Introduction
A hip fracture changes an older adult’s life in a single moment. Without fast, coordinated care, many patients lose their independence or develop dangerous complications. Because nurses watch patients around the clock, they shape outcomes more than almost anyone else. This guide covers surgical timing, preoperative priorities, postoperative recovery, and the discharge steps that help patients return to their lives.
Table of Contents
- What Is a Hip Fracture?
- Causes and Risk Factors
- Signs and Symptoms
- Why Surgical Timing Matters
- Preoperative Nursing Care
- Pain Management and Nerve Blocks
- Medication Considerations
- Surgical Options
- Postoperative Nursing Care
- Hip Precautions
- Complications
- Discharge and Rehabilitation
- NCLEX Tips and Memory Tricks
- Clinical Pearls
- Key Takeaways
- FAQs
- References
What Is a Hip Fracture?
A hip fracture is a break in the upper femur near the hip joint. Common types include femoral neck fractures and intertrochanteric fractures. Because older adults often have several chronic conditions, a hip fracture can trigger a chain of complications. For that reason, care works best with a team approach that includes orthopedics, anesthesia, geriatrics, nursing, and physical therapy.
Causes and Risk Factors
- Falls, the most common cause
- Osteoporosis and low bone density
- Advanced age
- Poor vision and impaired balance
- Medications that cause dizziness or sedation
- Frailty, low muscle mass, and malnutrition
- Environmental hazards at home
Signs and Symptoms
- Severe groin or hip pain after a fall
- Inability to bear weight
- A shortened, externally rotated leg on the affected side, especially with displaced fractures
- Bruising and swelling around the hip
- Pain with any movement of the leg
- Confusion or agitation, sometimes the only sign in patients with dementia
Why Surgical Timing Matters
Across six clinical practice guidelines, every one recommended surgery within 24 to 48 hours. Delay beyond 48 hours is linked to higher rates of pneumonia, urinary tract infection, deep vein thrombosis, and mortality. At the same time, the HIP ATTACK trial found that operating at a median of 6 hours rather than 24 hours didn’t significantly lower mortality or major complications. The practical message is clear: operate as early as it is safe to do so, and don’t delay for unnecessary testing.
One example shows how delay happens. Preoperative echocardiography alone led to a 32 to 48 hour surgical delay in one study, without a clear difference in complications or mortality. Nurses can advocate by asking whether a test will change the plan.
Preoperative Nursing Care
- Assess pain often with an age-appropriate tool, and treat it promptly
- Check neurovascular status of the affected leg: color, temperature, capillary refill, pulses, sensation, and movement
- Position for comfort, support the leg, and move the patient slowly with enough staff
- Start IV fluids as ordered, because many patients arrive dehydrated or become hypovolemic during fasting
- Limit fasting to what the anesthesia team requires, since long fasting worsens dehydration
- Prevent pressure injuries. Older adults on a stretcher or hard bed can develop skin breakdown quickly, so inspect heels, sacrum, and hips and use pressure-relieving surfaces
- Screen for delirium, and document the patient’s cognitive baseline
- Review medications, including anticoagulants and antiplatelets
- Support nutrition and hydration
- Complete the preoperative checklist, consent, and family communication
Importantly, current guidelines advise against routine preoperative traction, because it doesn’t improve outcomes.
Pain Management and Nerve Blocks
Surgery itself is the best long-term pain relief for a hip fracture. Until then, nurses use multimodal analgesia. Early regional techniques, such as fascia iliaca or other nerve blocks, improve pain relief and make it easier for nurses and therapists to move the patient, and for anesthesia to position the patient for spinal anesthesia. Regional blocks also help reduce opioid doses, which lowers the risk of confusion and sedation in older adults.
Medication Considerations
- Warfarin: teams reverse it with vitamin K or prothrombin complex concentrate, and shouldn’t delay surgery beyond 48 hours to normalize INR, since delay was linked to 1.5 times higher mortality in one study
- Aspirin and clopidogrel: guidelines generally support proceeding without delay unless recent high-risk bleeding
- Tranexamic acid: many protocols give it to reduce blood loss and transfusion
- Diuretics and ACE inhibitors: some protocols hold them to prevent perioperative hypotension
- Beta-blockers: teams usually continue them
- VTE prophylaxis: clinicians start it before surgery according to protocol
Surgical Options
The surgeon chooses the procedure based on fracture type, displacement, bone quality, and the patient’s baseline function. Options include internal fixation with screws or nails, hemiarthroplasty, and total hip arthroplasty. Either spinal or general anesthesia is appropriate, and the anesthesia team decides based on the patient’s condition.
