Hip Fracture

Aka: Hip Fracture, Femur Fracture, Femoral Fracture

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II. Epidemiology: Osteoporosis Related

  1. Age of onset
    1. Most are over age 65 years
    2. Mean age of Hip Fracture 80 years old
  2. U.S. Incidence of Hip Fracture at age 65
    1. Overall: 300,000 per year
    2. Men: 4-5 per 1,000 (lifetime Prevalence 10%)
    3. Women: 8-10 per 1,000 (lifetime Prevalence 20%)
  3. Worldwide gender distribution of Hip Fracture
    1. Men: 30%
    2. Women: 70%
  4. Morbidity and Mortality
    1. Mortality 20-30% 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 16 to 25% of Hip Fractures
    4. Bedridden longterm in 11% of Hip Fractures
    5. Walking Aid needed in 80% of Hip Fractures
  5. References
    1. Cooper (1992) Osteoporos Int 2:285-9 [PubMed]
    2. Forsen (1999) Osteoporos Int 10:73-8 [PubMed]

III. Risk Factors: Non-modifiable

  1. See Osteoporosis Risk Factors
  2. Age over 65 years
    1. Women over age 85 years have a 10 fold increased risk over women age 60 to 70 years
  3. Female gender
  4. Family History of Hip Fracture
  5. Past history of Hip Fracture or any Fracture
  6. Female gender
  7. Lower socioeconomic status
  8. Fall Risk
  9. Deconditioning and decreased mobility
  10. Metabolic bone disease
  11. Malignancy involving bone (pathologic Fracture)

IV. Risk Factors: Modifiable

  1. Low Body Mass Index (BMI) <18.5 kg/m2
  2. Osteoporosis with Low Bone Mineral Density (BMD T-Score < -2.5)
    1. Present in 50% of Hip Fractures
  3. Physical inactivity (minimal weight bearing)
    1. Doubles Hip Fracture risk
  4. Low Vitamin D levels
  5. Medications lowering Bone Mineral Density
    1. Corticosteroids
      1. See Corticosteroid Associated Osteoporosis
    2. Levothyroxine
    3. Loop Diuretics
    4. Proton Pump Inhibitors
  6. Medications increasing Fall Risk
    1. See Fall Risk Factors
  7. Lifestyle
    1. Moderate to high Alcohol use (>1 oz Alcohol or >27 grams Alcohol per day)
    2. Tobacco Abuse
    3. Excessive Caffeine intake (>3 cups of coffee daily)

V. Precautions

  1. Low mechanism Trauma may result in Hip Fracture, with comorbid Osteoporosis or malignancy

VI. Types: Hip Fracture

  1. Images
    1. hipFractureRegions.jpg
  2. Hip Fractures account for 87% of Femur Fractures
  3. Intracapsular Fracture: Femoral Neck Fracture (45 to 53% of all Hip Fractures)
    1. Non-displaced Femoral Neck Fractures are the most commonly initially missed Fractures (9-10%)
    2. Higher risk of AVN, nonunion, malunion or degeneration
      1. Minimal cancellous bone, thin periosteum, poor blood supply
    3. Subcapital Femur Fracture (proximal neck Fracture)
    4. Transcervical neck Fracture (mid-neck Fracture)
  4. Extracapsular Fracture
    1. Intertrochanteric Fracture (38 to 50% of all Hip Fractures)
      1. Good blood supply and largely cancellous bone
      2. Heals well with ORIF
    2. Subtrochanteric Fracture (3% of all Hip Fractures)
      1. Often requires intramedullary rods or nails
      2. Higher risk of impact failure
    3. Femoral Shaft Fracture (or lower Femur Fracture, 5% of all Hip Fractures)
  5. Trochanteric Fracture (Hip Avulsion Fractures in young, active patients)
    1. Greater trochanteric Fracture or Lesser trochanteric Fracture
    2. Treated conservatively with non-weight bearing for 3-4 weeks (unless >1 cm displacement)
  6. Stress Fractures (frequently missed cause of anterior hip or Groin Pain)
    1. Hip Avulsion Fracture
    2. Femoral Neck Stress Fracture
    3. Femoral Shaft Stress Fracture
    4. Inferior Pubic Ramus Stress Fracture

VII. Symptoms

  1. Severe Hip Pain
    1. Pain is common at anterior groin
  2. Unable to ambulate or bear weight on affected limb (or painful gait)
  3. Referred pain may occur
    1. Knee Pain
    2. Distal femur pain
    3. Thigh or buttock

