Article: AENJ-D-17-00013 Date: January 15, 2018 Time: 21:31

Advanced Emergency Nursing Journal

Vol. 40, No. 1, pp. 8–15
Copyright 
C 2018 Wolters Kluwer Health, Inc. All rights reserved.

Imaging
Column Editor: Denise R. Ramponi, DNP, FNP-C, ENP-BC, FAEN, FAANP, CEN

Hip Fractures
Denise R. Ramponi, DNP, FNP-C, ENP-BC, FAEN, FAANP, CEN
Judith Kaufmann, DrPH, MA, MSN, FNP-BC
Gwendolen Drahnak, DNP(c), FNP-C

Abstract
Hip fractures are associated with significant morbidity and mortality and a major health problem in
the United States (L. M. Brunner, L. Eshilian-Oats, & T. Y. Kuo, 2003). Eighty percent of hip fractures
are experienced by 80-year-old women. Plain radiographs usually confirm the diagnosis, but if there
is a high level of suspicion of an occult hip fracture, magnetic resonance imaging or bone scan is
the next step to confirm the diagnosis. Areas of the hip bone have varied bone strength and blood
supply, making the femoral neck one of the most vulnerable areas for fracture. A consultation to an
orthopedic surgeon will determine surgical interventions. Key words: extracapsular, femoral head,
femoral neck, femur, hip fractures, intertrochanteric, intracapsular, subtrochanteric, trochanteric,
Ward’s triangle

T
HE HIP is a ball-and-socket joint where
the femur abuts the ilium, ischium, and
pubis of the pelvis. The femoral head
is the ball and the acetabulum is the socket
in this synovial joint. The proximal portion of
the femur consists of the head, neck, and the
greater and lesser trochanter (see Figure 1).
Author Affiliations: School of Nursing and Health
Sciences, Robert Morris University, Moon Township,
Pennsylvania (Drs Ramponi and Kaufmann); Her-
itage Valley Health System, Pittsburgh, Pennsylvania
(Dr Ramponi); St. Clair Health System, Bridgeville,
Pennsylvania (Dr Kaufmann); and Novartis Pharma-
ceuticals, Basel-City, Switzerland (Ms Drahnak).
Illustrations by Katherine Chemsak, Media Arts Stu-
dent, Robert Norris University.
Disclosure: The authors report no conflicts of interest.
Corresponding Author: Denise R. Ramponi, DNP,
FNP-C, ENP-BC, FAEN, FAANP, CEN, School of Nursing
and Health Sciences, Robert Morris University, Scaife
Hall, 6001 University Blvd, Moon Township, PA 15108
(dramponi@comcast.net).
DOI: 10.1097/TME.0000000000000180
The greater trochanter, a bony prominence
on the anterolateral surface of the proximal
shaft of the femur, is the insertion site for the
gluteus medius and gluteus minimus muscles.
The lesser trochanter, a bony prominence on
the proximal medial aspect of the femoral
shaft, is the insertion site for the iliopsoas
muscle. The intertrochanteric line is a raised
area of the bone that connects the greater
trochanter to the lesser trochanter.
There are several groups of trabecular can-
cellous bone that support the femoral head
and neck. The primary compressive trabecula
supports the medial femoral head and neck,
and this area around the medial femoral neck
is the densest cancellous bone of the hip. The
primary tensile trabecula supports the infe-
rior portion of femoral head and the superior
femoral neck. The secondary compressive tra-
becula supports the greater trochanter and
the lesser trochanter areas. An area referred

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 Article: AENJ-D-17-00013 Date: January 15, 2018 Time: 21:31

January–March 2018 r Vol. 40, No. 1 Hip Fractures 9

Figure 1. Anatomy of the hip bone. Illustration is the original artwork by Katherine Chemsak.

