Clinical Review & Education
JAMA | Review
Hip Fractures
A Review
Fjola Johannesdottir, PhD; Jimmie E. Roberts, PhD; Douglas P. Kiel, MD, MPH; Joy N. Tsai, MD
Multimedia
IMPORTANCE More than 14.2 million people worldwide and 280 000 in the US experience CME at jamacmelookup.com
a hip fracture each year. The median 1-year mortality rate after a hip fracture is 22% and
approximately 42% to 71% of patients regain their prefracture level of basic activities of daily
living within 6 months.
OBSERVATIONS Hip fractures are classified as intracapsular or extracapsular and most com-
monly occur after a fall. Intracapsular hip fractures include femoral neck (34%) and femoral
head (rare). Extracapsular fractures consist of intertrochanteric (48%) and subtrochanteric
fractures (5.8%). In the US, between 2008 and 2017, hip fractures were associated with
1-year mortality rates of 26.9% among men and 18.5% among women. Older age is a major
risk factor for hip fracture, with a hazard ratio of 1.35 (95% CI, 1.25-1.47) per 5-year increase in
age. Women have higher incidence of hip fractures than men due to accelerated bone loss
after menopause and higher incidence of falls. Other risk factors for hip fractures include low
bone mineral density (bone density of 1 SD or below that of healthy young adults measured
by dual-energy x-ray absorptiometry), prior fracture, and factors contributing to falls, such as
weak muscles, poor visual acuity, and smoking. Surgery for hip fracture typically consists of
hip joint replacement or hip joint stabilization, using embedded hardware (open reduction
and internal fixation). Patients with hip fracture benefit from physical therapy and fall
reduction strategies, such as muscle-strengthening exercises and modifying medications
associated with increased fall risk, such as antidepressants, and should be treated with
antiresorptive medications, such as bisphosphonates (alendronate, zoledronic acid) or Author Affiliations: Center for
denosumab to prevent subsequent fracture. To prevent a hip fracture, patients with Advanced Orthopaedic Studies,
vertebral osteoporosis at the spine may require anabolic therapy, such as teriparatide, Beth Israel Deaconess Medical Center
abaloparatide, or romosozumab, before starting an antiresorptive. Hip fractures may lead to and Harvard Medical School, Boston,
Massachusetts (Johannesdottir);
mobility limitations; declines in physical, emotional, and social functioning; and reduced Hinda and Arthur Marcus Institute for
health-related quality of life. Aging Research, Hebrew SeniorLife,
Boston, Massachusetts (Roberts,
CONCLUSIONS AND RELEVANCE Hip fractures are common among older people and are Kiel); Department of Medicine,
associated with a 1-year mortality rate of 22% and with reduced mobility and quality of life. Beth Israel Deaconess Medical Center
Surgical repair for hip fracture typically consists of joint replacement or open reduction and and Harvard Medical School, Boston,
Massachusetts (Kiel); Endocrine Unit,
internal fixation. Hip fracture treatment also includes physical therapy, fall reduction Department of Medicine,
strategies, and medications to protect against fracture, such as bisphosphonates; Massachusetts General Hospital and
denosumab; or anabolic drugs, such as parathyroid hormone analogues or Harvard Medical School, Boston
(Tsai).
romosozumab.
Corresponding Author: Douglas P.
Kiel, MD, MPH, Hinda and Arthur
JAMA. doi:10.1001/jama.2026.11895 Marcus Institute for Aging Research,
Published online July 16, 2026. 1200 Centre St, Boston, MA 02131
().
A
pproximately 2 hip fractures occur every minute in the
US, and approximately 27 per minute worldwide. Methods
Most hip fractures occur among older adults with acci-
dental falls.1 Lifetime risks of hip fracture are 22.9% in women We searched PubMed for English-language studies published be-
and 10.7% in men at age 50 years and 19.3% and 9.1%, respec- tween January 1995 and November 2025, using the search terms
tively, at age 80 years.2 Among 66 746 patients with hip fracture, hip fracture, falls, fall risk, fracture rehabilitation, and fracture liaison
11 899 (20%) died during 12-month follow-up. Hip fractures cause service for clinical trials, observational studies, practice guidelines,
impaired mobility, pain, and substantial health care costs.3,4 This meta-analyses, and systematic reviews. Additional articles were iden-
review summarizes current evidence regarding the epidemiology, tified from references of articles identified in the search. Of 5454
pathophysiology, diagnosis, treatment, and prevention of hip identified articles, 101 were included, consisting of 11 randomized
fractures. clinical trials, 21 meta-analyses, 15 reviews, 13 clinical guidelines or
jama.com (Reprinted) JAMA Published online July 16, 2026 E1
© 2026 American Medical Association. All rights reserved, including those for text and data mining, AI training, and similar technologies.
