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Hip Fractures Summary

Study guide:

Definition:

Hip fractures are defined as fractures that occur to the proximal part of the femur. Therefore, they are also referred to as proximal femoral fractures.

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Epidemiology:

The incidence of hip fractures is increasing with time, especially in the aging population.

Epidemiological studies show that:

  • An estimated 340,000 hip fractures occur each year. Estimates indicate that in 2040, approximately 500,000 hip fractures will occur.

  • Nine of 10 hip fractures occur in elderly females.

  • Caucasian females have been reported to be twice as likely to fracture their hips than black and Hispanic females.

  • The rate of fractures is low in adolescent and young athletic populations, estimated to be less than 2% of all hip fractures (and mostly from motor-vehicle accidents)

Basic Anatomy of the Hip Joint:

  • To understand the types and pathophysiology of hip fractures, it’s essential to know the anatomy of the hip joint.

  • The hip joint is a ball and socket synovial joint that mainly functions as a weight bearing joint. The two articulating surfaces are head of the femur and the acetabulum on the lateral aspect of the hip, both of which are covered with articular cartilage.

  • The articulating surfaces are surrounded by a strong fibrous capsule that attaches proximally to the acetabulum, anteriorly to the greater trochanter of the femur, and posteriorly to the intertrochanteric crest.

  • The capsule is reinforced by three ligaments that are continuous with the capsule:

  1. Iliofemoral ligament (Anterior): As the name suggests, it originates below the anterior superior iliac spine in the ilium and attaches to the femur at the intertrochanteric line. It is the strongest ligament and it prevents hyperextension.

  2. Pubofemoral (Anterior): Arises from the iliopubic eminence and ultimately blends with the fibers of the capsule. It prevents hyper abduction.

  3. Ischiofemoral (Posterior): Runs from the ischium to the greater trochanter of the femur. It prevents hyperextension.

 

 

  • The main blood supply to the hip joint is through the medial and lateral circumflexes arteries, branches of the profunda femoris artery.

    • These vessels form a ring around the neck of the femur and run superiorly towards the head (so any injury, such as a femoral neck fracture, will compromise the blood flow to the head of the femur, leading to avascular necrosis)

Figure 1: Hip Joint Ligaments.

Figure 2: Blood Supply of Hip Joint.

Types of Hip Fractures:

Hip fractures are divided into 3 groups, according to the location of the fracture. Each type has its own treatment plan.

  1. Intracapsular fracture:

Located within the capsule of the hip Joint (i.e the head and neck of the femur). This type of fracture results in compromise to the blood flow of the femoral head.

 

   2. Intertrochanteric fracture:

This fracture occurs between the two trochanters of the femur, or less commonly between the neck and the lesser trochanter of the femur.

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   3. Subtrochanteric fracture:

Located below the lesser trochanter, in the proximal part of the femur.

NB: Multiple types may occur at once, increasing the complexity of the fracture.

Causes:

Hip fractures are either caused by falling to the ground or a direct blow to the hip region.

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Risk factors:

  • Increasing age:

    • The natural process of aging is associated with loss of bone density, making the bones weaker and more susceptible to fractures.

    • Also, it leads to vision and balance problems, which the chances of falling to the ground.

  • History of Hip fracture

  • Malnutrition:

    • Vitamin D deficiency affects the homeostasis of calcium in the body.

  • Race:

    • Caucasians have a higher incidence.

  • Gender:

    • Females, especially postmenopausal ones due to the loss of the bone sparing effect of estrogen.

  • Disorders that are associated with reduced bone density such as osteopenia and osteoporosis.

  • Hyperthyroidism

  • Intestinal disorders:

    • Impaired absorption of vitamin D and calcium.

  • Corticosteroids:

    • By inhibit osteoblast activity, resulting in a reduced bone density.

  • Sedentary life style: Lack of exercise weakens bones

  • Alcohol and smoking: Alter the process of bone building, increasing the rate of bone loss and increasing fragility.

Pathophysiology:

  • Damage to the periosteum and intramedullary areas of the bone.

  • Depending on the type of fracture, there may be disruption to the inner cancellous architecture.

  • In addition, an acute inflammatory response is initiated as a result of the irritation caused by the fractured bone.

Symptoms:

  • Extreme pain in the groin region and upper outer thigh accompanied with bruising, swelling, and stiffness.

  • Discomfort when attempting to move the hip joint

  • External rotation of the knee and foot.

Diagnostic Tests:

  • Radiographs represent the best first test for evaluation.

  • The American Committee of Radiology (ACR)’s guidelines in diagnosing suspected hip fractures:

  • 1st test to order is a plain x-ray. (An AP pelvic x-ray and AP and lateral views of the affected hip should be taken.

  • CT and bone scintigraphy are second-line modalities if there is high suspicion of a hip fracture with a negative x-ray result.

  • Patients >50 years old with fractures from minimal or no trauma should undergo a DXA study for osteoporosis evaluation.

Figure 3: X-ray of Hip Fracture.

​Treatment:

  • All treatment plans are preceded by analgesia to relieve pre-operative pain

Intracapsular Fractures:

  1. In this type of fracture, there is a high concern of avascular necrosis.

  2. Consequently, trearment must be urgent.

  3. Types:

    1. Intracapsular Fractures with no femoral displacement:

      1. Treated by internal fixation a dynamic hip screw or multiple cannulated screws, and intravenous prophylactic antibiotics before surgery to avoid infection (mainly cephalosporin or vancomycin if the patient is allergic to penicillin)

      2. After the operation, a rehabilitation program is initiated that mainly involves range-of-motion and weight bearing exercises

    2. Intracapsular fractures with displacement:

      1. Follows the same treatment plan but the displacement needs to be anatomically corrected via open reduction. (Arthroscopy in elderly patiens)

 

 

Intertrochanteric fractures:

  1. No femoral displacement:

    1. Internal fixation with a cephalomedullary nail.

    2. The Prophylactic antibiotics and post-operative rehabilitation are the same as the Inctracapsular fractures.

  2. Displaced femur:

    1. Same treatment plan as a non-displaced femur but the displacement needs to be anatomically corrected via open reduction. (Arthroscopy in elderly patients)

  3. Subtrochanteric Hip Fracture:

    1. Treatment of choice is internal fixation with an intra-medullary nail. The Prophylactic antibiotics and post-operative rehabilitation are the same as the other types of fracture.

    2. The American Academy of Orthopaedic Surgeons’s on the management of hip fractures in patients over the age of 65. Recommendations supported by strong evidence include the following:

  • Regional analgesia can be used to improve preoperative pain control in patients with hip fracture.

  • -Arthroplasty should be used for patients with unstable (displaced) femoral neck fracture.

  • -In asymptomatic postoperative hip fracture patients, a blood transfusion threshold of no higher than 8g/dl should be used.

  • -Intensive post-discharge physical therapy improves functional outcomes.

  • -Use of an interdisciplinary care program in hip fracture patients with mild to moderate dementia improves functional outcomes.

  • -Multimodal pain management should be used after hip fracture surgery.

Follow-up:

Usually lasts until union and complete healing and functional recovery

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Complications:

  • Infections

  • Deep vein thrombosis

  • Muscle wasting

  • Pressure sores

References:

 

Written by:           Jumana Aldhalaan

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Reviewed by:        Areej Madani

                              Fatima Basakran

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Web Publisher:    Seba AlMutairi 

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