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Hip Fracture
From WikiSM
Contents
Other Names
- Femoral Neck (FN) fractures
- Intertrochanteric (IT) fractures
- Subtrochanteric (ST) fractures
Background
- This page refers to fractures of the proximal femur, commonly referred to as a "hip fracture"
Definition
- The term "hip fracture" can be a misnomer
- Included in this terminology are
- Femoral Neck (FN) fractures
- Intertrochanteric (IT) fractures
- Subtrochanteric (ST) fractures
- Not included on this page are Acetabular Fractures and Femoral Shaft Fractures, which are discussed separately
History
Epidemiology
- 1.66 million cases annually in 1999, expected to rise to 6 million cases anually by 2050[1]
- Socioeconomic Impact
- 2010: Costs in US were roughly $20 billion, one of medicares top expenses[2]
- General
- Have a bimodal distribution caused by high energy trauma in young males and low energy trauma in older patients[3]
- Intertrochanteric Fractures
- Represent of 50% of hip fractures in the elderly[4]
Pathophysiology
Femoral Neck Fractures
- Defined as fractures between the femoral head and the trochanters
- Femoral neck has inherently poor biological healing potential
- Most FN fractures are intracapsular where synovial fluid inhibits angiogenesis
Intertrochanteric Fractures
- Fractures located between the greater and lesser trochanter
- Extracapsular
- Intertrochanteric region is the transition from femoral neck to femoral shaft
- Highly vascularized with good healing potential
Subtrochanteric Fractures
- Proximal femur fractures occurring below the intertrochanteric region and within 5 cm of the lesser trochanter
- Higher rates of implant failure, nonunion and malunion because of the flared cortical bone
- Deforming forces from muscle attachments on the Greater Trochanter and Lesser Trochanter on proximal fragment
- Distal fragment is due to Adductor Muscles
- Common in patients undergoing bisophosphonate therapy for osteoporosis[5]
Pathoanatomy
- Femur
- Greater Trochanter attachments
- Lesser Trochanter attachments
Associated Injuries
- Femoral Shaft Fractures in about 5-10% of FN fractures
Risk Factors
- Systemic
- Osteoporosis
- Osteopenia
- "Poor overall health"
- Bisphosphonate use
- Low Estrogen
- Demographic
- Female gender
- Caucasian
- Other
- Tobacco Use Disorder
- History of prior fracture
- History of recurrent or prior falls
Differential Diagnosis
- Fractures And Dislocations
- Arthropathies
- Muscle and Tendon Injuries
- Bursopathies
- Ligament Injuries
- Neuropathies
- Other
- Pediatric Pathology
- Transient Synovitis of the Hip
- Developmental Dysplasia of the Hip (DDH)
- Legg-Calve-Perthes Disease
- Slipped Capital Femoral Epiphysis (SCFE)
- Avulsion Fractures of the Ilium (Iliac Crest, ASIS, AIIS)
- Ischial Tuberostiy Avulsion Fracture
- Avulsion Fractures of the Trochanters (Greater, Lesser)
- Apophysitis of the Ilium (Iliac Crest, ASIS, AIIS)
Clinical Features
- History
- Patients will endorse a traumatic mechanism
- Complain of pain in the hip and thigh region
- Pain is worse with movement
- Physical Exam: Physical Exam Hip
- If displaced, the limb may be shortened, externally rotated, flexed and abducted
- Special Tests
Evaluation
Radiographs
- Standard Pelvic Radiographs include AP Pelvis, Cross-table lateral
- Recommended to avoid frog-leg view as it can displace fractures
- Traction-internal rotation AP view can be helpful to evaluate FN or IT fractures
- Additionally, Standard Femur Radiographs should be obtained as well as Standard Knee Radiographs
- Subtrochanteric Fracture
- Proximal fragment is flxed, abducted
- Distal fragment adducted, externally rotated
CT
- CT can be beneficial
- Better characterizes fracture pattern
- Not required as part of a standard workup
MRI
- Useful for occult or pathologic fractures
