What is Hip Fracture Overview?
Hip fractures are common injuries that often lead to visits to the emergency room and calls to orthopedic trauma teams. Hip fracture and neck of femur fracture are two terms that are used interchangeably. In both cases, the break occurs in the upper part of the thigh bone, which is between the femoral head (the ball of the hip joint) and a point 5 cm below the lesser trochanter (a smaller, bony prominence on the thigh bone).
What Causes Hip Fracture Overview?
Hip fractures mostly happen due to falls among older people. Several factors increase the chances of falls in this age group. These include a previous fall incident, issues with walking or balance, using walking aids, dizziness, Parkinson’s disease, and certain epilepsy medications. Often, these individuals have more than one of these factors playing a part. Along with a decrease in bone strength because of their age, these factors can lead to quite a number of hip fractures.
In younger adults, hip fractures are typically caused by severe accidents or trauma. These individuals may have multiple injuries. They should be evaluated and treated according to the guidelines followed by local health services for dealing with trauma.
For about 5% of hip fractures, there’s no record of trauma. In such circumstances, another reason behind the fracture should be considered. A fracture is classified as ‘pathological’ when it’s caused by a disease, not injury. Cancer and the use of a specific drug class known as bisphosphonates, are among the most common culprits causing hip fractures in such cases. Some argue that even more hip fractures could genereally be classified as ‘pathological’, as the underlying issue is often osteoporosis, a condition that weakens bones. However, osteoporosis is rarely recognized or labelled as such.
Risk Factors and Frequency for Hip Fracture Overview
In 1990, global incidents of hip fractures were recorded at 1.3 million. The prediction is that by 2050, this number will rise to between 7 and 21 million. In the United States, every year, for every 100,000 people, there are between 197 and 201 hip fractures in men, and between 511 and 553 in women. The likelihood of a hip fracture increases as people get older, with the average age of a patient with a hip fracture being 80 years old.
The cost of treating a hip fracture can be hefty. On average, a patient may spend up to $40,000 in just the first year after the fracture. In fact, the United States spends more than $17 billion every year on care for hip fractures.
Signs and Symptoms of Hip Fracture Overview
Hip fractures are usually noticeable due to a painful hip and an inability to walk after a fall. It’s important for doctors to consider other potentially dangerous reasons for the fall, like a heart attack or stroke. As many people who experience hip fractures are older and may have other health conditions, it’s necessary to take a complete medical history. This includes understanding the person’s previous health conditions as well as their current lifestyle at home, as this information can help plan for their recovery after surgery.
It’s also recommended that all patients who come in with a hip fracture have their cognitive function assessed, both when they are admitted to the hospital and after surgery. This is done to identify patients who may have dementia or might be experiencing an acute confusion, both of which can make their prognosis worse.
Physical examination usually shows pain, inability to move, and occasionally a visibly deformed limb. The extent of this deformation depends on where the fracture is and how much displacement has occurred. A classic indicator of a hip fracture is a shortened and externally rotated leg, which occurs due to the pull of a muscle on the lesser trochanter. Further examination often reveals pain when the groin or greater trochanter is touched, the hip is axially loaded, or the leg is ‘pin-rolled’.
Finally, a full trauma assessment should be carried out to check for any other injuries. Assessing the person’s heart and lung function prior to surgery is also useful. Doctors may also conduct specific examinations to identify the cause of the fall.
Testing for Hip Fracture Overview
Most hip fractures can be identified using simple x-ray images. One would usually take an x-ray from the front (anteroposterior view) of the pelvis and a side view of the affected hip. However, there are also “hidden” (occult) fractures that are not seen on x-rays, which make up between 2% to 10% of all hip fractures. In these cases, an MRI is considered the best method for diagnosis, thanks to its high accuracy. If an MRI is not available, a CT scan can be a good alternative, but it might miss some fractures.
It’s important to understand the type of fracture by looking at the x-ray images. This is because the type of fracture will decide the kind of surgery needed. Hip fractures are classified depending on their location relative to a specific part of the bone (called the joint capsule) that covers the femoral neck. Fractures that happen within this capsule are called intracapsular, while those outside are extracapsular.
