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Fragility fractures may occur at various sites such as the wrist, humerus, vertebrae, pelvis, tibia and the ankle, but the most common and serious fractures occur at the hip. The majority of those who suffer a hip fracture are frail, elderly and often have significant comorbidities, which result in 10% in-hospital and 30% 1-year mortality. More than half of patients do not return to previous functional status and the cost of care is high. Current knowledge strongly supports early surgical fixation and mobilization, but since this often involves a frail older person who has fallen, multidisciplinary collaboration from the outset is important. Future studies need to seek answers as to the optimum setting to provide such care, improved surgical and anesthetic techniques, safe and effective pain management, nutrition, thromboprophylaxis and falls prevention. We discuss the current evidence and probable optimal clinical care for patients presenting to hospital with an acute hip fracture. The general principles of care would be applicable to older patients admitted to hospital with other forms of fragility fractures.