Classification
Femoral Neck Fractures
Garden Classification
- Based on AP radiographs
- Type I: Incomplete fracture
- Type II: Complete fracture, nondisplaced
- Type III: Complete fracture, partially displaced
- Type IV: Complete fracture, fully displaced
Powell Classification
- Type I: < 30° from horizontal
- Type II: 30° to 50° from horizontal
- Type III: > 50° from horizontal
- Most unstable, highest risk of nonunion or AVN
Intertrochanteric Fractures
- Several classification systems exist, none widely used
- Stability appears to be most reliable method
- Stable: intact posteromedial cortex
- Unstable: comminuted posteromedial cortex, thin lateral wall
Subtrochanteric Fractures
Russel-Taylor Classification
- Type I: No extension into piriformis fossa
- Type II: Extension into greater trochanter with involvement of piriformis fossa
Management
Prognosis
- Associated with a high morbidity and mortality
- 1-year mortality rate in elderly patients is 20% to 30%[6]
- Early operative intervention has been shown to decrease complications such as pneumonia, pressure sores[7]
- Early surgery also decreases mortality at one year (need citation)
- Nonoperative management can be associated with prolonged immobility and associated with[8]
- Pneumonia
- Urinary tract infections
- Decubitus wounds
- Deep venous thromboses
- Factors that increase mortality (need citation)
- Male gender (25-30% mortality) vs female (20% mortality)
- Higher in intertrochanteric fracture (vs FN, IT)
- Operative delay of more than 48 hours
- Age >85 years
- 2 or more pre-existing medical conditions
- ASA classification (ASA III and IV increases mortality)
Nonoperative
- Indications
- Rarely indicated
- Consider in non-ambulatory patients with minimal pain
- Consider in sick patients with high surgical risk
Nonoperative
- Technique (FN)
- Closed reduction percutaneous fixation (CRPF)
- Open reduction internal fixation (ORIF)
- Total hip arthroplasty (THA)
- Hemiarthroplasty (HA)
- Technique (IT)
- Cephalomedullary nail (CMN)
- Sliding hip comprsesion screw
- Arthroplasty
- Technique (ST)
- Intramedullary rod
- Fixed Angle Plate
Rehab and Return to Play
Rehabilitation
- Needs to be updated
Return to Play
- Individualized but athlete should be
- Off pain medication
- Relatively pain free
- Full range of motion
Complications
- Femoral Neck Fractures
- Osteonecrosis
- Nonunion
- Dislocation
- Failure Rates
- Intertrochanteric fractures
- Implant failure
- Anterior perforation
- Nonunion
- Malunion
- Subtrochanteric fractures
- Nonunion
- Varus/ procurvatum malunion
- Bisphosophate fractures increased risk of surgical fracture or hardware failure
See Also
- Internal
- External
- Sports Medicine Review Hip Pain: https://www.sportsmedreview.com/by-joint/hip/
References
- ↑ Dennison E, Mohamed MA, Cooper C. Epidemiology of osteoporosis. Rheum Dis Clin North Am. 2006; 32:617–629.
- ↑ Roberts KC, Brox WT, Jevsevar DS, et al. Management of hip fractures in the elderly. J Am Acad Orthop Surg. 2015; 23:131–137.
- ↑ Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int. 2006; 17:1726–1733.
- ↑ Koval KJ, Aharonoff GB, Rokito AS, et al. Patients with femoral neck and intertrochanteric fractures. Are they the same? Clin Orthop Relat Res. 1996; 330:166–172.
- ↑ Puhaindran ME, Farooki A, Steensma MR, et al. Atypical subtrochanteric femoral fractures in patients with skeletal malignant involvement treated with intravenous bisphosphonates. J Bone Joint Surg Am. 2011; 93:1235–1242.
- ↑ Giversen IM. Time trends of mortality after first hip fractures. Osteoporos Int. 2007; 18:721–732.
- ↑ Simunovic N, Devereaux PJ, Sprague S, et al. Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis. CMAJ. 2010; 182:1609–1616.
- ↑ Ahn J, Bernstein J. Fractures in brief: intertrochanteric hip fractures. Clin Orthop Relat Res. 2010; 468:1450–1452.