Hip fractures

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 older adults 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 the most common and 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.

• Peak incidence: > 70 years
• Sex: ♀ > ♂

References:^[1]

Epidemiological data refers to the US, unless otherwise specified.

• Mechanism of injury
  • Older adults
    • Fall onto greater trochanter/lateral hip
    • Forced lateral rotation (e.g., from tripping)
    • Chronic overburdening can lead to insufficiency fractures which can then completely fracture spontaneously
    • Pathological fracture due to metastases
  • Children and young adults: high-speed trauma (e.g., motor vehicle accidents or falls from great heights) or underlying disease (e.g., fibrous dysplasia)
• Risk factors
  • Osteoporosis (especially postmenopausal women and older individuals)
  • Muscle weakness
  • Difficulty walking and impaired coordination
  • Estrogen deficiency
  • Low body weight
  • Poor nutrition (vitamin D deficiency or calcium deficiency)
  • Smoking, alcohol use

References:^[2]

Diagnostics ^[3]

If hip fracture is suspected, perform a detailed evaluation to determine the cause and identify other injuries.

• Imaging ^[4]
  • X-ray hip (initial modality)
  • Consider MRI hip and pelvis to assess for occult fracture.
• Preoperative diagnostics: for intermediate- or high-risk surgery
• Additional studies: as clinically indicated
  • Diagnostics for osteoporosis (e.g., to establish a pretreatment baseline) ^[5]
  • Workup for falls in older adults and causes of syncope ^[6]

Management ^[7][8]

Operative intervention within 48 hours of admission may be associated with improved patient outcomes.

• Surgical treatment: Surgical options vary by type of hip fracture.
  • Consider nonoperative management in patients with adequate pain control and any of the following:
    • High perioperative risk
    • Nonambulatory baseline
    • Advanced comorbid conditions (e.g., severe neurodegenerative conditions)
  • Perioperative antibiotic prophylaxis is typically indicated (e.g., cefazolin).
• Multidisciplinary care
  • Orthopedics: surgical and follow-up plan (e.g., drain management, determination of weight-bearing precautions)
  • Geriatrics: geriatric assessment and co-management for older patients
  • Physical therapy and occupational therapy: early mobilization
  • Registered dietitian: Poor nutritional status is associated with functional decline and complications.
• Supportive care
  • Pain management according to the WHO analgesic ladder
  • VTE prophylaxis (both pharmacological and mechanical) ^[9]
• Management of comorbidities
  • Optimize bone health (e.g., bisphosphonates for osteoporosis). ^[10]
  • Delirium prevention and treatment
• Advance care planning: especially in patients with a high frailty scale score

Weight-bearing status is determined by orthopedics. Clarify weight-bearing precautions and range of motion prior to consulting physical and occupational therapy.

Hip fractures are divided into:

• Intracapsular
  • Femoral head
  • Femoral neck
• Extracapsular
  • Trochanteric
  • Intertrochanteric
  • Subtrochanteric

• Occurrence: uncommon but often associated with a posterior hip dislocation following a dashboard injury
• Clinical features
  • Groin pain
  • Local swelling and ecchymosis
• Diagnostics
  • Hip x-ray (AP with internal rotation and lateral view; should include the proximal thigh) : abnormal trabecular pattern, cortical defects, shortening and angulation of the femoral neck ^[11]
  • MRI if findings are unclear or if an occult fracture is suspected

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.

• Clinical features
  • Groin pain
  • Shortened and externally rotated leg
  • Minimal bruising
• Diagnostics
  • X-ray (AP and lateral view of the pelvis with internal rotation of the affected limb)
  • MRI or bone scan if clinical suspicion is high despite absent findings on x-ray

• Treatment
  • Conservative management
    • Indication: stable, nondisplaced fractures, especially abduction fractures , mostly in debilitated patients
    • Methods
      • Temporary bed rest; or use of crutches followed by mobilization with physical therapy
      • Venous thromboembolism prophylaxis ^[12]
  • Surgery (usually within 72 hours ; ) is indicated for unstable fractures , typically adduction fractures, and fragment dislocation
    • For children and young adults
      • Attempt preservation of the femoral head
      • Early open reduction internal fixation (ORIF) (within 6 hours)
    • For older adults: total hip replacement (THR) or hip hemiarthroplasty

• Etiology
  • Greater trochanteric fracture
    • Avulsion of the greater trochanter apophysis due to forceful contraction of the gluteus medius and minimus muscles (typically during physical activity)
    • Direct trauma to the greater trochanter (e.g., due to a fall onto the hip)
  • Lesser trochanteric fracture: avulsion of the lesser trochanter apophysis due to forceful contraction of the iliopsoas muscle
• Clinical features
  • Greater trochanteric fracture: local pain exacerbated by abduction
  • Lesser trochanteric fracture: groin pain, which radiates to the knee or posterior thigh and worsens with hip flexion and rotation
• Diagnostics
  • X-ray showing avulsion of the greater or lesser trochanter
  • MRI if a pathological fracture is suspected or in individuals at risk of fracture extension (e.g., patients with osteoporosis)
• Treatment ^[13]
  • Typically self-limiting and conservative treatment suffices (e.g., no weight-bearing on the affected leg, ice, and physical therapy).
  • Surgical repair in fractures with displacement > 1 cm

• Clinical features
  • Hip pain and swelling
  • Shortened and externally rotated leg
  • Significant ecchymosis
  • Often associated with other injuries (e.g. other extremity fractures)
• Diagnostics
  • X-ray (AP view with maximal internal rotation and lateral view): proximal femur fracture between the greater and lesser trochanters
  • MRI if a pathological fracture is suspected
• Treatment
  • Nonsurgical approach for high risk patients
  • Surgery
    • Dynamic hip screw (DHS) for stable fractures
    • Intramedullary nail (Gamma nail) for stable or unstable fractures, fractures extending into the subtrochanteric region, or reverse oblique fractures
    • Arthroplasty may be considered for comminuted fractures, pathological fractures, or if other surgical modalities fail.

• Clinical features
  • Hip pain with swelling
  • Shortened and externally rotated leg
  • Significant ecchymosis
• Diagnostics
  • X-ray : fracture between the lesser trochanter up to 5cm below that (distally)
  • MRI if a pathological fracture is suspected
• Treatment
  • Consider conservative approach (e.g., traction) in surgically unstable patients
  • Surgery is indicated in displaced/nondisplaced fractures in adults, especially if associated with multiple trauma, an open fracture, or pathological fractures
    • Long intramedullary nail with a lag screw
    • Locking plate may be considered for complicated fractures (e.g., pre-existing femoral deformity, associated femoral neck fracture)

Hip fractures, especially fractures of the femoral head, are often associated with a hip dislocation.

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

• Avascular necrosis (AVN) of the femoral head
• Thromboembolism
• Infection
• Chronic pain and posttraumatic arthritis
• Nonunion
• Dislocation

Thrombolytic therapy reduces the risk of deep vein thrombosis in patients with hip fractures.

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

• Intracapsular fractures (e.g., femoral head and neck fractures) have an increased rate of nonunion which leads to AVN
• Intertrochanteric fractures have a good prognosis following surgery
• Subtrochanteric fractures have a high rate of implant failure

Hip fractures have a high rate of associated morbidity and mortality in older adults.

• 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