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Hip fracture in older adults
A hip fracture in an older adult is a geriatric event, not just an orthopaedic one: operate early (in Israel a quality indicator — within 48 hours), treat pain with a nerve block, prevent delirium, mobilise the day after surgery, and start osteoporosis treatment to prevent the next fracture — all within a joint orthopaedic-geriatric team.
Why it matters in the exam
The exam asks about the operation by fracture type: a displaced intracapsular (femoral neck) fracture — joint replacement (hemi- or total), and an extracapsular (intertrochanteric) fracture — fixation with an intramedullary nail or a sliding hip screw. Other questions: what delays surgery and what does not (warfarin — reverse with vitamin K; clopidogrel is no reason to delay), and how pain is treated (fascia iliaca block).
Recurring points: mortality in the first year after hip fracture is about 20%–30%; joint orthogeriatric management reduces mortality and complications; thromboprophylaxis with low-molecular-weight heparin for about 4–5 weeks; and zoledronic acid after hip fracture reduced new fractures and mortality (HORIZON-RFT trial) — but only after vitamin D has been replaced.
The exam also asks about common complications after surgery: delirium (in about a third of patients), anaemia, urinary tract infection, pressure injuries and venous thrombosis. A patient with dementia after a hip fracture benefits from rehabilitation, so rehabilitation must not be denied only because of the diagnosis. Candidates are also asked about the link between hip fracture and a previous fall and untreated osteoporosis, and about hip fracture being a "fragility" fracture that requires treatment even without a bone density test.
Key points
- Early surgery — within 48 hours; joint orthogeriatric management.
- Displaced neck — arthroplasty; intertrochanteric — sliding screw or nail.
- Pain — fascia iliaca block; mobilise the next day.
- Thromboprophylaxis for about 4–5 weeks; delirium prevention.
- Osteoporosis treatment before discharge.
Summary table
| Fracture type | Blood supply and risk | Usual operation |
|---|---|---|
| Undisplaced femoral neck (intracapsular) | Relatively low risk of necrosis | Screw fixation, or arthroplasty in the very old |
| Displaced femoral neck (intracapsular) | High risk of necrosis and non-union | Hemiarthroplasty; total hip replacement for an active, lucid patient walking independently |
| Intertrochanteric (extracapsular) | Good blood supply, heals | Sliding hip screw (stable) or intramedullary nail (unstable) |
| Subtrochanteric | High mechanical load | Intramedullary nail |
| General care | Surgery within 48 hours, nerve block, mobilisation the next day | Prevent delirium and thrombosis, treat osteoporosis |
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Sources
- NICE guideline — Hip fracture: management, CG124 (updated 2023) — Timing of surgery, analgesia, implants and rehabilitation
- AAOS clinical practice guideline — Management of hip fractures in older adults, 2021 — Surgical timing and implant choice
- Geriatrics Review Syllabus (American Geriatrics Society), 11th edition (2022) — Hip fracture and orthogeriatric care
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.