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.

• Pain

  Older patients with dementia, who are unable to provide a self-report of pain post hip fracture in the ED are at risk for under-detection and under-treatment of acute pain. [ncbi.nlm.nih.gov]

  Pain Management Pain after an injury or surgery is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover faster. [web.archive.org]

• Swelling

  Among the cases, the main symptoms were severe pain or swelling with large-scale ecchymosis in the thigh or perineum. We used arterial duplex to diagnose pseudoaneurysm and treated the injury using interventional intravascular embolization. [ncbi.nlm.nih.gov]

  [G. fr. phlegma, inflammation] p. cerulea dolens thrombosis of the veins of a limb, with sudden severe pain with swelling, cyanosis, and edema of the part, followed by … Medical dictionary phlegmasia alba dolens — см. [translate.enacademic.com]

  Call 911 Call 911 right away if you have any of the following: Chest pain Shortness of breath When to call your healthcare provider Call your healthcare provider right away if you have any of the following: Hip pain gets worse Pain or swelling of your [fairview.org]

  Symptoms include: Severe pain in the groin area The injured leg looks shorter when you lie down Light-headedness or weakness Bruising and swelling Sometimes, with a mild hip fracture, you have only a little pain and can walk Doctors will: Do surgery to [msdmanuals.com]

• Surgical Procedure

  CONCLUSIONS: Hypoalbuminemia is a powerful independent risk factor for mortality following a surgical procedure for geriatric hip fracture. [ncbi.nlm.nih.gov]

  However, patients undergoing orthopaedic surgery may require distinct transfusion criteria since benefits and potential harm often vary considerably based on patient characteristics and surgical procedures. [doi.org]

• Fatigue

  The 2 subtypes are those that demonstrate a fatigue line less than 50% of the femoral neck width and those with a fatigue line greater than or equal to 50%. [emedicine.medscape.com]

  Fall Gaucher disease Bone cysts Osteoporosis Medications Sporting activities Sedentary lifestyle Alcohol use Dementia Stroke Poor eye sight Increase caffeine intake Other risk factors that may contribute to hip fractures in young people include muscle fatigue [symptoma.com]

  Any changes in your general health should also be reported, including: chest pain or shortness of breath numbness, weakness, change in vision or hearing fatigue, feeling cold, weight gain change in urination habits Read our metal-on-metal implant advice [nhs.uk]

• Inflammation

  An inflammation; more particularly, an inflammation of the internal organs. [1913 Webster] {Phlegmasia dolens} (d[=o] l[e^]nz) [NL.], milk leg. [1913 Webster] … The Collaborative International Dictionary of English Phlegmasia — Phleg*ma si*a, n. [translate.enacademic.com]

  KEYWORDS: Aging; Biomarker; Clinical outcome; Hip-fracture; Inflammation [ncbi.nlm.nih.gov]

  Learn more about Acetabular Labral Tear Arthritis Arthritis is condition that involves the breakdown of the protective cartilage around the joints, which results in pain, stiffness and inflammation. [emoryhealthcare.org]

  It’s also possible that chronic inflammation develops after a fracture, which could contribute to persistent frailty, the researchers suggested. The findings are based on a review of data including nearly 123,000 men and women. [cbsnews.com]

• Abdominal Pain

  pain or altered bowel habit). [doi.org]

• Ulcer

  Pain control, delirium, and pressure ulcer prevention are important inpatient care elements. Multidisciplinary models incorporating these care elements can decrease complications during inpatient stay. [ncbi.nlm.nih.gov]

  Pressure ulcers in elderly patients with hip fractures across the continuum of care. J Amer Geriatr Soc. 2009;57(5):863–70. View Article Google Scholar Vu T, Day L, Finch CF. [bmchealthservres.biomedcentral.com]

  Pressure ulcers - a pressure ulcer is an ulcerated area of skin caused by irritation and continuous pressure on part of your body. [patient.info]

• Skin Ulcer

  Discharge to RAC or to other facilities, Parkinsonism, skin ulceration and surgical site sepsis were all associated with increases of at least 30 per cent. Community patients who died had a shorter total LOS. [bmchealthservres.biomedcentral.com]

  There were inconclusive data for pressures sores (skin ulcers) and other complications. One trial reported three adverse effects (sensory disturbance and skin blisters) related to skin traction; all were minor. [doi.org]

