Musculoskeletal · PANCE / PANRE

Hip Fracture (Femoral Neck and Intertrochanteric)

Fragility fracture of the proximal femur in older adults; surgical repair within 24-48 h and aggressive secondary fracture prevention.

Also known as: hip fracture, femoral neck fracture, intertrochanteric fracture, subtrochanteric fracture, proximal femur fracture

Overview

Fracture of the proximal femur, classified by anatomic location: intracapsular (femoral neck, subcapital) or extracapsular (intertrochanteric, subtrochanteric). Most often a fragility fracture in older adults from a low-energy fall; high-energy fractures occur in younger patients.

Epidemiology

Over 300,000 hip fractures annually in the US. Lifetime risk in white women ~15%. Mortality at one year is ~20-30%; many survivors lose independence. Mean age 80.

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Risk factors

Age >65, female sex
Osteoporosis (T-score ≤ -2.5)
Prior fragility fracture
History of falls, gait/balance impairment, sarcopenia
Chronic glucocorticoids, sedatives, polypharmacy
Vitamin D deficiency
Smoking, excessive alcohol
Cognitive impairment, dementia
Visual impairment
Atypical femoral fracture risk: long-term bisphosphonate or denosumab use, asian ancestry

Pathophysiology

Reduced bone strength (osteoporosis) plus increased fall risk leads to fracture from a low-energy mechanism. The femoral neck is intracapsular — its blood supply via the medial femoral circumflex artery is at high risk of disruption with displaced fractures, leading to osteonecrosis. Intertrochanteric and subtrochanteric fractures occur through cancellous trochanteric bone and heal more reliably but with greater blood loss.

Clinical presentation

Symptoms

Hip, groin, or knee pain after a fall (referred to the knee via obturator nerve — always examine the hip in older adult with knee pain)
Inability to bear weight
Occult fracture: groin pain with normal X-ray and inability to bear weight or perform straight-leg raise

Signs / physical exam

Affected leg shortened and externally rotated (displaced femoral neck or intertrochanteric)
Pain with any hip motion, especially log-roll
Inability to straight-leg raise against gravity
Tenderness over greater trochanter or in groin
Distal neurovascular exam typically intact
Look for cause of fall: arrhythmia, syncope, medication effect, infection, dementia

Differential diagnosis

Pubic ramus fracture — Groin pain after fall; tender pubic ramus; AP and inlet/outlet pelvis radiographs
Greater trochanter contusion or fracture — Lateral hip pain, can bear weight
Acute hip OA flare — Chronic pain pattern, X-ray with arthritic change
Occult or stress fracture — Pain without obvious X-ray fracture; MRI sensitive — strongly consider when X-ray negative but exam positive
Pathologic fracture — Known malignancy, atraumatic onset, lytic lesion on imaging
L2-L4 radiculopathy / herniated disc — Back pain, dermatomal pattern, positive femoral nerve stretch

Diagnostic workup

Labs

CBC, BMP, coagulation studies, type and screen
Vitamin D, calcium, alkaline phosphatase, intact PTH (initiate workup for osteoporosis)
ECG and CXR — preoperative
Identify cause of fall: orthostatic vitals, UA, glucose, medication review

Imaging

AP pelvis and AP/cross-table lateral of the affected hip
If X-ray negative and clinical suspicion remains, MRI within 24 hours (most sensitive for occult fracture); CT is an alternative
Bone scan — alternative if MRI contraindicated (less sensitive in first 48-72 h)

Diagnostic algorithm

Fracture Type	Anatomy	Typical Surgery
Femoral neck — nondisplaced (Garden I-II)	Intracapsular	Percutaneous cannulated screws or sliding hip screw
Femoral neck — displaced (Garden III-IV), older adult	Intracapsular	Hemiarthroplasty or total hip arthroplasty
Femoral neck — displaced, young adult	Intracapsular	Urgent ORIF (head preservation)
Intertrochanteric — stable	Extracapsular	Sliding hip screw
Intertrochanteric — unstable	Extracapsular	Cephalomedullary nail
Subtrochanteric	Extracapsular	Cephalomedullary nail (long)

Hip fracture classification and typical operative treatment.

Complications

Mortality 5-10% at 30 days, 20-30% at 1 year
Delirium (very common; targeted prevention reduces incidence)
DVT/PE
Pneumonia
Pressure injury
Decline in functional status; many do not return to prefracture level
Femoral neck-specific: osteonecrosis of the femoral head, nonunion (especially with displaced fractures)
Hardware failure, periprosthetic fracture
Periprosthetic infection
Recurrent fracture (especially contralateral hip — secondary prevention is essential)

PANCE pearls

Knee pain in an older adult after a fall warrants a hip examination — referred pain via the obturator nerve is classic.
Negative X-ray does not exclude hip fracture in a patient who cannot bear weight — MRI within 24 hours is the next step.
Surgery within 24-48 hours is associated with lower mortality and complication rates.
Always initiate osteoporosis treatment after a hip fracture — it is the single most underused intervention.
Multidisciplinary geriatric co-management improves outcomes — delirium, polypharmacy, and rehabilitation deserve as much attention as the fixation.

References

AAOS 2021 — AAOS Clinical Practice Guideline on Management of Hip Fractures in Older Adults (2021)
ACS NSQIP/AGS 2016 — Optimal Perioperative Management of the Geriatric Patient (Mohanty et al., J Am Coll Surg 2016)
HEALTH Trial — Total Hip Arthroplasty vs Hemiarthroplasty for Displaced Femoral Neck Fracture (NEJM 2019)

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