Hip Fracture

A hip fracture is a serious injury that most often occurs as a result of a fall. It primarily affects older adults. Treatment generally involves surgery, followed by rehabilitation—that is, care aimed at restoring mobility and the ability to perform daily activities. If you or a loved one is going through this ordeal, a significant recovery is still possible with the right care.

What is a Hip Fracture?

A hip fracture is a break in the upper part of the femur, the thighbone, near the hip joint. It primarily affects older adults following a fall and usually requires surgery followed by rehabilitation.

Types of Fractures

There are three main types of hip fractures, classified by their location:

In a study of 2,430 people over the age of 65 who underwent surgery in Crete, extra-capsular fractures were more common than intra-capsular fractures of the neck². This result describes the patients in this study.

Hip Anatomy

The femoral neck is the narrow part that connects the head of the femur (the ball that articulates with the pelvis) to the rest of the bone. This area bears a large portion of the body's weight when walking.

Osteoporosis reduces bone strength. As people age, this fragility increases the risk of fracture even from a fall from a low height.

What Causes a Hip Fracture?

A hip fracture often occurs after a fall, especially when osteoporosis has weakened the bones. For an older adult, a fall from standing height may be enough. In younger people, a significant impact is a common cause, but other mechanisms can also lead to a hip fracture.

Risk factors

Several factors increase the risk of hip fracture:

• Osteoporosis: A decrease in bone strength makes bones more fragile
• Advanced age is a major risk factor. The risk of a hip fracture increases significantly with age.
• Female gender: In the study conducted in Crete, there were 2.9 times as many women as men among patients over the age of 65 who underwent surgery². This report describes the characteristics of patients who underwent surgery; it does not directly measure individual risk or the effect of menopause.
• Previous Falls: A Previous Fall Increases the Risk
• Muscle Weakness: Reduces the ability to prevent falls
• Balance Disorders: Increase the risk of falling
• Medications: Some medications can cause dizziness

Mechanism of Injury

Most hip fractures in older adults result from a fall from standing height. A direct impact to the side of the hip is a common cause.

In younger people, a car accident or a fall from a height can cause a fracture. Repeated stress can also lead to a stress fracture—that is, a crack caused by repeated stress on the bone. According tothe American Academy of Orthopaedic Surgeons, some very fragile bones can break during an ordinary movement.

What are the Symptoms of a Hip Fracture?

A hip fracture can cause severe pain in the hip or groin, difficulty bearing weight, and a leg that appears shorter or turned outward. Some fractures still allow the person to take a few steps; therefore, being able to walk does not rule out a fracture.

Typical Signs

After a fall, the following signs suggest a hip fracture:

• Severe pain in the hip or groin
• Inability to stand up or walk
• One leg appears shorter than the other
• Foot pointing outwards (external rotation)
• Swelling or bruising on the hip

When to call emergency services

• Severe hip pain after a fall or injury
• Inability to stand up, move the leg, walk, or bear weight, even without a known injury
• Visible leg deformity
• The person is confused or has lost consciousness
• Tingling or loss of sensation in the hip or leg following an injury

Important: Do not try to get the person to walk or straighten their leg. Keep them warm and follow the instructions given by 911. Do not move them unless an immediate danger requires it.

An urgent medical evaluation is also necessary for severe pain that comes on suddenly without a fall, a swollen and warm hip, or a change in skin color. Hip pain accompanied by general malaise, fever, chills, or alternating feelings of hot and cold also requires urgent medical attention. These situations are described in the UK National Health Service (NHS) guidance on hip fractures.

How is a hip fracture treated?

Treatment for a hip fracture usually involves surgery to stabilize the broken bones or replace part of the joint. Osteosynthesis involves stabilizing the broken bones with screws, a plate, or a rod inserted into the bone. A prosthesis replaces the damaged parts. The surgical team selects the treatment based on the type of fracture, your overall health, and your functional abilities prior to the injury.

Surgical emergency

Surgery usually takes place on the day of admission or the following day, according to the British organization NICE’s guidelines on hip fractures. The team promptly addresses any medical issues that could make the surgery unsafe.

Studies have linked prolonged waiting times after admission—beyond 24 or 48 hours, depending on the study—to higher rates of death or^{complications.³, ⁴} Complications include, in particular, respiratory infections and blood clots³. These associations do not prove that the delay alone accounts for all such events.

A delay is also associated with delirium—a state of sudden confusion—in patients who already have mild to moderate difficulties with memory or reasoning. This association was not clear in the other groups in the study⁵.

Surgical Options

The decision to undergo total joint replacement also takes into account the patient’s prospects for independence in the years ahead. These guidelines serve as a basis for discussion with the surgeon; they should not be used to decide on surgery on one’s own. The indications and recommendations for support are based on the NICE guidelines and the explanations provided by the orthopedic surgery association.

