Hip Fractures in the Elderly
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Direct answer
A hip fracture in an elderly person is usually a fragility fracture after a trivial fall, sited within the hip capsule (femoral neck) or outside it (intertrochanteric, subtrochanteric). The patient cannot stand and classically lies with the limb shortened and externally rotated. Displaced intracapsular fractures risk avascular necrosis and non-union and are treated by hemiarthroplasty or total hip replacement in the elderly, while extracapsular fractures are fixed with a dynamic hip screw or nail. Prompt surgery, within a day or two, is itself the treatment of the deadly complications of bed rest.
What you must remember
- Two families: intracapsular (subcapital, transcervical) versus extracapsular (intertrochanteric, subtrochanteric); the capsule decides the prognosis because intraosseous retinacular vessels are torn in displaced intracapsular breaks.
- Blood supply to the head: mainly from the medial circumflex femoral artery's retinacular branches; the ligamentum teres contributes little in adults — hence avascular necrosis and non-union of displaced neck fractures.
- Garden classification: I incomplete or valgus-impacted and II complete but undisplaced (both stable, treated by in-situ fixation with cannulated screws), III partially displaced and IV fully displaced (both needing arthroplasty in most elderly).
- Extracapsular fixation: stable intertrochanteric fractures take a dynamic hip screw; reverse-obliquity and subtrochanteric patterns take an intramedullary nail.
- Clinical picture: pain, inability to weight-bear, shortening and external rotation — most marked in displaced extracapsular fractures; a valgus-impacted neck fracture may allow limping.
- Perioperative care decides mortality: operate within 24 to 48 hours where possible, with regional anaesthesia preferred, thromboprophylaxis, chest physiotherapy, pressure-area care, delirium prevention and early mobilisation.
- This is an osteoporosis sentinel event: every patient needs calcium, vitamin D assessment and bone-protective therapy such as bisphosphonates to prevent the next fracture.
Common confusion
Neck versus trochanter is the recurring fork, and it decides the operation. Inside the capsule, a displaced head loses its blood supply, so fixation alone risks non-union and avascular necrosis — replace the head in the elderly. Outside the capsule, fragments are well vascularised and unite when bridged by a hip screw or nail. Garden III and IV are both displaced — in III the fragments stay partly linked, in IV fully dissociated — and both usually get arthroplasty. A hip that cannot bear weight despite clean films still needs MRI to exclude an impacted fracture.
Exam-focused takeaway
NEET-PG constructs three question types. Classification stems describe trabecular alignment and displacement to demand a Garden stage. Management stems pair undisplaced neck fracture with cannulated screws, displaced neck fracture in the elderly with hemiarthroplasty or total hip replacement, and intertrochanteric fracture with a dynamic hip screw or nail. Perioperative stems test surgery within 24 to 48 hours, thromboprophylaxis and the bed-rest killers — pneumonia, pressure sores, delirium, urinary sepsis — while image stems show a displaced transcervical or comminuted trochanteric fracture with the classic posture.
Frequently asked questions
How are hip fractures classified in the elderly?
By site into intracapsular femoral neck and extracapsular intertrochanteric or subtrochanteric fractures, with the Garden system grading neck fractures I to IV by displacement.
Why do displaced femoral neck fractures develop avascular necrosis?
Displacement tears the retinacular branches of the medial circumflex femoral artery, cutting the adult head's chief blood supply while the ligamentum teres contributes little.
What is the treatment of a displaced femoral neck fracture in the elderly?
Hemiarthroplasty, or total hip replacement in active patients with good cognition, since fixation alone risks non-union and avascular necrosis.
How are intertrochanteric fractures treated?
By operative fixation, usually a dynamic hip screw for stable patterns and an intramedullary nail for reverse-obliquity or subtrochanteric patterns, with early mobilisation.
Why should hip fracture surgery not be delayed?
Early surgery within 24 to 48 hours reduces pain, delirium, pneumonia, pressure sores, thrombosis and mortality, and gets the patient upright quickly.