VIII. Signs

  1. Shortened limb on Fracture side
  2. Deformity present in most cases (except in non-displaced Fracture)
  3. Hip externally rotated and abducted
  4. Tenderness to palpation over injured hip
  5. Ecchymosis is a late finding
  6. Limited and painful range of motion (especially hip rotation)
    1. Do not test ROM unless XRay normal
    2. Resisted passive range of motion
    3. Unable to perform active Straight Leg Raise
    4. Pain with Log Roll maneuver (gentle internal and external rotation of lower leg and thigh)

IX. Exam

  1. Careful and repeated neurovascular exam (In addition to evaluation of Fracture specific signs as above)
  2. Perform leg Neurologic Exam (sensory, motor, Deep Tendon Reflexes)
  3. Perform vascular exam
    1. Femoral pulse
    2. Dorsalis pedis pulse
    3. Posterior tibial pulse
    4. Capillary Refill and distal Skin Coloration

X. Imaging

  1. Hip XRay
    1. Cross Table lateral and anteroposterior views
      1. Usually identifies Fracture
    2. Do not perform frog leg view
      1. Risk of displacement of a non-displaced Fracture
    3. Hip XRay may miss non-displaced Femoral Fractures
      1. Consider MRI or CT for negative XRay with higher index of suspicion
      2. Parker (1992) Arch Emerg Med 9(1): 23-7 [PubMed]
      3. Hakkarinen (2012) J Emerg Med 43(20: 303-7 +PMID:22459594 [PubMed]
  2. CT Hip
    1. Test Sensitivity: 87%
    2. May miss Trabecular Bone injury or Fracture line associated marrow edema
    3. However, may be useful in evaluation for concurrent Pelvic Fracture
  3. Ultrasound
    1. Test Sensitivity: 100% (operator dependent)
    2. May identify joint effusion, Hematoma or Fracture line
  4. Hip MRI (T1-weighted)
    1. Indicated for high suspicion despite normal XRay
    2. Test Sensitivity: 100%
    3. Does not require delay after injury
  5. Hip Bone Scan with Technetium Tc99m Polyphosphate
    1. Test Sensitivity: 98%
    2. Delay scan at least 72 hours after time of injury

XI. Differential Diagnosis

  1. See Hip Pain

XII. Management: Acute, emergent management

  1. ABC Management
  2. Bilateral large bore intravenous lines (transfusion may be required)
  3. Strongly consider regional Nerve Block in hip and Femur Fractures
    1. PENG Block (preferred)
      1. Provides Regional Anesthesia to most of the hip and femur
      2. Does not block the posteromedial hip capsule (innervated by sciatic nerve)
    2. Fascia Iliaca Block
      1. Provides Regional Anesthesia of the proximal femur (anteromedial thigh) to the knee
    3. Femoral Nerve Block
      1. Provides Regional Anesthesia covering proximal femur to the knee
    4. Efficacy
      1. Hip Peripheral Nerve Blocks are safe with a very low Incidence of nerve injury (0.03%) and LAST Reaction (0.01%)
      2. Blocks improve pain management, decreases Opioid use, Delirium, and other complications (e.g. Pneumonia)
        1. Guay (2020) Cochrane Database Syst Rev 11(11):CD001159 +PMID: 33238043 [PubMed]
        2. Simic (2022) Acta Clin Croat 61(Suppl 1):78-83 +PMID: 36304813 [PubMed]
      3. Femoral Nerve Block and Fascia Iliaca Block are equally effective at offering excellent Anesthesia
        1. Reavley (2014) Emerg Med J +PMID:25430915 [PubMed]
  4. Hare Traction Splint in Femur Fracture (typically Femoral Shaft Fracture)
    1. erTraumaFemurTraction.png
    2. Traction has not been found to be beneficial in Hip Fracture or Femoral Shaft Fracture
      1. Does not decrease blood loss or reduce the Fracture
      2. May decrease pain on transport
      3. May be helpful in pulseless extremity after Femoral Shaft Fracture
    3. References
      1. Orman and Ramadorai in Herbert (2017) EM:Rap 17(6): 9-10
      2. Handoll (2011) Cochrane Database Syst Rev (12): CD000168 [PubMed]

