Musculoskeletal

Hip fracture: workup and perioperative management

Clinical Overview and When to Suspect Hip Fracture

— Intracapsular: femoral neck, subcapital (risk of AVN, nonunion due to disrupted medial femoral circumflex blood supply)

— Extracapsular: intertrochanteric, subtrochanteric (better vascularity, heal with fixation)

— >300,000 US hospitalizations/year; female:male ≈ 3:1

— Mean age ~80; 90% from low-energy falls in osteoporotic bone

— 1-year mortality 20–30% — comparable to many cancers

— Elderly: ground-level fall, often with syncope, polypharmacy, or postural hypotension trigger

— Young patient: high-energy trauma → also workup for ipsilateral femoral shaft fracture (missed in 5–10%)

— Atypical subtrochanteric fracture in patient on long-term bisphosphonates or denosumab → prodromal thigh pain

— Hip, groin, or referred knee pain after fall

— Inability to bear weight or ambulate

— Shortened, externally rotated leg

— Occult fracture: persistent pain with normal radiographs, especially in osteoporotic women — MRI is the answer

— Osteoporosis, prior fragility fracture, age >65

— Female sex, postmenopausal, low BMI

— Chronic glucocorticoids, PPI use, SSRIs, anticonvulsants

— Vitamin D deficiency, vision impairment, sarcopenia

— Alcohol use, smoking, dementia, Parkinson disease

Definition: Fracture of the proximal femur, anatomically subdivided into:

Epidemiology:

Mechanism cues:

When to suspect even without obvious trauma:

Step 3 management: A nursing home resident transferred to ED for "knee pain after a fall" with normal knee films deserves dedicated hip imaging — referred groin/knee pain from a femoral neck fracture is a classic miss and a safety event if discharged.

Risk factors:

Board pearl: A displaced femoral neck fracture in a patient <65 is a surgical emergency — reduction and internal fixation ideally within 6–12 hours to preserve femoral head vascularity and reduce AVN risk. In the elderly, time-to-surgery target is <48 hours to reduce mortality, delirium, and pressure injury but is not a vascular emergency.

Presentation Patterns and Key History

— Elderly patient, post-fall, complaining of groin or anterior thigh pain

— Unable to ambulate or bear weight on affected side

— Pain worsened with any hip motion, including log-roll

— Referred knee pain only — obturator nerve innervation of hip + knee; always examine the hip in elderly knee pain

— Vague "I just feel weak" or new immobility in a nursing home patient

— Confusion or delirium as the chief complaint, with fracture discovered on exam

— Continued ambulation with a limp → suggests impacted/nondisplaced femoral neck fracture or pubic ramus fracture

— Mechanism: ground-level vs high-energy; if minimal trauma in young patient, think pathologic fracture or atypical femur

— Pre-fall symptoms: syncope, chest pain, palpitations, focal weakness, vertigo → cardiac/neuro workup before attributing to mechanical fall

— Time of last oral intake (for OR planning)

— Anticoagulants/antiplatelets: warfarin, DOAC (last dose timing critical), aspirin, clopidogrel — drives delay strategy

— Baseline functional status: community ambulator vs walker vs wheelchair — guides surgical approach (arthroplasty vs fixation) and rehab disposition

— Cognitive baseline: dementia, MoCA, capacity for consent

— Comorbidities: CAD, CHF, COPD, CKD, diabetes, prior VTE

— Medication reconciliation: beta-blockers (continue perioperatively), statins, antihypertensives, hypoglycemics, opioids, benzodiazepines

— Social: lives alone, stairs at home, support system, advance directive, code status

Classic presentation:

Atypical presentations to recognize:

Critical history elements (ask every patient):

Key distinction: A "mechanical fall" diagnosis is a diagnosis of exclusion. Step 3 frequently tests recognition that pre-syncopal arrhythmia, orthostatic hypotension from new antihypertensive, hypoglycemia, or stroke caused the fall — missing this guarantees a recurrent event.

Board pearl: Document prefracture ambulatory status explicitly — it is the strongest single predictor of postoperative recovery and discharge destination, and frames goals-of-care discussions.

Always ask about prior fragility fractures — wrist, vertebral, humerus — confirms osteoporosis and triggers secondary prevention planning at discharge.

Physical Exam Findings and Hemodynamic Assessment

— Affected leg classically shortened, abducted, and externally rotated in displaced extracapsular fractures

— Nondisplaced or impacted fractures may show minimal deformity

— Ecchymosis is often absent acutely — appears 24–48 hours later

— Skin integrity: look for open fracture (rare in low-energy falls), pressure injuries over sacrum/heels from prolonged floor time

— Tenderness over greater trochanter or groin

— Axial load test (gentle heel tap) and log-roll elicit pain — sensitive screening maneuvers

— Avoid attempts at active straight-leg raise if fracture suspected — diagnostic but painful

— Distal pulses: dorsalis pedis, posterior tibial

— Capillary refill, skin temperature, color

— Sensation in saphenous, sural, peroneal, tibial distributions

— Motor: dorsiflexion (peroneal), plantarflexion (tibial), quadriceps

— Sciatic nerve injury is a known complication of posterior hip dislocation and arthroplasty — baseline exam is medicolegally essential

— Isolated hip fracture rarely causes shock, but can lose 500–1500 mL into thigh, especially subtrochanteric

— Tachycardia, hypotension, or Hb drop >2 g/dL → look for other source (retroperitoneal bleed, GI, occult pelvic fracture)

— Orthostatics if syncope suspected

— Head/cervical spine exam (concomitant injury in 5–10% of falls)

— Skin: pressure ulcers, hematomas

— Cardiopulmonary baseline (murmur of AS often discovered preop)

— Cognitive screen: orientation, attention (months backward) — establishes delirium baseline

Inspection:

Palpation/motion:

Neurovascular exam (document before and after any manipulation):

Hemodynamic assessment:

Secondary survey:

Board pearl: A systolic murmur at the right upper sternal border in an elderly hip fracture patient → get a preop TTE to evaluate for severe aortic stenosis before spinal/general anesthesia; severe AS dramatically increases perioperative risk and changes anesthetic plan.

