Hip fractures are one of the most common fractures seen in the emergency room and by orthopedic trauma teams. The terms hip fracture and neck of femur fracture are interchangeable. Both terms refer to a proximal femoral fracture between the femoral head and 5 cm distal to the lesser trochanter.
They are most commonly caused by a fall. Risk factors include osteoporosis, taking various medications, drinking alcohol, and having metastatic cancer. X-rays are commonly used to make a diagnosis. Magnetic resonance imaging, a CT scan, or a bone scan may be required to make the diagnosis in some cases.
Opioids or nerve blocks may be used to treat pain. Surgery is usually recommended within two days if the patient's health allows it. Surgery options include total hip replacement or screw stabilization of the fracture. Following surgery, treatment to prevent blood clots is advised.
Around 15% of women will break their hip at some point in their lives; women are more likely to be affected than men. Hip fractures become more common as people get older. In older people, the risk of death in the year following a fracture is about 20%.
How common is Hip Fracture?
Globally, the annual incidence of hip fractures was 1.3 million in 1990, and this figure is expected to rise to 7 to 21 million by 2050. In the United States, the yearly incidence per 100,000 people is estimated to be between 197 and 201 for men and 511 to 553 for women. The average age of patients presenting with a hip fracture is 80 years old, and the incidence rises with age.
It is estimated that a patient spends $40,000 in the first year after a hip fracture, and the annual cost of hip fracture care in the United States exceeds $17 billion.
Who’s Most at Risk?
Each year about 300,000 Americans, most of them over age 65.
It happens to women more often than men. That’s because women fall more often and are more likely to have osteoporosis, a disease that makes bones weak.
Hip fracture following a fall is likely to be a pathological fracture. The most common causes of weakness in bone are:
- Other metabolic bone diseases such as Paget's disease, osteomalacia, osteopetrosis and osteogenesis imperfecta. Stress fractures may occur in the hip region with metabolic bone disease.
- Elevated levels of homocysteine, a toxic 'natural' amino acid.
- Benign or malignant primary bone tumors are rare causes of hip fractures.
- Metastatic cancer deposits in the proximal femur may weaken the bone and cause a pathological hip fracture.
- Infection in the bone is a rare cause of hip fracture.
- Tobacco smoking (associated with osteoporosis).
Also, distance runners and ballet dancers sometimes develop thin cracks called stress fractures in their hips. They can grow bigger over time if they’re not treated.
Causes of Hip Fracture
The majority of hip fractures in the elderly population are the result of a fall. A previous history of falls, gait abnormalities, the use of walking aids, vertigo, Parkinson disease, and antiepileptic medications are all independent risk factors for falls in the elderly population. Many patients have multiple risk factors, and this, along with age-related decreased bone quality, is the root cause of the majority of hip fractures.
Hip fractures in young adults are frequently the result of high-energy trauma. These patients are likely to have multiple injuries and should be evaluated and managed in accordance with local trauma guidelines.
Around 5% of hip fractures have no history of trauma, and an alternative cause should be suspected in these cases. A pathological fracture is one that is caused by a disease process rather than trauma. Malignancy and bisphosphonate use are the two most common causes of hip fractures. Many more hip fractures could conceivably be classified as pathological due to underlying osteoporosis, but this group is rarely labeled as such.
Signs and symptoms of Hip Fracture
Most hip fractures can be diagnosed, or at least suspected, based solely on history. A fall, in most cases, results in a painful hip and the inability to walk. Clinicians should investigate any potentially dangerous causes of the fall, such as syncope, stroke, or myocardial infarction. Because these patients are frequently elderly and have a complex medical history, a thorough medical history is essential.
This should include both a history of the presentation as well as a thorough assessment of the patient's medical history. A thorough social history that provides baseline mobility as well as the patient's home circumstances is also extremely valuable and will most likely guide postoperative rehabilitation and discharge planning.
It is recommended that a cognitive assessment be performed in all patients presenting with hip fractures. Ideally, this should be done both on admission and pos-operatively. The aim of this is to recognize patients with underlying dementia or those who are developing an acute delirium, both of which are associated with a poorer prognosis.
The physical exam will reveal pain, immobility, and possibly a deformed limb. The degree of deformity seen is determined by the anatomical configuration of the fracture as well as the amount of displacement. The classic description is a shortened and externally rotated limb caused by the unopposed pull of the iliopsoas muscle, which attaches to the lesser trochanter. Recognizing this, deformity raises the possibility of a hip fracture. Further examination frequently reveals pain on any or all of the following: groin or greater trochanter palpation, axial loading of the hip, and 'pin-rolling' of the leg.
To rule out other injuries, a full primary and secondary trauma assessment should be performed on the patient. Prior to surgery, it is always a good idea to check the patient's cardiovascular and respiratory status. Specific tests to determine the cause of the fall should also be considered.
