Powell J, et al. - In elderly people with neck of femur (NOF) fracture, derangement in liver function tests (LFTs) has been frequently identified in the peri-operative period and is possibly indicative of serious and treatable underlying pathology as well as prognosis. On admission, underlying bone pathology such as osteomalacia or Paget’s disease may be suspected when raised alkaline phosphatase (ALP) levels with normal gamma-glutamyl transferase (GGT) are identified but these do not confirm or exclude osteoporosis. Non-bone pathology such as congestive cardiac failure and chronic kidney disease can also be suspected in cases with elevated ALP. In cardiac failure, LFT derangement is linked with poorer prognosis. Overall findings suggest that there is wide differential diagnosis for deranged LFTs in the elderly peri-operatively; however, careful history and examination can aid in eliciting most causes with occasional need for further investigations.