XIII. Management: Perioperative management

  1. See specific Fracture management
    1. Femoral Neck Fracture
    2. Subtrochanteric Fracture
    3. Intertrochanteric Fracture
    4. Femoral Shaft Fracture
  2. Early surgery within 24-48 hours lowers risk
    1. Lowers 1 year mortality and Pulmonary Embolism risk (and also lowers Pneumonia and skin breakdown risk)
      1. Even a delay >24 hours increases mortality at 30 days
      2. Pincus (2017) JAMA 318(20): 1994-2003 [PubMed]
    2. Early surgery allows for earlier mobilization, rehabilitation and functional recovery
    3. Stabilize comorbidities within 72 hours if unstable
    4. Accelerated surgery time (<6 hours) decreases complications, mobilization time and hospital length of stay
      1. (2020) Lancet 395(10225): 698-708 [PubMed]
  3. Thromboembolic Prevention
    1. See DVT Prevention in Perioperative Period
    2. Start LMWH or similar agent within 12 hours of surgery (was extended from 4 hours due to bleeding risk)
    3. Use intermittent pneumatic compression until patient is ambulatory
    4. Continue prophylaxis for 35 days (instead of prior 10-14 days)
    5. Aspirin has been shown in some studies to offer equivalent efficacy to Anticoagulants
      1. Hu (2021) J Orthop Surg Res 16(1): 135 [PubMed]
      2. Matharu (2020) JAMA Intern Med 180(3): 376-84 [PubMed]
  4. Prevention of infection
    1. See Surgical Antibiotic Prophylaxis
    2. Protocol: Staphylococcus aureus prevention
      1. No Beta-lactam allergy: Cefazolin 1-2 g, one to two hours before surgery and then every 8 hours for 24 hours
      2. Beta-lactam allergy: Vancomyin 1 g within 1 hour surgery and then every 12 hours for 24 hours
    3. Remove Foley Catheter within 24 hours of surgery
  5. Hemorrhage Management
    1. Blood Transfusion (pRBC) indicated in hemolobin <8 g/dl
  6. 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. Use Regional Anesthesia in place of Opioids (see above)
    3. Consider treatment if no cause identified
      1. Low dose Haloperidol, Risperidone, Olanzapine
  7. 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
    3. Nonoperative Indications
      1. Non-operative care (in place of surgical repair) increases mortality 4 fold at one year
      2. May consider nonoperative care in non-ambulatory, severely debilitated or end-of-life

XIV. Management: Rehabilitation

  1. Early rehabilitation and weight bearing started in first 24 hours after surgery improves mobility outcomes
  2. 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
  3. 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
  4. Assistive Devices
    1. See Canes
    2. See Walkers

XV. Monitoring

  1. Avascular necrosis
    1. Increased risk after displaced Hip Fracture
    2. Periodic Hip XRay surveillance
      1. Consider Hip MRI if higher level of suspicion and Hip XRay non-diagnostic (especially if <6 months since surgery)

XVI. Prevention

  1. See Osteoporosis Prevention
  2. See Fall Prevention in the Elderly
  3. Physical Activity reduces Hip Fracture risk
    1. Exercise program to include low to moderate aerobic Exercise, Resistance Training, proprioception training
      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 [PubMed]
      5. Guirguis (2018) JAMA 319(16): 1705-16 [PubMed]
    2. Tai Chi may reduce risk of fall with injury by 50%
      1. Lomas-Vega (2017) J Am Geriatr Soc 65(9): 2037-43 [PubMed]
  4. Prevention of recurrent Hip Fracture
    1. Calcium supplement 1000 mg orally daily
    2. Vitamin D 800 IU daily supplementation
      1. Also obtain Vitamin D Levels and initiate full Vitamin D Replacement if <10 ng/ml
    3. Bisphosphonates
    4. Additional management if low Bone Mineral Density at time of Hip Fracture (e.g. Parathyroid analogs, RANKL inhibitors)

XVII. References

  1. Gurr in Marx (2002) Rosen's Emergency Med, p. 655-60
  2. Huddleston (2001) Mayo Clin Proc 76:295-8 [PubMed]
  3. Brunner (2003) Am Fam Physician 67(3):537-42 [PubMed]
  4. LeBlanc (2014) Am Fam Physician 89(12): 945-51 [PubMed]
  5. Rao (2006) Am Fam Physician 73(12):2195-202 [PubMed]
  6. Schroeder (2022) Am Fam Physician 106(6): 675-83 [PubMed]

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