Hip fracture
Hip fracture | |
---|---|
Other names | Proximal femur fracture; Opioids, nerve block[1] |
Prognosis | ~20% one year risk of death (older people)[3][1] |
Frequency | ~15% of women at some point[1] |
A hip fracture is a break that occurs in the upper part of the femur (thigh bone), at the femoral neck or (rarely) the femoral head.[2] Symptoms may include pain around the hip, particularly with movement, and shortening of the leg.[2] Usually the person cannot walk.[3]
A hip fracture is usually a femoral neck fracture. Such fractures most often occur as a result of a fall.
Pain management may involve
About 15% of women break their hip at some point in life;[1] women are more often affected than men.[1] Hip fractures become more common with age.[1] The risk of death in the year following a fracture is about 20% in older people.[1][3]
Signs and symptoms
The classic
Complications
Nonunion, failure of the fracture to heal, is common in fractures of the neck of the femur, but much more rare with other types of hip fracture. Avascular necrosis of the femoral head occurs frequently (20%) in intracapsular hip fractures, because the blood supply is interrupted.[5]
Malunion, healing of the fracture in a distorted position, is very common. The thigh muscles tend to pull on the bone fragments, causing them to overlap and reunite incorrectly. Shortening, varus deformity, valgus deformity, and rotational malunion all occur often because the fracture may be unstable and collapse before it heals. This may not be as much of a concern in patients with limited independence and mobility.[citation needed]
Hip fractures rarely result in
Medical
Many people are unwell before breaking a hip; it is common for the break to have been caused by a
Hip fracture patients are at considerable risk for
Urinary tract infection (UTI) can occur. Patients are immobilized and in bed for many days; they are frequently catheterised, commonly causing infection.
Prolonged immobilization and difficulty moving make it hard to avoid
Risk factors
Hip fracture following a fall is likely to be a pathological fracture. The most common causes of weakness in bone are:[citation needed]
- Osteoporosis.
- Other metabolic bone diseases such as Paget's disease, osteomalacia, osteopetrosis and osteogenesis imperfecta. Stress fractures may occur in the hip region with metabolic bone disease.
- Elevated levels of homocysteine, a toxic 'natural' amino acid.
- Benign or malignant primary bone tumors are rare causes of hip fractures.
- Metastatic cancer deposits in the proximal femur may weaken the bone and cause a pathological hip fracture.
- Infection in the bone is a rare cause of hip fracture.
- Tobacco smoking (associated with osteoporosis).[10]
Mechanism
Functional anatomy
The
Biomechanics
The hip joint is unique in that it experiences combined mechanical loads. An axial load along the shaft of the
Neurological factors
Elderly individuals are also predisposed to hip fractures due to many factors that can compromise proprioception and balance, including medications, vertigo, stroke, and peripheral neuropathy.[5][14][15]
Diagnosis
Physical examination
Displaced fractures of the trochanter or femoral neck will classically cause external rotation and shortening of the leg when the patient is laying supine.[5]
Imaging
Typically, radiographs are taken of the hip from the front (AP view), and side (lateral view). Frog leg views are to be avoided, as they may cause severe pain and further displace the fracture.[5] In situations where a hip fracture is suspected but not obvious on x-ray, an MRI is the next test of choice. If an MRI is not available or the patient can not be placed into the scanner a CT may be used as a substitute. MRI sensitivity for radiographically occult fracture is greater than CT. Bone scan is another useful alternative however substantial drawbacks include decreased sensitivity, early false negative results and decreased conspicuity of findings due to age-related metabolic changes in the elderly.[16]
A case demonstrating a possible order of imaging in initially subtle findings:
-
X-ray showing a suspected compressive subcapital fracture as a radiodense line
-
CT scan shows the same, atypical for a fracture since the cortex is coherent
-
turbo spin echo, MRIconfirms a fracture, as the surrounding bone marrow has low signal from edema.
As the patients most often require an operation, full pre-operative general investigation is required. This would normally include blood tests, ECG and chest x-ray.
