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Hip Fracture

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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
  • Common in patients undergoing bisophosphonate therapy for osteoporosis[5]

Pathoanatomy

Associated Injuries

Risk Factors

Differential Diagnosis

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

  • Ultrasound of hip demonstrating intertrochanteric fracture

  • Pelvix XR demonstrating left femoral neck fracture

  • Pelvic XR demonstrating left intertrochanteric hip fracture

  • Pelvis XR comminuted, overlapping intertrochanteric and subtrochanteric femur fracture

  • Hip XR demonstrating subcapital femur fracture

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

References

  1. ↑ Dennison E, Mohamed MA, Cooper C. Epidemiology of osteoporosis. Rheum Dis Clin North Am. 2006; 32:617–629.
  2. ↑ Roberts KC, Brox WT, Jevsevar DS, et al. Management of hip fractures in the elderly. J Am Acad Orthop Surg. 2015; 23:131–137.
  3. ↑ Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int. 2006; 17:1726–1733.
  4. ↑ 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.
  5. ↑ 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.
  6. ↑ Giversen IM. Time trends of mortality after first hip fractures. Osteoporos Int. 2007; 18:721–732.
  7. ↑ 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.
  8. ↑ Ahn J, Bernstein J. Fractures in brief: intertrochanteric hip fractures. Clin Orthop Relat Res. 2010; 468:1450–1452.
Created by:
John Kiel on 5 July 2019 08:28:38
Authors:
Last edited:
5 October 2022 13:03:51
Categories:
Lower Extremity | Trauma | Hip | Fractures | Acute

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