Different classification systems are used to understand intracapsular hip fractures. One is the Pauwels classification, which divides fractures into three categories based on their angle: less than 30 degrees (Type 1), 31-50 degrees (Type 2), and more than 50 degrees (Type 3). The greater the angle, the less stable and less likely the fracture is to heal. But this classification system isn’t always agreed upon, particularly for displaced fractures.
The more commonly used Garden classification describes four fracture patterns depending on the completeness and displacement of the fracture. These range from Type 1 (incomplete and no displacement) to Type 4 (complete and fully displaced). However, this classification too can be subject to variation, and many clinicians prefer to simplify it as either displaced or undisplaced. The fractures are also described based on their position along the femoral neck.
Extracapsular fractures are divided into trochanteric (occurring between the greater and lesser trochanter) and subtrochanteric fractures. These are classified using the AO classification method, which is centred around how many parts the fracture is in and its stability. Recognising these different types is crucial as it influences how the fracture is treated surgically.
Subtrochanteric fractures happen between the lesser trochanter and 5 cm below it. Historically, these were classified using the Russell-Taylor system, but now the modernized AO system is used. Both systems are often academic and rarely influence management.
As part of the patient evaluation, blood tests should be done to check for anemia, kidney function, clotting profile, and potential for significant blood loss during surgery. These evaluations should involve a team approach, with surgeons, doctors, anesthetists, physiotherapists, pharmacists, and dieticians all weighing in to make sure the patient gets the best treatment before, during, and after surgery. Hospitals are advised to formalize a hip fracture program to improve outcomes and reduce death rates after surgery.
Treatment Options for Hip Fracture Overview
When a patient comes into the emergency department with a femoral fracture, they might lose up to 1 liter of blood. So, the first steps are usually replacing lost fluids and considering blood transfusions. It’s also important not to let the patient fast for long periods. They should get nutritional supplements until it’s certain when surgery will take place. Long periods of fasting can lead to problems like breaking down of body tissues, low blood sugar, a weakened immune system, and dehydration. Since they’re already at risk of dehydration, people with hip fractures should be sure to hydrate well before and during surgery.
There may also be guidelines on when to stop eating and drinking before surgery – it’s often 2 hours for liquids and 6 hours for food. Painkillers can help manage discomfort, though it can sometimes be tough to control pain fully. Just to note, traction (a way to pull the broken bones back into place) or trying to push the bones back into place in the emergency department is not advisable.
Decisions on the best course of treatment often depend on where the fracture is and how severe it is. The patient’s pre-injury functionality, medical history, and personal preferences are also taken into account. In general, the aim is to get patients moving about as quickly as possible after surgery. This is because not performing surgery (conservative management) for fractured hips often results in a higher risk of death within 30 days and within 1 year. It’s usually used only for patients who aren’t physically fit for surgery. Having surgery within 48 hours of being admitted is often linked with better outcomes. Having surgery within 6 hours does not seem to increase risks, and may even reduce confusion after surgery and the length of the hospital stay.
How hip fractures are treated depends also on the blood supply to the head of the femur. Blood is supplied there through arteries that pass upward through the joint capsule. In intracapsular fractures, when these vessels are damaged, the head of the femur may not receive enough blood, causing the death of that part of the bone. For elderly patients with displaced intracapsular hip fractures, a joint replacement often provides better outcomes than fixation in terms of pain, function after surgery, and complications. Around 30% of patients may have to have another operation within 24 months of fixation.
When it comes to joint replacements, there are a couple of options: total hip replacement or hemiarthroplasty. Both procedures show similar mortality rates. However, some evidence suggest that total hip replacement could help improve postoperative pain and reduce wear and tear of the acetabulum. In addition, in patients with low functional demand, a joint replacement known as hemiarthroplasty is generally recommended. It’s a quicker and simpler procedure and usually results in a satisfactory recovery. Displaced intracapsular hip fractures in young, highly active patients might first be treated with open reduction and internal fixation, despite the high risk of displacement, non-union, death of the bones due to lack of blood supply, and subsequent revision surgery.
For uninjured intracapsular fractures, treatment can be conservative or surgical, but non-surgical management is usually reserved for surgical high-risk cases or patients who are managing well despite the fracture. Generally, efforts are made to keep the natural joint intact as this allows for better long-term function and mobility.