Hospitalization

The length of your hospital stay depends on your health, any complications, and the support available after discharge. A study conducted in northern India found an average of 13.5 days⁶; this duration is not a prediction of how long you will stay in Quebec. During your hospital stay, the team will monitor your condition and begin rehabilitation as soon as your health and postoperative instructions allow.

What is the role of physiotherapy after a hip fracture?

Physical therapy after a hip fracture helps you regain the ability to walk, build strength, and resume daily activities. You’ll usually be encouraged to get out of bed the day after surgery, unless your health or the surgeon’s instructions prevent you from doing so. The program includes exercises, strength training, and walking practice.

After a hip fracture, balance training can improve physical function, walking ability, and leg strength, according to a review of nine studies⁷. The programs studied vary; the frequency and difficulty of the exercises should be tailored to each individual.

The First Movements After Surgery

Patients who begin moving within 48 hours after surgery often have shorter hospital stays and better mobility, according to studies⁸. Most of these studies observe the care received without randomly assigning patients to groups. Better health may also make it easier to get out of bed early; therefore, these results do not prove that moving early alone accounts for all the differences.

Getting out of bed and moving around early are part of the care aimed at reducing complications associated with prolonged bed rest.The Orthopedic Surgery Association specifically highlights their role in preventing blood clots, pneumonia, and pressure sores. The medical team may also prescribe other measures, such as blood-thinning medications. Problems to prevent include:

• Blood clots in the veins, known as venous thrombosis
• Pneumonia, an infection of the lungs
• Pressure sores, caused by prolonged pressure on the skin
• Muscle loss

Rehabilitation Goals

The main goals are:

• Regaining the Ability to Walk: Use a walker or cane, then gradually reduce your reliance on it as your balance and safety allow
• Strengthen your muscles: Focus especially on the quadriceps, at the front of the thighs, and the glutes, in the buttocks
• Improve balance: Reduce the risk of new falls
• Resume daily activities: Stairs, hygiene, dressing

What the research shows

The 2021 physical therapy guide recommends a program that combines the following elements for older adults who have suffered a hip fracture⁹:

• Get out of bed and walk with assistance as soon as possible, at least once a day while in the hospital, unless your health or postoperative instructions prevent it
• Progressive strengthening, with resistance that is challenging enough to improve strength and tailored to individual abilities
• Balance and gait training
• Home exercise program

Exercise can still be beneficial several months after a fracture. The amount and duration of exercise vary depending on individual needs; a longer or more intense program isn't necessarily better for everyone.

A small study examined 26 people about six months after their fractures. A home-based strengthening program was offered twice a week for ten weeks. The comparison group also met with a physical therapist but received electrical stimulation through electrodes placed on the skin and imagined movements, without the strengthening exercises.

One year after the fracture, the results of strength, walking, and physical task tests were more favorable in the strengthening group¹⁰. However, the questionnaire on perceived physical abilities did not show a clear benefit. This result encourages the continuation of appropriate exercises; it does not prescribe the same intensity immediately after surgery.

A meta-analysis of 13 studies found a slight improvement in mobility with structured exercise programs compared to the other treatments studied. The results were more favorable in studies that included progressive strength training and in those conducted outside the hospital¹¹. These comparisons involve different programs; they do not prove that one setting or duration is better suited for every individual.

How does rehabilitation proceed?

Rehabilitation after a hip fracture progresses from getting out of bed for the first time to walking, strengthening, and resuming activities. The three stages below describe goals rather than a mandatory timeline. Moving on to the next stage depends on your safety, your tolerance for exertion, and your surgeon’s instructions.

If difficulties with strength, balance, or daily activities persist beyond 8 to 16 weeks, the 2021 guidelines recommend offering additional exercises and treatments⁹. These can continue at a clinic, at home, or in an appropriate community-based program. This guideline does not require waiting eight weeks to reassess a difficulty.

Step 1: The First Mornings at the Hospital

This stage usually begins the day after surgery, once the medical team confirms that the patient is allowed to get out of bed:

• Transfers: Learning to safely move from bed to a chair
• First steps: Walking with a walker under supervision
• Exercises in bed: Move your ankles up and down and tighten your thighs, following the instructions you were given
• Compliance with restrictions: Follow the surgeon's instructions regarding the weight limit on the leg

Step 2: Increase your walking distance and strength

This phase often continues at a rehabilitation center or at home with follow-up care. The exercises become more advanced as transfers and walking become safer:

• Gradual walking: Increase the distance and switch from a walker to a cane if it remains safe to do so
• Strengthening: Exercises for quadriceps and glutes
• Balance: Standing exercises with support
• Stairs: Learning to use stairs with a handrail under supervision

Step 3: Resume More Activities

This stage aims to achieve as much independence as possible. The program focuses on activities that remain difficult, even several months after the fracture:

• Independent Walking: Without assistive devices if possible
• More Challenging Strength Training: Increase Resistance Based on Your Ability
• Functional exercises: Practice, for example, standing up from a chair and moving around the house as needed
• Fall Prevention: Long-term balance program

How long does recovery take?

