may increase the risk of heart problems. if operative treatment is refused or the risks of surgery are considered to be too high the main emphasis of treatment is on pain relief. skeletal traction may be considered for long-term treatment. aggressive chest physiotherapy is needed to reduce the risk of pneumonia and skilled rehabilitation and nursing to avoid pressure sores and dvt/pulmonary embolism most people will be bedbound for several months. non-operative treatment is now limited to only the most medically unstable or demented patients or those who are nonambulatory at baseline with minimal pain during transfers. surgery on the same day or day following the break is estimated to reduce postoperative mortality in people who are medically stable. intracapsular fractures fracture treated with cannulated screws for low-grade fractures (garden types 1 and 2), standard treatment is fixation of the fracture in situ with screws or a sliding screw/plate device. this treatment can also be offered for displaced fractures after the fracture has been reduced. fractures managed by closed reduction can possibly be treated by percutaneously inserted screws. in elderly patients with displaced or intracapsular fractures surgeons may decide to perform a hemiarthroplasty, replacing the broken part of the bone with a metal implant. however, in elderly people who are medically well and still active, a total hip replacement may be indicated. independently mobile older adults with hip fractures may benefit from a total hip replacement instead of hemiarthroplasty. traction is contraindicated in femoral neck fractures due to it affecting blood flow to the head of the femur. the latest evidence suggests that there may be little or no difference between screws and fixed angle plates as internal fixation implants for intracapsular hip fractures in older adults. the findings are based on low quality evidence that can't firmly conclude major difference in hip function, quality of life, and additional surgery. trochanteric fracture fracture supported by dynamic hip screw a trochanteric fracture, below the neck of the femur, has a good chance of healing. closed reduction may not be satisfactory and open reduction then becomes necessary. the use of open reduction has been reported as 8-13% among pertrochanteric fractures, and 52% among intertrochanteric fractures. both intertrochanteric and pertrochanteric fractures may be treated by a dynamic hip screw and plate, or an intramedullary rod. the fracture typically takes 3–6 months to heal. as it is only common in elderly, removal of the dynamic hip screw is usually not recommended to avoid unnecessary risk of second operation and the increased risk of re-fracture after implant removal. the most common cause for hip fractures in the elderly is osteoporosis; if this is the case, treatment of the osteoporosis can well reduce the risk of further fracture. only young patients tend to consider having it removed; the implant may function as a stress riser, increasing the risk of a break if another accident occurs. subtrochanteric fractures subtrochanteric fractures may be treated with an intramedullary nail or a screw-plate construction and may require traction pre-operatively, though this practice is uncommon. it is unclear if any specific type of nail results in different outcomes than any other type of nail. a lateral incision over the trochanter is made and a cerclage wire is placed around the fracture for reduction. once reduction has been achieved a guide canal for the nail is made through the proximal cortex and medullary. the nail is inserted through the canal and is fixated proximally and distally with screws. x-rays are obtained to ensure proper reduction and placement of the nail and screws are achieved. rehabilitation rehabilitation has been proven to increase daily functional status. forty percent of individuals with hip fractures are also diagnosed with dementia or mild cognitive impairment which often results in poorer post-surgical outcomes. in such cases enhanced rehabilitation and care models have been shown to have limited positive effects in reducing delirium and hospital length of stay. it is unclear if the use of anabolic steroids effects recovery. a updated cochrane review (2022) involving over 4000 patients found evidence that gait training, balance and functional tasks training to be particularly effective when compared to conventional care. there is also moderate-certainty evidence that rehabilitation after hip fracture surgery, when delivered by a multidisciplinary team and supervised by an appropriate medical specialist, results in fewer cases of 'poor outcome', like death and deterioration in residential status. nutrition supplementation oral supplements with non-protein energy, protein, vitamins and minerals started before or early after surgery may prevent complications during the first year after hip fracture in aged adults; without seemingly effects on mortality. surgical complications deep or superficial wound infection has an approximate incidence of 2%. it is a serious problem as superficial infection may lead to deep infection. this may cause infection of the healing bone and contamination of the implants. it is difficult to eliminate infection in the presence of metal foreign bodies such as implants. bacteria inside the implants are inaccessible to the body's defence system and to antibiotics. the management is to attempt to suppress the infection with drainage and antibiotics until the bone is healed. then the implant should be removed, following