Step 3 management: Always perform a fall etiology assessment — orthostatic vitals, ECG, glucose, focused neuro — within the initial workup, not as an afterthought.

Diagnostic Workup — Initial Labs and Imaging

— AP pelvis + AP and cross-table lateral of affected hip — standard radiographic series

— Look for: cortical break, sclerotic line (impacted fracture), disrupted Shenton line, trabecular angulation, lesser trochanter avulsion

— Classify intracapsular fractures by Garden classification (I–IV); displaced (III/IV) favors arthroplasty, nondisplaced (I/II) may allow internal fixation

— Classify extracapsular by stability (intertrochanteric) and AO/OTA for subtrochanteric

— MRI hip without contrast is the test of choice — sensitivity ~100% within 24 hours

— CT is an acceptable alternative when MRI contraindicated (pacemaker without MRI-conditional, severe claustrophobia), though slightly less sensitive for nondisplaced femoral neck fractures

— Never discharge a non-ambulatory elderly patient with "negative x-rays" and persistent hip pain

— CBC (baseline Hb, platelets), BMP (creatinine, electrolytes, glucose)

— Coags (PT/INR, PTT) — essential if on warfarin; INR target <1.5 for surgery, <1.8 for spinal anesthesia

— Type and screen (consider type and cross for intertrochanteric/subtrochanteric)

— Troponin if any chest symptoms or ECG changes; routine screening troponin not required but commonly elevated and prognostic

— Vitamin D 25-OH (informs osteoporosis workup)

— TSH, BMP, calcium, phosphate, albumin (secondary causes of osteoporosis)

— On every patient — establishes baseline, identifies AF, ischemia, conduction abnormalities, prolonged QTc (affects anesthetic choice)

— Preoperative baseline; rules out aspiration, effusion, infiltrate

Initial imaging — first study:

If radiographs negative but suspicion persists (occult fracture):

Labs (preoperative panel):

ECG:

Chest x-ray:

Step 3 management: Order labs, ECG, CXR, and type-and-screen at ED triage simultaneously with imaging — do not sequence them. Time-to-surgery <48 h is a quality metric tied to mortality, delirium, and pressure injury reduction.

Board pearl: A normal initial radiograph in an elderly patient with hip pain and inability to bear weight is not reassuring — MRI within 24 hours is the standard of care. Missed occult fractures progress to displaced fractures with much worse outcomes.

Diagnostic Workup — Advanced and Confirmatory Studies

— Gold standard for occult and stress fractures

— Identifies marrow edema within hours of injury

— Differentiates fracture from contusion, AVN, malignancy, transient osteoporosis

— Order limited protocol (coronal STIR + T1) to reduce scan time in frail patients

— Use when MRI contraindicated or unavailable

— Better for comminution mapping in intertrochanteric/subtrochanteric fractures preoperatively

— Identifies associated pelvic ring injuries, acetabular fractures

— High-energy trauma in young patient → pan-scan per ATLS

— Hip fracture surgery = intermediate-risk procedure

— Use RCRI or NSQIP MICA to estimate MACE risk

— Functional capacity often unassessable in acute fracture → rely on clinical/biomarker assessment

— Do not delay surgery for routine stress testing or revascularization unless active cardiac condition (unstable angina, decompensated HF, severe valvular disease, symptomatic arrhythmia)

— TTE only if new murmur, unexplained dyspnea, or suspected severe valvular disease

— Routine PFTs not indicated

— ABG only if hypoxia or known severe COPD

— New systolic murmur → TTE to evaluate for severe AS, MR

— Severe AS (mean gradient ≥40 mmHg, valve area ≤1 cm²) → cardiology + anesthesia coordination; consider avoiding spinal anesthesia

— Not acute — schedule outpatient within 6–12 weeks

— All hip fracture patients are presumed osteoporotic regardless of T-score and warrant pharmacotherapy

— TSH, 25-OH vitamin D, calcium, phosphate, PTH

— SPEP/UPEP (multiple myeloma)

— Morning testosterone (men)

— 24-h urinary calcium, cortisol if clinically suspicious

MRI hip:

CT hip/pelvis:

Preoperative cardiac evaluation (per ACC/AHA):

Pulmonary evaluation:

Echocardiography:

DXA scan:

Workup for secondary osteoporosis (especially men or premenopausal women):

CCS pearl: Order MRI hip, CBC, BMP, coags, type and screen, ECG, CXR, and orthopedic consult in the first ED time block. Add internal medicine co-management consult early — proactive geriatric/medicine co-management reduces mortality, delirium, and LOS.

Key distinction: Pathologic fracture (lytic lesion, age <50, atypical mechanism) requires biopsy and oncologic workup before definitive fixation when feasible — fixing through unrecognized metastasis worsens outcomes.