Recovery from a hip fracture often takes several months and can take even longer, according to the NHS. Bone healing and the ability to walk again do not necessarily progress at the same pace. Weight-bearing may be permitted before the bone has fully healed. Some people do not regain all the abilities they had before the fracture¹².

Factors influencing recovery

Several factors affect the speed of recovery:

• Age and functional abilities prior to the fracture: Advanced age and pre-existing difficulties may limit recovery
• Fractures and Surgery: The Stability of the Repair and Weight-Bearing Guidelines Influence Recovery
• Participation in Rehabilitation: A tailored program followed regularly can improve abilities
• Other health issues: Diabetes, heart disease, or dementia—a condition that affects memory and reasoning, among other things—can complicate care

Recovery varies from person to person

Recovery varies greatly from person to person. Study results help guide care planning, but they do not accurately predict a person's individual recovery journey:

• A study conducted in 19 countries among adults aged 50 and older found that between 14.4% and 28.3% of participants died within a year of the fracture, depending on the country¹³. These deaths have various causes. Another review links a surgical delay of more than 48 hours after admission to a higher number of deaths, though it could not rule out the effect of other health problems⁴.
• A significant number of survivors do not fully regain the abilities they had before the fracture¹²
• For people living in long-term care facilities, a fracture can also lead to a lasting loss of independence. A U.S. study of 60,111 residents found a significant decline in their ability to move around and perform daily activities.

These challenges warrant appropriate rehabilitation and sufficient support for mobility and personal care. Many people improve their independence, even if they continue to face certain limitations. The care team and family members can adjust goals as progress is made.

How to prevent hip fractures?

Hip fracture prevention combines bone-strengthening care, balance exercises, and measures to reduce the risk of falls. Programs that focus on balance and activities such as standing up or walking reduce falls among older adults living at home¹⁴. Strength training can complement these exercises; its standalone effect on falls is less certain.

Fractures associated with brittle bones often occur at home. In a study of 264 patients conducted in northern India, 86.7% of the fractures occurred inside the home⁶. This proportion reflects this patient group and may differ elsewhere.

Preventing falls

Most hip fractures result from falls. To prevent them:

• Balance exercises: Practice appropriate movements, such as tai chi or standing while holding onto a nearby support. After a fracture, have the healthcare team select the exercises for you.
• Strength Training: Gradually work on your legs at least twice a week, as your condition allows. The post-fracture program may require a different schedule.
• Vision Correction: Have a decline in vision evaluated and maintain appropriate vision correction
• Home adaptation: Adequate lighting, fixed rugs, grab bars
• Medication review: Some medications cause dizziness

Strengthening bones

To prevent osteoporosis and strengthen bones:

• Bone Assessment: A bone densitometry test measures the amount of mineral in the bones to help assess their strength. The timing of this test depends on age and risk factors. In Canada, a baseline test is recommended at age 70 for people without risk factors, or earlier depending on previous fractures and other risk factors.
• Treatment: After a fragility fracture of the hip, discuss osteoporosis treatment with your doctor. Medications such as bisphosphonates slow bone loss and reduce the risk of fractures in affected individuals¹⁵. The choice takes into account the expected benefits, side effects, and your overall health.
• Calcium and Vitamin D: Meet your needs through diet and as-recommended supplements. A calcium supplement is not always necessary if your diet provides enough.
• Physical activity: Weight-bearing exercises, particularly strength training, can stimulate bone formation in the areas being worked. Walking alone tends mainly to limit bone loss¹⁶. After a fracture, weight-bearing activities must follow the healthcare team’s instructions.

The guidelines for bone assessment, nutrition, and exercise are based on the 2023 Canadian guidelines on osteoporosis. These guidelines apply to postmenopausal women and men aged 50 and older. Following a fragility fracture, it is helpful to assess bone health and the risk of another fall without waiting until the usual screening age.

Conclusion and next steps

The next steps after a hip fracture are prompt medical care, followed by appropriate rehabilitation to regain as much independence as possible. You’ll usually be encouraged to get out of bed the day after surgery, if your condition allows it. Exercises may continue for several months, depending on the challenges you face and the progress you make.

In a trial involving 232 people who had completed their standard rehabilitation program, six months of at-home exercises focused on daily activities modestly improved physical abilities compared with nutrition education sessions¹⁷. This finding supports the continuation of adapted exercise programs when difficulties persist.

