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: 250,000 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% 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
  5. References
    1. Cooper (1992) Osteoporos Int 2:285-9 [PubMed]
    2. Forsen (1999) Osteoporos Int 10:73-8 [PubMed]

III. Risk Factors

  1. See Osteoporosis Risk Factors
  2. Age over 65 years
  3. Female gender
  4. Family History of Hip Fracture
  5. Past history of Hip Fracture
  6. Female gender
  7. Low socioeconomic status
  8. Fall Risk
  9. Deconditioning and decreased mobility

IV. Precautions

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

V. Types: Hip Fracture

  1. Intracapsular Fracture: Femoral Neck Fracture
    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)
  2. Extracapsular Fracture
    1. Intertrochanteric Fracture
      1. Good blood supply and largely cancellous bone
      2. Heals well with ORIF
    2. Subtrochanteric Fracture
      1. Often requires intramedullary rods or nails
      2. Higher risk of impact failure
    3. Femoral Shaft Fracture (Femur Fracture)
  3. 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)
  4. Stress Fractures
    1. Hip Avulsion Fracture
    2. Femoral Neck Stress Fracture
    3. Femoral Shaft Stress Fracture
    4. Inferior Pubic Ramus Stress Fracture

VI. Symptoms

  1. Severe Hip Pain
  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

VII. 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. 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

VIII. 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

IX. Imaging

  1. Hip XRay
    1. Usually identifies Fracture
    2. Do not perform frog leg view (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

X. Differential Diagnosis

  1. See Hip Pain

XI. Management: Acute, emergent management

  1. ABC Management
  2. Bilateral large bore intravenous lines (transfusion may be required)
  3. 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]
  4. Consider regional Nerve Block in mid-shaft Femur Fracture
    1. Femoral Nerve Block
      1. Provides Regional Anesthesia covering proximal femur to the knee
    2. Fascia Iliaca Block
      1. Provides Regional Anesthesia of the proximal femur (anteromedial thigh) to the knee
    3. Efficacy
      1. Femoral Nerve Block and Fascia Iliaca Block are equally effective at offering excellent Anesthesia
      2. Reavley (2014) Emerg Med J +PMID:25430915 [PubMed]

XII. 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)
    2. Early surgery allows for earlier mobilization, rehabilitation and functional recovery
    3. Stabilize comorbidities within 72 hours if unstable
  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. Continue prophylaxis for 35 days (instead of prior 10-14 days)
    4. Use intermittent pneumatic compression until patient is ambulatory
  4. Prevention of infection
    1. See Surgical Antibiotic Prophylaxis
    2. Protocol: Staphylococcus aureus prevention
      1. No Beta-lactam allergy: Cefazolin 1-2 g within 1 hour 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. 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

XIII. 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

XIV. 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)

XV. 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 [PubMed]
  4. Prevention of recurrent Hip Fracture
    1. Calcium supplement 1000 mg orally daily
    2. Vitamin D 800 IU daily (or more)
    3. Bisphosphonates

XVI. 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]

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Related Studies

Ontology: Femoral Fractures (C0015802)

Definition (NCI) A traumatic or pathologic injury to the femur in which the continuity of the femur is broken.
Definition (MSH) Fractures of the femur.
Definition (CSP) breaks or rupture in bone situated between the hip and the knee, the femur.
Concepts Injury or Poisoning (T037)
MSH D005264
ICD10 S72 , S72.9
SnomedCT 208570005, 157232000, 157236002, 208595006, 263224006, 71620000
English Femoral Fracture, Femoral Fractures, Fractures, Femoral, Fracture, Femoral, femur fracture, Fracture of femur, NOS, Fracture femur, Fracture of femur, part unspecified, Thigh fracture NOS, Upper leg fracture NOS, Femoral fractures, FRACTURE FEMUR, Femur fracture, Femur fracture NOS, Fracture of upper leg NOS, Fracture of thigh NOS, Femoral Fractures [Disease/Finding], femoral fracture, thigh fracture, fracture of femur, Fracture;femur, femoral fractures, femur fractures, fracture of femur (diagnosis), Fracture of femur, NOS (disorder), Upper leg fracture NOS (disorder), Femoral fracture, Femur--Fractures, Fracture of Femur, Fracture of femur, Fracture of thigh, Fracture of femur (disorder), Fracture of upper leg, Fracture: femur, femur; fracture, fracture; femur, Fracture of thigh, NOS, Fracture of upper leg, NOS, Femur Fracture, fractured femur
Italian Frattura di femore, Frattura del femore, Frattura di femore NAS, Fratture del femore
Dutch femurfractuur NAO, Fractuur femur, femur; fractuur, fractuur; femur, Fractuur van femur, deel niet gespecificeerd, femurfractuur, Femurfracturen, Femurfractuur, Fracturen, femur-, Fractuur, femur-
French Fracture du fémur SAI, FRACTURE DU FEMUR, Fracture du fémur, Fractures du fémur, Fractures fémorales
German Oberschenkelfraktur NNB, Fraktur, Oberschenkel, Fraktur des Femurs, Teil nicht naeher bezeichnet, Fraktur des Femurs, Oberschenkelfraktur, Oberschenkelfrakturen
Portuguese Fractura do fémur NE, FRACTURA DO FEMUR, Fraturas Femorais, Fratura Femoral, Fractura do fémur, Fraturas do Fêmur
Spanish Fractura de fémur NEOM, fractura del muslo, fractura del fémur (trastorno), fractura del fémur, fractura de fémur, fractura de fémur (trastorno), fractura de fémur, SAI (trastorno), fractura de fémur, SAI, fractura de la porción superior de la pierna, SAI (trastorno), Fracture of femur, NOS, fractura de la porción superior de la pierna, SAI, Fracturas Femorales, Fractura Femoral, Fractura de fémur, fractura de la parte superior de la pierna, Fracturas del Fémur
Japanese 大腿骨骨折, 大腿骨骨折ＮＯＳ, ﾀﾞｲﾀｲｺﾂｺｯｾﾂ, ﾀﾞｲﾀｲｺﾂｺｯｾﾂNOS
Swedish Lårbensfrakturer
Czech femur - fraktury, Zlomenina femuru NOS, Zlomenina kosti stehenní, Zlomenina femuru
Finnish Reisiluun murtumat
Russian BEDRENNOI KOSTI PERELOMY, БЕДРЕННОЙ КОСТИ ПЕРЕЛОМЫ
Korean 넓적다리뼈의 골절, 상세불명의 넓적다리뼈 부분의 골절
Croatian FEMUR, FRAKTURE
Polish Złamania kości udowej
Hungarian Combcsonttörés, Femurtörés k.m.n., Femurtörés
Norwegian Lårbeinsbrudd, Lårbeinsfrakturer, Femurfrakturer, Lårbensbrudd, Lårbensfrakturer
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Hip Fractures (C0019557)