• Fracture

  Computed tomography, however, is not as sensitive as MRI for seeing hidden hip fractures. Types of Fractures In general, there are three different types of hip fractures. The type of fracture depends on what area of the upper femur is involved. [web.archive.org]

  Top diagram is a single fracture line intertrochanteric fracture. Bottom diagram is a displaced, or multiple fracture line, intertrochanteric fracture. [emedicine.com]

  […] pre-fracture, within-fracture recovery phase and post-fracture (minimum of two years). [ncbi.nlm.nih.gov]

• Osteoporosis

  National Osteoporosis Foundation (NOF). Clinician’s Guide to Prevention and Treatment of Osteoporosis. Available at: www.nof.org/files/nof/public/content/file/344/upload/159.pdf‎. Accessed August 29, 2013. [web.archive.org]

  Physicians, especially orthopedists, who face with these fractures should be careful in terms of osteoporosis. [ncbi.nlm.nih.gov]

  Osteoporosis Menu What is osteoporosis? Osteoporosis ("porous bone") is a disease that weakens bones, putting them at greater risk for sudden and unexpected fractures. Osteoporosis results in an increased loss of bone mass and strength. [my.clevelandclinic.org]

  Signs and Symptoms Know Your Risk Secondary Osteoporosis Osteoporosis and Osteoarthritis Men and Osteoporosis Diagnosis Why Should I Get Tested My Next Steps Treatment Bisphosphonates Parathyroid Hormone Hormone Therapy Provincial Drug Coverage SERMs [osteoporosis.ca]

• Arthritis

  Learn more about Acetabular Labral Tear Arthritis Arthritis is condition that involves the breakdown of the protective cartilage around the joints, which results in pain, stiffness and inflammation. [emoryhealthcare.org]

  Degeneration of the Spine As we age, strain to the neck causes wear and tear arthritis. [web.archive.org]

  Aside from lower HRQOL, clinical factors, including increased body height, no experience with estrogen therapy, rheumatoid arthritis, use of walking aids, less weight-bearing exercise, and diuretics use, were significant risk factors for hip fracture [ncbi.nlm.nih.gov]

  A complete hip replacement may be considered if you: already have a condition affecting your joints, such as arthritis are very active have a reasonable life expectancy For people with an extracapsular fracture, some form of very strong plate and screw [hse.ie]

  septic arthritis, crystalloid arthritis, osteoid osteoma, osteitis pubis, acetabular tear Muscle, tendon, bursa Contusion, iliotibial band syndrome, muscle strain, tendonitis, trochanteric bursitis, iliopsoas bursitis, pyriformis syndrome, myositis [aafp.org]

• Hip Pain

  Diagnostic algorithms have been formulated to evaluate the patient with hip pain and negative initial radiographs. The auscultatory percussion technique can alert the physician of the presence or absence of an occult hip fracture. [ncbi.nlm.nih.gov]

  […] fracture can cause hip pain, swelling or bruising, and the hip may look deformed. [drugs.com]

• Back Pain

  It can also help with back pain. 3. When the back hurts, it can only rest for 1 day. 4. When lying down, place a pillow under the knee to prevent back pain [youtube.com]

  The pain na “gumagapang” does not necessarily means it is really bad. As I said most people with back pain recovers in time. [pinoytransplant.com]

  A cane that is too long or too short can cause low back pain, poor posture, and instability. The cane should be held on the side opposite the injured leg. [msdmanuals.com]

  It is important to alert your physician if you experience any of the following hip conditions: extreme hip pain that may radiate to the knee; an inability to walk without a device such as a crutch or cane; low back pain an inability to put any weight [my.clevelandclinic.org]

• Unable to Walk

  They are often unable to walk, and they may exhibit shortening and external rotation of the affected limb. Frequently, they have hip pain. [ncbi.nlm.nih.gov]

  You may be unable to walk. Your skin around the injury may also swell, get red or bruise. Some people with hip fractures can still walk. They might just complain of vague pain in their hips, butt, thighs, groin or back. [webmd.com]

  Unable to walk The injured leg may look shorter than the other leg. [familydoctor.org]