Postoperative Nursing Care
- Monitor vital signs and oxygen saturation closely in the first 24 hours
- Control pain with scheduled multimodal analgesia, and reassess often
- Give VTE prophylaxis and encourage leg exercises
- Assess the incision for bleeding, drainage, redness, and swelling
- Check neurovascular status of the operated leg regularly
- Mobilize early. Standard protocols mobilize patients on postoperative day 1 with a physiotherapist, and early surgery has been linked to faster mobilization
- Encourage deep breathing and incentive spirometry to prevent pneumonia
- Screen for delirium every shift, and use reorientation, glasses, hearing aids, sleep promotion, and early mobility
- Monitor urinary function, and remove urinary catheters early
- Track intake and output and bowel function
- Monitor hemoglobin, since postoperative anemia is common
- Provide nutrition and hydration support
- Reposition regularly and protect the skin
Hip Precautions
Precautions depend on the surgical approach and the surgeon’s orders. For many patients after hemiarthroplasty or total hip replacement, common instructions include avoiding hip flexion beyond 90 degrees, avoiding crossing the legs or adducting past midline, and avoiding internal rotation. Patients often use an abduction pillow in bed and raised toilet seats. Because rules vary, always follow the surgeon’s specific orders and teach the patient and family clearly.
Complications
- Pneumonia
- Urinary tract infection
- Deep vein thrombosis and pulmonary embolism
- Pressure injuries
- Postoperative delirium
- Surgical site infection
- Hip dislocation after arthroplasty
- Postoperative anemia
- Loss of mobility and independence
- Increased mortality, especially with delayed surgery
Discharge and Rehabilitation
- Coordinate with physical and occupational therapy for gait training and equipment
- Arrange rehabilitation, skilled nursing, or home health as needed
- Teach fall prevention and home safety, including removing rugs, adding grab bars, and improving lighting
- Review pain management and medication changes
- Discuss osteoporosis evaluation and treatment to prevent another fracture
- Teach signs of infection, clots, and dislocation
- Include caregivers in every teaching session
NCLEX Tips and Memory Tricks
- Shortened, externally rotated leg suggests a hip fracture.
- Aim for surgery within 24 to 48 hours.
- Avoid routine preoperative traction.
- Check neurovascular status before and after surgery.
- Mobilize early, usually postoperative day 1.
- Follow hip precautions according to the surgeon’s orders.
- Mnemonic — “HIP FIX”: Hydrate and treat pain, Inspect skin and neurovascular status, Prevent clots, Fast surgery, Immediate mobilization, Xtra delirium screening.
Clinical Pearls
- Sudden confusion after a fall may signal a fracture, pain, or infection. Don’t dismiss it as “just dementia.”
- Ask whether a test will change management. Unnecessary testing delays surgery and harms patients.
- Use teach-back for hip precautions. Patients and families often forget instructions after anesthesia and pain medicine.
Key Takeaways
- Guidelines consistently recommend hip fracture surgery within 24 to 48 hours.
- Preoperative nursing focuses on pain, hydration, neurovascular checks, skin protection, and delirium prevention.
- Nerve blocks improve pain control and reduce opioid needs.
- Early mobilization, VTE prophylaxis, and delirium screening drive recovery.
- Discharge planning should include rehabilitation, fall prevention, and osteoporosis follow-up.
FAQs
How soon should hip fracture surgery happen?
Guidelines generally recommend surgery within 24 to 48 hours of admission, provided the patient is medically stable.
What nursing care does a patient need before hip fracture surgery?
Pain control, IV hydration, neurovascular checks, careful positioning, pressure injury prevention, delirium screening, medication review, and preoperative preparation.
Why are nerve blocks used for hip fracture pain?
They improve pain relief, reduce opioid use, and make it easier to move and position the patient.
What are hip precautions after surgery?
Movement limits that protect the new joint, such as avoiding excessive hip flexion, crossing the legs, and internal rotation. The exact rules depend on the surgeon and the surgical approach.
How soon after hip fracture surgery should a patient walk?
Many protocols mobilize patients on postoperative day 1 with a physiotherapist.
References
- AAOS — Management of Hip Fractures in Older Adults Clinical Practice Guideline
- PMC — Clinical Practice Guideline Recommendations for Orthopedic Surgical Management of Traumatic Hip Fractures: A Systematic Review
- Orthopaedic Reviews/EOR — Management and Optimisation in the Preoperative Phase for Patients with a Fractured Hip
- Cleveland Clinic Journal of Medicine — Update on Medical Management of Acute Hip Fracture
- World Federation of Societies of Anaesthesiologists — Neck of Femur Fracture: Perioperative Management
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