About This Page
This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Classically: elderly patient with fall → unable to weight-bear, shortened and externally rotated leg
- Intracapsular (subcapital): displaced = hemiarthroplasty or THR; undisplaced = internal fixation (cannulated screws)
- Extracapsular (intertrochanteric/subtrochanteric): dynamic hip screw (DHS) or intramedullary nail
- Surgery within 36 hours of admission — delay increases morbidity and mortality
- Assess and treat osteoporosis in ALL hip fracture patients — start bone protection before discharge
Overview
Hip fracture (fracture of the proximal femur) is one of the most common and devastating fragility fractures. It is classified as intracapsular (subcapital — within the hip joint capsule, affecting the femoral neck) or extracapsular (intertrochanteric or subtrochanteric — outside the capsule). This distinction is critical because the blood supply to the femoral head (retinacular arteries from the medial circumflex femoral artery) runs along the femoral neck intracapsularly and is disrupted in displaced intracapsular fractures, causing avascular necrosis (AVN) of the femoral head in ~20–30%. Extracapsular fractures preserve the blood supply and heal with internal fixation.
Epidemiology
Approximately 66,000 hip fractures occur annually in England alone. Mean age is ~80 years. Female:male ratio is approximately 3:1 (reflects osteoporosis prevalence). Risk factors include osteoporosis, falls, advancing age, female sex, previous fragility fracture, and reduced mobility. 30-day mortality is approximately 6–8%, and 1-year mortality is ~30%. Only ~50% return to previous mobility level. Hip fracture is the most common reason for emergency orthopaedic surgery.
Clinical Features
Symptoms
Pain in groin, hip, or thigh after a fall (or sometimes spontaneous in severe osteoporosis)
Inability to weight-bear
History of fall — often a simple mechanical fall from standing height
Signs
Shortened, externally rotated leg (displaced fracture)
Tenderness over greater trochanter
Pain on axial loading (heel tap test) and log roll of the leg
Undisplaced fractures: may be able to weight-bear with pain — do NOT dismiss if X-ray initially normal
Investigations
First-line
AP pelvis and lateral hip X-rayFirst-line. Shows fracture line and classifies as intracapsular or extracapsular. Garden classification for intracapsular (I-II undisplaced, III-IV displaced)
BloodsFBC, U&Es, coagulation, group and save/cross-match, ECG — pre-operative assessment
Second-line
MRI hipIf X-ray normal but clinical suspicion remains (occult fracture). MRI is gold standard for occult hip fractures — much more sensitive than repeat X-ray
CT hipAlternative if MRI unavailable or contraindicated
Specialist
DXA scanAssess BMD before discharge or arrange outpatient — virtually all hip fracture patients have osteoporosis
1
Pre-operative
- Surgery within 36 hours of admission (NICE CG124) — delay increases complications and mortality
- Optimise: hydration, analgesia (fascia iliaca block — effective nerve block), medical comorbidities
- Avoid prolonged fasting — offer clear fluids up to 2 hours pre-op
- VTE prophylaxis: mechanical (stockings, IPCD) until surgery; LMWH postoperatively
2
Surgical management
- Displaced intracapsular (Garden III/IV): arthroplasty (hemiarthroplasty or total hip replacement). THR if: independently mobile, cognitively intact, medically fit, not acutely unwell (NICE CG124)
- Undisplaced intracapsular (Garden I/II): internal fixation with cannulated screws (preserves native hip)
- Intertrochanteric: dynamic hip screw (DHS) or intramedullary nail (IM nail)
- Subtrochanteric: intramedullary nail (long nail preferred)
3
Post-operative care
- Early mobilisation: weight-bear as tolerated from day 1
- MDT rehabilitation: physiotherapy, OT, geriatrician review
- Delirium prevention and management — very common post hip fracture
- VTE prophylaxis: LMWH for 28 days post-operatively
- Osteoporosis assessment and treatment: start bisphosphonate, calcium, vitamin D BEFORE discharge
- Falls assessment and prevention programme
Complications
- Mortality: ~30% at 1 year — reflects frailty and comorbidity in this population
- AVN of femoral head: ~20–30% of displaced intracapsular fractures — blood supply disrupted. Main reason arthroplasty is preferred over fixation for displaced fractures
- Non-union: Higher risk with intracapsular fractures
- Infection: Surgical site or prosthetic joint infection
- Delirium: Affects ~30% of hip fracture patients — pre-existing dementia is the strongest risk factor
- DVT/PE: Despite prophylaxis — high-risk population
- Pressure ulcers: Immobility pre- and post-surgery
- Loss of independence: Only ~50% return to previous level of mobility
UKMLA Exam Tips
- 1Elderly fall + shortened externally rotated leg + unable to weight-bear = hip fracture until X-ray proves otherwise
- 2If X-ray normal but clinically suspicious: MRI (gold standard for occult fractures) — do NOT just repeat X-ray
- 3Intracapsular displaced: hemiarthroplasty or THR. Extracapsular: DHS or IM nail. This is a key surgical decision point
- 4Surgery within 36 hours reduces mortality (NICE CG124)
- 5AVN risk is the reason displaced intracapsular fractures get arthroplasty (not fixation) — blood supply is disrupted
- 6ALL hip fracture patients should be assessed and treated for osteoporosis — start before discharge
- 7Fascia iliaca block: effective regional analgesia for hip fractures — reduces opioid requirements
practicetest your knowledge on hip fractureApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — musculoskeletal and beyond.
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