Hip fractures

A hip fracture is a broken thigh bone (femur) near to the hip joint.

With an aging population, such fractures are becoming increasingly common. This is usually due to osteoporosis (bone atrophy) – especially in women.

It is particularly common for the bone to break at the femoral neck (neck of the femur). This is the area that connects the femoral head to the femoral shaft.

How are the hip joint and thigh connected?

The hip joint comprises a spherical femoral head and the hip socket in the pelvic bone. The smooth joint surfaces are surrounded by a joint capsule.

A short, slanted neck connects the femoral head to the long femoral shaft, which extends to the knee joint.

The lesser trochanter is located directly below the femoral head, with the greater trochanter to the side of it. These are bony protuberances (bumps) that serve as attachment sites for various muscles, which are of great importance for walking as they prevent the pelvis from dropping to the side.

What kinds of hip fractures are there? 

Depending on where the bones break, a differentiation is made between three types of hip fractures: 

• Femoral neck fractures involve a fracture line within the hip joint capsule 
• Pertrochanteric femoral fractures involve a fracture line between the greater and lesser trochanter 
• Subtrochanteric femoral fractures involve a fracture line below the two trochanters 

Hip fractures generally trigger pain in the hip, groin, buttock or thigh area. Sometimes, the pain can radiate into the knee. One of the main symptoms is a shortening of the leg, which is usually rotated outward.

The pain occurs straight after the fall. In most cases, the leg can no longer weight bear. Furthermore, the injured person is unable to stand up on their own. In very rare cases, the bone ends are so firmly wedged that the pain is only mild and people can still walk.

If the bone fracture is outside the joint capsule, a large area of bruising can also be visible.  

Most hip fractures in older age are caused by people falling sideways and landing directly on their hip.

Sometimes, fractures are triggered by a twisting motion if the foot has got trapped somewhere.

Elderly people can fall for many reasons. Falls are often caused by medical conditions such as cardiovascular disease, visual impairments, medical conditions involving dizziness or the side-effects of medication.

Often, falls simply result from elderly people generally being weaker and no longer able to catch themselves if they lose their balance.

If they also suffer from bone atrophy (osteoporosis), all it can take to break bones is a fall from a standing position as these are no longer as stable as they once were.

If, on the other hand, younger people fracture a bone in the hip area, this is usually the result of a serious accident with a fall from a great height or at great speed. 

The key risk factors for a hip fracture are the following: 

• Osteoporosis (bone atrophy) 
• Higher susceptibility to falls in old age  

The factors that increase the risk of falls and therefore fractures include:  

• cardiovascular diseases 
• metabolic disorders such as diabetes 
• an overactive thyroid
• impaired vision
• medical conditions involving dizziness
• certain medication that increases the tendency to fall or weakens the bones 

People who have previously incurred a hip fracture are at higher risk of breaking a bone again.  

Hip fractures are typically incurred by older people.

Every year in Germany, between 6 and 9 of every 1,000 people aged 65 or older break a bone in the hip area.  

Women are affected around three times more often than men. This is because they often suffer from osteoporosis (bone atrophy) following the menopause. Their bone density declines quicker than that of men for hormonal reasons, increasing their risk of a fracture. 

Femoral neck fractures are a typical type of hip fracture. The fracture can damage blood vessels that supply the head of the femur with nutrients.

If the head of the femur no longer receives enough blood, it can die. This is referred to as femoral head necrosis. The risk of this is higher if the broken bone ends have shifted in position.

What are the potential complications?

Despite suitable treatment, the following complications can occur:

• Lasting pain
• Displacement of the broken bone ends
• Fracture does not heal
• Restricted mobility
• Walking difficulties with a dropped pelvis
• Infected bone

Elderly people in particular are often hospitalized for longer periods. This can cause the following complications:

• Thrombosis (blood clots)
• Pneumonia
• Urinary tract infection
• Wound healing disorders of the skin
• Bedsores (decubitus)
• Delirium (confusion) 

Elderly patients often already have underlying illnesses such as cardiovascular disorders or dementia. These factors influence the treatment success and the extent to which complications occur.  

It is therefore imperative to operate on such patients within the first 24 hours so that they can get back out of bed as quickly as possible. This is the best way to reduce the risk of the aforementioned complications.

The risk of dying increases in the first few months after surgery. Only about half of elderly people are able to walk unassisted following a hip fracture. One in five will require long-term care.    

All measures that strengthen bone structure and prevent falls help to prevent hip fractures. These include:

• regular physical exercise from as early an age as possible
• testing for osteoporosis: If found, this should be treated, for example with bisphosphonates. These are a form of prescription medicine that strengthens the bones.
• a good calcium and vitamin D intake
• avoiding smoking and alcohol
• weight training
• eliminating trip hazards in the home
• suitably treating underlying health conditions that increase the risk of falls

Hip fractures are usually easy to see on an x-ray. It can be useful to compare the image with an x-ray of the healthy hip joint.

Computed tomography (CT) is only used in the event of doubt – and magnetic resonance imaging (MRI) on even rarer occasions.

These imaging procedures make it possible to determine the type of fracture. Precise classification helps doctors decide what kind of surgery is required.

A careful physical examination can be used to determine whether other areas of the body have also been injured.

If the reason for the fall is unclear, the surgery is followed by further investigations to determine the cause.  

Most hip fractures are treated surgically as quickly as possible. The aim is to immediately restore the bone’s ability to bear weight so the patient can get around again. At first, the pain has to be treated with painkillers. 

The type of surgery depends on the type of fracture. The bone fracture can be stabilized with screws (this procedure is only used for young patients), a nail can be implanted or the broken femoral head can be removed and replaced with an artificial hip joint.

The choice of treatment also depends on the patient’s age and how physically active they are. If young people fracture their hip, doctors always try to preserve their own hip joint.

When is surgery not an option?

In rare cases, surgery is not performed. This applies in the following cases: 

• The broken bone ends are wedged together and the patient can walk with little pain. In many cases, however, screws are implanted to avoid the bones from slipping in the future. 
• Patients were already bedridden or suffering from dementia before incurring the fracture and are in little pain 
• The patient has other medical conditions that make surgery impossible

What other treatments are used?

Pain therapy is an important part of the treatment. Painkillers can be administered in the form of tablets, infusions, injections or nerve blocks.

As bed rest can quickly lead to the formation of blood clots in the leg veins, patients are given preventative medication that inhibits blood clotting.

Special breathing exercises are important in the event of pneumonia. 

Straight after a hip fracture has been treated, the patient should start physiotherapy with mobilization from the bed – for example in the form of sitting or standing up – as well as physical exercises.

Depending on the treatment method used, it is important to initially avoid certain movements or leg positions. Healthcare professionals will explain what these are.

The main aim is for patients to regain their mobility and their ability to walk independently as quickly as possible. To enable elderly people to fully bear weight on their leg, the fracture is fixed with nails or a prosthesis is used.

The acute treatment is usually followed by follow-up care or rehabilitation. In the case of elderly patients, this should occur in a geriatric hospital.

If the cause of the fall was unclear, the time in the hospital can be used to determine the precise reason and instigate appropriate treatment.