• Clinical science

Hip fractures

Abstract

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: > [1]
  • More common in whites[1]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

  • Mechanism of injury
    • Elderly
    • Youth; : High-speed trauma (e.g., motor vehicle accidents or falls from great heights) or underlying disease (e.g., fibrous dysplasia) [1]
  • Risk factors[2]
    • Osteoporosis (especially post-menopausal women and elderly)
    • Muscle weakness
    • Difficulty walking and impaired coordination
    • Estrogen deficiency
    • Low body weight
    • Poor nutrition (vitamin D or calcium deficiency)
    • Smoking, alcohol use

Pathophysiology

Types of hip fractures

Hip fractures are generally divided into intracapsular or extracapsular

Femoral head fracture

  • Uncommon but often associated with a posterior hip dislocation following a dashboard injury
  • Clinical features
  • 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
    • MRI if findings are unclear or if an occult fracture is suspected
    • Pre-surgical determination of blood type, cross-matching
    • Exclude surgical and anesthetic risks by performing a chest x-ray, ECG, and cardiac markers (especially in the elderly)
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).

  • Surgical: open reduction internal fixation, e.g., with a traction bolt
  • Conservative: immobilization
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).

  • Surgical: open reduction internal fixation, e.g., with a traction bolt
Pipkin III Pipkin I or II fracture in combination with a medial fracture of the femoral neck
  • Surgical
    • Young patients: open reduction internal fixation with maintenance of the femoral head
    • Elderly patients or those with predispositions: total hip replacement
Pipkin IV Pipkin I or II fracture in combination with an acetabular fracture
  • Surgical
    • Young patients: open reduction internal fixation with maintenance of the femoral head
    • Elderly patients or those with predispositions or instabilities: total hip replacement

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

  • Clinical features
    • Groin pain
    • Shortened and externally rotated leg[1]
    • 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
Garden Classification
Garden I

Impaction fracture, nondisplaced and incomplete

Garden II

Nondisplaced but complete fracture

Garden III

Varus displacement of the femoral head, partially displaced complete fracture

Garden IV

Entirely displaced, complete fracture

  • Treatment
    • Conservative management
      • Indication: stable, nondisplaced fractures, especially abduction fractures (Garden I), mostly in debilitated patients
      • Methods
        • Temporary bed rest; or use of crutches followed by mobilization with physical therapy
        • Thrombolytic therapy
    • Surgical therapy (usually within within 72 hours[1] is indicated for unstable fractures (; Garden II–IV), typically adduction fractures, and fragment dislocation
      • For young patients[1]
        • Attempt preservation of the femoral head
        • Early open reduction internal fixation (ORIF) (within 6 hours)
      • For elderly patients: total hip replacement (THR) or hemiarthroplasty

A femoral neck fracture may be associated with femoral shaft fractures in ∼8% of cases

Trochanteric fracture

  • Clinical features
    • A greater trochanter fracture is suggested by local pain exacerbated by abduction
    • A lesser trochanter fracture presents with 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 )
  • Treatment
    • Most heal with conservative treatment (e.g., nonweightbearing)
    • Surgical repair for displaced fractures (> 1 cm)

Subtrochanteric fracture

Intertrochanteric fracture

  • 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

Fracture-dislocation

Type of hip dislocation Etiology Clinical features Diagnostics Treatment Complications
Posterior hip dislocation (90% of cases)
  • Dashboard injury in which a posteriorly directed force (e.g., dashboard during a motor vehicle accident) is directed towards an internally rotated, flexed, and adducted hip
  • Hip pain which radiates to the knee
  • Shortened, internally rotated (adducted) hip
  • X-ray
  • CT/MRI to exclude associated (especially pathological) fractures
  • Closed reduction within 6 hours
  • Open reduction if closed reduction is unsuccessful, the joint is unstable, or if bony fragments/tissue sit within the joint space
Anterior hip dislocation (10% of cases)
  • Direct blow to the posterior hip or to an abducted leg
  • Hip pain which radiates to the knee
  • Lengthened, externally rotated leg

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!

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!

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
last updated 11/07/2017
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