A hip fracture in an older adult is not simply a broken bone. It is an event with mortality comparable to some cancers, and the outcome depends heavily on how quickly surgery happens and how comprehensively the rest of the person is managed.
Families frequently ask whether surgery is necessary at eighty five. In most cases it is, and delaying it is more dangerous than performing it.
Why It Is So Serious
The danger comes less from the fracture than from immobility and the physiological stress that follows.
- Pneumonia from lying flat and shallow breathing
- Blood clots in the legs and lungs
- Pressure sores developing within days
- Urinary infection, often from catheterisation
- Delirium, which is common and worsens outcomes
- Rapid muscle loss, at a rate that is hard to reverse in an older person
- Loss of independence, with a substantial proportion never returning to their previous mobility
This is why the aim is to get the patient upright and walking within a day of surgery. Every day spent in bed compounds all of the above.
Surgery Within 48 Hours
Operating within twenty four to forty eight hours is associated with lower mortality, fewer complications and better functional recovery. Delay beyond that worsens outcomes measurably.
The most common reason for delay is waiting to optimise medical conditions. Some optimisation is necessary, such as correcting severe anaemia or dangerous electrolyte levels. But prolonged delay for marginal improvements generally causes more harm than it prevents.
Blood thinning medication is a frequent cause of delay and needs a considered plan rather than an automatic wait. Our orthopaedic trauma service and anaesthetists assess these patients jointly to avoid unnecessary postponement.
The Types of Hip Fracture and Their Treatment
Where the bone breaks determines the operation.
- Femoral neck fracture: disrupts the blood supply to the head. Usually treated with hemiarthroplasty or total hip replacement, particularly in older patients
- Intertrochanteric fracture: below the neck, with intact blood supply. Fixed with a plate and screws or an intramedullary nail
- Subtrochanteric fracture: further down the shaft, usually fixed with a long nail
A more active older person with a displaced femoral neck fracture often does better with a total hip replacement than a hemiarthroplasty, giving better function and less need for later revision.
Managing the Whole Patient
Outcomes improve substantially when an older patient with a fracture is managed jointly by orthopaedics and physicians rather than by surgeons alone.
- Review of all medications, particularly sedatives and blood pressure drugs that contributed to the fall
- Delirium prevention: good lighting, familiar objects, glasses and hearing aids available, minimal night disturbance
- Nutrition support, since many older patients are already malnourished
- Pain control adequate enough to allow movement, using nerve blocks where possible to reduce opioid use
- Early mobilisation, ideally the day after surgery
- Pressure area care from admission
- Bone protection treatment started before discharge
Our geriatric medicine team works alongside orthopaedics for exactly this reason.
Delirium Is Common and Frightening
Acute confusion affects a large proportion of older patients after a hip fracture, and families are often unprepared for it.
It presents as sudden confusion, disorientation, agitation or unusual drowsiness, typically fluctuating and worse at night. It is caused by the combination of pain, anaesthesia, medication, infection, dehydration and unfamiliar surroundings.
It usually resolves, though it can take days to weeks. Family presence, familiar routines, correcting dehydration, ensuring glasses and hearing aids are worn, and avoiding sedatives where possible all help considerably.
Tell the team about any change from the person's normal mental state. Families notice this before staff who have not met the patient before.
The Recovery Trajectory
Recovery is slower and less complete than after planned joint replacement, and expectations should be realistic.
- Day 1 after surgery: sitting up, standing with support
- Days 2 to 5: walking with a frame, increasing distance
- Week 1 to 2: discharge home or to rehabilitation, depending on support available
- Weeks 2 to 12: progressive walking, physiotherapy, gradual reduction of walking aids
- 3 to 12 months: continued improvement, with the final level of function usually reached by a year
Roughly half of patients regain their previous level of mobility. Prior fitness, cognitive state and the speed of surgery are the strongest predictors, which is another reason not to delay.
Preventing the Second Fracture
Having one fragility fracture is the strongest predictor of having another, and the risk is highest in the following year. Yet a large proportion of patients leave hospital with no bone protection at all.
- Assessment and treatment for osteoporosis before discharge, not at a later appointment
- Calcium and vitamin D correction
- Bisphosphonate or other bone protection treatment
- Falls assessment, including vision, medication review and balance
- Home hazard assessment, particularly bathrooms and lighting
- Strength and balance exercise programme
Ask specifically before discharge what is being done to prevent the next fracture. It is the question families most often do not think to ask.
The Decision Not to Operate
Occasionally surgery is not the right choice, and this deserves honest discussion rather than avoidance.
Non operative management may be appropriate for a patient who was already bed bound before the fracture, or where the person is in the final stage of a terminal illness and the burden of surgery outweighs any benefit.
It is rarely appropriate simply because of age. An eighty eight year old who was walking to the shops last week will do far better with surgery than without, and refusing on grounds of age alone condemns them to immobility and its complications.
Where the decision is genuinely difficult, it should involve the patient where possible, the family, the surgeon and a physician together.
Treat a hip fracture in an older adult as urgent. Push for surgery within forty eight hours, expect and prepare for delirium, insist on early mobilisation, and make sure bone protection and falls prevention are arranged before discharge rather than left to a future appointment.
Our trauma surgery and geriatric medicine teams at T. Nagar manage these patients jointly.
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