Risk Stratification and Surgical Decision Logic

— Goal: surgery within 24–48 hours of admission in medically optimized patients

— Delay >48 h associated with increased 30-day and 1-year mortality, pneumonia, VTE, pressure ulcers, delirium

— Acceptable reasons to delay: active MI, decompensated HF, sepsis, severe electrolyte derangement, supratherapeutic anticoagulation requiring reversal

— Not acceptable: routine cardiac testing, awaiting outpatient cardiologist, weekend

— Warfarin: hold; reverse with vitamin K 5–10 mg IV if INR >1.5 and surgery needed urgently; 4-factor PCC if INR severely elevated or surgery within hours

— DOACs: apixaban/rivaroxaban — hold 48 h if normal renal function (longer with CKD); idarucizumab for dabigatran if emergent; andexanet alfa for factor Xa inhibitors (cost-prohibitive, rarely used for hip fracture timing)

— Aspirin/clopidogrel: generally continue aspirin; clopidogrel often continued or briefly held per cardiology/surgery shared decision — do not delay surgery beyond 48 h for antiplatelet washout in most cases

— Nondisplaced femoral neck (Garden I/II): percutaneous screw fixation or sliding hip screw

— Displaced femoral neck (Garden III/IV):

— Intertrochanteric: sliding hip screw (stable) or cephalomedullary nail (unstable, reverse oblique)

— Subtrochanteric: cephalomedullary nail (long)

— Nottingham Hip Fracture Score predicts 30-day mortality

— RCRI, ASA class for perioperative cardiac risk

Surgical timing:

Anticoagulation management preop:

Surgical procedure selection:

Active, community-ambulatory patient → total hip arthroplasty (THA) — better functional outcome, lower revision rate

Lower-demand or cognitively impaired patient → hemiarthroplasty

Risk scoring tools:

Step 3 management: A patient on apixaban for AF who fell and has a displaced femoral neck fracture — hold apixaban, proceed to surgery at 48 h from last dose; do not routinely bridge with heparin (no evidence of benefit, increases bleeding).

Board pearl: Choosing THA over hemiarthroplasty in an otherwise healthy, independently ambulatory patient with a displaced femoral neck fracture reduces pain and reoperation at 2–5 years — preferred for active patients with reasonable life expectancy.

Pharmacotherapy — Perioperative Medication Management

— Multimodal, opioid-sparing approach is standard

— Scheduled acetaminophen 1 g q6h (cap 3 g/day in elderly/hepatic)

— Fascia iliaca compartment block or femoral nerve block in ED — reduces opioid use, delirium, improves pain at rest

— Low-dose oxycodone or hydromorphone for breakthrough; avoid meperidine (delirium, seizures) and avoid tramadol (serotonergic, lowers seizure threshold, drug interactions)

— Avoid NSAIDs in elderly (renal, GI, cardiac risk) and immediately post-fixation (theoretical effect on bone healing)

— Gabapentin: small dose may help neuropathic component but causes delirium in elderly — use cautiously

— Start within 12–24 h postop once hemostasis achieved

— Options (ACCP/AAOS): LMWH (enoxaparin 40 mg SC daily), fondaparinux, low-dose DOAC (apixaban 2.5 mg BID, rivaroxaban 10 mg daily), or warfarin (INR 2–3) — LMWH most evidence

— Aspirin alone acceptable for low-risk arthroplasty patients per AAOS but LMWH or DOAC preferred for hip fracture

— Duration: 28–35 days post-op

— Mechanical prophylaxis (SCDs) while in bed, especially before pharmacologic agent started or if bleeding risk high

— Cefazolin 2 g IV (3 g if >120 kg) within 60 minutes of incision

— Vancomycin if MRSA colonized or severe beta-lactam allergy (start 90–120 min preop)

— Continue ≤24 h post-op — longer duration increases C. difficile risk without infection reduction

— Continue beta-blockers perioperatively (abrupt withdrawal → rebound ischemia)

— Hold ACEi/ARB morning of surgery (intraop hypotension)

— Hold SGLT2 inhibitors 3–4 days preop (euglycemic DKA)

— Hold metformin day of surgery

— Statins: continue

— Sliding scale + basal insulin for diabetics; target glucose 140–180 mg/dL

Analgesia:

VTE prophylaxis (high-risk surgery — VTE rate >50% without prophylaxis):

Antibiotic prophylaxis:

Chronic medication management:

Board pearl: Fascia iliaca block in the ED reduces opioid requirements, delirium incidence, and pain scores — high-yield Step 3 answer for perioperative analgesia in elderly hip fracture.

Surgical and Anesthetic Management

— Spinal (neuraxial) vs general: large recent trials (REGAIN, others) show equivalent mortality and ambulation outcomes — choice is patient/anesthetist preference

— Spinal traditionally favored for lower delirium and pulmonary complications but evidence equivocal

— Severe aortic stenosis → general anesthesia often preferred (avoid sympathectomy of spinal); coordinate with cardiac anesthesia

— Anticoagulation timing affects spinal: 24 h after prophylactic LMWH, 48–72 h after therapeutic DOAC depending on agent and renal function

— Open or percutaneous approach depending on fracture type

— Cementless vs cemented arthroplasty: cemented femoral stem favored in elderly osteoporotic bone — lower periprosthetic fracture risk, but watch for bone cement implantation syndrome (hypotension, hypoxemia, arrhythmia, embolism during cementing)

— Posterior approach to hip → higher dislocation risk; anterior approach → lower dislocation but more neurovascular risk

— Standard ASA monitors + arterial line if hemodynamic instability or severe cardiac disease

— Temperature management — hypothermia increases infection, bleeding, cardiac events

— Tranexamic acid (TXA) 1 g IV at incision reduces transfusion needs in arthroplasty without increasing VTE

— Restrictive: Hb <8 g/dL or symptomatic anemia (recent FOCUS, MINT trials)

— Avoid liberal transfusion to Hb 10 — no outcome benefit, increases TRALI/TACO

— Admit to ortho or medicine co-management service

— Vital signs q4h, pulse oximetry, telemetry if cardiac history

— Diet: advance as tolerated when alert

— Early mobilization: out of bed and weight-bearing as tolerated on POD 0 or 1 — most modern fixation/arthroplasty tolerates immediate WBAT

— PT/OT consult day of surgery

— Foley out POD 1 (CAUTI prevention)

— Bowel regimen (senna + docusate) with opioids

— Delirium precautions: reorientation, glasses/hearing aids, sleep hygiene, avoid restraints, avoid benzodiazepines and anticholinergics

Anesthesia choice:

Surgical principles:

Intraoperative monitoring:

Transfusion threshold:

Postoperative orders (CCS pattern):

CCS pearl: Orders to chain: cefazolin → surgery → TXA intraop → enoxaparin 12 h postop → mobilize POD 1 → PT/OT → DXA outpatient → bisphosphonate at discharge. Each step is a board-testable beat.