Types
X-rays of the affected hip usually make the diagnosis obvious;
Capsule | Area | Classification | ||
---|---|---|---|---|
Intracapsular | femoral head | AO 31-C1 – 31-C3 | Pipkin classification
| |
femoral neck | Subcapital | AO 31-B1 – 31-B3 | Pauwel's classification
| |
Transcervical | ||||
Basicervical | ||||
Extracapsular | Trochanteric | Intertrochanteric (between the greater and lesser trochanter[18]) | AO 31-A1 – 31-A2 | Evans' classification (1949), Ramadier's classification (1956), Boyd and Griffin's classification (1949), Decoulx & Lavarde's classification (1969), Ender's classification (1970), Tronzo's classification (1973), Evans-Jensen classification (1975), Deburge's classification (1976), Briot's classification (1980)
|
Pertrochanteric (through the trochanters[18][19]) | AO 31-A3 | |||
Subtrochanteric | AO 32 | Seinsheimer classification |
Trochanteric fractures are subdivided into either intertrochanteric (between the greater and lesser trochanter[18]) or pertrochanteric (through the trochanters[18][19]) by the Müller AO Classification of fractures.[20] Practically, the difference between these types is minor. The terms are often used synonymously.[21][22] An isolated trochanteric fracture involves one of the trochanters without going through the anatomical axis of the femur, and may occur in young individuals due to forceful muscle contraction.[23] Yet, an isolated trochanteric fracture may not be regarded as a true hip fracture because it is not cross-sectional.[citation needed]
Prevention
The majority of hip fractures are the result of a fall, particularly in the elderly. Therefore, identifying why the fall occurred, and implementing treatments or changes, is key to reducing the occurrence of hip fractures. Multiple contributing factors are often identified.[24] These can include environmental factors and medical factors (such as postural hypotension or co-existing disabilities from disease such as Stroke or Parkinson's disease which cause visual and/or balance impairments). A recent study has identified a high incidence of undiagnosed cervical spondylotic myelopathy (CSM) amongst patients with a hip fracture.[25] This is relatively unrecognised consequent of CSM.[26]
Additionally, there is some evidence to systems designed to offer protection in the case of a fall.
Management
Most hip fractures are treated surgically by
Red blood cell transfusion is common for people undergoing hip fracture surgery due to the blood loss sustained during surgery and from the injury. The benefits of giving blood when the hemoglobin is less than 10 g/dL versus less than 8 g/dL are not clear.[33] Waiting until the hemoglobin was less than 8 g/dL or the person had symptoms may increase the risk of heart problems.[34] Intravenous iron is used in some centres to encourage an increase in haemoglobin levels, but it not known whether this makes a significant difference to outcomes that matter to patients.[35]
If operative treatment is refused or the risks of surgery are considered to be too high the main emphasis of treatment is on pain relief. Skeletal traction may be considered for long-term treatment. Aggressive chest
Surgery on the same day or day following the break is estimated to reduce postoperative mortality in people who are medically stable.[36]
Intracapsular fractures
For low-grade fractures (Garden types 1 and 2), standard treatment is fixation of the fracture in situ with screws or a sliding screw/plate device. This treatment can also be offered for displaced fractures after the fracture has been reduced.[citation needed]
Fractures managed by
In elderly patients with displaced or intracapsular fractures surgeons may decide to perform a
Traction is contraindicated in femoral neck fractures due to it affecting blood flow to the head of the femur.[40]
The latest evidence suggests that there may be little or no difference between screws and fixed angle plates as internal fixation implants for intracapsular hip fractures in older adults.[41] The findings are based on low quality evidence that can't firmly conclude major difference in hip function, quality of life, and additional surgery.
Trochanteric fracture
A trochanteric fracture, below the neck of the femur, has a good chance of healing.
