Retinacular vessels travel along femoral neck within capsule
Ligamentum teres artery (obturator artery branch) minor contribution
Fracture disrupts retinacular vessels
Displaced fractures cause higher vascular disruption
Avascular necrosis risk proportional to displacement degree
Intracapsular hematoma
Increases intracapsular pressure
Compresses vessels further
Tamponade effect worsens ischemia
Osteoporosis mechanism
Trabecular bone loss
Ward triangle region particularly vulnerable
Cortical thinning of femoral neck
Femoral neck geometry
Wider neck-shaft angle increases stress
Longer hip axis length increases fracture risk
Fall biomechanics
Fall direction matters
Lateral fall directly onto greater trochanter highest risk
Hip abductor muscle strength reduces impact transmission
Impact attenuation
Soft tissue padding in obese patients protective
Low BMI patients have less cushioning
Therapeutic Considerations
Surgical timing evidence
Surgery within 24 to 48 hours of admission
Associated with reduced 30-day and 1-year mortality
Reduces pain duration and complication risk
Medical optimization before surgery
Delay acceptable for reversible acute conditions
Chronic stable conditions should not delay surgery
Cochrane 2024 review on ultra-early surgery
Ultra-early (< 12 hours) versus early (12 to 48 hours): no significant mortality difference
Larger RCTs ongoing
Arthroplasty versus internal fixation for displaced fractures
Cochrane 2022 network meta-analysis
THA associated with better functional outcomes than hemiarthroplasty
Both superior to internal fixation for displaced fractures in elderly
Internal fixation failure rates
Nonunion rate 18.5% for displaced fractures managed with fixation
Avascular necrosis rate 9.7% for displaced fractures managed with fixation
Revision surgery rates
Internal fixation has higher revision rates than arthroplasty in elderly
Nerve block evidence
FICB versus systemic opioids
Meta-analysis: FICB reduces pain score by approximately 3 points on 10-point scale
Reduces opioid consumption by approximately 50%
May reduce delirium incidence
PENG block emerging data
2025 RCT (Di Pietro et al., Anaesthesia) comparable efficacy to FICB
Motor-sparing advantage permits earlier fall risk assessment
JAMA 2025 review supports nerve block recommendation for hip fracture
Patient Discharge Instructions
copy discharge instructions
Hip fracture home care instructions
You have a hip fracture and have had surgery
Follow all weight-bearing restrictions given by your surgeon
Do not skip physiotherapy appointments
Wound care
Keep surgical incision clean and dry for 2 weeks
No submerging in water until cleared by your surgeon
Watch for signs of infection at the wound site
Blood clot prevention
Take blood-thinning medication as prescribed
Compression stockings as instructed
Leg exercises (ankle pumps) regularly while resting
Medications after discharge
Pain medications
Take acetaminophen regularly as prescribed
Use stronger painkillers only as needed and for the shortest time
Bone medications
Start bisphosphonate medication as instructed (usually 2 weeks after surgery)
Take weekly bone pill on empty stomach with a full glass of water
Sit or stand upright for 30 minutes after taking bone pill
Calcium and vitamin D
Take calcium and vitamin D supplements daily as prescribed
Fall prevention at home
Remove throw rugs and trip hazards from floors
Especially at night pathways to bathroom
Install grab bars in shower and beside toilet
Use assistive device (walker or cane) as prescribed
Ensure adequate lighting in all areas at night
Nightlight in bedroom and hallways
Wear supportive footwear at all times
Non-slip soles
Return to emergency department immediately if
Increased pain, swelling, redness, or warmth at the hip or incision site
May indicate wound infection or fracture displacement
Fever above 38.3 degrees Celsius
Sign of possible infection
Calf pain, swelling, or redness
May indicate deep vein thrombosis
Sudden shortness of breath or chest pain
May indicate pulmonary embolism
Feeling that the hip has shifted or given way
Suggests prosthesis dislocation or implant failure
New confusion, extreme drowsiness, or unusual behavior
Delirium or medication side effects
Inability to bear weight as previously instructed
Suggests mechanical complication
Follow-up appointments
Orthopedic surgeon at 2 weeks for wound check
Then at 6 weeks, 3 months, and 1 year
Family doctor within 1 week of discharge
Medication reconciliation and blood pressure check
Physiotherapy starting within days of discharge
Critical for functional recovery
References
Guidelines and key sources
Orthopedic and trauma guidelines
AAOS Management of Hip Fractures in Older Adults Evidence-Based Clinical Practice Guideline 2022
Switzer JA, O'Connor MI, JAAOS 2022
Strong recommendation for co-management model
American College of Surgeons Best Practices Orthopaedic Trauma 2015
Davis ML et al.
WSES 2023 Guidelines on Trauma in Elderly and Frail Patients
De Simone B et al., World Journal of Emergency Surgery 2024
VTE prophylaxis evidence
PREVENT CLOT Trial
METRC Consortium, NEJM 2023
Aspirin non-inferior to LMWH for fracture VTE prophylaxis
ACCP Antithrombotic Therapy 9th Edition
Falck-Ytter Y et al., Chest 2012
Minimum 10 to 14 days pharmacologic prophylaxis
Surgical approach evidence
Cochrane Surgical Interventions for Intracapsular Hip Fractures 2022
Lewis SR et al.
THA versus hemiarthroplasty versus internal fixation network meta-analysis
Cochrane Arthroplasties for Hip Fracture 2022
Lewis SR et al.
Cochrane Ultra-Early versus Early Surgery for Hip Fracture 2024
Viamont-Guerra MR et al.
Nerve block evidence
Peripheral Nerve Blocks for Hip Fractures JAMA 2025
Liu YT, Tovar Hirashima E, Yadav K
Fascia Iliaca Block for Hip Fractures in ED Meta-Analysis
Makkar JK et al., American Journal of Emergency Medicine 2021
PENG versus FICB RCT Anaesthesia 2025
Di Pietro S et al.
Anticoagulation and DOAC management
International Consensus Statement on DOACs in Hip Fracture
Mitchell RJ et al., Anaesthesia 2024
Safety of Expedited Surgery in Anticoagulant-Treated Hip Fracture
You D et al., Canadian Journal of Surgery 2023
Osteoporosis and secondary prevention
ACP Living Clinical Guideline Pharmacologic Treatment of Osteoporosis 2023
Qaseem A et al., Annals of Internal Medicine
Osteoporosis JAMA 2025
Morin SN, Leslie WD, Schousboe JT
ACR Appropriateness Criteria Acute Hip Pain 2024 Update
Bartolotta RJ et al., JACR 2025
Delirium prevention
AGS Guideline for Postoperative Delirium in Older Adults 2015
Journal of the American Geriatrics Society
Delirium in Hospitalized Older Adults NEJM 2017
Marcantonio ER
Postoperative Delirium in Geriatric Patients with Hip Fractures
Chen Y et al., Frontiers in Aging Neuroscience 2023
Fall prevention and risk
Risk Assessment and Prevention of Falls JAMA 2024
Colon-Emeric CS et al.
Medications as Risk Factor for Fragility Hip Fractures
Mortensen SJ et al., Calcified Tissue International 2020
Hip Fractures Diagnosis and Management American Family Physician 2022
Schroeder JD, Turner SP, Buck E
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.