Multidisciplinary assessment of the reason for the fall will reduce the risk of further fractures, and the components of such assessments are well described.11,12
Nearly all patients with hip fracture meet the criteria for such an assessment, which should be performed routinely as part of inpatient rehabilitation care (box 4). A medical cause for the fall should be sought; specifically, hypotension, postural hypotension, arrhythmia, vasovagal syncope, and carotid sinus hypersensitivity. Examination should include lying and standing blood pressure and a 12 lead electrocardiogram.
About 3% of hip fractures are related to localised bone weakness at the fracture site, secondary to tumour, bone cysts, or Paget's disease. More than half of the remaining patients have osteoporosis, and nearly all are osteopenic. Over the age of 80, a woman with normal bone mineral density for her age will have a T score of around - 2.5 (the diagnostic threshold for osteoporosis). Thus, assessment of bone density is probably not necessary in older age groups, and current UK guidelines only recommend a dual energy x ray absorptiometry scan for women under the age of 75.13
In men and younger women, routine preoperative blood counts and basic biochemistry may need to be accompanied by tests for causes of bone fragility. Malnutrition, low body weight, alcoholism, and deficiency of calcium or vitamin D are common and important at all ages. Treatment with steroids, renal failure, liver disease, hyperthyroidism, hyperparathyroidism, and hypogonadism are other potential causes of bone fragility.
Pharmacological prevention of hip fracture is controversial. An early study showed a benefit of calcium and vitamin D supplementation in residents of care homes. A similar regimen was therefore adopted among people recovering from hip fracture, but this approach has not been supported by later studies.14,15
Oral bisphosphonates are widely recommended for secondary prevention of fragility fractures; UK guidelines advocate them for all women over 75 and for younger women with confirmed osteoporosis.16
The effectiveness of bisphosphonates in the very elderly is not known, although no reason exists to doubt their efficacy in this situation.17
Careful explanation and counselling are crucial to the effective use of these drugs. Pre-existing gastrointestinal problems raise concern over upper gastrointestinal intolerance, and some frailer patients may have difficulty adhering to the dosing regimen.
Strontium may be an effective and convenient alternative in frailer patients.w49 Suggestions that strontium may predispose patients to thromboembolism have not been confirmed, but prescription should be delayed until the patient is mobile. Calcium and vitamin D status should be optimised in patients taking bisphosphonates or strontium.
Hormone replacement therapy and selective oestrogen receptor antagonists should be avoided in women recovering from hip fractures, as they greatly increase the risk of thromboembolism.18,19
Early reports of hip protectors, which absorb or spread the energy of a fall, were promising, but recent studies have questioned their effectiveness.20,21
Current and future directions for research
New designs and developments in surgical implants
Assessment of many aspects of perioperative care
Definition of the optimum method of rehabilitation
Evaluation of proposed methods for reducing the risk of further fractures
Additional educational resources
Parker MJ, Handoll HHG. Hip fracture. Clinical evidence. BMJ Publishing, 20054
National Osteoporosis Society, PO Box 10, Bath BA3 3YB (www.nos.org.uk
Hip fracture is the most common cause of acute orthopaedic admission in older people
Treatment is generally surgical to replace or repair the broken bone
Mortality is 5-10% after one month and about 30% after one year
Some loss of function is to be expected in most patients
Multidisciplinary rehabilitation is needed for the patient to return home
Ways to reduce the risk of further fracture should be considered