to as Ward’s triangle (see Figure 2), where
three of the trabeculae intersect, is an area of
relative weakness, making this area very vul-
nerable to fractures (Shivji, Green, & Forward,
2015).
INCIDENCE
Eighty percent of hip fractures occur in
women with an average age of 80 years
(LeBlanc, Muncie, & LeBlanc, 2014). The ma-
jority of hip fractures occur with a fall-related
injury. Decreased bone mineral density is also
a major contributing factor. The prevalence
of having a hip fracture in one’s lifetime is
20% for women and 10% for men (Landefeld,
2011). Hip fractures have been associated
with an increased mortality, demonstrated by
12%–17% of patients who die within the first
year after sustaining a hip fracture (LeBlanc
et al., 2014). Approximately, 25% of patients
are able to return to a full capacity of ac-
tivities of daily living after a hip fracture
(Magaziner, Simonsick, Kashner, Hebel, &
Kenzora, 1990).
RISK FACTORS
The majority of hip fractures occur as a
result of a fall, and other risk factors include
decreased bone mineral density (T score
less than −2.5 on dual-energy x-ray absorp-
tiometry scan), reduced activity levels, and
medications for chronic conditions (LeBlanc

Figure 2. Ward’s triangle. Illustration is the original artwork by Katherine Chemsak.

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 Article: AENJ-D-17-00013
10
et al., 2014). An increased risk for hip
fractures is also associated with the follow-
ing: low socioeconomic status, previous
hip fracture, and a family history of hip
fractures (Quah, Boulton, & Moran, 2011).
Medications associated with an increased risk
of falls include selective serotonin reuptake
inhibitors, inhaled and oral steroids, and
benzodiazepines (Huang, 2012). In addition,
there are proton pump inhibitors, which are
taken on a long-term basis and are associated
with an increased risk of fractures due to de-
creased calcium absorption (Turner, 2011),
and levothyroxine, which decreases bone
density.
TYPES OF FRACTURES
Two general classifications of hip fractures
are extracapsular and intracapsular frac-
tures. Extracapsular fractures include the
intertrochanteric and subtrochanteric hip
fractures (see Figure 3). Intertrochanteric
hip fractures occur between the neck of
the femur and the lesser trochanter. Sub-
trochanteric hip fractures occur in the shaft
of the femur. Because these fractures have a
large amount of cancellous bone and a very
Figure 3. Extracapsular hip fractures: intertrochanteric and subtrochanteric. Illustration is the original
artwork by Katherine Chemsak.
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Date: January 15, 2018 Time: 21:31
Advanced Emergency Nursing Journal
good blood supply, they most commonly heal
well.
Intracapsular hip fractures include the
femoral head and femoral neck areas (see
Figure 4). Femoral neck hip fractures occur at
the head of the femur and within the capsule
of the hip. These fractures have little cancel-
lous bone and a relatively poor blood supply,
thus there is a higher incidence of avascular
necrosis. Figure 5 is a plain radiograph show-
ing a left extracapsular hip fracture.
EMERGENCY DEPARTMENT MANAGEMENT OF
POTENTIAL HIP FRACTURES
Clinical Manifestations
Patients present with groin pain and inability
to bear weight on the affected leg after a
fall from a standing position. Patients with
hip fracture often complain of groin or hip
pain that commonly radiates to the knee.
When the patient is in the supine position,
the affected leg will appear shortened and
externally rotated on physical examination if
the fracture is displaced. Pain occurs with any
rotation movement, which causes internal or
external rotation of the hip. Distal motor and
neurovascular status of the distal leg may be
 Article: AENJ-D-17-00013 Date: January 15, 2018 Time: 21:31

January–March 2018 r Vol. 40, No. 1 Hip Fractures 11

Figure 4. Intracapsular hip fractures: femoral head and femoral neck. Illustration is the original artwork
by Katherine Chemsak.

compromised. Patients rarely present with
ecchymosis or swelling in the hip area. Neu-
rovascular status of the affected extremity
should be compared with the unaffected
limb, and a full body checkup should be
completed to assess for associated trauma.
Elderly patients who have long-standing
neurological deficits are more likely to die
following a fall that causes a hip fracture:
OR = 2.1; 95% CI [1.4, 3.1] (Deprey,
Biedrzycki, & Klenz, 2017).
Preoperative Management in the Emergency
Department
Because the majority of proximal femoral frac-
tures occur in the elderly, assessment in the
emergency department (ED) needs to include

Figure 5. Plain radiograph showing an example of left intracapsular hip fracture of the femoral neck.
Reprinted with permission.

