A fractured hip is almost always treated with surgery, typically within 24 to 48 hours of arriving at the hospital. The specific operation depends on where the bone broke and the patient’s age and activity level, but the goal is the same: stabilize or replace the damaged joint so the person can get moving again as quickly as possible. Lying in bed for weeks while a hip heals on its own carries serious risks, including blood clots, pneumonia, and pressure sores, so surgery is the standard path for nearly everyone.
Diagnosis: X-Rays and Beyond
When someone arrives at the emergency department with hip pain after a fall, the first step is a set of X-rays of the pelvis and the affected hip. Most fractures show up clearly on these images. But some breaks, called occult fractures, don’t appear on initial X-rays despite obvious symptoms like an inability to bear weight and sharp pain when rotating the leg.
If a fracture is suspected but the X-ray looks normal, MRI is the recommended next step because it can detect breaks that plain films miss. When MRI isn’t available within 24 hours or isn’t safe for the patient (such as those with certain implants), a CT scan is used instead. The priority is confirming the fracture quickly so surgery isn’t delayed.
Pain Control Before Surgery
The hours between diagnosis and surgery can be intensely painful. Rather than relying heavily on opioid painkillers, which cause confusion and drowsiness (especially in older adults), hospitals increasingly use nerve blocks as a first-line treatment. Both the Association of Anaesthetists and the American Academy of Orthopaedic Surgeons recommend peripheral nerve blocks for preoperative hip fracture pain.
The most common technique involves injecting a numbing medication beneath a layer of tissue in the upper thigh, blocking several nerves at once. This provides significantly better pain relief than standard pain medications alone, particularly for pain during movement. It also reduces opioid use and lowers the risk of delirium, a state of acute confusion that frequently affects older patients after a hip fracture.
Where the Break Is Determines the Surgery
Hip fractures fall into two broad categories based on location, and the location drives the surgical decision more than almost any other factor.
Femoral Neck Fractures
These breaks happen across the narrow “neck” of the thighbone, just below the ball that fits into the hip socket. Blood supply to the ball of the joint runs through this area, so a displaced fracture here can cut off circulation and cause the bone to die. That’s why displaced femoral neck fractures in older adults are typically treated with joint replacement rather than repair.
Fractures in this area are graded on a scale from type I to type IV. Types I and II are stable, with little or no displacement, and can often be fixed in place with screws. Types III and IV are unstable with significant shifting of the bone ends, and these carry a high risk of complications if treated conservatively, including nonunion (the bone never heals), blood clots, and infections from prolonged bed rest.
Intertrochanteric Fractures
These occur slightly lower, in the region between two bony bumps on the upper thighbone. Blood supply is generally preserved in this area, so the bone can heal if it’s held in the right position. These fractures are typically fixed with internal hardware rather than replaced with an artificial joint.
Repair: Holding the Bone Together
When the fracture is stable enough to heal on its own with support, surgeons use metal hardware to hold everything in alignment. There are two main approaches.
Screws alone work well for stable, minimally displaced femoral neck fractures. These are threaded screws designed for the spongy bone inside the hip. The surgeon typically places two or three screws across the fracture line to hold the pieces together while the bone knits.
A sliding hip screw (also called a dynamic hip screw) is a more robust option often used for intertrochanteric fractures. It consists of a large screw that passes through the fracture into the ball of the hip, connected to a metal plate anchored along the outer side of the thighbone. The design is intentionally “dynamic,” meaning the screw can slide slightly within the plate. This controlled movement allows the bone ends to compress together as the patient puts weight on the leg, which actually promotes healing.
For certain intertrochanteric and subtrochanteric fractures, a metal rod is inserted down through the hollow center of the thighbone itself, with screws passing through the rod and into the hip joint. This approach is particularly useful for unstable fracture patterns because the rod bears some of the body’s weight internally.
Replacement: Partial or Total
When the fracture has disrupted blood supply to the femoral head or the bone is too damaged to repair, the broken parts are removed and replaced with artificial components. The choice between partial and total replacement depends on the patient’s age, activity level, bone quality, and the degree of existing arthritis.
A partial replacement (hemiarthroplasty) swaps out only the ball of the hip joint, leaving the natural socket intact. This is a shorter, less complex operation and is the most common choice for older, less active patients with displaced femoral neck fractures.
A total hip replacement removes both the ball and resurfaces the socket with an artificial cup. It generally produces better long-term function and less socket pain, making it the preferred option for younger, more active patients or those who already had arthritis in the hip before the fracture. The tradeoff is a slightly longer and more involved surgery.
What Happens Right After Surgery
The push to get patients upright starts almost immediately. Physical therapists typically visit within a day of surgery to begin working on sitting at the edge of the bed, standing, and taking initial steps with a walker. Early movement is one of the most important factors in preventing complications like blood clots and pneumonia.
Your surgeon will assign a weight-bearing status that tells you and your physical therapist how much load you can put through the operated leg. “Weight bearing as tolerated” means you’re cleared to put as much weight on it as you can handle, limited only by your pain and balance. This is the most common instruction after joint replacement or stable fixation. “Partial weight bearing” means roughly 30% to 50% of your body weight through that leg, usually with a walker or crutches taking the rest. “Non-weight bearing” means the foot shouldn’t touch the ground at all during standing or walking, though this is less common with modern surgical techniques.
Blood clot prevention is a major focus of postoperative care. Clots in the leg veins are a well-known risk after hip surgery. Patients receive blood-thinning medication, typically starting in the hospital and continuing after discharge. In-hospital treatment usually lasts 7 to 14 days, but international guidelines recommend extending clot prevention for up to 35 days after major hip surgery. Compression stockings or intermittent compression devices that squeeze the calves are often used alongside medication.
Recovery Timeline
Recovery from a hip fracture is measured in months, not weeks, and different abilities come back on different schedules. Research from the Baltimore Hip Studies mapped out this timeline under typical conditions. Depression, upper body function, and thinking clarity tend to recover within about 4 months. Balance and walking ability take longer, reaching their peak around 9 months. The slowest areas to bounce back are social activities, household tasks like cooking and cleaning, and lower body functions like bathing and dressing, which can take up to 12 months to reach maximum recovery.
Most people transition from a walker to a cane over the first few weeks to months, depending on their surgery type and how quickly strength returns. Formal physical therapy usually continues for several weeks after leaving the hospital, either at a rehabilitation facility or through home health visits, then transitions to outpatient sessions or a home exercise program.
It’s worth understanding the stakes clearly. One-year mortality following a hip fracture ranges between 17% and 25%, with affected individuals facing a three to four times higher risk of death compared to people of the same age who haven’t fractured a hip. The elevated risk comes largely from complications of immobility and the overall frailty that made the fracture likely in the first place. This is precisely why the entire treatment approach, from early surgery to aggressive rehabilitation, is designed to get people back on their feet and functioning as independently as possible.