Definition (NCI) Traumatic or pathological injury to the hip in which the continuity of either the femoral head, femoral neck, intertrochanteric or subtrochanteric regions is broken. Symptoms include pain in the hip or groin, bruising and swelling in and around the hip area. The injured hip is turned outward and the leg appears shorter on that side.
Definition (NCI_CTCAE) A finding of traumatic injury to the hip in which the continuity of either the femoral head, femoral neck, intertrochanteric or subtrochanteric regions is broken.
Definition (CSP) breaks or rupture in bones or cartilages of the hip; for fractures of the femoral shaft below the subtrochanteric region use LIMB FRACTURE.
Definition (MSH) Fractures of the FEMUR HEAD; the FEMUR NECK; (FEMORAL NECK FRACTURES); the trochanters; or the inter- or subtrochanteric region. Excludes fractures of the acetabulum and fractures of the femoral shaft below the subtrochanteric region (FEMORAL FRACTURES).
Concepts Injury or Poisoning (T037)
MSH D006620
ICD10 S72.00
SnomedCT 263230006, 208520007, 208566002, 263225007, 5913000
LNC MTHU020794
English Fractures, Hip, Hip Fractures, Hip fracture NOS, fracture of hip, fracture of hip (diagnosis), Broken hip, Fractured hip, x-ray of hip: fracture (procedure), x-ray of hip: fracture, Fracture of hip NOS, Hip Fractures [Disease/Finding], broken hips, fractured hips, hip fracture, Fracture;hip, broken hip, hip fractures, Hip fracture NOS (disorder), FRACTURE, HIP, HIP FRACTURE, Hip fracture, Fracture of hip, fracture; hip, hip; fracture, Fracture of hip, NOS, Hip Fracture, fractured hip
Italian Frattura dell'anca, Anca fratturata, Fratture dell'anca
Dutch gebroken heup, fractuur; heup, heup; fractuur, heupbreuk, Fracturen, heup-, Fractuur, heup-, Heupfracturen, Heupfractuur
French Hanche cassée, Hanche fracturée, Fracture de la hanche, Fractures de la hanche, Fractures de l'extrémité supérieure du fémur, Fractures de la tête fémorale
German gebrochene Huefte, Fraktur der Huefte, Hüftfrakturen
Portuguese Anca fracturada, Anca partida, Fraturas Subtrocanterianas, Fratura Pertrocantérica, Fratura Trocantérica, Fraturas Pertrocantéricas, Fratura Subtrocantérica, Fraturas Trocanterianas, Fraturas Intertrocanterianas, Fratura Intertrocantérica, Fractura da anca, Fraturas do Quadril
Spanish Cadera rota, Cadera fracturada, fractura de la cadera, SAI (trastorno), fractura de la cadera, SAI, Fracturas Pertrocantéreas, Fractura Pertrocantérea, Fracturas Intertrocantéreas, Fracturas Pertrocantéricas, Fractura Pertrocanteriana, Fractura Subtrocanteriana, Fractura Trocanteriana, Fractura Trocantérea, Fracturas Subtrocantéricas, Fracturas Pertrocanterianas, Fracturas Trocantéricas, Fractura Intertrocanteriana, Fracturas Intertrocantéricas, fractura de cadera, Fractura de cadera, Fracturas de Cadera
Japanese 股関節骨折, 股関節部骨折, ｺｶﾝｾﾂｺｯｾﾂ, ｺｶﾝｾﾂﾌﾞｺｯｾﾂ
Swedish Höftfrakturer
Czech kyčel - fraktury, Zlomená kyčel, Zlomenina kyčle
Finnish Lonkkamurtumat
Russian NADVERTEL'NYE PERELOMY, VERTEL'NYE PERELOMY, MEZHVERTEL'NYE PERELOMY, BEDRA VERKHNEI TRETI PERELOMY, БЕДРА ВЕРХНЕЙ ТРЕТИ ПЕРЕЛОМЫ, ВЕРТЕЛЬНЫЕ ПЕРЕЛОМЫ, МЕЖВЕРТЕЛЬНЫЕ ПЕРЕЛОМЫ, НАДВЕРТЕЛЬНЫЕ ПЕРЕЛОМЫ
Croatian KUK, FRAKTURE
Polish Złamania biodra
Hungarian Törött csípő, Csípőtörés
Norwegian Hoftebrudd
Derived from the NIH UMLS (Unified Medical Language System)

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