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.
Keep reading — start your free trial
You've read your 2 free diagnosis previews. Create your free account to unlock the full Hip Fracture (Femoral Neck and Intertrochanteric) outline — plus all 514 diagnoses, 5,500+ board-style questions, flashcards, and an AI tutor. Your 7-day free trial includes everything, and there's no credit card required.
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) |
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)
Practice Musculoskeletal questions on FirstPassPA
Turn this outline into retention. 5,500+ board-style questions with an AI tutor that explains every answer — free to start, no card required.
Start studying free → Browse all 514 diagnosesEducational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA or PAEA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants; End of Rotation™ is a program of the Physician Assistant Education Association.