemia or another injury after high-energy trauma
New delirium, reduced consciousness or inability to give a reliable history
Anticoagulation, major cardiac or respiratory disease, renal impairment or severe frailty
A normal X-ray despite ongoing pain and inability to weight-bear
Neurovascular compromise, open injury or suspected pathological fracture
Pressure injury, dehydration, infection or rapidly worsening medical instability while awaiting surgery

Investigations

AP pelvis and lateral hip radiographs

Use adequate plain radiographs to confirm the fracture, assess displacement and identify whether it is intracapsular, trochanteric or subtrochanteric. Examine the pelvis and the rest of the film for another injury or pathological lesion.

Expected finding: A fracture line, cortical disruption or displaced femoral-neck/trochanteric pattern, often with loss of Shenton's line in a displaced fracture.

¹

MRI for occult hip fracture

Offer MRI when hip fracture remains suspected despite negative adequate X-rays. MRI shows marrow oedema and fracture lines that may be invisible on radiographs and prevents false reassurance and unsafe mobilisation.

Expected finding: A fracture line with marrow oedema or an alternative soft-tissue or pelvic diagnosis. If MRI cannot be performed or is not available within 24 hours, consider CT.

¹

Pre-operative blood tests, group and save and ECG

Assess anaemia, renal function, electrolytes, glucose, coagulation and other reversible issues relevant to anaesthesia, transfusion and peri-operative medicines. ECG and chest assessment are guided by the clinical history rather than used to create avoidable delay.

Expected finding: Anaemia, dehydration, electrolyte disturbance, renal impairment, anticoagulant effect or cardiac comorbidity requiring prompt, targeted correction and senior anaesthetic review.

^1,2

Frailty, cognitive and delirium assessment

Assess baseline mobility, activities of daily living, cognition, frailty, falls, nutrition, continence, medicines, social support and goals of care from admission. Screen for delirium and look for reversible precipitants while preserving the plan for timely surgery.

Expected finding: Frailty, cognitive impairment, delirium, polypharmacy, dehydration, infection or a functional baseline that influences arthroplasty choice and rehabilitation goals.

^1,2

Management

Step	Detail	Source
Give immediate analgesia and reassess it	Offer analgesia immediately, including to people with cognitive impairment. Use regular paracetamol unless contraindicated, add immediate-release opioid analgesia if needed and consider a trained-practitioner nerve block when systemic analgesia is insufficient or opioid reduction is desirable. Reassess pain within 30 minutes of initial analgesia and hourly until settled; do not use a nerve block as a reason to delay surgery. Follow current BNF and local protocol for doses and contraindications.^1,4,5,6	NICE CG124 recommendations 1.3.1 to 1.3.6; BNF analgesic monographs
Start the Hip Fracture Programme and correct reversible problems	From admission, provide coordinated orthogeriatric or orthopaedic care with rapid optimisation, delirium prevention and early rehabilitation goals. Identify and treat anaemia, anticoagulation, volume depletion, electrolyte disturbance, uncontrolled diabetes, heart failure, arrhythmia, ischaemia, acute chest infection and other reversible problems immediately, but do not pursue non-essential optimisation that creates avoidable delay.^1,2	NICE CG124 recommendations 1.2.2 and 1.8.1; BOAST care of the older or frail orthopaedic trauma patient
Operate on the day of or day after admission	Schedule surgery on a planned trauma list, with consultant or senior supervision of the anaesthetic, surgical and theatre teams. NICE recommends surgery on the day of, or the day after, admission; document the reason for any delay and continue active medical, pressure-area, delirium and thrombosis prevention while waiting.^1,7	NICE CG124 recommendations 1.2.1 and 1.5.1 to 1.5.2
Match the operation to the fracture pattern and patient goals	Offer replacement arthroplasty for a displaced intracapsular fracture. Consider total hip replacement rather than hemiarthroplasty when the person walked independently outdoors with no more than a stick, has no condition or comorbidity making the procedure unsuitable, and is expected to perform activities of daily living independently beyond 2 years. Use cemented implants for arthroplasty. Treat the relevant extracapsular pattern with fixation: use an extramedullary implant such as a sliding hip screw for trochanteric fractures above and including the lesser trochanter except reverse oblique patterns, and an intramedullary nail for subtrochanteric fractures.^1,4	NICE CG124 recommendations 1.6.1 to 1.6.10, including 2023 surgical updates
Aim for unrestricted weight bearing and mobilise early	Plan the operation and implant to allow full weight bearing without restriction in the immediate post-operative period where medically and surgically appropriate. Offer physiotherapy assessment and mobilisation on the day after surgery unless contraindicated, then mobilise at least daily with regular physiotherapy review and multidisciplinary rehabilitation toward the pre-fracture residence and function.^1,7,2	NICE CG124 recommendations 1.6.1 and 1.7.1 to 1.7.2; NHFD 2025 report
Prevent common peri-operative complications	Assess venous thromboembolism and bleeding risk on admission and provide appropriate mechanical and/or pharmacological prophylaxis under current NICE, BNF and local guidance. Monitor for delirium, pressure injury, infection, constipation, urinary retention, pneumonia, acute kidney injury and deconditioning; review analgesia and medicines daily.^8,1,9,5	NICE NG89 and CG124; BNF anticoagulant and analgesic monographs
Link the fracture to bone health and falls prevention	Treat a low-trauma hip fracture as a sentinel fragility fracture. Arrange fracture liaison or osteoporosis assessment, investigate relevant secondary causes, assess falls risk and start appropriate bone-protection and vitamin D/calcium management according to current NOGG guidance, renal function, contraindications and local pathways. Include the patient and carers in rehabilitation, discharge and prevention planning.^3,1,2	NOGG 2024 clinical guideline; NICE CG124 multidisciplinary Hip Fracture Programme

