Hip

Hip Fracture

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Hip Fracture, Femur Fracture, Femoral Fracture

  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]
  • 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
  • Precautions
  1. Low mechanism Trauma may result in Hip Fracture, with comorbid Osteoporosis or malignancy
  • 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
  • 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
  • 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
  • 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. 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
  4. CT Hip
    1. Not recommended in most cases of suspected Hip Fracture
    2. May miss Trabecular Bone injury or Fracture line associated marrow edema
  • Differential Diagnosis
  1. See Hip Pain
  • 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]
  • 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
  • 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
  • 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)
  • 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