Closed reduction may not be satisfactory and open reduction then becomes necessary.[42] The use of open reduction has been reported as 8-13% among pertrochanteric fractures, and 52% among intertrochanteric fractures.[43] Both intertrochanteric and pertrochanteric fractures may be treated by a dynamic hip screw and plate, or an intramedullary rod.[42]
The fracture typically takes 3–6 months to heal. As it is only common in elderly, removal of the
Subtrochanteric fractures
Subtrochanteric fractures may be treated with an
A lateral incision over the trochanter is made and a cerclage wire is placed around the fracture for reduction. Once reduction has been achieved a guide canal for the nail is made through the proximal cortex and medullary. The nail is inserted through the canal and is fixated proximally and distally with screws. X-rays are obtained to ensure proper reduction and placement of the nail and screws are achieved.[45]
Rehabilitation
Rehabilitation has been proven to increase daily functional status. Forty percent of individuals with hip fractures are also diagnosed with dementia or mild cognitive impairment which often results in poorer post-surgical outcomes.[46] In such cases enhanced rehabilitation and care models have been shown to have limited positive effects in reducing delirium and hospital length of stay.[46] It is unclear if the use of anabolic steroids affects recovery.[47]
A updated Cochrane review (2022) involving over 4000 patients found evidence that gait training, balance and functional tasks training to be particularly effective when compared to conventional care.[48] There is also moderate-certainty evidence that rehabilitation after hip fracture surgery, when delivered by a multidisciplinary team and supervised by an appropriate medical specialist, results in fewer cases of 'poor outcome', like death and deterioration in residential status.[49]
Nutrition supplementation
Oral supplements with non-protein energy, protein, vitamins and minerals started before or early after surgery may prevent complications during the first year after hip fracture in aged adults; without seemingly effects on mortality.[50]
Surgical complications
Deep or superficial wound infection has an approximate incidence of 2%. It is a serious problem as superficial infection may lead to deep infection. This may cause infection of the healing bone and contamination of the implants. It is difficult to eliminate infection in the presence of metal foreign bodies such as implants. Bacteria inside the implants are inaccessible to the body's defence system and to antibiotics. The management is to attempt to suppress the infection with drainage and antibiotics until the bone is healed. Then the implant should be removed, following which the infection may clear up. Implant failure may occur; the metal screws and plate can break, back out, or cut out superiorly and enter the joint. This occurs either through inaccurate implant placement or if the fixation does not hold in weak and brittle bone. In the event of failure, the surgery may be redone or changed to a
Prognosis
Hip fractures are very dangerous episodes, especially for elderly and frail patients. The risk of dying from the stress of the surgery and the injury in the first thirty days is about 7%.
Post operation
Among those affected over the age of 65, 40% are transferred directly to long-term care facilities, long-term rehabilitation facilities, or
Among those affected over the age of 50, approximately 25% die within the next year due to complications such as
]Patients with hip fractures are at high risk for future fractures including hip, wrist, shoulder, and spine. After treatment of the acute fracture, the risk of future fractures should be addressed. Currently, only 1 in 4 patients after a hip fracture receives treatment and work up for osteoporosis, the underlying cause of most of the fractures. Current treatment standards include the starting of a bisphosphonate to reduce future fracture risk by up to 50%.[citation needed]
Epidemiology
Hip fractures are seen globally and are a serious concern at the individual and population level. By 2050, it is estimated that there will be six million cases of hip fractures worldwide.
Given the high morbidity and mortality associated with hip fractures and the cost to the health system, in England and Wales, the National Hip Fracture Database is a mandatory nationwide audit of care and treatment of all hip fractures.[61]
Population
All populations experience hip fractures but numbers vary with race, gender, and age. Women have three times as many hip fractures as men.[62] In a lifetime, men have an estimated 6% risk whereas postmenopausal women have an estimated 14% risk of having a hip fracture.[63] These statistics provide insight over a lifespan, and conclude that women are twice as likely to have a hip fracture. The overwhelming majority of hip fractures occur in white individuals, while blacks and Hispanics have a lower rate of them. This may be due to their generally greater bone density and also because whites have longer overall lifespan and higher likelihood of reaching an advanced age where the risk of breaking a hip goes up.[63] Deprivation is also a key factor: in England, it has been found that people in the poorest parts of the country are more likely to fracture a hip and less likely to recover well than those in the least deprived areas.[64]
Age is the most dominant factor in hip fracture injuries, with most cases occurring in people over 75. The increase of age is related to the increase of the incidence of hip fracture,[56] which is the most frequent cause of hospitalization in centenarians, overcoming congestive heart failure and respiratory infection.[65] Falls are the most common cause of hip fractures; around 30–60% of older adults fall each year. This increases the risk for hip fracture and leads to the increased risk of death in older individuals, the rate of one year mortality is seen from 12 to 37%.[66] For those remaining patients, half of them need assistance and cannot live independently. Also, older adults sustain hip fractures because of osteoporosis, which is a degenerative disease due to age and decrease in bone mass. The average age for sustaining a hip fracture is 77 years old for women and 72 years old for men.[67]
References
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External links
- Fractures of the Femoral Neck Wheeless Textbook of Orthopaedics
- Intertrochanteric Fractures Wheeless' Textbook of Orthopaedics