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 Article: AENJ-D-17-00013 Date: January 15, 2018 Time: 21:31

12 Advanced Emergency Nursing Journal

evaluation of mental status and significant
chronic and acute comorbidities, suitability
of the patient to undergo surgical repair, and
anticipatory guidance to address advanced
directives, activity and rehabilitation goals,
discharge preferences, and DNR (do not
resuscitate) status (Koso, Sheets, Richardson,
& Galanos, 2017). Immediate surgical repair
is associated with reduced pain and de-
creased length of stay, but it is not associated
with long-term functionality or mortality
(Orasz et al., 2004). Therefore, in stable pa-
tients, the clinician has the time to perform a
diagnostic holistic examination that is focused
on potential for perioperative and postopera-
tive risk factors. Assurance of medical stability
is essential. Surgical outcomes are dependent
on respiratory status, cardiac comorbidities,
kidney function, and potential for bleeding
and thromboembolic events in the perioper-
ative and 30-day postoperative periods. Since
1941, the American Society of Anesthesiolo-
gists (ASA) classification system has been used
and frequently updated, but there are limi-
tations to the use of the ASA Physical Status
Classification System (see Figure 6). Although
this system provides a systematic approach
to the assessment of anesthetic risk factors,
it addresses only physical status factors and
lacks predictive value for individual cases
(Jo Fitz-Henry, 2011). Other risk-predictive
factors such as patient age, gender, support
systems, socioeconomic factors, as well as the
type, site, and duration of surgery, should also
be included. Prior to surgery, patients should
receive prophylactic antibiotics, specifically
to prevent Staphylococcus aureus infection,
which is the primary causative organism
in postoperative infections (LeBlanc et al.,
2014). Low-molecular-weight heparin is the
drug of choice to prevent thromboembolic
complications (LeBlanc et al., 2014).
PAIN ASSESSMENT
Older adults with hip fracture are at risk for
underassessment of pain. Pfrunder, Falk, and
Lindstrom (2017) found that only 50% of
patients with hip fracture receive analgesic
medications during ambulance transport and
therefore it is imperative for clinicians to
evaluate and provide initial management of
pain upon presentation to the ED. A number
of risk factors for delayed or inadequate pain
management include patient age, gender,
transport from a nursing home, dementia,
multiple comorbidities, disenfranchised
status, ED crowding, and mean length of
ED stay (Hwang, Richardson, Sonuyi, &
Morrison, 2006). Sale, Frankel, Thielke, and
Funnell (2017) conducted a post-fracture
study of elderly patients and found that

Figure 6. ASA classification system. ASA = American Society of Anesthesiologists. From “The ASA clas-
sification and peri-operative risk,” by J. Fitz-Henry, 2011, Annals of The Royal College of Surgeons of
England, 93, pp. 185–187. Copyright 2011 by the Annals of The Royal College of Surgeons of England.
Reproduced with permission.

