Hip (neck of femur) fracture
An elderly patient who fell and cannot walk, with a short, externally rotated leg. Pain relief and a nerve block early, find out why they fell, prepare for surgery within 36 hours, and prevent delirium.
An 82-year-old woman slipped in the bathroom last night and lay on the floor until morning. She cannot stand. Her right leg is short and turned outwards. She is a little confused, and her family says she was sharp yesterday. Pulse 98, BP 112/64.
What do you do before she goes to theatre?
- Pain relief nowParacetamol plus small titrated opioid doses.
- Fascia iliaca nerve blockBy a trained doctor, early. It reduces opioid needs and delirium.
- BloodsCBC, urea, creatinine, electrolytes, CK if long lie, group and save, clotting, sugar.
- ECG and chest X-rayAnd look for why she fell.
- Delirium screen4AT score. New confusion needs a cause.
- FluidsMany are dry after a long lie.
- Prepare for surgeryWithin 36 hours of admission (day of or day after). Anaesthetic and medical review.
- Prevent complicationsPressure areas, clot prevention, catheter only if needed.
- Long lie on the floor
- Collapse, chest pain or palpitations before the fall
- New confusion
- Fever, cough or burning urine
- Minimal injury with night pain or weight loss
- The cause of the fall
- Long-lie complications: rhabdomyolysis, pressure sores, hypothermia
- Hidden fracture with a normal X-ray
- Pathological fracture
| Paracetamol | 1 g every 6 hours (15 mg/kg if under 50 kg) |
| Morphine | 1–2.5 mg IV, titrated slowly in the frail |
| Fascia iliaca block | Local anaesthetic within the maximum dose, by a trained doctor |
| Surgery | Ideally within 36 hours of admission |
| Enoxaparin | 40 mg SC daily, held 12 hours before surgery |
Check every dose against a current drug reference and your hospital protocol.
On this page
Recognising it
- An older person, often a woman, after a fall from standing.
- Pain in the hip or groin, cannot bear weight.
- Short, externally rotated leg (not always present in undisplaced fractures).
- Some can still walk with an impacted fracture: if pain persists and the X-ray is normal, get an MRI or CT.
- Blood supply to the femoral head may be damaged
- Displaced: hemiarthroplasty or total hip replacement
- Undisplaced: screws may be possible
- Blood supply preserved
- Fixation with a dynamic hip screw or nail
Why did she fall?
- Medical collapse: arrhythmia, heart block, MI, stroke, low sugar, postural hypotension, infection (UTI, pneumonia), dehydration.
- Medicines: BP tablets, sedatives, diuretics, many medicines in older people.
- Mechanical: slipped, poor eyesight, poor footwear, loose rugs, bathrooms.
- A fall that was a blackout needs an ECG and cardiac review: see Collapse and syncope.
Long lie
If the patient lay on the floor for hours:
- Rhabdomyolysis: CK, creatinine, potassium, dark urine. IV fluids.
- Pressure areas: check heels, sacrum, hips.
- Hypothermia and dehydration.
- Pneumonia from aspiration.
Pain relief
- Fascia iliaca block (or femoral nerve block) by a trained doctor: early, ideally in the emergency department. It gives good pain relief with fewer opioid side effects and less delirium.
- Avoid NSAIDs in the elderly: kidney injury, bleeding.
Getting ready for surgery
- Bloods and group and saveCBC, creatinine, electrolytes, clotting, sugar.
- ECGArrhythmia, ischaemia.
- Chest X-rayIf indicated.
- AnticoagulantsWarfarin: reverse with vitamin K per protocol. DOACs: timing per anaesthetic advice. Do not delay surgery unnecessarily.
- Medical optimisationCorrect what can be corrected quickly: dehydration, potassium, sugar, infection. Do not delay surgery for things that cannot be fixed quickly.
- Consent and capacityInvolve the family. Capacity may be affected by delirium.
- Nil by mouthPer anaesthetic guidance (clear fluids until 2 hours before).
Surgery within 36 hours (the day of admission or the day after) lowers death and complications. Delays for minor issues cost more than they gain.
Delirium
- 4AT score on admission and daily.
- Causes: pain, infection, dehydration, drugs (opioids, sedatives, anticholinergics), urine retention, constipation, low sodium.
- Prevention: good pain relief, glasses and hearing aids, family visits, day-night routine, avoid unnecessary catheters and sedatives.
After surgery
- Mobilise the day after surgery with physiotherapy.
- Pain relief, clot prevention (usually 28–35 days).
- Bone health: vitamin D and calcium, then bone-protecting treatment (such as a bisphosphonate) per local protocol.
- Falls prevention: review medicines, eyesight, home safety.
- Nutrition: many are malnourished.
Common mistakes
- Delaying pain relief "until the ortho team sees her".
- Not doing a nerve block.
- Missing the medical cause of the fall.
- Forgetting the CK after a long lie.
- Delaying surgery for days for minor abnormalities.
- Sedating a delirious patient instead of finding the cause.
- Sending home a patient who cannot walk with a "normal" X-ray.
Frequently asked questions
How soon should a hip fracture be operated on?
Ideally within 36 hours of admission, on the day of admission or the day after.
What is a fascia iliaca block?
A regional nerve block with local anaesthetic, injected under the fascia iliaca in the groin, that numbs the nerves to the hip. It gives good pain relief and reduces the need for opioids.
What is the difference between intracapsular and extracapsular hip fractures?