Downloaded from jamanetwork.com by World Health Organization user on 07/19/2026
, Clinical Review & Education Review A Review of Hip Fractures
position statements, 10 epidemiologic studies, and 16 retrospec- within or outside of the fibrous capsule that surrounds the hip joint.
tive observational and 15 prospective observational studies. Intracapsular hip fractures include femoral neck fractures (34% of
all hip fractures) and femoral head fractures (rare), whereas extra-
capsular fractures include intertrochanteric (48% of all hip frac-
tures) and subtrochanteric fractures (5.8% of all hip fractures); 11.8%
Epidemiology
of hip fractures could not be classified (Figure 1).16
In 2019, approximately 14.2 million people experienced hip frac-
tures and 23.6 million people had a history of hip fracture worldwide.1
A meta-analysis of 9 US observational studies between 2001 and
Risk Factors for Hip Fracture
2018 among adults 60 years and older found that the mean age at
the time of hip fracture was 81 years.3 The global incidence of hip Hip fractures are uncommon before age 70 years, but the inci-
fractures among adults 55 years and older in 2019 was higher in dence progressively increases after age 70 years.17 In a global study
women (833.9 per 100 000) than in men (510.0 per 100 000).5 of 9 578 000 hip fractures in men and women, 1 189 000 hip frac-
Between 2005 and 2018, the median 1-year mortality rate af- tures occurred in people aged 70 to 74 years and 4 111 000 oc-
ter hip fracture was 22% worldwide.5 In the US, from 2008 to 2017, curred in people 80 years and older.18 In men and women with BMD
the 1-year mortality rate after hip fracture was 26.9% among men T-scores of less than −2.5 SD, the 10-year probability of hip fracture
and 18.5% among women.3,5 The most common causes of mortal- increased from 5.2% in men and 2.9% in women at age 50 years to
ity after hip fracture include pneumonia, sepsis, myocardial infarc- 21.2% and 23.8%, respectively, at age 80 years.19 Female sex is as-
tion, pulmonary embolism, and cancer.6 sociated with higher rates of hip fracture because of accelerated bone
After a hip fracture, approximately 20.1% of patients require loss after menopause and because older women have higher rates
long-term nursing facility care and 6.6% become newly eligible for of falling than older men.20 Based on self-reported race in a large
Medicaid or for a low-income subsidy under Medicare Part D.4 Ap- study of women, the highest age-standardized hip fracture inci-
proximately 25.5% of adults who experience a hip fracture have an- dence rates per 10 000 person-years occurred in women who were
other fracture within the subsequent year.7 In 3 observational stud- White (38% [95% CI, 37%-39%]) compared with women who were
ies from the US and Canada that included 1443 patients with hip Asian (17% [95% CI, 14%-22%]) or Black (9% [95% CI, 8%-11%]).21
fracture, 42% to 71% of patients regained their prefracture level of Reasons for racial differences in hip fracture incidence are unclear
basic activities of daily living, defined using the Modified Barthel In- but may be due to variation in BMD, life expectancy, hip axis length
dex or the Katz Activities of Daily Living Scale, by 6 months.8 Hip and femoral geometry, skeletal microarchitecture, or genetic fac-
fractures in adults 65 years and older are often associated with de- tors (Box).22,23
clines in physical, emotional, and social functioning, along with re- Certain lifestyle factors have been associated with an increased
duced health-related quality of life.9 risk of hip fractures. A meta-analysis of 18 prospective cohorts in men
and 23 prospective cohorts in women reported that current smok-
ing was associated with a 1.7-fold increased risk of hip fracture (men,
95% CI, 1.5-2.1; women, 95% CI, 1.5-1.8) compared with people who
Pathophysiology of Hip Fracture
never smoked, after adjusting for age and time since baseline (abso-
Thinning of cortical bone and loss of trabecular bone with aging are lute rates not available).24 In 3 longitudinal observational cohorts that
associated with osteoporosis and increased susceptibility to hip included 17 379 men and 13 393 women 20 years or older, men who
fracture.10 Osteoporosis is characterized by low bone mineral den- currently smoked cigarettes had a hip fracture incidence of 1.7 per
sity (BMD) and abnormal microarchitecture, with porous cortical 1000 person-years vs 0.8 per 1000 person-years in men who had
bone thinning and a loss and thinning of trabeculae leading to in- never smoked cigarettes. Among women, hip fracture incidence rates
creased susceptibility to fractures.11 Hip fracture occurs when the were 3.1 per 1000 person-years for those who smoked cigarettes and
force applied to the hip exceeds its strength. Therefore, the key de- 3.5 per 1000 person-years for women who never smoked cigarettes.25
terminants of hip fracture risk are bone strength and excessive forces In a meta-analysis of 8 cohort studies involving 240 871 individuals
exerted on the hip during a fall. Some risk factors for hip fracture, (64% women), daily alcohol consumption of 3 and 4 standard drinks
