Hip fracture

A hip fracture is a fracture in the proximal end of the femur (the long bone running through the
thigh), near the hip joint.

Classification
Many subtypes of fractures about the hip joint are colloquially known as 'hip fractures'. Although
a true hip fracture involves the joint, the following four proximal femur fractures are commonly
referred to as hip fractures. The differences between them are important because each is treated
differently.

 Femoral head fracture denotes a fracture involving the femoral head. This is usually the
result of high energy trauma and a dislocation of the hip joint often accompanies this
fracture.
 Femoral neck fracture (sometimes Neck of Femur (NOF), subcapital, or intracapsular
fracture) denotes a fracture adjacent to the femoral head in the neck between the head and
the greater trochanter. These fractures have a propensity to damage the blood supply to
the femoral head, potentially causing avascular necrosis. Widely used classifications were
established by Pauwels and Garden.
 Intertrochanteric fracture denotes a break in which the fracture line is between the
greater and lesser trochanter on the intertrochanteric line. It is the most common type of
'hip fracture' and prognosis for bony healing is generally good if the patient is otherwise
healthy.
 Subtrochanteric fracture actually involves the shaft of the femur immediately below the
lesser trochanter and may extend down the shaft of the femur.

Symptoms of Hip fracture

The list of signs and symptoms mentioned in various sources for Hip fracture includes the 3
symptoms listed below:

 Severe hip pain

 Hip swelling
 Inability to walk

Risk factors

 Osteoporosis. Hip fractures are one of the most serious complications of osteoporosis; in
fact a measure of success or failure of treatment of osteoporosis is the proportion of
patients who sustain a hip fracture. Vitamin D deficiency is a common problem causing
 osteoporosis, and supplementing with vitamin D and calcium has been shown to reduce
hip fractures by 43%.[2]
 Homocysteine, a toxic 'natural' amino acid linked to the cause of heart disease, stroke and
bone fractures, reduced by B-vitamins in this study[3], it reduced the amount of hip
fractures by 80% after 2 years. This was despite no differences in bone density and in the
number of falls between the vitamin and the placebo groups.
 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.
 Benign or malignant primary bone tumours 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.

Diagnosis
 X-rays of the affected hip usually make the diagnosis obvious; AP and lateral views
should be obtained.
 In situations where a hip fracture is suspected but is not obvious on x-ray, a CT scan with
3D reconstruction may be helpful. MRI has gained importance in the diagnosis of occult
fractures of the femoral neck. Within 24 hours changes can be seen on MRI. Bone scan is
less useful because it may take up to 1 week to demonstrate changes especially in the
elderly.
 As the patients most often require an operation, full pre-operative general investigation is
required. This would normally include blood tests, ECG and chest x-ray.
 Hip fractures are treated in one of two ways: Traction or orthopedic surgery.

Management
 Most hip fractures are treated by orthopedic surgery, which involves implanting an
orthosis. The surgery is a major stress on the patient, particularly in older people. Pain is
significant, forcing the patient to remain immobilized. Since prolonged immobilization
can be more of a health risk than the surgery itself, post-op patients are encouraged to
become mobile as soon as possible, often with the assistance of physical
therapy(physiotherapy).
 If operative treatment is refused or the risks of surgery are considered to be too high the
main emphasis of treatment is on pain relief. Skeletal traction may be considered for long
term treatment. Aggressive chest physiotherapy is needed to reduce the risk of
pneumonia and skilled nursing to try to avoid pressure sores and DVT/pulmonary
embolism Most patients will be bedbound for several months. Non-operative treatment is
no longer an alternative in developed countries with modern health carecitation needed.
 For low-grade fractures (Garden types 1 and 2), standard treatment is fixation of the
fracture in situ with screws or a sliding screw/plate device. This treatment can also be
offered for displaced fractures after the fracture has been reduced.
  In elderly patients with displaced fractures many surgeons prefer to undertake a
Hemiarthroplasty, replacing the broken part of the bone with a metal implant. The
advantage is that the patient can mobilize without having to wait for healing.
 An intertrochanteric fracture, below the neck of the femur, has a good chance of healing.
Treatment involves stabilizing the fracture with a lag screw and plate device to hold the
two fragments in position. A large screw is inserted into the femoral head, crossing
through the fracture; the plate runs down the shaft of the femur, with smaller screws
securing it in place.
 The fracture typically takes 3–6 months to heal. As it is only common in elderly, removal
of the dynamic hip screw is usually not recommended to avoid unnecessary risk of
second operation and the increased risk of re-fracture after implant removal. The most
common cause for hip fractures in the elderly is osteoporosis; if this is the case, treatment
of the osteoporosis can well reduce the risk of further fracture. Only young patients tend
to consider having it removed; the implant may function as a stress riser, increasing the
risk of a break if another accident occurs.