Evaluation of patient with Hip Fracture
Plain film radiographs can be used to diagnose the vast majority of hip fractures. An anteroposterior view of the pelvis, as well as a lateral view of the affected hip, should be obtained. Occult fractures are those that are not visible on x-ray and account for 2% to 10% of hip fractures. MRI has been shown to have 100% sensitivity and 93 % to 100% specificity in diagnosing occult hip fractures, making it the gold standard. If MRI is not available, CT is a viable option; however, it has the potential to miss fractures, particularly those that occur in the axial plane.
The fracture pattern on radiographic images must be recognized because it will dictate surgical management. Hip fractures are generally described by comparing their location to the insertion of the joint capsule on the femoral neck. The hip joint capsule arises from the acetabulum and encompasses the entire femoral neck. The capsule inserts into the femur anteriorly at the intertrochanteric line and posteriorly at the intertrochanteric crest.
Three ligaments support the capsule: the iliofemoral and pubofemoral ligaments anteriorly, and the ischiofemoral ligament posteriorly. Fractures close to the capsular insertion are called intracapsular, while those farther away are called extracapsular.
Intracapsular hip fractures may be classified using the Pauwel classification. This classification divides fractures into three groups based on the angle of the fracture from the horizontal plane:
- Type 1: <30 degree.
- Type 2: 31-50 degrees.
- Type 3: >50 degrees.
An increased angle is associated with increasing shear forces and is, therefore, a more unstable fracture with reduced healing potential. This classification demonstrates marked inter-observer variation, particularly in displaced fractures.
The Garden classification is a more commonly recognized classification system for intracapsular hip fractures. It describes four fracture patterns and defines them based on the completeness and displacement of the fracture:
- Type 1: incomplete fracture and no displacement.
- Type 2: complete fracture and no displacement.
- Type 3: complete fracture and partial displacement.
- Type 4: complete fracture and complete displacement.
This classification is more reproducible than the Pauwel classification, but it exhibits intra-observer variation once again. Many clinicians reduce this classification to displaced or undisplaced, as this is ultimately what guides management. These fractures can also be classified based on where they occur on the femoral neck. Sub-capital fractures are the most proximal intracapsular fractures, followed by transcervical fractures and, finally, basicervical fractures at the femoral neck's base.
Extracapsular fractures can be divided into trochanteric and subtrochanteric fractures. Trochanteric fractures are fractures that occur between the greater and lesser trochanter. These fractures are historically classified with Evan’s classification, which assesses the stability of the fracture. In modern practice extracapsular fractures are typically described using the AO classification:
- A1: two-part, stable fracture
- A2: comminuted, unstable fracture
- A3: reverse or transverse, unstable fracture
Recognizing the various fracture types is critical because it determines surgical therapy. Subtrochanteric fractures are those that occur between the lesser trochanter and 5 cm distal to it. These were formerly categorized using the Russell-Taylor classification system, but are now classed using the revised AO classification system. Both of these categorization approaches are frequently academic and have little impact on management.
On admission, all patients should undergo blood tests to examine anemia, renal function, and coagulation profile as part of the clinical evaluation. A bone scan can also help with the management of underlying osteoporosis or calcium imbalances. Finally, because operational treatment for broken hips is linked with severe blood loss, a cross-match should be undertaken.
Patient evaluation should be approached in an interdisciplinary manner, with the surgical, medical, and anesthetic teams, as well as physiotherapists, pharmacists, and dieticians, all participating. This multidisciplinary approach guarantees that the patient is thoroughly analyzed and optimized prior to surgery. It is advised that hospitals use this strategy and create a hip fracture program in order to enhance postoperative results and minimize mortality.
Treatment of Hip Fracture
The emergency department is where the first management begins. Patients can lose up to 1 liter of blood due to proximal femoral fractures, hence fluid replacement and blood transfusion should be considered as away.
Prolonged preoperative fasting should be avoided, and nutritional supplements should be made accessible until the expected time of operational intervention is determined. Fasting over an extended period of time is related with increased catabolism, hypoglycemia, immunosuppression, and dehydration. Hip fracture patients are more vulnerable to dehydration problems, hence enough pre- and peri-operative hydration should be provided. Fasting times before surgery differ depending on the hospital. The European Society of Anaesthesiology recommends a 2-hour fast from fluids and a 6-hour fast from food prior to surgery.
Oral or intravenous analgesia should be administered, but achieving adequate pain control can be challenging. It is now recommended that a fascia-iliaca nerve block be used in the preoperative period to reduce analgesia requirements and associated morbidity. It is not advisable to apply limb traction, or attempt closed reduction in the emergency department.
The definitive management is largely dependent on the fracture location and configuration. The pre-morbid function and medical background of the patient are also considered, as well as their personal preferences. The approach, as with assessment, should involve the wider interprofessional team. The primary aim is to restore the patient’s mobilization status as swiftly as possible, and therefore operative intervention is normally preferred.
