Hip Fracture and Treatment
Hip fractures are a significant cause of debilitating injury which occur especially in older people. These may occur from minor trauma such as a simple fall or twisting injury. Hip fractures may also occur in higher energy injuries such as motor vehicle accidents or falls from bicycles or result from sports or traumatic injury. In the older individual, hip fracture is often associated with poor nutritional intake, osteoporosis, limited strength, and poor balance. Associated urinary tract infection or other general medical condition can result in dizziness and a fall which results in hip fracture.
Symptoms are usually obvious with an inability to ambulate and groin pain. With displaced fractures, limb length has been altered and the affected leg often lies in external rotation relative to the normal side. The severity of fracture is often related to the level of symptoms. With non-displaced, stable fractures, patients may be able to ambulate with minor groin discomfort with a cane or crutch or walker.
Hip fracture is generally diagnosed by plain x-ray. In situations where x-ray itself is not definitive, CT or MRI will often show a fracture and help to demonstrate the fracture geometry and aid in a plan of treatment. With a known hip fracture, a medical workup is helpful for vitamin D deficiency and ultimately bone density is helpful in understanding the risk of further fracture risk.
Fracture treatment depends on fracture anatomy and stability. Hip fractures can be non-displaced or displaced. Occasionally, non-displaced fractures can be treated without surgical measures, monitoring fracture healing with simple office x-ray at intervals. In most cases, it is safest to stabilize the fracture to avoid ultimate displacement and a more problematic situation.
Hip fractures generally are described at 3 anatomic locations: 1) femoral neck, 2) intertrochanteric, 3) subtrochanteric. Femoral neck fractures occur just below the ball of the hip joint. Intertrochanteric hip fractures occur between the 2 prominences at the site of muscular attachment sites of the hip. Subtrochanteric hip fracture occurs below the hip flexor attachment to the lesser trochanter and is essentially a high femoral shaft fracture.
Femoral neck fractures can be treated with percutaneous screw fixation when not displaced or if reduction can be obtained quickly in a young patient without coexistent arthritis. In situations where displacement is severe or arthritis is present, especially with osteoporosis, hemiarthroplasty is indicated or total hip with associated severe osteoarthritis.
Intertrochanteric hip fractures can be treated with a compression screw and side plate with stable geometry at the fracture site. In recent years, intramedullary nail with compression screw fixation has become more popular. This was initially introduced as a means to more safely stabilize subtrochanteric hip fractures but has become more popular for both intertrochanteric and subtrochanteric hip fracture.
Surgical intervention is best carried out as quickly as possible following hip fracture to lower the risk of complications. In general, patients who have fracture fixation and are out of bed the following day do very well. Stabilizing any medical problem prior to surgical intervention is important to minimize the risk of complication. The decision for surgical intervention should not be taken lightly, however, hip fracture patients, in general, do very poorly without fixation which will allow a rapid return to ambulation. The fixation method and treatment depend on multiple factors which depend on the patient, age, and level of activity prior to the injury. These decisions are best made between the surgeon and the family prior to surgery.
In most cases, hip fracture patients do well. The patient generally loses at least 1 unit of blood prior to surgery from bleeding at the fracture site itself. This may require a blood transfusion. There is a risk of deep venous thrombosis which is treated with anticoagulation following surgery. The risk of surgical site infection is very low but real. Urinary tract infection should be treated prior to surgery when present and avoided after surgery by quickly removing urinary catheters. Sound fracture fixation is generally obtained, however, there is a small risk of loss of fixation as a consequence of the fracture geometry and bone quality.
Rehabilitation following hip fracture generally requires partial weight-bearing unless hip replacement or hemiarthroplasty is performed. In this case, full weight-bearing is generally allowed. The ability to weight-bear only partially may help determine the surgical treatment. Young patients may be able to return home immediately with assistance at home. Older patients, especially with limited help at home, may require temporary nursing home placement. This is decided on an individual basis depending on patient, family and fracture characteristics.
Hip fracture is a serious injury which can result in limited ambulatory tolerance and difficulty returning home without appropriate treatment. Surgical treatment is generally required and when performed quickly, limits the risk of complications.
Compliments of Sports Medicine and Orthopaedics, East Providence Rhode Island