Intracapsular (femoral neck) fractures can damage the blood supply to the femoral head and often need joint replacement. Extracapsular fractures keep the blood supply and are fixed with a screw or nail.
Can you walk with a fractured hip?
Most people cannot bear weight, but some can still walk with an impacted or undisplaced fracture. Persistent hip or groin pain after a fall with a normal X-ray needs an MRI or CT.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. An 82-year-old woman with a hip fracture was found on the floor after lying there all night. Which additional blood test is most important?
Answer: Creatine kinase. A long lie causes rhabdomyolysis. Check CK with creatinine and potassium, and give fluids.
- Thyroid function: Not urgent.
- Vitamin B12: Not urgent.
- Amylase: Not relevant.
- Troponin in every patient: Only if cardiac symptoms or ECG changes.
2. An elderly woman has hip pain after a fall and cannot bear weight. The hip X-ray is normal. What is the next step?
Answer: MRI or CT. If a hip fracture is suspected despite a normal X-ray, MRI (or CT if MRI is unavailable) is done promptly.
- Bone scan in 3 months: Too late.
- Physiotherapy and mobilise: Unsafe until fracture excluded.
- Discharge with analgesia: A hidden fracture may be missed.
- Repeat X-ray in 6 weeks: Too late.
3. A patient with a hip fracture becomes newly confused on the ward. What is the best approach?
Answer: 4AT and look for causes. Delirium is common after hip fracture. Treat reversible causes and avoid sedatives.
- Restrain the patient: Worsens delirium.
- Wait for surgery to fix it: Look for causes now.
- CT head for all: Only if specific indications.
- Haloperidol for all: Drugs only if distressed or dangerous.
4. A 58-year-old active man falls and has groin pain but can walk with difficulty. X-ray shows an undisplaced (impacted) intracapsular femoral neck fracture. What is the usual treatment?
Answer: Cannulated screw fixation. Undisplaced intracapsular (Garden I–II) neck of femur fractures have a lower risk of AVN, so the head is preserved with internal fixation (cannulated screws), especially in younger patients. Displaced (Garden III–IV) fractures in older patients need arthroplasty; in young adults, urgent anatomical reduction and fixation to save the head. Some impacted fractures allow walking — a missed diagnosis can later displace.
- Total hip replacement: Arthroplasty is for displaced fractures in older patients.
- Dynamic hip screw: A dynamic hip screw is for extracapsular fractures.
- Bed rest for 6 weeks: Bed rest risks displacement.
5. An 84-year-old woman with mild dementia, who walks with a frame indoors, falls and has a displaced intracapsular fracture of the neck of femur. What is the most appropriate operation?
Answer: Hemiarthroplasty. Displaced intracapsular fractures disrupt the blood supply to the femoral head (retinacular vessels), so fixation risks avascular necrosis and non-union. They are replaced: total hip replacement for fit, independently mobile patients without cognitive impairment; hemiarthroplasty for others. Operate on the day of, or day after, admission. Undisplaced fractures may be fixed with screws.
- Dynamic hip screw: A dynamic hip screw is for extracapsular (intertrochanteric) fractures; a displaced intracapsular fracture has a poor blood supply to the head.
- Cannulated screws: High AVN and non-union risk when displaced.
- Total hip replacement: Total hip replacement is for fit, independently mobile patients; with dementia and a frame, hemiarthroplasty is preferred.
6. Denosumab treats osteoporosis by which mechanism?
Answer: Anti-RANKL antibody. Denosumab binds RANKL (mimicking osteoprotegerin), reducing bone resorption; given 6-monthly by subcutaneous injection; stopping it causes rebound bone loss and vertebral fractures. Bisphosphonates inhibit farnesyl pyrophosphate synthase in osteoclasts. Teriparatide (PTH 1–34) given intermittently is anabolic. Raloxifene is a SERM.
- PTH analogue on osteoblasts: Teriparatide.
- Blocks FPP synthase: Bisphosphonates.
- Selective ER modulation: Raloxifene.
- Calcitonin receptor agonism: Calcitonin.
7. After a femoral artery catheterisation with a large haematoma, a patient cannot extend the knee, the knee jerk is absent, and sensation is lost over the anterior thigh and medial leg. Which nerve is injured?
Answer: Femoral nerve. The femoral nerve (L2–L4) enters the thigh lateral to the femoral sheath (NAVY: nerve, artery, vein, Y-fronts/canal from lateral to medial) and supplies quadriceps (knee extension), sartorius, pectineus and iliacus, plus skin of the anterior thigh (anterior cutaneous branches) and medial leg and foot (saphenous nerve). Injury (haematoma, pelvic surgery, psoas abscess) causes weak knee extension, a buckling knee, absent patellar reflex and sensory loss. The obturator nerve supplies the adductors and medial thigh skin.
- Obturator nerve: Weak adduction, medial thigh numbness.
- Sciatic nerve: Hamstrings and below-knee muscles.
- Common peroneal nerve: Foot drop.
- Lateral cutaneous nerve of thigh: Pure sensory, lateral thigh.
References and dose sources
- NICE CG124: Hip fracture, management
- National Hip Fracture Database
- Paracetamol dosing: Drugs.com: Acetaminophen (paracetamol) dosage (see also our paracetamol dose page)
- Morphine dosing: Drugs.com: Morphine dosage (see also our morphine dose page)
- Enoxaparin dosing: Drugs.com: Enoxaparin dosage (see also our enoxaparin dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.