Conservative treatment for fractured hips is associated with a greater 30-day and 1-year mortality and is often reserved for individuals who are not surgical candidates. Because early surgery is associated with better outcomes in hip fracture patients, it is suggested that surgery be performed within 48 hours of admission. Hyper-acute surgery, defined as surgery performed within 6 hours, did not lower mortality or the rate of serious complications, but it also does not increase patient risk. Hyper-acute surgery reduces the rate of delirium and shortens the hospital stay by one day.
Standard treatment for low-grade fractures (Garden types 1 and 2) is in-situ fixation of the fracture with screws or a sliding screw/plate system. After the fracture has been reduced, this technique can also be used to treat displaced fractures.
Closed reduction fractures may be treated with percutaneously inserted screws. Many surgeons choose to perform hemiarthroplasty on older patients with displaced or intracapsular fractures, which involves replacing the damaged component of the bone with a metal implant. A total hip replacement may be indicated in elderly adults who are medically sound and remain active. Independently mobile elderly people with hip fractures may benefit from total hip replacement rather than hemiarthroplasty.
Traction is contraindicated in femoral neck fractures due to it affecting blood flow to the head of the femur.
The most recent evidence suggests that screws and fixed angle plates may have little or no difference as internal fixation implants for intracapsular hip fractures in older adults. The conclusions are based on low-quality research that cannot conclusively establish a significant difference in hip function, quality of life, or the need for subsequent surgery.
A trochanteric fracture, which occurs below the femoral neck, has a high likelihood of healing. Closed reduction may not be sufficient, necessitating open reduction. Open reduction has been reported to be used in 8-13 percent of pertrochanteric fractures and 52 percent of intertrochanteric fractures. A dynamic hip screw and plate, or an intramedullary rod, can be used to treat both intertrochanteric and pertrochanteric fractures.
The fracture usually heals in 3–6 months. Because it is only prevalent in the elderly, removing the dynamic hip screw is usually not advised in order to avoid the unnecessary risk of a second operation and the increased risk of re-fracture after implant removal. Osteoporosis is the most prevalent cause of hip fractures in the elderly; if this is the case, treating the osteoporosis can significantly minimize the risk of further fracture. Only young patients are likely to consider having it removed; the implant may act as a stress raiser, increasing the likelihood of a break if another accident occurs.
Subtrochanteric fractures may be treated with an intramedullary nail or a screw-plate structure, as well as pre-operative traction, however this is uncommon. It is uncertain whether any one type of nail produces different results than any other type of nail.
A lateral incision is created over the trochanter, and a cerclage wire is wrapped around the fracture to reduce it. After reduction, a guiding canal for the nail is created through the proximal cortex and medullary. The nail is introduced through the canal and screwed in place proximally and distally. X-rays are taken to confirm that the nail and screws are properly reduced and placed.
Complications of surgical management of hip fracture.
Infection from deep or superficial wounds occurs at a rate of about 2%. It is a major issue since surface infection might progress to deep infection. This could result in infection of the healing bone as well as contamination of the implants. Infection is difficult to eradicate in the presence of metal foreign bodies such as implants. Bacteria within the implants are immune to the body's defense mechanism and antibiotics. The treatment plan is to use drainage and antibiotics to try to keep the infection at home until the bone heals.
The implant should then be removed, and the infection should clear up. The metal screws and plate may break, back out, or cut out superiorly and enter the joint, resulting in implant failure. This can happen as a result of incorrect implant placement or if the fixation fails to hold in weak and fragile bone.
If the operation fails, it may be repeated or replaced with a total hip replacement. Mal-positioning: The fracture might be repaired and then healed in an improper position, particularly rotation. This may not be a serious issue, or it may necessitate later osteotomy surgery to be corrected.
Prognosis of Hip Fracture
Hip fractures are extremely harmful, especially in the old and frail. In the first thirty days, the chance of death from the stress of the surgery and injuries is roughly 10%. This may reach 30% one year after the fracture. If the ailment is not treated, the patient's pain and immobility enhance the risk. Immobility exacerbates problems such as pressure sores and chest infections. Untreated hip fractures have a very bad prognosis.
A hip fracture is a break in the top quarter of the thighbone, which is also called the femur. It can happen for lots of reasons and in many ways. Falls, especially those to the side are among the most common causes. Some hip fractures are more serious than others, but most are treated with surgery.
If your doctor suspects you have a broken hip, he or she will inquire about any recent injuries or falls. They'll perform a physical examination and obtain X-rays.
If the X-ray image is indistinct, an MRI or bone scan may be required. A bone scan is performed by injecting a very small amount of radioactive dye into a vein in your arm. The dye passes through your bloodstream and into your bones, revealing fractures.
The management is determined by the type of fracture, your age, and your overall health. However, your doctor will most likely request a series of testing, including blood and urine tests, chest X-rays, and an electrocardiogram (EKG).
The greatest way is to ensure that your bones remain strong and healthy. To that aim, your doctor may advise you to try one or more of the following: Calcium supplements, vitamin D supplements, bisphosphonate drugs, regular physical activity, cessation of tobacco and alcohol use.