• Clinical science

Hip fractures

Summary

Hip fractures are classified according to their anatomical location as intracapsular, which involves the femoral head and neck, and extracapsular, which includes intertrochanteric, trochanteric, and subtrochanteric fractures. A low impact fall is the typical mechanism of injury in the eldery and is often associated with underlying osteoporosis. Motor vehicle accidents are typical in younger individuals. Clinical features include groin pain and deformity of the hip. An x-ray is usually diagnostic, while an MRI may be required to confirm a pathological fracture. Surgical therapy is usually considered definitive treatment, especially for unstable or displaced hip fractures. Thromboembolism and avascular necrosis are common but serious complications.

Hip fractures, especially fractures of the femoral head, are often associated with a hip dislocation. Posterior hip dislocations account for 90% of hip dislocations and typically follow a dashboard injury. Early reduction is vital to avoid vascular compromise and sciatic nerve injury.

Epidemiology

  • Peak incidence:> 70 years
  • Sex: >
  • More common in whites

References:[1]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

References:[1][2]

Types of hip fractures

Hip fractures are generally divided into intracapsular or extracapsular

Femoral head fracture

Pipkin Classification
Description Treatment after rapid repositioning
Pipkin I

Luxational fracture of the femoral head: The fracture line lies below the fovea capitis, ie. not in the weight-bearing portion (horizontal fracture).

Pipkin II

Luxational fracture of the femoral head: The fracture line lies above the fovea capitis. The fragment is attached to the femoral head ligament. and thus in the weight-bearing portion (vertical fracture).

Pipkin III Pipkin I or II fracture in combination with a medial fracture of the femoral neck
Pipkin IV Pipkin I or II fracture in combination with an acetabular fracture

A patient with an MVA dashboard injury may present with a femoral head fracture and hip dislocation!

Watch out for sciatic nerve injury in patients with femoral head fractures!

References:[1]

Femoral neck fracture

A femoral neck fracture may be associated with femoral shaft fractures in ∼8% of cases References:[1]

Trochanteric fracture

  • Clinical features
  • Diagnostics
    • X-ray showing avulsion of the greater or lesser trochanter
    • MRI if a pathological fracture is suspected )
  • Treatment
    • Most heal with conservative treatment (e.g., nonweightbearing)
    • Surgical repair for displaced fractures (> 1 cm)

Subtrochanteric fracture

Intertrochanteric fracture

Fracture-dislocation

Type of hip dislocation Etiology Clinical features Diagnostics Treatment Complications
Posterior hip dislocation (90% of cases)
  • X-ray
  • CT/MRI to exclude associated (especially pathological) fractures
Anterior hip dislocation (10% of cases)

Fracture dislocations are at greatest risk of avascular necrosis of the femoral head!

Complications

Thrombolytic therapy reduces the risk of deep vein thrombosis in patients with hip fractures!References:[1]

We list the most important complications. The selection is not exhaustive.

Prognosis

Hip fractures have a high rate of associated morbidity and mortality in elderly patients!References:[1]

Prevention

  • Fall risk assessment, for example with the Tinetti-Test, which is used to evaluate a patient's gait and balance.
  • Early preventative efforts such as fall training, physical therapy, removal of tripping hazards, appropriate shoes, etc.
  • Osteoporosis prophylaxis