In developed countries, the treatment of a hip fracture requires a wide range of disciplines, as the patient will present to the ambulance service and the accident and emergency unit, then pass through departments of radiology, anaesthetics, orthopaedic surgery, medicine, and rehabilitation. Medical and social services in the community may be needed when the patient leaves hospital.

Mortality associated with a hip fracture is about 5-10% after one month. One year after fracture about a third of patients will have died, compared with an expected annual mortality of about 10% in this age group.^{2,3 w2} Thus, only a third of deaths are directly attributable to the hip fracture itself, but patients and relatives often think that the fracture has played a crucial part in the final illness.^w2

More than 10% of survivors will be unable to return to their previous residence. Most of the remainder will have some residual pain or disability.^2,3

Most hip fractures result from a fall or stumble—only about 5% of cases have no history of injury.^w4-w8

Fractures can be classified radiographically into intracapsular and extracapsular fractures (figure). These may be further subdivided, depending on the level of the fracture and the presence or absence of displacement and comminution.^w13-w15

Extracapsular fractures can be managed with traction, but this must be maintained for one to two months. The frail older people who typically sustain this injury are poorly equipped to cope with prolonged immobilisation, which may result in loss of mobility and independence.^{w19 w20} This may precipitate placement into a long term care home—an outcome that some perceive as worse than death.^w21 Thus, most hip fractures are treated by surgery.

Intracapsular fractures may be treated by fixing the fracture and preserving the femoral head.^w22 Preservation of the femoral head is appropriate for undisplaced fractures and for displaced fractures in “younger” patients (under 70). In frail or older people, displaced intracapsular fractures may be treated by reduction and fixation, but the incidence of non-union and avascular necrosis is 30-50% for this procedure, so the femoral head is replaced in most patients.^{w23 w24} The approach may be hemiarthroplasty, where just the femoral head is replaced, or a total hip replacement, where both sides of the joint are replaced. Cementing the prosthesis in place results in less pain and better mobility (figs A and B on bmj.com).^w25

Thromboembolic prophylaxis is a contentious issue. People who sustain a hip fracture are at high risk of thromboembolic complications but are also at risk of the adverse effects of prophylactic drugs. The incidence of thromboembolic complications has fallen as a result of the measures listed in box 2, and the adverse effects of prophylaxis may outweigh the benefits. A systematic review of heparins and a large randomised trial of low dose aspirin noted a reduction in thromboembolic complications with prophylaxis, but at the expense of increased bleeding complications.^{w37 w42}

Many patients who sustain a hip fracture fear that it will result in death or disability, and it is important to set reasonable expectations to restore their morale. However, over optimistic reassurance about the success of surgery may lead to disappointment if rehabilitation is slow. Assessment must be comprehensive in order to identify impediments to recovery, set realistic goals, and coordinate appropriate rehabilitation.

Five broad categories of rehabilitation have been described (box 3).⁸

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 w47, w48}

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