Preventing and Treating Hip Fractures

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Published: 28 February 2021

Hip fractures are potentially catastrophic injuries, particularly in older adults, that are associated with death, disability and loss of independence (ACSQHC 2017).

There are approximately 19 000 people over the age of 50 admitted to hospital for hip fractures every year in Australia. That’s 52 people every day (ACSQHC 2016).

This number is only expected to increase as the Australian population ages (ACSQHC 2016).

However, despite the severity of these injuries, some patients do not receive best-practice care (ACSQHC 2017).

What is a Hip Fracture?

hip fracture hip joint diagram

The head of the femur (thigh bone) fits into a socket in the pelvis to form the hip joint (Fischer & Gray 2020).

A hip fracture occurs when the top of the femur cracks or breaks (NHS 2019).

Areas where the femur may fracture include:

  • The femoral head
  • The femoral neck
  • The intertrochanteric area (between the greater and lesser trochanters)
  • The subtrochanteric area (under the greater and lesser trochanters).

(Fischer & Gray 2020)

Femoral neck fractures are the most common, accounting for about 56% of injuries (AIHW 2018).

Hip fractures are classified according to the extent of displacement:

  • Non-displaced fractures occur when the femur cracks without separating
  • Minimally displaced fractures occur when the femur shifts along or away from the fracture
  • Displaced fractures occur when part of the bone detaches completely.

(Harvard Health Publishing 2020)

Hip fractures are potentially life-threatening, with 6 to 10% of injuries resulting in death within 30 days. Many of those who survive experience permanent impairments to their daily functioning (ACSQHC 2016).

Potential consequences of hip fractures and associated immobility include:

(ACSQHC 2016; Mayo Clinic 2020)

Hip fractures are most common in older adults over 65 and may indicate poor underlying health (ACSQHC 2016).

Causes of Hip Fractures

Most hip fractures are caused by falls (ACSQHC 2016). In 2015-2016, 93% of new hip fractures were fall-related, with 87% being only minimal trauma falls (AIHW 2018).

Furthermore, hip fractures account for 20% of all fall-related hospital admissions (ACSQHC 2017).

Other potential causes include:

  • Severe impact (e.g. a car accident)
  • Twisting or tripping
  • Standing or walking (in cases of severe bone weakness).

(Mayo Clinic 2020; Fischer & Gray 2020)

Risk Factors for Hip Fractures

  • Age, as bone density and muscle mass decrease naturally over time
  • Vision and balance issues
  • Being female, as the reduction in estrogen caused by menopause increases bone density loss
  • Osteoporosis
  • Certain medical conditions that cause bones to weaken, including endocrine disorders and intestinal disorders
  • Neurological conditions, which may increase the risk of falling
  • Low blood sugar or hypotension, which may increase the risk of falling
  • Inadequate calcium and vitamin D intake, which reduces peak bone mass
  • Lack of physical activity, which may lead to frailty
  • Smoking and alcohol use, which may disrupt bone building and maintenance processes
  • Being an Aboriginal or Torres Strait Islander person.

(Mayo Clinic 2020; ACSQHC 2016)

Symptoms of Hip Fractures

  • Acute pain in the groin and upper thigh
  • Bruising and swelling near the hip
  • Difficulty standing
  • Difficulty bearing weight on the injured leg
  • Difficulty moving, lifting or turning the upper leg or knee
  • A noticeable difference in length between legs (the injured leg may look shorter than the other leg)
  • The injured leg turning outwards.

(Fischer & Gray 2020; NHS 2019)

Note: It is possible that someone with a hip fracture will still be able to stand or walk. Bruising is not always present (NHS 2010).

Treatment of Hip Fractures

Most hip fractures require surgery. This should ideally be performed within 48 hours of hospital presentation. Surgery involves using internal fixations to hold the bone together. In some cases, patients require a partial or complete hip replacement (NHS 2019; Mayo Clinic 2020).

Preventing Hip Fractures

hip fracture preventing falls
Falls prevention is especially important after an initial hip fracture.

Read: Falls Prevention

The main ways to prevent hip fractures are by:

  • Preventing falls
  • Maintaining bone strength through regular exercise and adequate calcium and vitamin D intake.

(Harvard Health Publishing 2020)

Falls prevention is especially important after an initial hip fracture, as people who have experienced one hip fracture are at increased risk of experiencing another (Sheikh et al. 2019).

Read: Managing Falls Risk After Discharge

Hip Fracture Care Clinical Care Standard

In 2016, the Australia Commission on Safety and Quality in Health Care released the Hip Fracture Care Clinical Care Standard. This standard aims to ensure patients receive appropriate and consistent care for hip fractures (ACSQHC 2016).

The standard contains seven quality statements:

1. Care at Presentation

Patients who present with a suspected hip fracture should receive prompt assessment and management including diagnostic imaging, pain relief and cognitive assessment.

(ACSQHC 2016)

2. Pain Management

Patients with hip fractures should undergo regular pain assessments to ensure they are receiving adequate pain relief. Multimodal analgesia may be required.

Pain assessments should be performed regularly as part of routine nursing. Additionally, they should be performed:

  • Upon presentation
  • Within 30 minutes of initial analgesia provision
  • Every hour until the patient is settled in the ward.

(ACSQHC 2016)

3. Orthogeriatric Model of Care

Hip fracture treatment should be based on an orthogeriatric model of care, which is defined in the Australian and New Zealand Guideline for Hip Fracture Care.

(ACSQHC 2016)

4. Timing of Surgery

Patients should undergo surgery within 48 hours of presentation, as long as:

  • The patient wants to undergo surgery, and
  • There are no contraindications.

(ACSQHC 2016)

5. Mobilisation and Weight-Bearing

Patients should be mobilised the day after surgery and then at least once per day (unless there are contraindications). This may involve:

  • Moving between postures (e.g. sitting to standing)
  • Maintaining an upright posture
  • Walking with increasing complexity (e.g. increased speed, direction changes, multi-tasking).

Following surgery, patients should bear weight on the affected leg depending on their tolerance.

(ACSQHC 2016)

hip fracture rehabilitation

6. Minimising Risk of Another Fracture

Prior to discharge, patients should undergo a risk assessment in order to identify potential risk factors for future injuries. Prevention strategies may include exercises to improve muscle strength and balance, as well as osteoporosis medicines if required.

(ACSQHC 2016)

7. Transition From Hospital Care

Prior to discharge, patients and their carers should work with clinicians to develop an individualised care plan containing:

  • Medicine changes
  • New medicines to manage risk factors
  • Required rehabilitation services
  • Required rehabilitation equipment
  • Mobilisation activities
  • Wound care
  • Post-injury functioning
  • Secondary fracture prevention strategies.

Within 48 hours of discharge, a copy of this plan should be forwarded to the patient, their general practitioner and any ongoing clinical providers.

(ACSQHC 2019)

Additional Resources


References

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