Special Populations — Elderly and Renal/Hepatic Impairment

— Geriatric/medicine co-management reduces mortality, delirium, LOS, and readmissions — strongly supported model

— Comprehensive geriatric assessment: cognition, function, nutrition, polypharmacy

— Delirium screening (CAM) daily — incidence 30–50% postoperatively

— Polypharmacy review: discontinue Beers-criteria medications (diphenhydramine, long-acting benzos, anticholinergics, muscle relaxants)

— Nutrition: oral protein supplementation reduces complications; consult dietitian

— Pressure injury prevention: turn q2h, heel offloading, specialty mattress

— Bone health: vitamin D 800–1000 IU + calcium 1000–1200 mg/day from admission

— LMWH dose-adjust: enoxaparin 30 mg SC daily if CrCl <30 mL/min; or use UFH 5000 U SC q8h

— Fondaparinux contraindicated if CrCl <30

— DOACs: apixaban dose-reduce or avoid in severe CKD; rivaroxaban avoid if CrCl <30

— Avoid NSAIDs entirely

— Contrast imaging: avoid in CKD when possible; MRI without contrast preferred

— Watch for postop AKI — track urine output, daily creatinine

— Acetaminophen cap 2 g/day in cirrhosis

— Avoid NSAIDs (varices, AKI, hepatorenal)

— Coagulopathy from synthetic dysfunction may worsen bleeding; consider TEG/fibrinogen

— Opioid metabolism altered — start low, titrate slow; hydromorphone preferred over morphine in renal failure (no active metabolite accumulation)

— Surrogate decision-maker, advance directive review

— Higher hemiarthroplasty preference over THA (lower dislocation risk than THA in noncompliant patients)

— Avoid antipsychotics for delirium unless severe agitation endangers patient/staff; haloperidol 0.25–0.5 mg if needed; avoid in Parkinson/Lewy body → use quetiapine

— Clinical Frailty Scale informs goals-of-care discussion

— Severely frail (CFS 7–9) → palliative-leaning approach acceptable; surgery still often appropriate for pain control even if comfort goals

Elderly (>75) — the modal hip fracture patient:

Chronic kidney disease:

Hepatic impairment:

Dementia/cognitive impairment:

Frailty:

Board pearl: Co-management between orthopedics and medicine/geriatrics is a Level 1A intervention for hip fracture outcomes — the "ortho-geriatric" model is the answer when stem asks about reducing complications and mortality.

Special Populations — Young Patients, Pregnancy, and Atypical Femur

— Usually high-energy trauma — MVC, fall from height, sports

— Full ATLS evaluation: look for ipsilateral femoral shaft fracture (missed in 5–10%), pelvic ring injuries, acetabular fractures, intra-abdominal injuries

— Surgical emergency for displaced femoral neck — reduction and internal fixation within 6–12 h to preserve femoral head vascularity (medial femoral circumflex artery)

— Fixation preferred over arthroplasty to preserve native joint — even with higher AVN/nonunion risk

— Counsel about AVN risk (10–30% in displaced young fractures) and possible future arthroplasty

— Lytic or blastic lesion on imaging

— Common primaries: breast, prostate, lung, kidney, thyroid, multiple myeloma

— CT chest/abdomen/pelvis, SPEP/UPEP, PSA, mammogram, thyroid exam

— Biopsy before definitive fixation when feasible

— Prophylactic fixation for impending pathologic fracture (Mirels score ≥9)

— Transverse, lateral cortex, subtrochanteric or diaphyseal, often bilateral

— Associated with long-term bisphosphonates (>5 years) or denosumab

— Prodromal thigh pain weeks to months before fracture — image with MRI/CT

— Treat with cephalomedullary nail; discontinue bisphosphonate; consider teriparatide to promote healing

— Imaging contralateral femur — bilateral lesions common

— Rare; mostly transient osteoporosis of pregnancy (third trimester, postpartum) — usually nondisplaced femoral head/neck stress fractures

— MRI safely diagnoses

— Conservative management (protected weight-bearing) often sufficient

— Anesthesia/OR: left lateral tilt, fetal monitoring, multidisciplinary

— Rare; high-energy or pathologic

— Delbet classification I–IV

— Urgent fixation; high AVN risk (especially Delbet I/II)

— Pediatric orthopedic referral mandatory

Young patient hip fracture (<65):

Pathologic fracture workup (any age, atypical mechanism):

Atypical femur fracture:

Pregnancy:

Pediatric hip fracture:

Key distinction: A subtrochanteric transverse fracture in a 70-year-old woman on alendronate for 8 years is an atypical femur fracture, not osteoporotic; bisphosphonate must be stopped, contralateral femur imaged, and teriparatide considered — opposite of typical osteoporotic fracture management.

