Hip fracture: what to expect and how decisions are made

These figures describe a very large group and do not predict what will happen to one person. In the same study, outcomes were worst in people over 90, people with advanced comorbidity or very severe cognitive impairment, and people who did not have surgery ³⁵. A resident who was walking independently and is otherwise well can expect to do better than the average.

They are also American figures from 2005 to 2009. They are used here because the study is large and specific to nursing home residents.

Repairing the fracture is usually the most effective way to control pain and to make it possible for the person to sit up, be moved and be cared for comfortably. For that reason surgery is offered to most people, including many who are not expected to walk again.

In a US study of 3,083 nursing home residents with advanced dementia and a hip fracture, 85% had surgery. After statistical adjustment, those who had surgery were less likely to die (adjusted hazard ratio 0.88, 95% CI 0.79 to 0.98) and, among those alive at six months, had less pain and fewer pressure injuries. Few survivors in either group were still walking. This was an observational study, so the residents chosen for surgery are likely to have differed from those who were not, and pain was common in both groups ³⁶.

The Australian clinical care standard sets out surgery within 36 hours of arrival, getting up without weight-bearing restrictions on the day of or the day after surgery, and a falls and bone health plan before leaving hospital ³⁸. In New South Wales between 2015 and 2018, people whose care met more of the standard’s indicators had lower mortality: 4.1% at 30 days with high adherence, against 10.8% with low adherence (adjusted risk ratio 0.40, 95% CI 0.30 to 0.52). People who had been living in the community were over-represented in the high-adherence group, so part of that difference reflects who the patients were ³⁹.

A Dutch study followed 172 frail people aged 70 and over living in institutions who had a hip fracture and a limited life expectancy. After a shared decision with the family, 88 chose not to have surgery and 84 chose surgery. Quality of life in the non-operative group stayed within the margin the researchers had set in advance, adverse events were fewer (67 against 167), and satisfaction with treatment was high in both groups. Within 30 days, 83% of the non-operative group and 25% of the surgical group had died. About half of the families and carers in the non-operative group who rated it described the quality of dying as good to almost perfect ³⁷.

The two groups chose their own treatment and were not alike, so this study cannot show that surgery prolongs life or that avoiding it shortens it. What it shows is that, for a very frail person close to the end of life, comfort-focused care without an operation is a legitimate option when it is chosen with the family ³⁷.

The Australian standard allows for the same judgement. Where a hip fracture complicates or precipitates a terminal illness, it asks clinicians to consider the role of surgery as part of a palliative approach, to relieve symptoms and minimise suffering ³⁸.

In a trial of 2,127 people whose hip fracture had been repaired, a yearly zoledronic acid infusion started within 90 days reduced new clinical fractures from 13.9% to 8.6% and deaths from 13.3% to 9.6% over about two years. The average age was 74.5, younger than most aged care residents ³¹.

Back in the facility, the things that matter most are good pain control, getting up and moving as early as the surgeon allows, watching for delirium, and looking again at the causes of the fall.