Hip Fracture in Older Adults - Perioperative Care

Key Points

• Hip fracture is a geriatric emergency, not simply a broken bone; delay increases medical complications and loss of independence.
• Negative initial radiographs do not exclude an occult fracture when pain and inability to bear weight persist.
• Use focused preoperative optimization and avoid delaying surgery for minor chronic abnormalities.
• Current orthopedic guidance supports surgery within 24 to 48 hours when medically feasible.
• Regional nerve blocks can improve analgesia and reduce opioid burden.
• Delirium prevention begins on arrival and depends heavily on nonpharmacologic care.
• Venous thromboembolism prophylaxis and early mobilization are routine components of care unless contraindicated.
• Every fragility hip fracture should trigger osteoporosis and fall-risk evaluation.

Algorithm

1. Confirm hip fracture with radiographs; obtain MRI or CT when clinical suspicion remains high despite negative films.
2. Provide multimodal analgesia and consider regional nerve block.
3. Perform focused assessment for unstable cardiopulmonary disease, infection, severe electrolyte abnormalities, anemia, anticoagulant effect, and delirium.
4. Correct time-sensitive reversible problems while coordinating early operative repair.
5. Select fixation or arthroplasty based on fracture pattern, displacement, function, bone quality, and goals of care.
6. Initiate VTE prophylaxis and delirium-prevention measures.
7. Mobilize early with physical and occupational therapy and provide adequate nutrition.
8. Plan rehabilitation, fall prevention, and secondary osteoporosis treatment before discharge.

Clinical Synopsis & Reasoning

Older adults with hip fracture may present after an obvious fall, but some have only groin pain, inability to bear weight, new functional decline, or pain referred to the knee. Examine limb length and rotation, palpate the hip and pelvis, assess distal neurovascular status, and look for injuries that contributed to or resulted from the fall. The diagnostic priority is confirmation of fracture and identification of reversible medical problems that materially affect anesthesia or surgery. Plain radiographs of the pelvis and affected hip are first line. If radiographs are negative but the patient has persistent pain, inability to bear weight, or a convincing mechanism and examination, obtain MRI when available or CT when MRI cannot be obtained promptly.

The perioperative evaluation should be focused rather than an open-ended search for every abnormality. Common high-value issues include dehydration, acute blood loss anemia, hypoxia, uncontrolled heart failure, unstable arrhythmia, active myocardial ischemia, severe electrolyte derangement, infection, anticoagulant effect, and delirium. Many chronic abnormalities do not justify postponing repair. Delay itself increases immobility, pain, delirium, pressure injury, pneumonia, and thromboembolic risk. Current orthopedic guidance supports surgery within approximately 24 to 48 hours when medically feasible, while allowing short targeted optimization for truly unstable conditions.

Delirium risk is high and should be assessed from arrival. Obtain collateral information about baseline cognition, function, medications, sensory impairment, and living situation. Evaluate why the patient fell, including orthostatic hypotension, sedatives, visual impairment, arrhythmia, stroke symptoms, environmental hazards, and osteoporosis. A hip fracture is often a sentinel fragility fracture and should trigger secondary prevention planning rather than being treated as an isolated orthopedic event.

Treatment Strategy & Disposition

Provide analgesia early. Acetaminophen, carefully titrated opioids, and regional anesthesia such as a fascia iliaca or femoral nerve block can reduce pain and opioid exposure. Avoid undertreating pain because pain itself contributes to delirium, immobility, and respiratory compromise. At the same time, minimize medications with strong anticholinergic or sedating effects when safer alternatives exist. Give IV fluids only when volume depletion is present rather than routinely flooding older adults who may have heart or kidney disease.

Coordinate surgery with orthopedics, anesthesia, geriatrics or hospital medicine, and pharmacy. Reverse anticoagulation when clinically indicated using agent-specific strategies, but avoid unnecessary delays once hemostatic safety is acceptable. Treat major electrolyte abnormalities, uncontrolled infection, acute coronary syndrome, decompensated heart failure, or other unstable conditions promptly. Most patients benefit from operative repair rather than prolonged traction or bed rest. Procedure choice depends on fracture location, displacement, prefracture function, bone quality, and patient goals. Femoral neck fractures may require internal fixation, hemiarthroplasty, or total hip arthroplasty. Intertrochanteric and subtrochanteric fractures are commonly treated with fixation devices.

Begin venous thromboembolism prophylaxis unless contraindicated and continue according to the operative pathway. Use mechanical prophylaxis when pharmacologic therapy must be delayed. Mobilize as early as the surgical construct and medical condition allow, commonly beginning on the first postoperative day. Delirium prevention should include orientation, hearing aids and eyeglasses, sleep protection, hydration, bowel and bladder management, early catheter removal, medication review, and frequent mobilization. Ensure adequate protein and calorie intake. At discharge, assess osteoporosis treatment, calcium and vitamin D intake when appropriate, fall risks, rehabilitation needs, home safety, and the ability to adhere to medications and follow-up.

Epidemiology / Risk Factors

• Hip fractures occur predominantly in older adults and are strongly associated with osteoporosis, falls, frailty, and impaired balance.
• Women are affected more often because of longer life expectancy and postmenopausal bone loss, although mortality after fracture can be high in both sexes.
• One-year mortality is substantial, and many survivors do not regain their previous level of mobility or independence.
• Prior fragility fracture is a strong predictor of future fracture, making secondary prevention a high-yield intervention.

Investigations

Optimization Snapshot

Pharmacology

Prognosis / Complications

• Earlier mobilization and coordinated geriatric-orthopedic care are associated with fewer complications and better functional recovery.
• Poor outcomes are associated with advanced frailty, dementia, severe comorbidity, prefracture immobility, postoperative delirium, and complications such as pneumonia or infection.
• Many patients require temporary or long-term rehabilitation, and some cannot return to independent living.
• Appropriate osteoporosis treatment and fall prevention reduce future fracture risk even though they do not alter the acute repair.

Patient Education / Counseling

• Explain that surgery is generally performed to restore mobility and reduce complications of prolonged bed rest, not simply to correct the x-ray appearance.
• Discuss realistic recovery expectations based on prefracture function, cognition, and frailty.
• Encourage family participation in orientation, mobility, hearing and vision support, and discharge planning.
• Review fall prevention, home hazards, footwear, assistive devices, and medication contributors to dizziness or sedation.
• Explain that osteoporosis evaluation and treatment are part of preventing another hip or vertebral fracture.

Notes

Hip fracture care works best as a coordinated pathway. Fragmented care in which each service waits for another to solve every problem can create harmful delays. The practical question for a preoperative abnormality is whether it represents a reversible unstable condition that meaningfully changes immediate perioperative risk. Chronic stable findings are often managed concurrently with fracture repair.

Postoperative delirium deserves active prevention rather than passive recognition. New confusion is not an expected consequence of age and should prompt evaluation for pain, infection, hypoxia, urinary retention, constipation, medication toxicity, metabolic disturbance, or environmental disorientation. Antipsychotics do not prevent delirium and should not replace correction of the cause or nonpharmacologic support.

Secondary prevention should begin during the fracture admission. A hip fracture after a low-energy fall generally establishes very high future fracture risk. Patients may qualify for osteoporosis pharmacotherapy even before a formal bone-density result is available, depending on clinical context. Coordination with primary care, endocrinology, geriatrics, or a fracture-liaison service improves the likelihood that prevention actually occurs.

References

1. AAOS Management of Hip Fractures in Older Adults Clinical Practice Guideline — Link
2. AAOS OrthoInfo: Hip Fractures — Link
3. American Geriatrics Society resources on postoperative delirium — Link