Hip
Hip Fracture
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Hip Fracture
, Femur Fracture, Femoral Fracture
See Also
Femoral Neck Fracture
Femoral Shaft Fracture
Pelvic Fracture
Epidemiology
Osteoporosis
related
Age of onset
Most are over age 65 years
Mean age of Hip Fracture 80 years old
U.S.
Incidence
of Hip Fracture at age 65
Overall: 250,000 per year
Men: 4-5 per 1,000 (lifetime
Prevalence
10%)
Women: 8-10 per 1,000 (lifetime
Prevalence
20%)
Worldwide gender distribution of Hip Fracture
Men: 30%
Women: 70%
Morbidity and Mortality
Mortality 20% within 1 year Hip Fracture
Men: 31% mortality in 1 year
Women: 17% mortality in 1 year
ADL assistance needed in 50% of Hip Fractures
Long term care needed in 25% of Hip Fractures
References
Cooper (1992) Osteoporos Int 2:285-9 [PubMed]
Forsen (1999) Osteoporos Int 10:73-8 [PubMed]
Risk Factors
See
Osteoporosis Risk Factors
Age over 65 years
Female gender
Family History
of Hip Fracture
Past history of Hip Fracture
Female gender
Low socioeconomic status
Fall Risk
Deconditioning and decreased mobility
Precautions
Low mechanism
Trauma
may result in Hip Fracture, with comorbid
Osteoporosis
or malignancy
Types
Hip Fracture
Intracapsular
Fracture
:
Femoral Neck Fracture
Non-displaced
Femoral Neck Fracture
s are the most commonly initially missed
Fracture
s (9-10%)
Higher risk of AVN, nonunion, malunion or degeneration
Minimal cancellous bone, thin periosteum, poor blood supply
Subcapital Femur Fracture
(proximal neck
Fracture
)
Transcervical neck
Fracture
(mid-neck
Fracture
)
Extracapsular
Fracture
Intertrochanteric Fracture
Good blood supply and largely cancellous bone
Heals well with ORIF
Subtrochanteric Fracture
Often requires intramedullary rods or nails
Higher risk of impact failure
Femoral Shaft Fracture
(Femur Fracture)
Trochanteric
Fracture
(
Hip Avulsion Fracture
s in young, active patients)
Greater trochanteric
Fracture
or Lesser trochanteric
Fracture
Treated conservatively with non-weight bearing for 3-4 weeks (unless >1 cm displacement)
Stress Fracture
s
Hip Avulsion Fracture
Femoral Neck Stress Fracture
Femoral Shaft Stress Fracture
Inferior Pubic Ramus Stress Fracture
Symptoms
Severe
Hip Pain
Unable to ambulate or bear weight on affected limb (or painful gait)
Referred pain may occur
Knee Pain
Distal femur pain
Signs
Shortened limb on
Fracture
side
Deformity present in most cases (except in non-displaced
Fracture
)
Hip externally rotated and abducted
Tenderness to palpation over injured hip
Limited and painful range of motion (especially hip rotation)
Do not test ROM unless XRay normal
Resisted passive range of motion
Unable to perform active
Straight Leg Raise
Exam
Careful and repeated neurovascular exam (In addition to evaluation of
Fracture
specific signs as above)
Perform leg
Neurologic Exam
(sensory, motor,
Deep Tendon Reflex
es)
Perform vascular exam
Femoral pulse
Dorsalis pedis pulse
Posterior tibial pulse
Capillary Refill
and distal
Skin Color
ation
Imaging
Hip XRay
Usually identifies
Fracture
Do not perform frog leg view (risk of displacement of a non-displaced
Fracture
)
Hip XRay
may miss non-displaced Femoral Fractures
Consider MRI or CT for negative XRay with higher index of suspicion
Parker (1992) Arch Emerg Med 9(1): 23-7 [PubMed]
Hakkarinen (2012) J Emerg Med 43(20: 303-7 +PMID:22459594 [PubMed]
CT Hip
Test Sensitivity
: 87%
May miss
Trabecular Bone
injury or
Fracture
line associated marrow edema
However, may be useful in evaluation for concurrent
Pelvic Fracture
Ultrasound
Test Sensitivity
: 100% (operator dependent)
May identify joint effusion, hematoma or
Fracture
line
Hip MRI (T1-weighted)
Indicated for high suspicion despite normal XRay
Test Sensitivity
: 100%
Does not require delay after injury
Hip Bone Scan with Technetium Tc99m Polyphosphate
Test Sensitivity
: 98%
Delay scan at least 72 hours after time of injury
Differential Diagnosis
See
Hip Pain