Complications and Adverse Outcomes

— Delirium (30–50%): prevent with reorientation, sleep, mobilization, avoid Beers meds, treat pain; CAM screening daily

— Postoperative anemia: transfuse for Hb <8 or symptomatic; iron supplementation outpatient

— AKI: pre-renal from volume depletion, NSAIDs, contrast; daily Cr, avoid nephrotoxins

— VTE: DVT 40–60% without prophylaxis, PE 1–10%; symptoms = leg swelling, dyspnea, tachycardia, hypoxia → CTPA or V/Q

— Pneumonia (aspiration or hospital-acquired): early mobilization, incentive spirometry, swallow assessment if delirium

— UTI/CAUTI: remove Foley POD 1

— Pressure injury: sacrum, heels; turn q2h, offloading

— Wound infection / prosthetic joint infection (PJI): erythema, drainage, fever; aspirate for culture; IV antibiotics + possible debridement or revision

— Bone cement implantation syndrome (BCIS): intraoperative hypotension, hypoxemia, arrhythmia during cementation

— AVN of femoral head: 10–30% displaced femoral neck fractures; presents months later with groin pain

— Nonunion: 5–30% femoral neck, lower with extracapsular

— Hardware failure: screw cutout, nail breakage — often related to osteoporotic bone or noncompliance

— Periprosthetic fracture: from fall or osteoporosis

— Prosthetic dislocation: posterior approach THA, especially with hip flexion >90°, internal rotation, adduction

— Leg length discrepancy: more common with THA

— Functional decline: only 40–60% return to prefracture ambulation

— Loss of independence: 20–30% discharged to long-term care

— Recurrent fracture: contralateral hip fracture risk 5–10% within 5 years — drives osteoporosis treatment urgency

— Mortality: 5–10% at 30 days, 20–30% at 1 year

Early postoperative complications:

Surgical complications:

Late complications:

Mortality predictors: age, male sex, dementia, ASA ≥3, time to surgery >48 h, postop pneumonia, postop MI, delirium

Board pearl: Postop type 2 MI is common (troponin elevation in 20–35%) and often silent — most patients with elevated troponin should still receive dual antiplatelet/statin/beta-blocker optimization outpatient cardiology referral, but acute revascularization is reserved for type 1 MI with ischemic symptoms or ECG changes.

When to Escalate Care — ICU, Consult, and Inpatient Triage

— Hemodynamic instability (shock, vasopressor need)

— Postoperative respiratory failure, need for noninvasive or invasive ventilation

— Acute MI (type 1) requiring catheterization/monitoring

— Massive PE requiring thrombolysis or thrombectomy

— Sepsis from PJI or other source

— Severe electrolyte derangement requiring CRRT or aggressive correction

— Bone cement implantation syndrome with cardiovascular collapse

— Known CAD, recent troponin elevation, arrhythmia

— Severe AS, decompensated HF baseline

— High-dose opioid requirements with respiratory comorbidity

— Orthopedic surgery: immediately for all confirmed fractures

— Medicine/geriatrics co-management: every elderly hip fracture (Level 1A evidence)

— Cardiology: only for active cardiac condition, severe valve disease, troponin elevation with ischemic features — not routine

— Anesthesia: preop evaluation, especially severe AS, difficult airway, severe COPD

— Hematology: complex coagulopathy, ITP, hemophilia, supratherapeutic anticoagulation

— Palliative care: severely frail (CFS 7–9), advanced dementia, goals-of-care clarification

— PT/OT: every patient, day of surgery

— Social work / case management: early for disposition planning

— Psychiatry: refractory delirium, suicidality, decisional capacity questions

— Pediatric hip fracture without pediatric ortho

— Pathologic fracture needing oncologic surgery coordination

— Complex revision arthroplasty

— Severe polytrauma exceeding facility capability

ICU admission criteria:

Stepdown/telemetry:

Specialty consults — when and why:

Transfer criteria (to higher-level center):

Step 3 management: A patient with severe AS (mean gradient 52 mmHg) and a displaced femoral neck fracture — do not delay for valve replacement; coordinate with anesthesia for arterial line, GA, judicious volume management. Postoperative cardiology referral for valve discussion is appropriate; TAVR before hip surgery is not standard and worsens delay-related mortality.

CCS pearl: Move the clock — order ED hip MRI, labs, consults, and fascia iliaca block in a tight bundle; advancing the clock past 48 h without surgery should trigger a documented justification.

Key Differentials — Other Musculoskeletal Causes of Hip Pain

— Elderly fall, groin pain, often still able to ambulate with limp

— Radiographs of pelvis show fracture line

— Treatment: nonoperative, weight-bearing as tolerated, analgesia, PT

— Key distinction: pubic ramus fracture allows weight-bearing; femoral neck fracture typically does not

— Higher-energy mechanism, central hip pain

— CT pelvis for characterization

— Treatment depends on displacement, weight-bearing dome involvement

— Usually traumatic or post-arthroplasty

— Posterior dislocation: leg shortened, internally rotated, adducted (vs externally rotated in femoral neck fracture)

— Emergent reduction within 6 h to reduce AVN risk

— Lateral hip pain, tender over greater trochanter

— Reproduced with resisted abduction

— No fracture on imaging

— Treat with NSAIDs, PT, possible corticosteroid injection

— Chronic groin pain, morning stiffness <30 min, reduced internal rotation

— Joint space narrowing on radiographs

— Conservative management; elective THA when refractory

— Risk factors: steroids, alcohol, sickle cell, lupus, prior fracture

— Groin pain, normal radiographs early → MRI shows crescent sign or marrow edema

— Treatment: core decompression early; THA late

— Anterior hip pain with hip flexion

— Often in athletes; benign

— Younger active patients, anterior groin pain with flexion/internal rotation

— MR arthrography diagnostic

— Endurance athletes, military recruits, female athlete triad

— Femoral neck stress fracture — MRI; tension-side fractures need urgent fixation; compression-side managed conservatively

Pubic ramus fracture:

Acetabular fracture:

Hip dislocation:

Greater trochanteric pain syndrome (trochanteric bursitis):

Hip osteoarthritis:

Avascular necrosis (AVN):

Iliopsoas tendinitis / snapping hip:

Femoroacetabular impingement / labral tear:

Stress fracture:

Board pearl: Posterior hip dislocation → leg shortened, internally rotated, adducted. Anterior femoral neck fracture → leg shortened, externally rotated, abducted. The rotation direction differentiates them clinically before imaging.

