Neck of Femur Fracture

(A near-identical duplicate of this note, nof.md, was retired to duplicates/ in an earlier review pass.) Scope here is what a GP/urgent-care clinician actually does: recognise it, stabilise and refer — not the hospital fixation/arthroplasty decision-making, which is orthopaedics’ call.

Epidemiology

More common in Caucasian women than men (osteoporosis-driven). Female incidence rises from 2.2/1,000/yr at 65–69 to 31.8/1,000/yr at 90–94; male from 0.9 to 20.8/1,000/yr over the same range. ~5% higher incidence in Indigenous Australians. Risk roughly doubles each decade after age 50, and a hip fracture is often a sentinel event signalling a broader decline in an older patient’s health — 10–20% one-year mortality, and worse still with male sex, advanced age, serious comorbidity or delirium at presentation.

Risk factors (falls-risk groups): peripheral neuropathy/neuromotor disease (e.g. Parkinson’s); frailty/cognitive impairment; previous lower-limb surgery (especially knee replacement); prior falls; systemic corticosteroid use; smoking, excess alcohol, low vitamin D; polypharmacy; vision impairment.

Not to miss

• Low-energy mechanism is the norm, not a reassuring sign — ~98% of hip fractures follow a simple ground-level fall (most directly onto the greater trochanter), so don’t let a trivial-sounding fall lower your suspicion.
• Occult/non-displaced fractures can still weight-bear — in one small series, 7 of 26 patients with an occult hip fracture were able to walk on it. A patient who can bear some weight after a fall has not ruled themselves out.
• Stress fractures — patient may still be able to (painfully) weight-bear.
• Pathological fractures — malignancy or other bone-resorptive disease; can occur in younger patients. Hip or groin pain that preceded the fall (rather than only appearing after it) is suspicious for this.
• Fractured NOF in a young patient is a red flag — either underlying pathology, or enough force to cause unseen pelvic/intra-abdominal injury.
• Infants/children with a fractured NOF — screen for non-accidental injury/neglect.

History and examination

Ask about the fall itself, and — as in any older-patient fall — what caused it (cardiac, postural, medication, visual, mechanical trip) and the patient’s baseline functional status (community ambulator vs bed-bound), since both shape the hospital’s management plan. Unilateral hip/upper thigh or groin pain (across the greater trochanter); new inability to weight-bear or pain on ambulation.

• Pain reproduced by axial loading (thump/push through the heel) or gentle log-rolling of the leg.
• Tender to passive movement (avoid >10° passive flexion if painful).
• Swelling/bruising over the tender area.
• Shortened, externally rotated limb (“frog leg”).
• Full neurovascular exam (pulses, sensation, strength) and a skin check for an open fracture.

Immediate management

• Analgesia early — pain control shouldn’t wait for imaging, and adequate analgesia is what makes a reliable exam possible.
• Don’t apply traction — it doesn’t help a hip fracture and just adds pain.
• Arrange same-day ED referral for any suspected fracture: even a clinically-confident, radiologically-normal hip in an older faller with persistent pain/inability to bear weight still needs same-day work-up (occult fracture accounts for ~2–9% of hip fractures; X-ray sensitivity is only 90–98%, and MRI is the gold standard for a clinically-suspected, X-ray-negative fracture).
• Corroborate the history with family/carers where possible, and document what caused the fall — the hospital will need this to plan management.

Fracture types

Type	Notes
Intracapsular (femoral neck)	~45% of hip fractures, most common in younger patients. Subcapital fractures carry higher AVN risk (disruption of the circumferential artery at the capsule insertion) — the dual blood supply may still be intact in younger patients but is often degenerated in older patients. Often impacted, so partial weight-bearing may still be possible.
Intertrochanteric	~45% of hip fractures; below the femoral neck, above the trochanteric line.
Subtrochanteric	5–10% of hip fractures, most common in the >84-year age group.

Definitive management (fixation vs arthroplasty, timing, rehab) is an inpatient orthopaedic decision, individualised by fracture type, age and comorbidity — not something to plan for in the GP/urgent-care setting beyond knowing that surgery within 48 hours followed by early mobilisation gives better outcomes, which is the argument for referring promptly rather than “watching and waiting” even in a frail patient.

Impact and follow-up (the GP’s part)

Hip fracture greatly affects patients and carers. Patients >65 are 3.5× more likely to die within a year of surgery. 10–20% of survivors become institutionalised; those already in residential care do worse still. Also associated with new/worsened depression, anxiety and cognitive impairment — screen for these in the following months. Any fragility fracture (hip, distal radius, proximal humerus, vertebral body, rib, pelvis) is a trigger for a bone-health assessment in general practice, and a home safety review/falls-prevention referral reduces the risk of a repeat fracture.