Hip replacement

 Main article: Hip replacement

 In some hip fractures, the doctor completely removes the head and neck of the femur, and
replaces it with a prosthetic implant.

Complications
 Nonunion, failure of the fracture to heal, is common (20%) in fractures of the neck of the
femur, but much more rare with other types of hip fracture. The rate of nonunion is
increased if the fracture is not treated surgically to immobilize the bone fragments.
 Malunion, healing of the fracture in a distorted position, is very common. The thigh
muscles tend to pull on the bone fragments, causing them to overlap and reunite
incorrectly. Shortening, varus deformity, valgus deformity, and rotational malunion all
occur often because the fracture may be unstable and collapse before it heals. This may
not be as much of a concern in patients with limited independence and mobility.
 Avascular necrosis of the femoral head occurs frequently (20%) in fractures of the neck
of femur, because the blood supply is interrupted. It is rare after intertrochanteric
fractures.
 Hip fractures rarely results in neurological or vascular injury.

Surgical

 Deep or superficial wound infection has an approximate incidence of 2%. It is a serious

problem as superficial infection may lead to deep infection. This may cause infection of
the healing bone and contamination of the implants. It is difficult to eliminate infection in
the presence of metal foreign bodies such as implants. Bacteria inside the implants are
inaccessible to the body's defence system and to antibiotics. The management is to
 attempt to suppress the infection with drainage and antibiotics until the bone is healed.
Then the implant should be removed, following which the infection may clear up.
 Implant failure may occur; the metal screws and plate can break, back out, or cut out
superiorly and enter the joint. This occurs either through inaccurate implant placement or
if the fixation does not hold in weak and brittle bone. In the event of failure, the surgery
may be redone, or changed to a total hip replacement.
 Mal-positioning: The fracture can be fixed and subsequently heal in an incorrect position;
especially rotation. This may not be a severe problem or may require subsequent
osteotomy surgery for correction.

Medical

 Many of patients are unwell before breaking a hip; it is not uncommon for the break to
have been caused by a fall due to some illness, especially in the elderly. Nevertheless, the
stress of the injury, and a likely surgery, does increase the risk of medical illness
including heart attack, stroke, and chest infection.
 Blood clots may result. Deep venous thrombosis (DVT) is when the blood in the leg
veins clots and causes pain and swelling. This is very common after hip fracture as the
circulation is stagnant and the blood is hypercoagulable as a response to injury. DVT can
occur without causing symptoms. A pulmonary embolism (PE) occurs when clotted
blood from a DVT comes loose from the leg veins and passes up to the lungs. Circulation
to parts of the lungs are cut off which can be very dangerous. Fatal PE may have an
incidence of 2% after hip fracture and may contribute to illness and mortality in other
cases.
 Mental confusion is extremely common following a hip fracture. It usually clears
completely, but the disorienting experience of pain, immobility, loss of independence,
moving to a strange place, surgery, and drugs combine to cause delirium or accentuate
pre-existing dementia.
 Urinary tract infection (UTI) can occur. Patients are immobilized and in bed for many
days; they are frequently catheterised, commonly causing infection.
 Prolonged immobilization and difficulty moving make it hard to avoid pressure sores on
the sacrum and heels of patients with hip fractures. Whenever possible, early
mobilization is advocated; otherwise, alternating pressure mattresses should be used.