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 Article: AENJ-D-17-00013
January–March 2018 r Vol. 40, No. 1
two thirds of patients reported persistent
fracture-related pain beyond 6 months after
repair or replacement.
The current treatment of pain is based
predominantly on the use of opioids, and the
escalating statistics on opioid addiction have
impacted clinical management decisions that
may result in inadequate pain control in ED
patients. Pain management evolves during
preoperative, intraoperative, and postoper-
ative periods, and data on the comparative
effectiveness of different pain management
interventions in patients with hip fractures
lack concrete supportive evidence for spe-
cific protocols. In the postoperative period,
prolonged pain impairs rehabilitation and
mobility and need for skilled nursing; yet,
overuse of opioid medications carries a risk of
dependency, poor communication, and need
for long-term care (Fabi, 2016). A Cochrane
database review by Sanzone (2016) evaluated
83 different pain management studies and
concluded that there is insufficient evi-
dence to guide definitive pain management
decisions that will be most effective and
associated with return to function following
hip fracture. Yet, a growing body of evidence
on certain interventions, such as nerve blocks
and multimodal analgesia, supports consider-
ation of these options. Multimodal analgesia
combines the use of opioids, which block
only nociceptive pain, with anesthetics and
analgesics that block pain perception in the
peripheral and central nervous systems. This
combined approach uses opioids along with
intra-articular injections, initiated preemp-
tively in the preoperative and intraoperative
periods, and has been shown to decrease the
need for opioids and provides more effective
control of pain than opioid drugs alone (Kang
et al., 2013).
DIAGNOSTIC IMAGING
Hip fractures can be diagnosed with imaging
studies, patient history, and physical exami-
nation. Plain radiographs are generally suffi-
cient to confirm hip fractures. Other radio-
graphic modalities can confirm hip fracture if
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Date: January 15, 2018 Time: 21:31
Hip Fractures 13
the plain film is inconclusive. Other diagnos-
tic imaging studies used to detect occult hip
fractures include bone scans, magnetic res-
onance imaging T1-weighted, and computed
tomographic scans (Brunner, Eshilian-Oates,
& Kuo, 2003). A T1-weighted magnetic reso-
nance image is shown to be 100% sensitive
in confirming a hip fracture when plain radio-
graphs have negative findings and is currently
the diagnostic imaging of choice for detecting
occult fractures (Iwata et al., 2012). A bone
scan of hip is 98% sensitive in confirming the
presence of a hip fracture (Brunner et al.,
2003).
NONSURGICAL MANAGEMENT OF HIP
FRACTURES
Nonsurgical treatments of hip fractures
may be used when there is a nondisplaced
hip fracture. Some of the treatment op-
tions may include the use of nonsteroidal
anti-inflammatory medications to treat in-
flammation and pain. Other treatments may
include non-weight-bearing of the affected
side and/or immobilizations with the use of
crutches, walker, cane, or wheelchair to assist
the patient with earlier mobilization. Physical
therapy may be recommended by physicians
to aid in healing of the affected area. Physical
therapy will increase blood flow, oxygen, and
nutrients to injured parts of the bone. Physical
therapy can help strengthen muscles, in-
crease flexibility, and aid in the ability to walk
again by restoring range of motion to affected
joints. Gregory, Kostakopoulou, Cool, and
Ford (2010) prospectively compared 1-year
outcomes of patients treated nonoperatively
with patients who underwent operative
repair. Nonoperative management entailed
active early mobilization in lieu of bed rest
or traction. They found increased 30-day
mortality in patients managed nonoperatively
due to preexisting medical conditions or asso-
ciated trauma. Early mobilization prevented
development of pneumonia, pressure sores,
or thromboembolic events, and at 1 year,
those patients who survived 30 days after
a fracture had mortality rates comparable
 Article: AENJ-D-17-00013 Date: January 15, 2018