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

Differentials

Occult hip fracture

Persistent hip or groin pain and inability to weight-bear with initially negative X-rays; MRI is required when suspicion remains.

Pelvic, acetabular or pubic ramus fracture

Groin or pelvic pain after a fall or trauma with a different fracture pattern on imaging; hip fracture can coexist.

Hip dislocation or proximal femoral fracture-dislocation

High-energy mechanism, deformity and marked restriction of movement, requiring urgent trauma assessment and imaging.

Pathological fracture

Fracture after minimal force with a lytic lesion, known malignancy or other features of abnormal bone.

Soft-tissue injury or trochanteric pain syndrome

Local tenderness with preserved weight-bearing and no fracture on appropriate imaging, but reassess if function deteriorates.

Septic arthritis or acute crystal arthritis

A hot, acutely painful joint with systemic or inflammatory features and no fracture explanation; urgent aspiration and specialist management may be needed.

Acute neurological or vascular limb problem

New focal neurological deficit, ischaemia or back-related symptoms rather than isolated hip pain; perform a documented neurovascular examination.

Complications

Delirium and cognitive or functional decline
Pressure injury, pneumonia, urinary infection, constipation and urinary retention
Venous thromboembolism and bleeding related to prophylaxis
Acute kidney injury, anaemia, transfusion and cardiac or respiratory decompensation
Avascular necrosis or non-union after intracapsular fracture
Dislocation, periprosthetic fracture, infection or reoperation after arthroplasty
Loss of mobility, independence and increased mortality

Prognosis

Outcome depends on pre-fracture mobility, frailty, cognition, comorbidity, fracture pattern, timely surgery and rehabilitation. Early orthogeriatric care, surgery on the day of or day after admission, prevention of complications and mobilisation from the day after surgery improve the chance of returning toward baseline, but many patients do not regain their previous independence.

Guidelines

Hip fracture: management (CG124) (NICE, 2023)
Clinical guideline for the prevention and treatment of osteoporosis (NOGG 2024) (National Osteoporosis Guideline Group, 2024)
The care of the older or frail orthopaedic trauma patient (BOASt) (British Orthopaedic Association, 2019)

Neck of Femur Fracture