which the infection may clear up. implant failure may occur; the metal screws and plate can break, back out, or cut out superiorly and enter the joint. this occurs either through inaccurate implant placement or if the fixation does not hold in weak and brittle bone. in the event of failure, the surgery may be redone or changed to a total hip replacement. mal-positioning: the fracture can be fixed and subsequently heal in an incorrect position; especially rotation. this may not be a severe problem or may require subsequent osteotomy surgery for correction. prognosis hip fractures are very dangerous episodes, especially for elderly and frail patients. the risk of dying from the stress of the surgery and the injury in the first thirty days is about 10%. at one year after fracture, this may reach 30%. if the condition is untreated the pain and immobility imposed on the patient increase that risk. problems such as pressure sores and chest infections are all increased by immobility. the prognosis of untreated hip fractures is very poor. post operation among those affected over the age of 65, 40% are transferred directly to long-term care facilities, long-term rehabilitation facilities, or nursing homes; most of those affected require some sort of living assistance from family or home-care providers. 50% permanently require walkers, canes, or crutches for mobility; all require some sort of mobility assistance throughout the healing process. most of the recovery of walking ability and activities of daily living occurs within 6 months of the fracture. after the fracture about half of older people recover their pre-fracture level of mobility and ability to perform instrumental activities of daily living, while 40–70% regain their level of independence for basic activities of daily living. among those affected over the age of 50, approximately 25% die within the next year due to complications such as blood clots (deep venous thrombosis, pulmonary embolism), infections, and pneumonia. patients with hip fractures are at high risk for future fractures including hip, wrist, shoulder, and spine. after treatment of the acute fracture, the risk of future fractures should be addressed. currently, only 1 in 4 patients after a hip fracture receives treatment and work up for osteoporosis, the underlying cause of most of the fractures. current treatment standards include the starting of a bisphosphonate to reduce future fracture risk by up to 50%. epidemiology age-standardised hip fracture rates. low (<150 / 100,000) medium (150–250 / 100,000) high (>250 / 100,000) hip fractures are seen globally and are a serious concern at the individual and population level. by 2050, it is estimated that there will be six million cases of hip fractures worldwide. one study published in 2001 found that in the us alone, 310,000 individuals were hospitalized due to hip fractures, which can account for 30% of americans who were hospitalized that year. another study found that in 2011, femur neck fractures were among the most expensive conditions seen in us hospitals, with an aggregated cost of nearly $4.9 billion for 316,000 inpatient hospitalizations. rates of hip fractures are declining in the united states, possibly due to increased use of bisphosphonates and risk management. falling, poor vision, weight, and height are all seen as risk factors. falling is one of the most common risk factors for hip fractures. approximately 90% of hip fractures are attributed to falls from standing height. given the high morbidity and mortality associated with hip fractures and the cost to the health system, in england and wales, the national hip fracture database is a mandatory nationwide audit of care and treatment of all hip fractures. population all populations experience hip fractures but numbers vary with race, gender, and age. women have three times as many hip fractures as men. in a lifetime, men have an estimated 6% risk whereas postmenopausal women have an estimated 14% risk of having a hip fracture. these statistics provide insight over a lifespan, and conclude that women are twice as likely to have a hip fracture. the overwhelming majority of hip fractures occur in white individuals, while blacks and hispanics have a lower rate of them. this may be due to their generally greater bone density and also because whites have longer overall lifespan and higher likelihood of reaching an advanced age where the risk of breaking a hip goes up. deprivation is also a key factor: in england, it has been found that people in the poorest parts of the country are more likely to fracture a hip and less likely to recover well than those in the least deprived areas. age related age is the most dominant factor in hip fracture injuries, with most cases occurring in people over 75. the increase of age is related to the increase of the incidence of hip fracture, which is the most frequent cause of hospitalization in centenarians, overcoming congestive heart failure and respiratory infection. falls are the most common cause of hip fractures; around 30–60% of older adults fall each year. this increases the risk for hip fracture and leads to the increased risk of death in older individuals, the rate of one year mortality is seen from 12 to 37%. for those remaining patients, half of them need assistance and cannot live independently. also, older adults sustain hip fractures because of osteoporosis, which is a degenerative disease due to age and decrease in bone mass. the average age for sustaining a hip fracture is 77 years old for women and 72 years old for men.