Key Differentials — Non-Orthopedic Causes of Hip/Groin Pain

— Fever, severe pain with any motion, refusal to bear weight

— Elevated WBC, ESR, CRP

— Joint aspiration: WBC >50,000, neutrophil predominance, positive Gram stain/culture

— Emergent washout + IV antibiotics

— Higher suspicion in immunocompromised, recent procedure, IVDU

— Fever, flank/groin pain, hip flexion contracture (psoas sign)

— CT abdomen/pelvis with contrast

— Drainage + antibiotics

— Associated with TB, Crohn disease, vertebral osteomyelitis

— Bulge, reducible or incarcerated

— Pain worse with Valsalva, lifting

— Surgical referral; emergent if strangulated

— Back pain radiating to groin/anterior thigh

— Positive femoral stretch test

— MRI lumbar spine

— Hip exam normal

— Renal colic: flank to groin pain, hematuria, CT stone protocol

— UTI/pyelonephritis: dysuria, fever, CVA tenderness

— Ovarian torsion / ectopic pregnancy: women of reproductive age — pelvic exam, beta-hCG, US

— Testicular torsion: scrotal pain referred to groin

— Aortoiliac occlusive disease: claudication, weak distal pulses

— AAA: pulsatile mass, hypotension if ruptured

— Appendicitis, diverticulitis, colitis — can refer to lower abdomen/groin

— Primary bone tumor (rare in elderly): osteosarcoma, chondrosarcoma

— Metastatic disease: breast, prostate, lung, kidney, thyroid, myeloma

— Persistent rest pain, night pain, weight loss → image and biopsy

— Meralgia paresthetica (lateral femoral cutaneous nerve): lateral thigh paresthesia, not hip joint pain

— Stroke causing fall — workup the fall, not just the fracture

Septic arthritis of the hip:

Iliopsoas abscess:

Inguinal/femoral hernia:

Lumbar radiculopathy (L1–L3):

Genitourinary causes:

Vascular causes:

Gastrointestinal causes:

Malignancy:

Neurologic:

Key distinction: A febrile elderly patient with hip pain and elevated inflammatory markers — distinguish septic hip (any motion painful, requires emergent arthrotomy) from fracture-related fever (typically low-grade, day 2–4 postop atelectasis, not painful with motion). Aspiration is the answer when in doubt.

Secondary Prevention and Discharge Planning

— Every fragility hip fracture patient receives osteoporosis treatment regardless of DXA

— Check vitamin D 25-OH, calcium, PTH, TSH, creatinine before initiation

— Replete vitamin D to >30 ng/mL before starting potent antiresorptive

— First-line: zoledronic acid 5 mg IV annually — single infusion overcomes adherence issues; reduces mortality after hip fracture (HORIZON trial)

— Alternative: oral alendronate 70 mg weekly or risedronate

— Denosumab 60 mg SC q6 months — for CKD (no renal adjustment) or bisphosphonate failure/intolerance; never discontinue without transition to bisphosphonate (rebound vertebral fractures)

— Anabolic agents (teriparatide, romosozumab, abaloparatide) for very high-risk patients (T-score <-3, multiple fractures) — followed by antiresorptive

— Avoid initiating IV bisphosphonate in the first 2 weeks postop — may slightly delay healing; most experts wait 2–4 weeks but treatment within hospitalization is acceptable and improves adherence

— Calcium 1000–1200 mg/day (diet preferred over supplements — supplements may slightly increase CV events)

— Vitamin D 800–1000 IU daily

— Home safety assessment: remove rugs, grab bars, lighting, raised toilet seat

— Vision check, hearing aids

— Medication reconciliation: deprescribe benzodiazepines, anticholinergics, sedating antihistamines, excess antihypertensives

— PT for strength and balance training, tai chi

— Vitamin D supplementation reduces falls in deficient patients

— LMWH or DOAC for 28–35 days post-op

— Skilled nursing facility, inpatient rehab, or home with home health based on prefracture function and progress

— Acute inpatient rehab requires ability to tolerate 3 h therapy/day

Osteoporosis pharmacotherapy — start before discharge:

Calcium and vitamin D:

Fall prevention:

VTE prophylaxis:

Discharge destination:

Board pearl: Only ~20% of hip fracture patients receive osteoporosis treatment — Step 3 frequently tests whether you remember to start zoledronic acid or alendronate at discharge. Missing this is a quality gap and a tested question.

Step 3 management: Order at discharge — zoledronic acid IV (or alendronate 70 mg PO weekly), vitamin D 1000 IU, calcium 1200 mg dietary target, enoxaparin 28–35 days, DXA in 6–12 weeks, PCP follow-up 1–2 weeks, ortho follow-up 2–6 weeks.