• Dizziness

  Ask your doctor or pharmacist to review your medicines to see if any might make you dizzy or sleepy. This should include prescription medicines and over-the counter medicines. [cdc.gov]

  Certain drugs or certain combinations of medications can make you dizzy and more prone to falling. [mayoclinic.org]

  Ask their doctor or pharmacist to review their medicines—both prescription and over-the counter—to identify medicines that may cause side effects or interactions such as dizziness or drowsiness. [web.archive.org]

• Irritability

  The incidence of adverse events while wearing hip protectors, including skin irritation, ranged from 0% to 5%. Adherence, particularly in the long term, was poor. [doi.org]

  RR 1.27 (95% CI 0.78 to 2.08); this is an absolute effect of one more person (95% CI 1 fewer to 5 more) per 1000 having a pelvic fracture when provided with hip protectors.The incidence of adverse events while wearing hip protectors, including skin irritation [ncbi.nlm.nih.gov]

  Pressure ulcers - a pressure ulcer is an ulcerated area of skin caused by irritation and continuous pressure on part of your body. [patient.info]

  […] joint impact activities should be avoided for six weeks postoperative depending on the surgical procedure is unloaded or partially loaded mobilize postoperatively crucial to the joint Avoid straight leg raise for 4 weeks postoperatively to not provoke irritation [physio-pedia.com]

• Vertigo

  The fracture may have been due to a medically related problem such as a syncopal episode, dehydration, overmedication, or vertigo. [emedicine.medscape.com]

  Elderly individuals are also predisposed to hip fractures due to many factors that can compromise proprioception and balance, including medications, vertigo, stroke, and peripheral neuropathy. [en.wikipedia.org]

• Hyperactivity

  Perhaps associated with hyperactive bone remodeling leading to an eventually weakened bony architecture, the efficacy of longer-term bisphosphonate use has come into question, especially in those with >5 years of therapy.This article describes a case [ncbi.nlm.nih.gov]

  While agitated, or hyperactive, delirium is more easily recognized, it is crucial to be aware of hypoactive delirium, as well. [mdedge.com]

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.

• Hemoglobin Decreased

  The use of intrafemoral device (vacuum drainage placed in the proximal femur) to decrease the intramedullary pressure during the prosthesis insertion can markedly decrease the incidence of fat embolism (from 93 to 13%). 24 In young patients, noncemented [anesthesiology.pubs.asahq.org]

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.

1. Shivji FS, Green VL, Forward DP. Anatomy, classification and treatment of intracapsular hip fractures. Br J Hosp Med (Lond). 2015 May;76(5):290-5
2. Yu JS. Easily Missed Fractures in the Lower Extremity. Radiol Clin North Am. 2015 Jul;53(4):737-755.
3. Butterwick D, Papp S, Gofton W, Liew A, Beaulé PE. Acetabular fractures in the elderly: evaluation and management. J Bone Joint Surg Am. 2015 May 6;97(9):758-68.
4. Grover A, LeBoff MS. o steoporosis: Prevention and Treatment. In: De Groot LJ, Beck-Peccoz P, Chrousos G, Dungan K, Grossman A, Hershman JM, Koch C, McLachlan R, New M, Rebar R, Singer F, Vinik A, Weickert MO, editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-.2013 Mar 22.
5. Fernandez MA, Griffin XL, Costa ML. Hip fracture surgery: improving the quality of the evidence base. Bone Joint J. 2015 Jul;97-B(7):875-9
6. Li S, Dai Z, Wu Q. Effect of coffee intake on hip fracture: a meta-analysis of prospective cohort studies. Nutr J. 2015 Apr 18;14:38
7. Stein MJ, Kang C, Ball V. Emergency department evaluation and treatment of acute hip and thigh pain. Emerg Med Clin North Am. 2015 May;33(2):327-43.
8. Diong J, Allen N, Sherrington C. Structured exercise improves mobility after hip fracture: a meta-analysis with meta-regression. Br J Sports Med. 2015 Jun 2. pii: bjsports-2014-094465
9. Hill KD, Hunter SW, Batchelor FA, Cavalheri V, Burton E. Individualized home-based exercise programs for older people to reduce falls and improve physical performance: A systematic review and meta-analysis. Maturitas. 2015 Apr 29. pii: S0378-5122(15)00642-8.