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Hip Fracture

Hip fractures are common  in elderly people with osteoporosis and in young people who are into sporting activities. If the diagnosis of hip fractures is missed, they carry a high morbidity and mortality. When treated promptly, the outcomes are reasonable in young people.


Presentation

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 accidentStress 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.
Unable to Stand
  • Symptoms of a hip fracture Symptoms of a hip fracture include: not being able to lift, move or rotate (turn) your leg being unable to stand or put weight on your leg, although in some cases this is possible a shorter leg, or your leg turning outwards[hct.nhs.uk]
  • […] to stand or put weight on your leg bruising and swelling around the hip area a shorter leg on the injured side your leg turning outwards more on the injured side A hip fracture won't necessarily cause bruising or prevent you from standing or walking.[nhsdirect.wales.nhs.uk]
  • Most patients are unable to stand. Always assess neurovascular status. Diagnosis of hip fracture is made with X-rays and physical exam. However since most patients need surgery, other blood work should be done and all abnormalities corrected.[symptoma.com]
  • Symptoms of a hip fracture Symptoms of a hip fracture after a fall may include: pain not being able to lift, move or rotate (turn) your leg being unable to stand or put weight on your leg bruising and swelling around the hip area a shorter leg on the[nhs.uk]
Difficulty Walking
  • walking Symptoms The symptoms of a hip fracture can vary from person to person, and they often resemble other medical conditions.[ucirvinehealth.org]
Pleuritic Pain
  • A 26-year-old man presented with dyspnea on exertion and pleuritic pain since the day before. Five weeks ago, he sustained multiple fractures at an accident--among others a complicated hip fracture needing screw fixation.[ncbi.nlm.nih.gov]
Cyanosis
  • Bradycardia, hypotension and cyanosis developed and quickly proceeded to a fatal cardiac arrest. Autopsy demonstrated diffuse pulmonary embolism of fat and thrombus.[ncbi.nlm.nih.gov]
Hip Pain
  • Traumatic hip pain is a commonly encountered complaint in the emergency department. Occasionally, initial radiographs fail to show a fracture. A delayed diagnosis can result in significant patient morbidity.[ncbi.nlm.nih.gov]
  • Frequently, they have hip pain. In some instances, however, patients with hip fracture may complain only of vague pain in their buttocks, knees, thighs, groin, or back.[ncbi.nlm.nih.gov]
  • During pregnancy, osteoporosis manifests itself with an insidious onset of hip pain and limp without any trauma or infective episode in clinical history.[ncbi.nlm.nih.gov]
  • We report the case of an 81-year-old woman with right hip pain after a fall.[ncbi.nlm.nih.gov]
  • Download a Free Guide on Hip Pain Treatment[my.clevelandclinic.org]
Low Back Pain
  • 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]
  • Signs of a problem may include: Hip pain and/or pain that can be felt in the knee Low back pain Inability to stand or walk Bruising or swelling Foot turned out at an odd angle, making the leg look shorter Consult your physician for a conclusive diagnosis[ucirvinehealth.org]
  • The following are the most common symptoms of a hip fracture: Hip pain or pain that you can feel in your knee Low back pain Inability to stand or walk Bruising and swelling Foot turned out at an odd angle, making your leg look shorter The symptoms of[urmc.rochester.edu]
Thigh Pain
  • Physicians should be aware of the possibility of a stress fracture when a patient has thigh pain after an intertrochanteric fracture has healed following repair with a short intramedullary nail.[ncbi.nlm.nih.gov]
  • pain and characteristic radiographic findings indicative of potential impending subtrochanteric insufficiency fracture.[ncbi.nlm.nih.gov]
  • The trial (113 participants) comparing the InterTan nail versus the PFNA II nail found very low quality evidence that more PFNA II group participants experienced thigh pain (3/47 versus 12/46; RR: 0.24, 95% CI 0.07 to 0.81).[ncbi.nlm.nih.gov]
  • All six participants reporting mid‐thigh pain in the static group had cortical hypertrophy. The other instance of cortical hypertrophy occurred in a participant of the dynamic group who did not report mid‐thigh pain.[doi.org]
Knee Pain
  • In rare cases, people have only thigh or knee pain. They may be able to walk. How is a hip fracture diagnosed? Doctors use X-rays to diagnose a broken hip.[myhealth.alberta.ca]
  • Hip fracture presenting as isolated knee pain. Ann Emerg Med . 1997;29:418–20. 24. Caviglia HA, Osorro PQ, Comando D. Classification and diagnosis of intra-capsular fractures of the proximal femur. Clin Orthop . June 2002(399):17–27. 25. Garden RS.[aafp.org]
  • Hip fracture presenting as isolated knee pain. Ann Emerg Med. 1997;29:418–20. 24. Caviglia HA, Osorro PQ, Comando D. Classification and diagnosis of intra-capsular fractures of the proximal femur. Clin Orthop. June 2002(399):17–27. 25. Garden RS.[aafp.org]
  • Messier, Baseline Balance and Functional Decline in Older Adults with Knee Pain: The Observational Arthritis Study in Seniors, Journal of the American Geriatrics Society, 51, 3, (331-339), (2003).[doi.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]
  • 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]
  • […] to walk The injured leg may look shorter than the other leg.[familydoctor.org]

Workup

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.

Treatment

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).

Prognosis

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%.

Etiology

Common causes and risk factors for hip fractures are:

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.

Epidemiology

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.

Sex distribution
Age distribution

Pathophysiology

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.

Prevention

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.

Summary

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].

Patient Information

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.

References

Article

  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.

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Last updated: 2019-07-11 22:23