Follow-Up, Monitoring, and Rehabilitation

— PCP / hospitalist follow-up: within 1–2 weeks of discharge — medication reconciliation, pain control, mood screening, wound check

— Orthopedic surgery: 2 weeks (wound), 6 weeks (radiographs, weight-bearing progression), 3 months, 1 year

— Geriatrics or osteoporosis clinic: 4–6 weeks for treatment initiation/optimization if not done inpatient

— PT outpatient or home health: 2–3×/week for 6–12 weeks

— Plain radiographs at 6 weeks, 3 months, 6 months, 1 year for healing assessment (extracapsular fractures)

— DXA scan within 6–12 weeks — establishes baseline; repeat in 2 years

— Concerning symptoms (groin pain at 3–6 months post femoral neck fixation) → MRI for AVN

— Zoledronic acid: check Cr, calcium, vitamin D before each infusion; hold if CrCl <35

— Denosumab: calcium and vitamin D before each dose (hypocalcemia risk, especially CKD)

— Bisphosphonates oral: annual creatinine

— Anticoagulation: CBC, Cr at LMWH transition; INR if warfarin

— POD 1: out of bed, weight-bearing as tolerated

— Week 1–2: walker ambulation, transfers

— Week 6: progressing to cane

— 3 months: most functional recovery achieved; further gains slow

— Only 40–60% return to prefracture ambulation level

— Dental exam before starting bisphosphonate or denosumab (osteonecrosis of jaw risk — low but real, especially with invasive dental work)

— Avoid bending hip >90°, crossing legs, low chairs for 6 weeks if posterior THA (dislocation precautions)

— Smoking cessation (impairs bone healing)

— Alcohol moderation

— Adequate protein intake (1.0–1.2 g/kg/day)

— PHQ-9 at follow-up — post-fracture depression common and worsens functional recovery

— Generally restricted 4–6 weeks; sooner for left hip in automatic transmission

Follow-up cadence:

Imaging follow-up:

Lab monitoring:

Functional milestones:

Counseling:

Depression screening:

Driving:

Board pearl: Persistent groin pain 3–9 months after femoral neck fixation in a young patient → MRI to evaluate for AVN of the femoral head; consider conversion to THA if collapse.

Step 3 management: At 6-week visit, order DXA, recheck Cr/calcium/vitamin D, confirm osteoporosis therapy adherence, screen for depression, advance ambulatory aid, plan home health discontinuation.

Ethical, Legal, and Patient Safety Considerations

— Assess decisional capacity: understanding, appreciation, reasoning, expression of choice — task-specific, not a global judgment

— Patients with mild-to-moderate dementia may retain capacity for surgical consent

— If patient lacks capacity → surrogate decision-maker (advance directive → durable POA → spouse → adult child per state law)

— Document capacity assessment explicitly

— Substituted judgment: surrogate decides what the patient would have wanted, not what surrogate wants

— Severely frail or end-stage dementia patient with hip fracture — surgery often still appropriate for pain control and nursing care, even with comfort-focused goals

— Nonoperative management has very high mortality (>50% at 6 months) and poor pain control — generally not "kinder"

— Document discussion, code status, hospice eligibility

— Hip fracture in elderly patient with inconsistent history, multiple bruises of different ages, malnutrition, poor hygiene, fearful affect, or caregiver who answers for the patient → mandatory APS report

— Required in all 50 states for healthcare providers

— Document findings; do not delay surgical care while investigating

— Medication reconciliation errors are the most common discharge safety event

— Provide written instructions: anticoagulation duration, osteoporosis medication, follow-up appointments scheduled before discharge, red flag symptoms

— Teach-back method: confirm patient/caregiver understanding

— Avoid weekend discharges when feasible (higher readmission risk)

— Fall prevention orders, delirium prevention, VTE prophylaxis, pressure injury prevention, CAUTI prevention, surgical site infection bundle

— Time-out before surgery — site marking, antibiotic timing, patient identity

— Wrong-site surgery, retained foreign object, intraoperative nerve injury → disclose promptly and honestly; involve risk management early

— Apology + transparent communication reduces malpractice claims and is ethically required

— Document and counsel; legal duty in some states for impaired drivers

Informed consent in cognitively impaired patients:

Goals-of-care discussions:

Mandatory reporting — elder abuse:

Transitions of care — high-risk:

Patient safety bundles:

Disclosure of complications:

Driving restriction:

Board pearl: A nursing home patient with a hip fracture, multiple unexplained bruises, and a caregiver who insists on speaking for the patient — proceed with surgery as indicated, perform separate patient interview to assess capacity and safety, and file an APS report. These are independent obligations, not sequential.

High-Yield Associations and Rapid-Fire Clinical Facts

— Medial femoral circumflex artery is the dominant blood supply to the femoral head — disrupted in displaced femoral neck fractures → AVN risk

— Ligamentum teres artery contribution minimal in adults

— I: incomplete/valgus impacted

— II: complete, nondisplaced

— III: complete, partially displaced

— IV: complete, fully displaced

— III/IV → arthroplasty in elderly

— 1-year mortality: 20–30%

— Contralateral hip fracture within 5 years: 5–10%

— Return to prefracture ambulation: 40–60%

— Time-to-surgery goal: <48 h

— VTE prophylaxis duration: 28–35 days

— Osteoporosis treatment rate in real practice: ~20% (low — testable gap)

— Cefazolin 2 g IV preop (3 g if >120 kg)

— Enoxaparin 40 mg SC daily (30 mg if CrCl <30)

— Zoledronic acid 5 mg IV annually

— Vitamin D 800–1000 IU daily

— Acetaminophen scheduled 1 g q6h

— Long-acting benzodiazepines, anticholinergics, sedating antihistamines, opioids, alpha-blockers

— PPIs (long-term, hip fracture risk)

— SSRIs (fall risk + bone density)

— Glucocorticoids (≥5 mg prednisone for ≥3 months → osteoporosis treatment indicated)

