Hip fracture: what actually happens, and why the weeks before surgery matter

Roughly 1.6 million hip fractures occur worldwide each year, and the figure is rising as populations age. One-year mortality is commonly reported between 20 and 30 per cent, and a substantial proportion of survivors never regain their previous level of function. Around half of those who were living independently before the fracture require some form of ongoing assistance afterwards.

Those numbers are worth knowing, because hip fracture is often discussed as an orthopaedic problem when it is really a marker of overall frailty that happens to present as a broken bone.

The two fracture types

Intracapsular fractures occur within the joint capsule, at the femoral neck. They can disrupt the blood supply to the femoral head, so a displaced intracapsular fracture is usually treated by replacing the head — hemiarthroplasty, or total hip replacement in fitter, more active patients, which produces better functional outcomes.

Extracapsular fractures occur below the capsule, in the trochanteric region, where the blood supply is preserved. These are fixed with a sliding hip screw or an intramedullary nail rather than replaced.

Almost all hip fractures are treated surgically. Non-operative management is reserved for patients too unwell to survive an anaesthetic, and it is not a gentler option — it means immobility, pain and a very poor outlook.

Time to surgery

Most national standards target surgery within 36 to 48 hours of admission. Delay beyond that is associated with higher mortality, more pneumonia, more pressure ulcers, more delirium and longer stays.

The commonest cause of avoidable delay is medical: anticoagulation that needs reversing or waiting out, uncontrolled cardiac disease, electrolyte disturbance. Some of this is unavoidable; a good deal of it is process. Units with a dedicated hip fracture pathway and orthogeriatric input consistently achieve better times and better outcomes.

What goes wrong afterwards

Delirium affects roughly half of hip fracture patients and is the single commonest complication. It is associated with worse functional recovery and higher mortality. Prevention — hydration, pain control, glasses and hearing aids, mobilisation, sleep, avoidance of sedating drugs — is more effective than treatment.

Undertreated pain, which is both a cause of delirium and a barrier to mobilising. Nerve blocks such as fascia iliaca blocks reduce opioid requirement substantially and are under-used.

Pneumonia and venous thromboembolism, both reduced by early mobilisation.

Pressure injury, which develops quickly in an immobile, poorly nourished older patient.

Malnutrition, present in a large proportion at admission and worsened by the metabolic demands of injury and surgery. Protein and energy supplementation improves outcomes in trials, and is easy to overlook on a surgical ward.

Mobilising, which should start the next day

Current standards call for mobilisation on the day after surgery, and weight-bearing as tolerated for the great majority of fixations. The historical practice of restricted weight-bearing has largely been abandoned, because older adults cannot reliably comply with it and the immobility does more harm than the theoretical protection is worth.

Rehabilitation intensity matters. The gains are largest in the first three months and continue for at least a year, and access to sustained rehabilitation after discharge is one of the biggest determinants of eventual function — and one of the most variable between systems.

The part almost always missed: the next fracture

A hip fracture is a sentinel event. The risk of a subsequent fragility fracture is high, and it is highest in the first two years — a phenomenon known as imminent fracture risk.

Despite this, audit after audit finds that a minority of hip fracture patients leave hospital on osteoporosis treatment. This is one of the clearest treatment gaps in medicine: the diagnosis has been made in the most unambiguous way possible, and the preventive drug is cheap and effective.

Anyone who has had a hip fracture should leave with, or shortly receive, an assessment for osteoporosis treatment, vitamin D and calcium status, a falls assessment, a medication review, and a plan. Fracture liaison services exist to do exactly this and reduce subsequent fractures where they are properly resourced. If nobody has mentioned bone protection at discharge, it is worth asking.

Prehabilitation, where there is time

Hip fractures are usually emergencies. But the same principles apply to elective hip and knee replacement, where there are weeks or months of warning, and where entering surgery stronger measurably improves recovery.

Strength work for the legs, protein intake at the upper end of the range, stopping smoking, optimising diabetes control and reviewing medication all help. The person who arrives at an operation able to stand from a chair without hands recovers on a different trajectory from the one who cannot, and the interval before surgery is usually long enough to change which of those they are.