Hip fractures

Last reviewed: 25 Aug 2022
Last updated: 05 Apr 2022
05 Apr 2022

Updated US guideline highlights importance of early surgery and interdisciplinary care to improve outcomes in older people with hip fractures

The American Academy of Orthopaedic Surgeons has issued an update to its 2014 guideline on the management of hip fractures in older patients. Updated information for patients aged 65 and over includes:

  • Strong evidence supports surgery for hip fractures within 24-48 hours of admission. Recent data from high volume centers has shown better outcomes if surgery is within 24 hours, although the guideline makes a recommendation of 24-48 hours to recognise variations in resources at different centers.

  • Interdisciplinary care programs are recommended for the care of hip fracture patients, based on strong evidence that they can decrease mortality and complications and improve outcomes.

  • In an upgraded recommendation, venous thromboembolism (VTE) prophylaxis is now strongly recommended based on significant established risk factors in these patients including age, major surgery and potential delays to surgery.

  • Arthroplasty is strongly recommended over fixation for unstable (displaced) femoral neck fractures based on updated evidence from randomized trials that report consistently better outcomes (reoperation rate, pain scores, functional status, and/or complication rate) for arthroplasty.

  • A new strong recommendation for tranexamic acid in all patients with hip fracture to reduce blood loss and blood transfusion.

  • Multimodal analgesia incorporating preoperative nerve block is recommended to treat pain after hip fracture.

See Management: approach

Original source of update



History and exam

Key diagnostic factors

  • inability to bear weight
  • pain in affected leg/hip
  • pain with hip movement
More key diagnostic factors

Other diagnostic factors

  • shortened and externally rotated leg
Other diagnostic factors

Risk factors

  • osteoporosis/osteopenia
  • age over 65 years
  • falls
  • low body mass index
  • female sex
  • high-energy trauma
  • dementia
More risk factors

Diagnostic investigations

1st investigations to order

  • plain x-rays
More 1st investigations to order

Investigations to consider

  • MRI pelvis
  • CT pelvis
  • technetium bone scan
More investigations to consider

Treatment algorithm


intracapsular (femoral neck) fracture

extracapsular (intertrochanteric) fracture



Herman Johal, MD, MPH, FRCSC

Orthopaedic Trauma Surgeon

Assistant Professor

Department of Surgery

McMaster University

Hamilton, Ontario



HJ declares that he has no competing interests.


Dr Herman Johal would like to gratefully acknowledge Dr Bradley A. Petrisor and Dr Mohit Bhandari, the previous contributors to this topic.


BAP and MB declare that they have no competing interests.

Peer reviewers

Marc F. Swiontkowski, MD


Department of Orthopedic Surgery

University of Minnesota




MFS is Editor-in-Chief of the Journal of Bone and Joint Surgery.

Rudolf Poolman, MD, PhD

Consultant Orthopaedic Surgeon

Onze Lieve Vrouwe Gasthuis

Teaching Hospital with The University of Amsterdam

Department of Orthopaedic Surgery


The Netherlands


RP has been reimbursed by LINK for organizing education and research consultancy.

David Hackam, MD, PhD

Assistant Professor of Surgery

Children's Hospital of Pittsburgh




DH declares that he has no competing interests.

  • Hip fractures images
  • Differentials

    • Acetabular fracture
    • Pubic rami fracture
    • Femoral shaft or subtrochanteric femur fracture
    More Differentials
  • Guidelines

    • Management of hip fractures in older adults
    • ACR appropriateness criteria: acute hip pain - suspected fracture
    More Guidelines
  • Patient leaflets


    More Patient leaflets
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