such as older age, low level of physical activity, and poor nutrition, (1 beer, wine, or mixed drink) was associated with an increased hip frac-
contribute to both low bone strength and high fall risk (Figure 1).12 ture risk (risk ratio [RR], 1.33 [95% CI, 1.04-1.69]; RR, 1.59 [95% CI, 1.23-
2.05], respectively) compared with people who did not drink any al-
cohol (absolute rates not available). 26 In pooled data from 3
longitudinal observational cohorts of 17 868 men and 13 917 women,
Clinical Presentation and Diagnosis
men who consumed 42 to 69 drinks per week had a hip fracture rate
More than 95% of hip fractures occur after a fall13 and present with of 2.05 per 1000 compared with men who consumed less than 1 drink
hip pain and an externally rotated leg. Plain radiographs are at least per week, who had a hip fracture rate of 1.90 per 1000. For women,
90% sensitive for hip fractures.14 Only approximately 1% of pa- the rates of hip fracture were not higher with greater alcohol intake,
tients with a likely hip fracture who do not have a fracture on radio- but fewer women consumed as much alcohol as men.27 In the Swed-
graph but for whom the clinician suspects a fracture based on pain ish National March Cohort, a longitudinal observational cohort of
and immobility should undergo computed tomography or mag- 23 881 participants 50 years and older who were followed up for a
netic resonance imaging.15 Hip fractures are classified as either in- mean of 12.2 years, participants in the lowest range of physical activ-
tracapsular or extracapsular, depending on whether the fracture is ity (<30.8 metabolic equivalent task h/wk) had a hip fracture rate of
E2 JAMA Published online July 16, 2026 (Reprinted) jama.com
© 2026 American Medical Association. All rights reserved, including those for text and data mining, AI training, and similar technologies.
Downloaded from jamanetwork.com by World Health Organization user on 07/19/2026
JAMA | Review
Hip Fractures
A Review
Fjola Johannesdottir, PhD; Jimmie E. Roberts, PhD; Douglas P. Kiel, MD, MPH; Joy N. Tsai, MD
Multimedia
IMPORTANCE More than 14.2 million people worldwide and 280 000 in the US experience CME at jamacmelookup.com
a hip fracture each year. The median 1-year mortality rate after a hip fracture is 22% and
approximately 42% to 71% of patients regain their prefracture level of basic activities of daily
living within 6 months.
OBSERVATIONS Hip fractures are classified as intracapsular or extracapsular and most com-
monly occur after a fall. Intracapsular hip fractures include femoral neck (34%) and femoral
head (rare). Extracapsular fractures consist of intertrochanteric (48%) and subtrochanteric
fractures (5.8%). In the US, between 2008 and 2017, hip fractures were associated with
1-year mortality rates of 26.9% among men and 18.5% among women. Older age is a major
risk factor for hip fracture, with a hazard ratio of 1.35 (95% CI, 1.25-1.47) per 5-year increase in
age. Women have higher incidence of hip fractures than men due to accelerated bone loss
after menopause and higher incidence of falls. Other risk factors for hip fractures include low
bone mineral density (bone density of 1 SD or below that of healthy young adults measured
by dual-energy x-ray absorptiometry), prior fracture, and factors contributing to falls, such as
weak muscles, poor visual acuity, and smoking. Surgery for hip fracture typically consists of
hip joint replacement or hip joint stabilization, using embedded hardware (open reduction
and internal fixation). Patients with hip fracture benefit from physical therapy and fall
reduction strategies, such as muscle-strengthening exercises and modifying medications
associated with increased fall risk, such as antidepressants, and should be treated with
antiresorptive medications, such as bisphosphonates (alendronate, zoledronic acid) or Author Affiliations: Center for
denosumab to prevent subsequent fracture. To prevent a hip fracture, patients with Advanced Orthopaedic Studies,
vertebral osteoporosis at the spine may require anabolic therapy, such as teriparatide, Beth Israel Deaconess Medical Center
abaloparatide, or romosozumab, before starting an antiresorptive. Hip fractures may lead to and Harvard Medical School, Boston,
Massachusetts (Johannesdottir);
mobility limitations; declines in physical, emotional, and social functioning; and reduced Hinda and Arthur Marcus Institute for
health-related quality of life. Aging Research, Hebrew SeniorLife,
Boston, Massachusetts (Roberts,
CONCLUSIONS AND RELEVANCE Hip fractures are common among older people and are Kiel); Department of Medicine,
associated with a 1-year mortality rate of 22% and with reduced mobility and quality of life. Beth Israel Deaconess Medical Center
Surgical repair for hip fracture typically consists of joint replacement or open reduction and and Harvard Medical School, Boston,
Massachusetts (Kiel); Endocrine Unit,
internal fixation. Hip fracture treatment also includes physical therapy, fall reduction Department of Medicine,
strategies, and medications to protect against fracture, such as bisphosphonates; Massachusetts General Hospital and
denosumab; or anabolic drugs, such as parathyroid hormone analogues or Harvard Medical School, Boston
(Tsai).
