Am Fam Physician. 2022;106(6):675-683
Patient information: See related handout on hip fractures, written by the authors of this article.
Author disclosure: No relevant financial relationships.
Hip fractures are common causes of disability, with mortality rates reaching 30% at one year. Nonmodifiable risk factors include lower socioeconomic status, older age, female sex, prior fracture, metabolic bone disease, and bony malignancy. Modifiable risk factors include low body mass index, having osteoporosis, increased fall risk, medications that increase fall risk or decrease bone mineral density, and substance use. Hip fractures present with anterior groin pain, inability to bear weight, or a shortened, abducted, externally rotated limb. Plain radiography is usually sufficient for diagnosis, but magnetic resonance imaging should be obtained if suspicion of fracture persists despite normal radiography. Operative management within 24 to 48 hours of the fracture optimizes outcomes. Fractures are usually managed by surgery, with the approach based on fracture type and location; spinal or general anesthesia can be used. Nonsurgical management can be considered for patients who are not good surgical candidates. Pre- and postoperative antistaphylococcal antibiotics are given to prevent joint infection. Medications for venous thromboembolism prophylaxis are also recommended. Physicians should be alert for the presence of delirium, which is a common postoperative complication. Early postoperative mobilization, followed by rehabilitation, improves outcomes. Subsequent care focuses on prevention, with increased physical activity, home safety assessments, and minimizing polypharmacy. Two less common hip fractures can also occur: femoral neck stress fractures and insufficiency fractures. Femoral neck stress fractures typically occur in dancers 20 to 30 years of age, endurance athletes, and military service members, often because of training overload. Insufficiency fractures due to compromised bone strength occur without trauma in postmenopausal women. If not recognized and treated, these fractures can progress to complete and displaced fractures with high rates of nonunion and avascular necrosis.
Hip fractures are among the 10 most common causes of disability globally, with more than 300,000 hip fractures occurring annually in the United States.1,2 The average age of patients with hip fractures is 80 years, and 75% to 80% of injuries occur in women.3,4 Mortality rates reach 10% at one month and approach 30% at one year.5–7 Of those who live, 11% are bedridden, 16% require admission to long-term care facilities, and 80% require a walking aid.8,9
| Recommendation | Sponsoring organization |
|---|---|
| Do not transfuse asymptomatic postoperative patients with hip fracture who have a hemoglobin level higher than 8 g per dL (80 g per L). | American Academy of Orthopaedic Surgeons |
Hip fractures account for 87% of all femur fractures.3 They are classified by their location relative to the hip capsule and their degree of displacement (Figure 1). Intracapsular (femoral neck) fractures, comprising 45% to 53%, and intertrochanteric (between the greater and less trochanter) fractures, comprising 38% to 50%, are the most common of all hip fractures.9,10 Subtrochanteric fractures account for only 3%, and femoral shaft and lower femoral fractures account for about 5% each.3
In addition to the more common fractures, this review also discusses femoral neck stress fractures and insufficiency fractures. These fractures are uncommon in the general population and are often misdiagnosed or even missed 75% of the time, but they are critical to consider in patients presenting with anterior hip or groin pain because of their risk of progressing to complete, displaced fractures with high rates of nonunion and avascular necrosis.11
Risk Factors
| General hip fracture Nonmodifiable12–17 Advanced age Bony malignancy or metastases Female sex History of fracture Lower socioeconomic status Metabolic bone disease Modifiable12,15,18–21 Chronic medications (e.g., corticosteroids, levothyroxine, loop diuretics, proton pump inhibitors) Falls High caffeine intake Low body mass index (< 18.5 kg per m2) Low vitamin D levels Moderate to high alcohol intake Osteoporosis or low bone mineral density Physical inactivity or poor functional status Smoking | Stress fracture of the hip Nonmodifiable16,22 Delayed menarche Elevated cortisol levels Female sex Femoral acetabular impingement Metabolic bone disease Modifiable16,22 Gluteus medius weakness Low aerobic fitness Low vitamin D levels Military service members Participation in long-distance running Relative energy deficiency Smoking Sudden increase in physical training distance or intensity or lack of recovery |
NONMODIFIABLE RISK FACTORS
The most significant nonmodifiable risk factors for hip fracture are older age and female sex. Women older than 85 years have a 10-fold increased risk compared with women in their 60s.12 Other nonmodifiable risk factors include history of any fracture, lower socioeconomic status, metabolic bone disease, and bony malignancy.13–17
MODIFIABLE RISK FACTORS
Several modifiable risk factors, of which falls are the most significant, are associated with up to 90% of hip fractures.18 Low body mass index (less than 18.5 kg per m2) is associated with a threefold higher risk.15,19 Low bone mineral density (BMD) also increases risk for fracture, with some estimates finding osteoporosis (T-score less than −2.5) associated with up to 50% of fractures.12,20 Physical inactivity carries a twofold higher risk because lack of weight-bearing activity promotes BMD loss.19,21 Low general health and low vitamin D levels are also associated with low BMD and hip fracture.15
Several medications also increase risk. Corticosteroids, levothyroxine, proton pump inhibitors, and loop diuretics can all decrease BMD, leading to higher fracture risk.12,18,19 Antihypertensives increase risk for postural hypotension and, therefore, falls and subsequent fractures.18 Selective serotonin reuptake inhibitors, benzodiazepines, and opioids may cause sedation and postural hypotension, increasing fall and fracture risk.12,18 Moderate to high alcohol intake (more than 27 g daily), smoking, and high caffeine intake (more than three cups of coffee per day) increase the odds of fracture by 1.5 to two times, likely secondary to appetite suppression and decreased BMD.15,19
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