14
with those patients who had surgical repair.
In addition, at 1 year, more than half of the
nonsurgically managed patients were able to
transfer without pain and were living in their
own homes (Gregory et al., 2010).
SURGICAL OPTIONS FOR HIP FRACTURES
Timely surgical management of hip fractures
is associated with earlier positive outcomes
that include postdischarge ambulatory status,
length of hospital stay, and long-term func-
tion (Tan, Tan, Jaipaul, Chan, & Sathaappan,
2017). Options for surgical repair are depen-
dent on the type of fracture. Hip surgery may
include reduction and fixation surgery, open
and closed reduction, internal and external
fixation, or hip replacement surgery. Reduc-
tion and fixation surgery stabilizes and fuses
the fragmented bones, allowing new bone
growth to occur. Closed hip fracture surgery
is less invasive and used for simple fractures
that do not have bone fragments and have not
broken through skin. Open reduction surgical
procedures are necessary for open fractures
where the bone breaks through the skin and
small bone fragments need to be removed.
Hip replacement surgical procedures include
partial or total prosthetic devices and are rec-
ommended for serious fractures of the femur.
(LeBlanc et al., 2014).
POSTOPERATIVE MANAGEMENT
The immediate postoperative focus is on pain
relief and rehabilitation, which includes phys-
ical therapy. Patients are able to go home as
soon as they are mobile and able to perform
activities of daily living. If patients are unable
to be discharged because of complications or
slow-healing process, they are referred to a re-
habilitation facility or admitted to an extended
care facility. Patients may be discharged the
same day dependent on the type of surgery
or as soon as 3 days postoperatively. Elderly
patients often are discharged to rehabilitation
or extended care facility until they are suffi-
ciently mobile and can safely negotiate their
home environment. Generally, home health is
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Time: 21:31
Advanced Emergency Nursing Journal
consulted for physical and occupational ther-
apy. Devices to aid in mobility are crutches,
canes, and walker and are used for 2–4 weeks
postoperatively (Brunner et al., 2003). Cur-
rent evidence provides support for the use of
multidisciplinary teams for geriatric patients
who sustain hip fractures. Length of stay in
both hospital and rehabilitation facilities de-
creases by 6.1–14.2 days; rates of pneumonia
and long-term mortality also decrease when
geriatric hip fracture clinical pathways are im-
plemented (Lau, Fang, & Leung, 2017).
CONCLUSION
Hip fractures are common injuries, especially
in the elderly women who often have osteo-
porosis and multiple comorbidities. Hip frac-
tures differ as a result of trauma, preexisting
bone density, blood supply, and overall health
status. Early recognition of factors impact-
ing plan of treatment, pain management, and
immediate- and long-term outcomes is imper-
ative for the ED clinician to address. Timely
diagnosis based on clinical history and phys-
ical includes plain radiographs and, possibly,
magnetic resonance images if radiographs are
not confirmatory. Early orthopedic consulta-
tion will determine the method of treatment
of the fracture, but the astute ED provider will
address the short- and long-term needs of the
patient.
REFERENCES
Brunner, L. C., Eshilian-Oates, L., & Kuo, T. Y. (2003).
Hip fractures in adults. American Family Physician,
67(3), 537–543.
Deprey, S. M., Biedrzycki, L., & Klenz, K. (2017). Iden-
tifying characteristics and outcomes that are as-
sociated with fall-related fatalities: Multi-year ret-
rospective summary of fall deaths in older adults
from 2005–2012. Injury Epidemiology, 4(1), 21.
doi:10.1186/s40621-017-0117-8
Fabi, D. W. (2016). Multimodal analgesia in the hip
fracture patient. Journal of Orthopaedic Trauma,
30(Suppl. 1), S6–S11.
Gregory, J. J., Kostakopoulou, K., Cool, W. P., & Ford, D.
J. (2010). One-year outcome for elderly patients with
displaced intracapsular fractures of the femoral neck
managed non-operatively. Injury, 41(12), 1273–
1276.
 Article: AENJ-D-17-00013 Date: January 15, 2018
January–March 2018 r Vol. 40, No. 1