romosozumab.
Corresponding Author: Douglas P.
Kiel, MD, MPH, Hinda and Arthur
JAMA. doi:10.1001/jama.2026.11895 Marcus Institute for Aging Research,
Published online July 16, 2026. 1200 Centre St, Boston, MA 02131
().
A
pproximately 2 hip fractures occur every minute in the
US, and approximately 27 per minute worldwide. Methods
Most hip fractures occur among older adults with acci-
dental falls.1 Lifetime risks of hip fracture are 22.9% in women We searched PubMed for English-language studies published be-
and 10.7% in men at age 50 years and 19.3% and 9.1%, respec- tween January 1995 and November 2025, using the search terms
tively, at age 80 years.2 Among 66 746 patients with hip fracture, hip fracture, falls, fall risk, fracture rehabilitation, and fracture liaison
11 899 (20%) died during 12-month follow-up. Hip fractures cause service for clinical trials, observational studies, practice guidelines,
impaired mobility, pain, and substantial health care costs.3,4 This meta-analyses, and systematic reviews. Additional articles were iden-
review summarizes current evidence regarding the epidemiology, tified from references of articles identified in the search. Of 5454
pathophysiology, diagnosis, treatment, and prevention of hip identified articles, 101 were included, consisting of 11 randomized
fractures. clinical trials, 21 meta-analyses, 15 reviews, 13 clinical guidelines or
jama.com (Reprinted) JAMA Published online July 16, 2026 E1
© 2026 American Medical Association. All rights reserved, including those for text and data mining, AI training, and similar technologies.
Downloaded from jamanetwork.com by World Health Organization user on 07/19/2026
, Clinical Review & Education Review A Review of Hip Fractures
position statements, 10 epidemiologic studies, and 16 retrospec- within or outside of the fibrous capsule that surrounds the hip joint.
tive observational and 15 prospective observational studies. Intracapsular hip fractures include femoral neck fractures (34% of
all hip fractures) and femoral head fractures (rare), whereas extra-
capsular fractures include intertrochanteric (48% of all hip frac-
tures) and subtrochanteric fractures (5.8% of all hip fractures); 11.8%
Epidemiology
of hip fractures could not be classified (Figure 1).16
In 2019, approximately 14.2 million people experienced hip frac-
tures and 23.6 million people had a history of hip fracture worldwide.1
A meta-analysis of 9 US observational studies between 2001 and
Risk Factors for Hip Fracture
2018 among adults 60 years and older found that the mean age at
the time of hip fracture was 81 years.3 The global incidence of hip Hip fractures are uncommon before age 70 years, but the inci-
fractures among adults 55 years and older in 2019 was higher in dence progressively increases after age 70 years.17 In a global study
women (833.9 per 100 000) than in men (510.0 per 100 000).5 of 9 578 000 hip fractures in men and women, 1 189 000 hip frac-
Between 2005 and 2018, the median 1-year mortality rate af- tures occurred in people aged 70 to 74 years and 4 111 000 oc-
ter hip fracture was 22% worldwide.5 In the US, from 2008 to 2017, curred in people 80 years and older.18 In men and women with BMD
the 1-year mortality rate after hip fracture was 26.9% among men T-scores of less than −2.5 SD, the 10-year probability of hip fracture
and 18.5% among women.3,5 The most common causes of mortal- increased from 5.2% in men and 2.9% in women at age 50 years to
ity after hip fracture include pneumonia, sepsis, myocardial infarc- 21.2% and 23.8%, respectively, at age 80 years.19 Female sex is as-
tion, pulmonary embolism, and cancer.6 sociated with higher rates of hip fracture because of accelerated bone
After a hip fracture, approximately 20.1% of patients require loss after menopause and because older women have higher rates
long-term nursing facility care and 6.6% become newly eligible for of falling than older men.20 Based on self-reported race in a large
Medicaid or for a low-income subsidy under Medicare Part D.4 Ap- study of women, the highest age-standardized hip fracture inci-
proximately 25.5% of adults who experience a hip fracture have an- dence rates per 10 000 person-years occurred in women who were
other fracture within the subsequent year.7 In 3 observational stud- White (38% [95% CI, 37%-39%]) compared with women who were