— Aromatase inhibitors, androgen deprivation therapy

— Atypical subtrochanteric fracture → long-term bisphosphonate or denosumab

— Avascular necrosis → steroids, alcohol, sickle cell, lupus, deep-sea diving, Gaucher

— Stress fracture of femoral neck → female athlete triad, military recruit

— Transient osteoporosis of pregnancy → third trimester/postpartum, MRI marrow edema

— Pathologic fracture → breast/prostate/lung/kidney/thyroid/myeloma mets

— Severe AS → avoid spinal sympathectomy

— Bone cement implantation syndrome → intraop hypotension during cementation

— Spinal vs general → equivalent mortality (REGAIN trial)

Anatomy and vascular supply:

Garden classification:

Approximate numbers (Step 3 testable):

Medications to remember:

Drugs that cause/worsen falls or fractures:

Classic associations:

Anesthetic associations:

Board pearl: TXA 1 g IV at incision reduces transfusion in hip arthroplasty without increasing VTE — a Step 3 perioperative pearl across hip and knee arthroplasty stems.

Board Question Stem Patterns

Stem 1 — Occult fracture: 82-year-old woman fell at home, complains of groin pain, cannot bear weight; AP pelvis and hip radiographs are normal. Best next step? → MRI of the hip. Common distractors: discharge with PT, CT, bone scan, repeat radiographs in 1 week.

Stem 2 — Knee pain after fall: 78-year-old man with knee pain after fall, knee radiographs normal, examiner palpates groin tenderness. → Image the hip (referred pain via obturator nerve).

Stem 3 — Anticoagulation timing: Patient with AF on apixaban falls and sustains displaced femoral neck fracture. When to operate? → Hold apixaban, surgery at ~48 h from last dose; do not bridge with heparin. Distractors: emergent reversal with andexanet, vitamin K, FFP.

Stem 4 — Procedure choice: Active 68-year-old, independent ambulator, displaced femoral neck fracture (Garden IV). → Total hip arthroplasty (not hemiarthroplasty, not screws).

Stem 5 — Cognitively impaired patient: 88-year-old with advanced dementia, displaced femoral neck. → Hemiarthroplasty (lower dislocation risk than THA in noncompliant patients).

Stem 6 — Severe AS: Hip fracture with new systolic murmur, TTE shows severe AS. → Proceed to surgery with GA, arterial line, anesthesia consultation; do not delay for valve replacement.

Stem 7 — Osteoporosis treatment at discharge: 80-year-old after hip fracture fixation, DXA not done. → Start zoledronic acid 5 mg IV annually (or alendronate); do not wait for DXA. Replete vitamin D first.

Stem 8 — Atypical femur fracture: 72-year-old woman on alendronate 8 years, prodromal thigh pain, transverse subtrochanteric fracture. → Discontinue bisphosphonate, cephalomedullary nail, image contralateral femur, consider teriparatide.

Stem 9 — Elder abuse: Nursing home patient with hip fracture, multiple bruises of different ages, caregiver dominates the conversation. → File APS report + proceed with surgical care.

Stem 10 — Postoperative delirium: POD 2, confused, agitated, pulling at lines. → Non-pharmacologic measures first; avoid benzodiazepines; low-dose haloperidol only if severe; rule out hypoxia, infection, pain, urinary retention.

Stem 11 — VTE prophylaxis duration: Discharge after hip fracture surgery. → Enoxaparin 40 mg SC daily for 28–35 days (or DOAC equivalent).

Stem 12 — Persistent groin pain at 6 months: Post femoral neck fixation, new groin pain, normal radiographs. → MRI for AVN of femoral head.

Board pearl: When a stem mentions "fell after starting a new medication" — the new medication (alpha-blocker, antihypertensive, sedative) is the fall etiology and discontinuation/dose adjustment is part of the answer.

One-Line Recap

Hip fracture in the elderly is a fragility fracture requiring expedited surgical fixation within 48 hours, multimodal perioperative optimization with medicine/geriatrics co-management, and aggressive secondary prevention with osteoporosis pharmacotherapy and fall reduction to limit the 20–30% 1-year mortality and 5–10% contralateral fracture risk.

Diagnosis: AP pelvis + AP/lateral hip radiographs first; if negative and suspicion persists, MRI hip within 24 hours — never discharge a non-ambulatory elderly patient with "negative x-rays."

Operative plan: Surgery <48 h; displaced femoral neck → THA in active community ambulators, hemiarthroplasty in low-demand/cognitively impaired; intertrochanteric → sliding hip screw or cephalomedullary nail; young patient with displaced femoral neck = surgical emergency for AVN prevention.

Perioperative bundle: Cefazolin within 60 min of incision, TXA 1 g IV intraop, multimodal analgesia (scheduled APAP + fascia iliaca block, opioid-sparing), enoxaparin 40 mg SC daily for 28–35 days, restrictive transfusion threshold (Hb <8), early mobilization POD 0–1, delirium prevention (avoid benzos/anticholinergics), continue beta-blockers, hold ACEi morning of surgery.

Discharge and longitudinal care: Zoledronic acid 5 mg IV annually (or oral bisphosphonate) for every fragility hip fracture, vitamin D 800–1000 IU + calcium 1200 mg, DXA at 6–12 weeks, fall prevention with home safety/medication deprescribing/PT, PCP follow-up 1–2 weeks, ortho 2–6 weeks, screen for depression and elder abuse, document goals of care and capacity for cognitively impaired patients.

Board pearl: The single most undertreated Step 3 gap in hip fracture care is initiating osteoporosis pharmacotherapy before discharge — if a stem ends with "what additional intervention reduces future fracture risk?", the answer is almost always zoledronic acid or alendronate, not another DXA.