Huang, A. R., Mallet, L., Rochefort, C. M., Equale, T.,
Buckeridge, D. L., & Tamblyn, R. (2012). Medication-
related falls in the elderly: causative factors and pre-
ventive strategies. Drugs and Aging, 29(5):359–376.
doi: 10.2165/11599460-000000000-00000
Hwang, U., Richardson, L. D., Sonuyi, T. O., & Morrison,
R. S. (2006). The effect of emergency department
crowding on the management of pain in older
adults with hip fracture. Journal of the American
Geriatrics Society, 54, 270–275. doi:10.1111/j.1532-
5415.2005.00587
Iwata, T., Nozawa, S., Dohjima, T., Yamamoto, T.,
Ishimaru, D., Tsugita, M., . . . Shimizu, K. (2012). The
value of T1-weighted coronal MRI scans in diagnos-
ing occult fracture of the hip. The Journal of Bone
and Joint Surgery British Volume, 94(7), 969–973.
doi:10.1302/0301-620X.94B7.28693
Fitz-Henry, J. (2011). The ASA classification and
peri-operative risk. Annals of The Royal Col-
lege of Surgeons of England, 93(3), 185–187.
http://doi.org/10.1308/147870811X565070a
Kang, H., Ha, Y. C., Kim, J. Y., Woo, Y. C., Lee, J. S., &
Jang, E. C. (2013). Effectiveness of multimodal pain
management after bipolar hemiarthroplasty for hip
fracture: A randomized, controlled study. The Jour-
nal of Bone and Joint Surgery American Volume,
95(4), 291–296.
Koso, R. E., Sheets, C., Richardson, W. J., & Galanos, A.
N. (2017, January 1). Hip fracture in the elderly pa-
tients: A sentinel event. The American Journal of
Hospice & Palliative Care, Advanced online publica-
tion. doi:10.1177/1049909117725057
Landefeld, C. S. (2011). Goals of care for hip fracture:
Promoting independence and reducing mortality.
Archives of Internal Medicine, 171(20), 1837–1838.
Lau, T. W., Fang, C., & Leung, F. (2017). The effectiveness
of a multidisciplinary hip fracture care model in im-
proving the clinical outcome and the average cost of
manpower. Osteoporosis International, 28(3), 791–
798. doi:10.1007/s00198-016-3845-7
LeBlanc, K. E., Muncie, H. L., Jr., & LeBlanc, L. L. (2014).
Hip fracture: Diagnosis, treatment, and secondary
prevention. American Family Physician, 89(12),
947–951.
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Time: 21:31
Hip Fractures 15
Magaziner, J., Simonsick, E. M., Kashner, T. M., Hebel, J.
R., & Kenzora, J. E. (1990). Predictors of functional
recovery one year following hospital discharge for
hip fracture: A prospective study. Journal of Geron-
tology, 45(3), 101–107.
Orasz, G. M., Magaziner, J., Hannan, E. L., Morri-
son, R. S., Koval, K., Gilbert, M., . . . Siu, A. L.
(2004). Association of timing of surgery for hip frac-
ture and patient outcomes. JAMA, 291(14), 1738–
1743.
Pfrunder, A. A., Falk, A. C., & Lindstrom, V. (2017).
Ambulance personnel’s management of pain for pa-
tients with hip fractures; based on ambulance person-
nel’s gender and years of experience. International
Journal of Orthopaedic and Trauma Nursing, 27,
23–27.
Quah, C., Boulton, C., & Moran, C. (2011). The influ-
ence of socioeconomic status on the incidence, out-
come and mortality of fractures of the hip. The Jour-
nal of Bone and Joint Surgery, 93(6):801–805. doi:
10.1302/0301-620X.93B6.24936.
Sale, J. E. M., Frankel, L., Thielke, S., & Funnell, L.
(2017). Pain and fracture-related limitations persist
6 months after a fragility fracture. Rheumatology In-
ternational, 37(8), 1317–1322. doi:10.1007/s00296-
017-3761-y
Sanzone, A. G. (2016). Current challenges in pain
management in hip fracture patients. Journal of
Orthopaedic Trauma, 30(Suppl. 1), S1–S5.
Shivji, F. S., Green, V. L., & Forward, D. P. (2015).
Anatomy, classification and treatment of intracap-
sular hip fractures. British Journal of Hospital
Medicine, 76(5), 290–295.
Tan, S. T., Tan, W. P., Jaipaul, J., Chan, S. P., & Sathaappan,
S. S. (2017). Clinical outcomes and hospital length
of stay in 2,756 elderly patients with hip fractures:
A comparison of surgical and non-surgical manage-
ment. Singapore Medical Journal, 58(5), 253–257.
doi:10.11622/smedj.2016045
Turner, M. R., Camacho, X., Fischer, H. D., Austin, P.
C., Anderson, G. M., Rochon, P. A., & Lipscombe, L.
L. (2011). Levothyroxine dose and risk of fractures
in older adults: Nested case-control study. BMJ, 342,
d2238. doi: 10.1136/bmj.d2238