History and exam

Key diagnostic factors

common

history of fall or trauma

Ask about a recent fall or trauma. The predominant mechanism of injury is a fall.​

  • In older patients, falling from a standing height can cause hip fracture.[1][48]​​ 

pain in the affected hip, groin, or thigh

Global pain is typically reported around the groin and the region of the greater trochanter.[1]​​ 

  • May radiate distally down the femur or up to the pelvis.[53] 

  • Pain is often increased with internal or external rotation of the leg or flexion of the hip.

  • Patients with severe cognitive impairment may present without obvious pain but with inability to weight bear.

  • Prodromal pain or night pain raise suspicion of metastatic bone disease and should be documented along with any circumstances of injury.[9]

inability to bear weight or move the hip

Weight bearing is either impossible or causes pain in the groin, hip, or femur.[1][48]​​ 

  • The leg cannot support body weight if the fracture is displaced.[53] 

  • Straight leg raising is unlikely to be possible (although it may be possible in a patient with an undisplaced fracture).

shortened, externally rotated leg

Examine for a shortened, externally rotated leg. This may indicate a displaced fracture.[1][48]​​

risk factors

Falls

Fall from a standing height is the predominant mechanism of injury.[1][48]​​​ 

  • Ask about any previous falls or fractures.

  • Gait and balance problems, muscle weakness, visual impairment, cognitive impairment, depression, functional decline, and particular medications are the most common underlying causes and risk factors for falls.[29][30]

  • Patients with low bone mineral density, as in osteoporosis, may rarely have no history of trauma.

Older age

Risk of hip fracture increases with age.[57]

  • The average age of people sustaining a hip fracture is 83 years.[11] 

  • Hip fracture is the most common reason for an older person with frailty to need surgery and anaesthesia.[11]

Osteoporosis/osteopenia

Low hip bone mineral density weakens the proximal femur and increases the risk of hip fracture.[27]​ 

Malignancy

Pathological fractures can be caused by metastatic cancer or, rarely, a primary bone tumour.

  • Patients with breast cancer or prostate cancer may be particularly at risk due to a loss in bone mineral density after chemotherapy or hormone therapy.[55][56]

Female sex

Hip fracture is more common in women.

  • Swedish population data found that the projected lifetime risk of hip fracture is 11.1% for men and 22.7% for women.[32]

High-energy trauma

Main cause in younger patients (e.g., motor vehicle accidents or fall from a height).[17]​ 

Medication

Ask about current medications. Some drugs increase the risk of falls or fracture.[29][33][34]​​​[35]

  • Drugs that increase the risk of fracture: 

    • Levothyroxine – decreases bone density​[60]

    • Loop diuretics – impair calcium absorption in kidneys[61]​ 

    • Proton-pump inhibitors – reduce calcium absorption[62][63]​ 

    • Corticosteroids – long-term use can lead to osteoporosis.[33] If the patient has been on corticosteroids for a long time, they may have adrenal suppression requiring an increase of the corticosteroid dose around the time of surgery[34][62][63]​​

    • Long-term bisphosphonates are rarely associated with atypical hip fractures.[64] Identify whether a patient is already taking a bone protection medication and, if so, how long they have been taking it for. 

  • Drugs that increase the risk of falls:

    • Medications that cause sedation (e.g., antidepressants, sedatives) – increase risk of falls due to sedation[29]​​

    • Antihypertensives – may increase the risk due to adverse effects such as postural hypotension and dizziness[35] 

    • Opioid analgesics – may increase the risk through their sedative effects.[29]​[65]​​​ 

Alcohol consumption

Ask about recent or regular alcohol consumption. It can increase the risk of falls and osteoporosis.

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