Hip Fracture

Presentation of hip fracture patient is variable but most patients do complain of fall in the history. Other may give history of a motor vehicle accident. Stress fractures can present insidiously without any history of trauma.

Pain is a universal complain. It may be localized to the hip or groin area. Others may complain of pain during walking. The pain may radiate to the thigh or knee. The pain is often progressive and worse during activity. Night pain may also be a common complaint.

Exam

• The hip will be shortened and externally rotated.
• Hip range of motion is limited.
• Pain on passive hip movements is present.
• Deep palpation in groin area may produce pain.
• Heel percussion may produce pain.
• Ecchymosis may be present.
• An antalgic gait is common.
• Most patients are unable to stand.
• Always assess neurovascular status.

Diagnosis of hip fracture is made with X-rays and physical exam [7]. However since most patients need surgery, other blood work should be done and all abnormalities corrected. Classic studies include:

• Complete blood count
• Coagulation profile
• Electrolytes
• Renal and liver function
• Other studies depend on patient’s comorbid conditions
• If plain X-ray is not conclusive but there is clinical suspicion of hip fracture, MRI or CT scan can be ordered. MRI has excellent sensitivity.
• Bone scan should not be ordered because of poor sensitivity.

Once a patient presents with a hip fracture, possible search for other injuries should be made.

• The patient should be hydrated intravenously and kept nil per os in case emergency surgery is required.
• Orthopedic consult should be made because the treatment decisions do vary depending on the injury and patients comorbidity.
• Parenteral analgesia is recommended. If anesthesia is available, a regional nerve block is acceptable for pain relief.
• Muscle relaxant may be necessary.

Guidelines for managing hip fracture in the elderly:

• Preoperative pain is better controlled with regional analgesia.
• Either regional or general anesthesia can be used for hip fracture surgery as the outcomes are similar.
• For unstable or displaced femoral neck fractures arthropathy should be used.
• Use of a cephalomedullary device is recommended for the treatment of patients with subtrochanteric or reverse obliquity fractures.
• Restrict blood transfusion in asymptomatic postoperative hip fracture patients if hemoglobin is higher than 8 g/dl.
• To improve functional outcomes, aggressive physical rehabilitation is recommended.
• To improve functional outcomes in patients with dementia, an interdisciplinary management team.
• After hip surgery, manage pain using several methods including patient controlled analgesia.

Surgery

• The management of intratrochanteric fractures, femoral neck fractures and most femoral stress fractures requires surgery.
• Tension fractures have a poor prognosis and tend to be unstable and surgery is required.
• Most compression fractures may heal with conservative management which include several days of rest followed by gradual weight bearing with crutches. These individuals need serial imaging studies to monitor progress of healing [8] [9].
• Early surgery (within 24-48 hr after admission) has been shown to have better outcomes such as low risk of blood clots, pulmonary embolism and pressure sores.
• Thromboprophylaxis is necessary. Once diagnosis is made, patients must be treated with a pharmacological agent theta may include heparin, LMWH or warfarin. Prophylaxis should continue for 10-14 days after surgery.
• Mechanical devices like calf pumping devices and use of TED stocking should be used.
• After surgery, it is important to start ambulating the patient to avoid complications of blood clots and pressure sores.
• For those with osteoporosis, calcium and vitamin D are recommended.

Complications

• Complications associated with hip fracture or misdiagnosed stress fractures include the following:
• AVN
• Non-union
• Osteonecrosis

These complications are serious and can be debilitating. Most patients become so disabled that they cannot perform any type of daily living activity.

Consultations

Because hip fractures often tend to occur in elderly individuals who have several other medical disorders a medical consultation is recommend. These patients are often dehydrated, overmedicated, may have heart disease, diabetes, or a prior stroke. The cause of the fall must be investigated.

Physical therapy

Physical therapy is essential whether the fracture has been managed medically or surgically. It helps improve range of motion, balance and strength. In young individuals, rehabilitation can help improve condition of the hip so that they can return to their previous life style. However, all athletes need to be pain free and have no symptoms before they return to sports related activities.

Aggressive rehabilitation is necessary to prevent bed sores, venous thrombosis, pneumonia and deconditioning, weight bearing has been shown to be safe in most patients. Initially most patients benefit from use of an ambulatory device (eg. crutches, cane walker).

The prognosis for patients with hip fracture depends on the age and presence of any comorbidity. Some young individuals who suffer a hip fracture may not be able to participate in contact sports. Some types of hip fractures can cause great instability and the individual may not be able to stand or walk.