Management
Acute, emergent management
ABC Management
Bilateral large bore intravenous lines (transfusion may be required)
Hare Traction splint in Femur Fracture (typically
Femoral Shaft Fracture
)
Traction has not been found to be beneficial in Hip Fracture or
Femoral Shaft Fracture
Does not decrease blood loss or reduce the
Fracture
May decrease pain on transport
May be helpful in pulseless extremity after
Femoral Shaft Fracture
References
Orman and Ramadorai in Herbert (2017) EM:Rap 17(6): 9-10
Handoll (2011) Cochrane Database Syst Rev (12): CD000168 [PubMed]
Consider regional
Nerve Block
in mid-shaft Femur Fracture
Femoral Nerve Block
Provides
Regional Anesthesia
covering proximal femur to the knee
Fascia Iliaca Block
Provides
Regional Anesthesia
of the proximal femur (anteromedial thigh) to the knee
Efficacy
Femoral Nerve Block
and
Fascia Iliaca Block
are equally effective at offering excellent
Anesthesia
Reavley (2014) Emerg Med J +PMID:25430915 [PubMed]
Management
Perioperative management
See specific
Fracture
management
Femoral Neck Fracture
Subtrochanteric Fracture
Intertrochanteric Fracture
Femoral Shaft Fracture
Early surgery within 24-48 hours lowers risk
Lowers 1 year mortality and
Pulmonary Embolism
risk (and also lowers
Pneumonia
and skin breakdown risk)
Early surgery allows for earlier mobilization, rehabilitation and functional recovery
Stabilize comorbidities within 72 hours if unstable
Thromboembolic Prevention
See
DVT Prevention in Perioperative Period
Start
LMWH
or similar agent within 12 hours of surgery (was extended from 4 hours due to bleeding risk)
Continue prophylaxis for 35 days (instead of prior 10-14 days)
Use intermittent pneumatic compression until patient is ambulatory
Prevention of infection
See
Surgical Antibiotic Prophylaxis
Protocol:
Staphylococcus aureus
prevention
No Beta-lactam allergy:
Cefazolin
1-2 g within 1 hour surgery and then every 8 hours for 24 hours
Beta-lactam allergy: Vancomyin 1 g within 1 hour surgery and then every 12 hours for 24 hours
Remove
Foley Catheter
within 24 hours of surgery
Prevention of
Delirium
Observe for medical causes
Electrolyte
abnormalities
Inadequate pain control
Occult infection
Avoid medications predisposing to
Delirium
Avoid
Polypharmacy
Avoid
Anticholinergic
s
Consider treatment if no cause identified
Low dose
Haloperidol
,
Risperidone
,
Olanzapine
Surgical care is appropriate even at end of life
Pain control is significantly improved after repair
Actual intraoperative risk is low
Complications are typically post-operative
Management
Rehabilitation
Evaluate for skilled nursing facility on day 1 post-op
Prefracture functionality poor (e.g. ADLs difficult)
Impaired cognitive function
Patient can perform therapy 2-3 hours daily
Protocol
Day 1: Quadriceps contractions, Gentle
Hip ROM
Day 2-3: Parallel bars
Day 3-5: Advance to weight bearing with walker/cane
Assistive Device
s
See
Canes
See
Walkers
Monitoring
Avascular necrosis
Increased risk after displaced Hip Fracture
Periodic
Hip XRay
surveillance
Consider Hip MRI if higher level of suspicion and
Hip XRay
non-diagnostic (especially if <6 months since surgery)
Prevention
See
Osteoporosis Prevention
See
Fall Prevention in the Elderly
Physical Activity
reduces Hip Fracture risk
Walking 4 hours per week or more (55% reduction)
Dose dependent effect: 6% reduction per MET-hour/week
Standing 10 hours per week also reduced risk
Feskanich (2002) JAMA 288:2300-6 [PubMed]
Prevention of recurrent Hip Fracture
Calcium
supplement 1000 mg orally daily
Vitamin D
800 IU daily (or more)
Bisphosphonates
References
Gurr in Marx (2002) Rosen's Emergency Med, p. 655-60
Huddleston (2001) Mayo Clin Proc 76:295-8 [PubMed]
Brunner (2003) Am Fam Physician 67(3):537-42 [PubMed]
LeBlanc (2014) Am Fam Physician 89(12): 945-51 [PubMed]
Rao (2006) Am Fam Physician 73(12):2195-202 [PubMed]
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