If you or a loved one has suffered a hip fracture, our physical therapists can help you work on movements and activities that are still difficult. The frequency and intensity of the exercises will be tailored to your health status, post-surgical guidelines, and your abilities. Starting early is recommended whenever possible; increasing the intensity without adjusting the exercises does not guarantee better results.

References

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2. Alpantaki K, Papadaki C, Raptis K, Dretakis K, Samonis G, Koutserimpas C. Gender and Age Differences in Hip Fracture Types among the Elderly: A Retrospective Cohort Study. Maedica (Bucharest). 2020;15(2):185-190. (Back to sections: 1, 2)
3. Pincus D, Ravi B, Wasserstein D, Huang A, Paterson JM, Nathens AB, et al. Association Between Wait Time and 30-Day Mortality in Adults Undergoing Hip Fracture Surgery. JAMA. 2017;318(20):1994-2003. (Back to sections: 1, 2)
4. Shiga T, Wajima Z, Ohe Y. Is a delay in surgery associated with increased mortality in patients with hip fractures? Systematic review, meta-analysis, and meta-regression. Can J Anaesth. 2008;55(3):146-54. (Back to sections: 1, 2)
5. Pioli G, Bendini C, Giusti A, Pignedoli P, Cappa M, Iotti E, et al. Surgical delay is a risk factor for delirium in patients with hip fractures and mild-to-moderate cognitive impairment. Aging Clin Exp Res. 2019;31(1):41-47. (Back to section: 1)
6. Dhibar DP, Gogate Y, Aggarwal S, Garg S, Bhansali A, Bhadada SK. Predictors and Outcomes of Fragility Hip Fractures: A Prospective Study from North India. Indian J Endocrinol Metab. 2019;23(3):282-288. (Back to sections: 1, 2)
7. Wu JQ, Mao LB, Wu J. Efficacy of balance training for patients with hip fractures: a meta-analysis of randomized controlled trials. J Orthop Surg Res. 2019;14(1):83. (Back to section: 1)
8. Mazarello Paes V, Ting A, Masters J, Paes MVI, Graham SM, Costa ML, et al. A systematic review of evidence regarding the association between time to mobilization following hip fracture surgery and patient outcomes. Bone Jt Open. 2025;6(7):741-747. (Back to section: 1)
9. McDonough CM, Harris-Hayes M, Kristensen MT, Overgaard JA, Herring TB, Kenny AM, et al. Physical Therapy Management of Older Adults With Hip Fractures. J Orthop Sports Phys Ther. 2021;51(2):CPG1-CPG81. (Back to sections: 1, 2)
10. Mangione KK, Craik RL, Palombaro KM, Tomlinson SS, Hofmann MT. Home-based leg-strengthening exercise improves function 1 year after a hip fracture: a randomized controlled study. J Am Geriatr Soc. 2010;58(10):1911-7. (Back to section: 1)
11. Diong J, Allen N, Sherrington C. Structured exercise improves mobility after a hip fracture: a meta-analysis with meta-regression. Br J Sports Med. 2016;50(6):346-55. (Back to section: 1)
12. Tang VL, Sudore R, Cenzer IS, Boscardin WJ, Smith A, Ritchie C, et al. Rates of Recovery to Pre-Fracture Function in Older Adults with Hip Fractures: An Observational Study. J Gen Intern Med. 2017;32(2):153-158. (Back to sections: 1, 2)
13. Sing CW, Lin TC, Bartholomew S, Bell JS, Bennett C, Beyene K, et al. Global Epidemiology of Hip Fractures: Secular Trends in Incidence Rate, Post-Fracture Treatment, and All-Cause Mortality. J Bone Miner Res. 2023;38(8):1064-1075. (Back to section: 1)
14. Sherrington C, Fairhall NJ, Wallbank GK, Tiedemann A, Michaleff ZA, Howard K, et al. Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2019;1(1):CD012424. (Back to section: 1)
15. Deardorff WJ, Cenzer I, Nguyen B, Lee SJ. Time to Benefit of Bisphosphonate Therapy for the Prevention of Fractures Among Postmenopausal Women With Osteoporosis: A Meta-analysis of Randomized Clinical Trials. JAMA Intern Med. 2022;182(1):33-41. (Back to section: 1)
16. Benedetti MG, Furlini G, Zati A, Letizia Mauro G. The Effectiveness of Physical Exercise on Bone Density in Patients with Osteoporosis. Biomed Res Int. 2018;2018:4840531. (Back to section: 1)
17. Latham NK, Harris BA, Bean JF, Heeren T, Goodyear C, Zawacki S, et al. Effect of a home-based exercise program on functional recovery following rehabilitation after a hip fracture: a randomized clinical trial. JAMA. 2014;311(7):700-8. (Back to section: 1)