ies from the US and Canada that included 1443 patients with hip Asian (17% [95% CI, 14%-22%]) or Black (9% [95% CI, 8%-11%]).21
fracture, 42% to 71% of patients regained their prefracture level of Reasons for racial differences in hip fracture incidence are unclear
basic activities of daily living, defined using the Modified Barthel In- but may be due to variation in BMD, life expectancy, hip axis length
dex or the Katz Activities of Daily Living Scale, by 6 months.8 Hip and femoral geometry, skeletal microarchitecture, or genetic fac-
fractures in adults 65 years and older are often associated with de- tors (Box).22,23
clines in physical, emotional, and social functioning, along with re- Certain lifestyle factors have been associated with an increased
duced health-related quality of life.9 risk of hip fractures. A meta-analysis of 18 prospective cohorts in men
and 23 prospective cohorts in women reported that current smok-
ing was associated with a 1.7-fold increased risk of hip fracture (men,
95% CI, 1.5-2.1; women, 95% CI, 1.5-1.8) compared with people who
Pathophysiology of Hip Fracture
never smoked, after adjusting for age and time since baseline (abso-
Thinning of cortical bone and loss of trabecular bone with aging are lute rates not available).24 In 3 longitudinal observational cohorts that
associated with osteoporosis and increased susceptibility to hip included 17 379 men and 13 393 women 20 years or older, men who
fracture.10 Osteoporosis is characterized by low bone mineral den- currently smoked cigarettes had a hip fracture incidence of 1.7 per
sity (BMD) and abnormal microarchitecture, with porous cortical 1000 person-years vs 0.8 per 1000 person-years in men who had
bone thinning and a loss and thinning of trabeculae leading to in- never smoked cigarettes. Among women, hip fracture incidence rates
creased susceptibility to fractures.11 Hip fracture occurs when the were 3.1 per 1000 person-years for those who smoked cigarettes and
force applied to the hip exceeds its strength. Therefore, the key de- 3.5 per 1000 person-years for women who never smoked cigarettes.25
terminants of hip fracture risk are bone strength and excessive forces In a meta-analysis of 8 cohort studies involving 240 871 individuals
exerted on the hip during a fall. Some risk factors for hip fracture, (64% women), daily alcohol consumption of 3 and 4 standard drinks
such as older age, low level of physical activity, and poor nutrition, (1 beer, wine, or mixed drink) was associated with an increased hip frac-
contribute to both low bone strength and high fall risk (Figure 1).12 ture risk (risk ratio [RR], 1.33 [95% CI, 1.04-1.69]; RR, 1.59 [95% CI, 1.23-
2.05], respectively) compared with people who did not drink any al-
cohol (absolute rates not available). 26 In pooled data from 3
longitudinal observational cohorts of 17 868 men and 13 917 women,
Clinical Presentation and Diagnosis
men who consumed 42 to 69 drinks per week had a hip fracture rate
More than 95% of hip fractures occur after a fall13 and present with of 2.05 per 1000 compared with men who consumed less than 1 drink
hip pain and an externally rotated leg. Plain radiographs are at least per week, who had a hip fracture rate of 1.90 per 1000. For women,
90% sensitive for hip fractures.14 Only approximately 1% of pa- the rates of hip fracture were not higher with greater alcohol intake,
tients with a likely hip fracture who do not have a fracture on radio- but fewer women consumed as much alcohol as men.27 In the Swed-
graph but for whom the clinician suspects a fracture based on pain ish National March Cohort, a longitudinal observational cohort of
and immobility should undergo computed tomography or mag- 23 881 participants 50 years and older who were followed up for a
netic resonance imaging.15 Hip fractures are classified as either in- mean of 12.2 years, participants in the lowest range of physical activ-
tracapsular or extracapsular, depending on whether the fracture is ity (<30.8 metabolic equivalent task h/wk) had a hip fracture rate of
E2 JAMA Published online July 16, 2026 (Reprinted) jama.com
© 2026 American Medical Association. All rights reserved, including those for text and data mining, AI training, and similar technologies.
Downloaded from jamanetwork.com by World Health Organization user on 07/19/2026