Overall, hip fractures carry a high morbidity. When the diagnosis of compression hip fracture is missed, it can lead to avascular necrosis, varus deformity, non-union, and chronic pain. If the femoral neck is displaced, leg shortening may occur and affect the gait. This can be disabling and limit one’s ability to work or stand.

Most compression hip fractures have a good prognosis and can be managed with physical therapy with good recovery. Hip fractures also predispose patients to blood clots and the risk of pulmonary embolism is high. A significant number of patients who survive 12 months after the hip fracture still have difficulty with gait and pain. Daily living activities are limited. In the elderly population, hip fractures can carry mortality rates of 10-30%.

Common causes and risk factors for hip fractures are:

• Accident
• Fall
• Gaucher disease
• Bone cysts
• Osteoporosis
• Medications 
• Sporting activities
• Sedentary lifestyle
• Alcohol use
• Dementia
• Stroke
• Poor eye sight
• Increase caffeine intake [6]

Other risk factors that may contribute to hip fractures in young people include muscle fatigue, improper foot wear, errors in training and training on slippery surfaces that increase the risk of falls.

Hip fracture is a global problem. Thousands of hip fractures are reported in countries all over the globe. With the aging and active population, hip fractures have a bimodal distribution. The active young people with hip fracture present in the 2-4 decade of life and the elderly usually present after the 6th decade of life. In the elderly, the majority of hip fractures occur in women, whereas in the active young population, most hip fractures occur in men. Overall Caucasian females are more likely than Asians or African to develop hip fractures.

Hip fractures may occur in the presence of osteoporosis because the bone is weak and thin. In other cases, hip fractures may occur because of significant trauma to the pelvic area. In general, pathological fractures of the hip require little force. Osteoporosis is a significant risk factor in post-menopausal women. Avascular necrosis occurs because the scant blood supply to the head of femur may be jeopardized after trauma or exercise.

The best way to prevent hip fractures is to reduce the risk factors for a fall. Thus, elderly patients must be assessed for their gait, balance, and vision. If there is unsteadiness in gait, an ambulatory device will help. For women with osteoporosis, supplement of calcium, vitamin D and bisphosphonate may lower the risk of hip fracture.

Patients should be told to discontinue smoking and cut down on alcohol. To prevent falls, risk factors like muscle weakness, use of medications, arthritis, depression balance. Gait, vision and activities should be assessed. Intervention may include physical therapy, use of hip protector, and ambulating devices.

Hip fractures have become very common in society and usually tend to occur in elderly people due to osteoporosis. However, hip fractures are also common in young people who are active in sports. Many types of contact sports, motor vehicle accidents and falls from heights result in hip fractures and in most cases, the individuals are young males. With a growing number of people participating in intense physical activity, femoral neck stress fractures have also become prominent. Besides the military, stress fractures are now seen in recreational athletes. It is vital not to miss a hip fracture because the disorder carries a high morbidity.

Stress fractures occur at the femoral neck and maybe due to compression (usually affects inferior segment of femoral neck) or tension (affects superior aspect of femoral neck).
Diagnosis of hip fracture is necessary to avoid complications like avascular necrosis (AVN). This complication is more frequently seen in young adolescents and children. The cause is due to the marginal blood supply to the femoral head.

Classifying fractures

Hip fractures are classified as:

• Intracapsular (femoral head and neck fractures) or extracapsular trochanteric, intertrochanteric and subtrochanteric
• Geographic location (head, neck, trochanteric, intertrochanteric, and subtrochanteric)
• Degree of displacement (the higher the degree of displacement the worse is the prognosis)

In general intracapsular fractures have poor healing due to the thick capsule that surrounds the femoral head from adjacent nutrient vessels. Non-union and AVN are complications may occur. The morbidity and presentation of a hip fracture depends on location, degree of angulation and comminution, and overall physical health of the patient [1] [2] [3] [4] [5].

Hip fracture is quite common in the elderly population. The combination of poor eyesight, bone thinning and stroke can easily cause a fall that can result in a hip fracture. Once hip fracture is diagnosed, the treatment depends on the severity of injury, personal preferences, and patient comorbidity. For patients who undertake conservative means, this may mean prolonged physical therapy and use of crutches. For those who elect to undergo surgery, there is still a need for physical therapy to help regain mobility and strength. Weight bearing is initially restricted and then gradually increased as bone healing occurs. Patients with hip fractures are also prone to developing blood clots; hence all patients need to be on blood thinners.

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