Hip fractures

Last updated: November 17, 2023

Summarytoggle arrow icon

Hip fractures are classified as intracapsular (femoral head, femoral neck) or extracapsular (intertrochanteric, trochanteric, or subtrochanteric). Hip fractures in older adults are typically low-impact injuries and are often associated with osteoporosis. Hip fractures in younger patients are usually caused by a high-energy impact (e.g., motor vehicle collision). Clinical features include groin pain and deformity of the hip. X-rays are usually diagnostic, but an MRI may be required to diagnose occult fractures or pathologic fractures. Comorbid conditions (e.g., anemia, acute kidney injury, delirium) are common with hip fractures. Management typically includes multidisciplinary consultation, early pain management, IV fluid hydration, venous thromboembolism prophylaxis, and early surgical fixation. Nonoperative management may be considered for patients with severe comorbidities, although it is associated with a high mortality rate. Older adults are at the highest risk of morbidity and mortality; early involvement of geriatric care specialists is recommended for these patients. Thromboembolism and osteonecrosis of the femoral head are common severe complications. Hip fractures can be associated with hip dislocation. Posterior hip dislocations account for 90% of hip dislocations and typically follow a dashboard injury. Early reduction is vital to avoid vascular compromise and sciatic nerve injury.

Epidemiologytoggle arrow icon

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

Initial managementtoggle arrow icon


Pain management [3][4][5]

A preoperative peripheral nerve block is recommended to improve pain control and reduce opioid consumption and the risk of perioperative delirium. [8]

Acute management of comorbidities

The following conditions are commonly associated with hip fractures and should be managed early as they can impact perioperative outcomes. See “Hip fracture in older adults” for age-related comorbidities.

Disposition [11]

All individuals with hip fractures require hospital admission and multidisciplinary care.

  • Consult orthopedics to determine if operative treatment is indicated.
  • Consult medical specialists for the comanagement of medical comorbidities as required.
  • Follow local protocols and admitting service agreements.
  • Consult other specialists as needed (e.g., physical therapist, occupational therapist, nutritionist, social worker).

Diagnosticstoggle arrow icon

Clinical evaluation [12]

Perform the following prior to imaging of suspected hip fractures because they can impact acute management. See “Subtypes and variants” for clinical features by fracture type.

Imaging [13]

Suspect occult fracture despite normal x-rays in patients with characteristic clinical features of hip fracture. [13]

Laboratory studies

Additional studies [12]

Consider the following based on clinical presentation:

Treatmenttoggle arrow icon

General principles

Operative treatment

Expedite medical evaluation and perioperative optimization to facilitate an operative repair within 48 hours of admission. [7]

Nonoperative treatment

Nonoperative management of hip fractures is uncommon as mortality rate is high. [19][23][24]

Weight-bearing status is determined by orthopedics. Clarify weight-bearing precautions and range of motion prior to consulting physical and occupational therapy.

Special patient groupstoggle arrow icon

Hip fractures in older adults

The following additional considerations apply to older adults with hip fractures (see also “Trauma in older adults”):

Older adults have higher morbidity and mortality following a hip fracture because of coincident frailty and/or other complex medical problems. [19][30][31]

Acute management checklisttoggle arrow icon

Subtypes and variantstoggle arrow icon

Hip fractures are classified as follows:

  • Intracapsular
    • Femoral head
    • Femoral neck
  • Extracapsular
    • Trochanteric
    • Intertrochanteric
    • Subtrochanteric

Femoral head fracturetoggle arrow icon

Pipkin Classification
Description Treatment after rapid repositioning
Pipkin I
Pipkin II
Pipkin III
Pipkin IV

A patient with an MVA dashboard injury may present with a femoral head fracture and hip dislocation.

Watch out for sciatic nerve injury in patients with femoral head fractures.

Femoral neck fracturetoggle arrow icon

Garden Classification
Garden I

Nondisplaced, incomplete, impaction fracture

Garden II

Complete, but nondisplaced fracture

Garden III

Partially displaced, complete fracture with medial contact of the fracture elements and varus displacement of the femoral head

Garden IV

Entirely displaced, complete fracture

Trochanteric fracturestoggle arrow icon

Intertrochanteric fracturetoggle arrow icon

Subtrochanteric fracturetoggle arrow icon

Hip fracture-dislocationtoggle arrow icon

General principles

Hip fracture-dislocations are associated with a high risk of osteonecrosis of the femoral head.

Overview of hip dislocation

Hip dislocation can occur in isolation or be associated with pelvic fractures (e.g., acetabular fractures) and/or hip fractures.

Posterior vs. anterior hip dislocation
Posterior hip dislocation Anterior hip dislocation
  • 90% of cases
  • 10% of cases
Clinical features

Complicationstoggle arrow icon

Thrombolytic therapy reduces the risk of deep vein thrombosis in patients with hip fractures.

We list the most important complications. The selection is not exhaustive.

Prognosistoggle arrow icon

Hip fractures have a high rate of associated morbidity and mortality in older adults.

Preventiontoggle arrow icon

Referencestoggle arrow icon

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