Orthopedics Book

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Hip Fracture

Aka: Hip Fracture, Femur Fracture
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  1. See Also
    1. Femoral Neck Fracture
    2. Femoral Shaft Fracture
    3. Pelvic Fracture
  2. Epidemiology: Osteoporosis related
    1. U.S. Incidence of Hip Fracture at age 65
      1. Overall: 250,000 per year
      2. Men: 4-5 per 1,000
      3. Women: 8-10 per 1,000
    2. Worldwide gender distribution of Hip Fracture
      1. Men: 30%
      2. Women: 70%
    3. Morbidity and Mortality
      1. Mortality 20% within 1 year Hip Fracture
        1. Men: 31% mortality in 1 year
        2. Women: 17% mortality in 1 year
      2. ADL assistance needed in 50% of Hip Fractures
      3. Long term care needed in 25% of Hip Fractures
    4. References
      1. Cooper (1992) Osteoporos Int 2:285-9
      2. Forsen (1999) Osteoporos Int 10:73-8
  3. Risk Factors
    1. Osteoporosis
  4. Hip Fracture Types
    1. Intracapsular Fracture: Femoral Neck Fracture
      1. Subcapital Femur Fracture (proximal neck Fracture)
      2. Transcervical neck Fracture (mid-neck Fracture)
    2. Extracapsular Fracture
      1. Intertrochanteric Fracture
      2. Subtrochanteric Fracture
      3. Femoral Shaft Fracture
      4. Trochanteric Fracture (Hip Avulsion Fracture)
        1. Greater trochanteric Fracture
        2. Lesser trochanteric Fracture
    3. Stress Fractures
      1. Hip Avulsion Fracture
      2. Femoral Neck Stress Fracture
      3. Femoral Shaft Stress Fracture
      4. Inferior Pubic Ramus Stress Fracture
  5. Symptoms
    1. Severe Hip Pain
    2. Unable to ambulate (or painful gait)
  6. Signs
    1. Shortened limb on Fracture side
    2. Hip externally rotated and abducted
    3. Tenderness to palpation over injured hip
    4. Limited range of motion
      1. Do not test ROM unless XRay normal
      2. Resisted passive range of motion
  7. Imaging
    1. Hip Xray
      1. Usually identifies Fracture
    2. Hip MRI (T1-weighted)
      1. Indicated for high suspicion despite normal XRay
      2. Test Sensitivity: 100%
      3. Does not require delay after injury
    3. Hip Bone Scan with Technetium Tc99m Polyphosphate
      1. Test Sensitivity: 98%
      2. Delay scan at least 72 hours after time of injury
  8. Differential Diagnosis
    1. See Hip Pain
  9. Management: General
    1. See specific Fracture management
      1. Femoral Neck Fracture
      2. Subtrochanteric Fracture
      3. Intertrochanteric Fracture
      4. Femoral Shaft Fracture
    2. Early surgery within 48 hours lowers risk
      1. Lowers 1 year mortality and Pulmonary Embolism risk
      2. Stabilize comorbidities within 72 hours if unstable
    3. Thromboembolic Prevention
      1. See DVT Prevention in Perioperative Period
    4. Prevention of infection
      1. See Surgical Antibiotic Prophylaxis
      2. Remove Foley Catheter within 24 hours of surgery
    5. Prevention of Delirium
      1. Observe for medical causes
        1. Electrolyte abnormalities
        2. Inadequate pain control
        3. Occult infection
      2. Avoid medications predisposing to Delirium
        1. Avoid Polypharmacy
        2. Avoid Anticholinergics
      3. Consider treatment if no cause identified
        1. Low dose Haloperidol, Risperidone, Olanzapine
    6. Surgical care is appropriate even at end of life
      1. Pain control is significantly improved after repair
      2. Actual intraoperative risk is low
        1. Complications are typically post-operative
  10. Management: Rehabilitation
    1. Evaluate for skilled nursing facility on day 1 post-op
      1. Prefracture functionality poor (e.g. ADLs difficult)
      2. Impaired cognitive function
      3. Patient can perform therapy 2-3 hours daily
    2. Protocol
      1. Day 1: Quadriceps contractions, Gentle hip ROM
      2. Day 2-3: Parallel bars
      3. Day 3-5: Advance to weight bearing with walker/cane
    3. Assistive Devices
      1. See Canes
      2. See Walkers
  11. Prevention
    1. See Osteoporosis Prevention
    2. See Fall Prevention in the Elderly
    3. Physical Activity reduces Hip Fracture risk
      1. Walking 4 hours per week or more (55% reduction)
      2. Dose dependent effect: 6% reduction per MET-hour/week
      3. Standing 10 hours per week also reduced risk
      4. Feskanich (2002) JAMA 288:2300-6
  12. References
    1. Gurr in Marx (2002) Rosen's Emergency Med, p. 655-60
    2. Huddleston (2001) Mayo Clin Proc 76:295-8
    3. Brunner (2003) Am Fam Physician 67(3):537-42
    4. Rao (2006) Am Fam Physician 73(12):2195-202

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