Broken hip

A broken hip is a fracture of the top of the thigh bone, where the leg joins the pelvis. It is not only the narrow neck of the bone that breaks: right below it lies the trochanteric region, and fractures there are just as common. To the person who falls, the difference is barely noticeable; to the surgeon it decides everything, because the exact line of the break determines what happens in theatre. What all these fractures share is that standing up unaided is usually impossible, and they are dealt with in hospital, never at home.

What exactly breaks

At its upper end the thigh bone narrows into a neck and finishes in a round head that sits in a socket in the pelvis. The neck is slender, and the blood vessels feeding the head run alongside it. If the fragments shift apart, those vessels tear, and the head can start to crumble even after the bone has healed. A little lower, between the two bony bumps called trochanters, the bone is thicker and far better supplied with blood: fractures there knit more readily but bleed heavily into the tissues of the thigh.

Who breaks a hip:

• older people with thinned bone, for whom a fall from standing height is enough, and sometimes a sharp twist in bed;
• younger people, but only with real force behind it: a road collision, a fall from height, a heavy contact sport;
• people whose bone has been altered by disease, in whom it gives way with almost no provocation.

That last point deserves a pause. A fracture with no real fall behind it, in someone middle-aged, means the cause should be looked for inside the bone itself. Secondary deposits from cancer of the breast, lung, prostate, kidney or thyroid, and myeloma, cause a dull ache in the groin or thigh for months, and then the bone gives way during an ordinary step. A separate story is years of bisphosphonate treatment for osteoporosis: rarely, these drugs change the structure of the bone so that an atypical fracture appears below the trochanters, preceded for weeks or months by a dull thigh ache. That ache should not be written off as age — it is worth investigating before the bone actually breaks.

How to tell a hip is broken

The classic picture is recognised from the doorway: after a fall the person is on the floor, the groin and outer thigh hurt, the leg cannot take any weight, it looks shorter, and the foot is turned outwards. Within a few hours a bruise spreads over the upper third of the thigh.

But there are versions in which the fracture is missed, and they are worth knowing in advance.

• The person is still walking. In an impacted fracture of the neck the fragments are wedged together and hold weight. The pain is moderate and appears only on standing or turning the leg. These people arrive two or three days later on their own feet, and their fracture is entirely real.
• The knee hurts, not the hip. The hip joint and the knee share a nerve supply, so pain is often referred downwards. An older person who has fallen complains about the knee, the knee is examined, and nothing is found.
• The X-ray is clean but the pain stays. An undisplaced crack is not always visible. If putting weight on the leg still hurts, a CT scan or an MRI is needed, and that call belongs to a doctor rather than to the passage of time.

When to call an ambulance

Straight away, without trying to drive yourself, if after a fall or a blow:

• standing or bearing weight on the leg is impossible;
• the leg looks shorter, or the foot is turned outwards;
• severe groin or thigh pain does not settle at rest;
• the foot goes numb, pale or cold, and the toes will not move;
• weakness, pallor, cold sweat or confusion are building up — these point to blood loss;
• an older person has fallen and cannot get up, even if the leg looks intact.

While you wait for the crew, do not lift the person and do not try to straighten the leg. Pack something soft along its sides in whatever position hurts least, keep the person warm and stay nearby. Do not offer food or drink: surgery is likely, and a full stomach delays it. Put together a list of their medicines, blood thinners above all, since the timing of the operation depends on them. Across Europe the emergency number is 112; elsewhere, use your local one.

Why waiting is dangerous

In a young adult a broken hip is a serious leg injury. In an older person it is an event that involves the whole body. The danger lies less in the break itself than in lying still: within days of being bedbound come chest infection, clots in the leg veins that may travel, pressure sores, urinary infection and confusion. It is these complications rather than the fracture that take the most lives — by various estimates, one older patient in five does not survive the first year after the injury.

Hence a rule that sounds harsh and is in fact protective: surgery is done as early as possible, within the first day or two, and the person is helped upright the day after the operation. There is nothing here to wait out until things improve, because on their own they will not.

How it is operated on

Pain relief comes first, then an X-ray, and a scan if the picture is unclear. After that the choice depends on where the fracture line runs, whether the fragments have shifted, the person's age and how well they walked beforehand.

• Holding the fragments. The bone is fixed with screws, with a nail inside the marrow canal, or with a plate. This is used when nothing has shifted or when the joint is worth preserving.
• Replacing the head. If the neck is broken and displaced and the head is bound to lose its blood supply, the head is replaced with a prosthesis while the person's own socket is left in place.
• Full joint replacement. Both head and socket are replaced, usually in active people who walked unaided before the fall, or when the joint was already worn.

Anaesthesia may be general or spinal, and the choice is discussed with the anaesthetist. Surgery is avoided only when the risk outweighs the benefit; then everything goes into pain control and nursing care. After the operation, blood-thinning medication is prescribed to prevent clots, and sitting and standing begin the same day or the next.

Recovery, and not breaking the other one

The bone takes several months to knit, but walking returns earlier — first with a frame, then with a stick. Sessions with a physiotherapist matter more than any medicine: they rebuild muscle strength and, above all, confidence on the feet. Some people never return to their previous level and keep using support; that is not a defeat but sensible insurance.

At home it pays to prepare in advance: clear away loose rugs and trip hazards, improve the lighting in the hallway and by the bed, fit a grab rail in the bathroom. In the diet, protein matters as much as calcium — without it muscle does not rebuild.

And the point most often missing from the discharge letter: a broken hip is not bad luck, it is evidence that the bone is weak. Without treatment a second fracture becomes a matter of time. So after discharge, bone density and vitamin D are checked, treatment for the skeleton is started, and the usual tablets are reviewed at the same time: sleeping pills, sedatives and blood pressure medicines are often the very reason the fall happened.

Online consultation

A fresh injury is not managed remotely — if a broken hip is suspected, call an ambulance. Everything around it, though, is well suited to a video appointment. The doctor can go through the hospital discharge summary, explain what the name of the operation and of the implant actually mean, describe what to expect from rehabilitation, and say when pain or swelling in the leg stops being normal. A separate topic is treatment for osteoporosis and a review of the medicines that cause dizziness: that is what decides whether there will be a second fracture.

This material is for information only and does not replace medical advice.