Hip Fracture and Hip Replacement Precautions

What it is

Hip fractures occur most often in older adults with osteoporosis after a fall and are intracapsular (femoral neck) or extracapsular (intertrochanteric or subtrochanteric). Most are repaired surgically, by internal fixation or arthroplasty, as soon as the client is medically stable. After a posterior-approach arthroplasty, hip flexion beyond 90 degrees, adduction past the midline and internal rotation lever the prosthetic head out of the socket, so positioning rules protect the joint while early mobility prevents the complications of immobility.

What the NCLEX focuses on

• Classic hip fracture: the affected leg is shortened and externally rotated, with severe hip or groin pain and inability to bear weight.
• Before surgery: Buck traction (if prescribed) with weights hanging freely, neurovascular checks, pain control, and prevention of pressure injury and delirium.
• Posterior hip precautions: abduction pillow between the legs, no hip flexion past 90 degrees, no crossing the legs, no internal rotation, a raised toilet seat and chairs with arms; an anterior approach follows the surgeon's own protocol.
• Prosthesis dislocation: sudden severe pain, a popping sensation, and a shortened, internally rotated leg; keep the client still and notify the surgeon.
• VTE prevention: prescribed anticoagulant, sequential compression devices and ankle pumps; report unilateral calf swelling, sudden dyspnea or chest pain.
• Older adults: new confusion is delirium with a cause (pain, hypoxia, urinary retention, infection), not expected aging.
• Infection: fever, spreading incision redness, purulent drainage or increasing pain.

Priority nursing actions

1. Assess neurovascular status of the operated leg, the incision, drain output and pain; give prescribed analgesia before activity.
2. Keep the abduction pillow in place and maintain hip precautions during every turn and transfer.
3. Give the prescribed anticoagulant, apply sequential compression devices, and coach ankle pumps and incentive spirometry hourly while awake.
4. Get the client out of bed with physical therapy on postoperative day 1, using a walker and the prescribed weight bearing.
5. If dislocation is suspected, keep the client still, support the leg and notify the surgeon.

Numbers to know

Common exam traps

• Choosing to sit in a low recliner or soft couch: wrong because it flexes the hip past 90 degrees.
• Choosing to cross the legs or lie on the side without a pillow between the knees: wrong because adduction and internal rotation dislocate the prosthesis.
• Choosing to move the leg to check a suspected dislocation, or to give an opioid first: wrong because movement causes further injury; immobilize and notify the surgeon.
• Choosing to document new confusion in an older adult as expected after surgery: wrong because delirium signals hypoxia, pain, retention or infection that needs assessment.
• Choosing to have a client with an unrepaired hip fracture walk to the bathroom: wrong because the fracture is unstable until surgical fixation.

What to teach

• Use a raised toilet seat, a firm chair with arms, a long-handled reacher, sock aid and shoehorn; do not bend to the feet.
• Keep a pillow between the knees when lying on the side; do not cross the legs or turn the toes inward.
• Complete the prescribed anticoagulant course; report calf pain or swelling, shortness of breath, fever or wound drainage.
• Prevent falls at home: remove throw rugs, use night lights, and keep the walker within reach.

Client handout: After Hip Replacement Surgery (nurse guide and printable patient handout).

Sources

• Harding MM, Kwong J, Hagler D, Reinisch C. Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 12th ed. Elsevier; 2023; Chapter: Musculoskeletal Trauma and Orthopedic Surgery.
• American Academy of Orthopaedic Surgeons. Management of Hip Fractures in Older Adults: Evidence-Based Clinical Practice Guideline. AAOS; 2021.