For patients with low functional demand or those who may not be able to restrict weight-bearing after surgery, joint replacement surgery may be the first choice. Joint replacement surgery gets rid of the risk of bone death, reducing the need for re-surgery. The risks and benefits of both options should be discussed with the patient or their caregiver. Joint replacement may also be preferred in patients with pre-existing arthritis as there is little point in trying to save a joint that is already damaged.
In extracapsular fractures, the blood supply to the head of the femur is rarely affected, and fixation is usually the preferred treatment. The type of fixation depends on the fracture pattern, which may not be clear until the patient is on the operating table for screening.
Stable trochanteric fractures can be treated favorably with intramedullary nails and sliding hip screws. The latter tends to result in less blood loss and shorter operation time and is also a cheaper option. Unstable trochanteric fractures are better treated with intramedullary nails as they give better functional outcomes. Subtrochanteric and reverse oblique trochanteric fractures can be tricky to manage due to their instability. These fractures may be associated with higher risk of the bones not knitting together and having fixation fail. Intramedullary devices are generally advised for these fractures, as they have lower risk of the bones not knitting together, compared with fixation techniques outside the marrow. Intramedullary devices can also ensure adequate fixation and have shorter operation times and reduced hospital admission periods.
After fixation of an intracapsular hip fracture, patients usually have to bear weight carefully in the immediate after-surgery period to avoid displacement of the fracture. If there is death of the bones due to lack of blood supply after fixation of uninjured intracapsular fractures, patients may need further surgery such as core decompression or joint replacement.
What else can Hip Fracture Overview be?
When experiencing hip pain, it’s important to remember that there might be other causes. For instance, pain from a hip that has been arthritic for a long time might feel worse after an injury, even if no new fracture has occurred. Severe dislocation in the hip could also lead to symptoms like pain, unusual shape or appearance, and trouble moving. It’s also necessary to consider the possibility of a pelvic fracture, for which a pelvic or hip x-ray would be suggested.
Hip pain could even be related to injuries in the spine, femoral shaft (the long bone in your thigh), and the knee. So, a detailed examination is needed to pinpoint the exact site of injury. If no trauma or fractures are found, then other factors causing hip pain may need to be considered, such as cancer or infection.
Surgical Treatment of Hip Fracture Overview
Pathological hip fractures are fractures that occur due to either primary bone tumors or spread of disease elsewhere in the body to the bone. If a doctor suspects that the fracture is due to cancer, an X-ray and MRI of the entire femur (thigh bone) are necessary to determine the extent of the disease. Following a discussion with cancer specialists, the treatment approach is decided based on the progression of the disease.
A curative resection and reconstruction is a potential treatment option if the disease is curable. This involves removing the part of bone affected by cancer and reconstructing the bone. For patients whose disease is incurable, pallitary procedures are recommended. These are treatments specifically aimed at reducing pain and restoring mobility, rather than curing the disease. Additionally, taking a small sample of the tissue during the operation can be helpful to figure out the origin of the primary tumor.
What to expect with Hip Fracture Overview
Studies report that 18% to 31% of people pass away within a year of experiencing a hip fracture. Age over 85, dependency, an ASA grade of 3 or more, being male, having a history of cancer, and complications after surgery all increase the risk of mortality. Certain models have been developed to predict both 30-day and 1-year mortality, and in the UK, these tools are used to identify patients at high risk who should be treated by a senior surgeon.
Furthermore, only 40% to 60% of patients are able to retain their normal mobility after a hip fracture. In fact, 20% to 60% of people who were independent before the fracture require help with at least one daily activity. People who lived in a care home before their injury are unlikely to regain their original level of independence.
Possible Complications When Diagnosed with Hip Fracture Overview
Having a hip fracture can lead to a host of issues. There’s a chance of infection after surgery – the rates of which can range from 0.6-3.6%, depending on what kind of surgery was done. Other common complications of surgery can include postoperative pain, bleeding, damage to nerves and blood vessels, and issues with the wound healing.
There are also complications that are unique to specific types of treatments. For example, those who have had a joint replaced (a procedure called arthroplasty) may experience issues such as the new joint coming out of place, the new joint becoming loose or wearing out, uneven leg length, and fractures near the prosthetic. For those who have had devices used to fix the fracture in place, complications can include failure of the fixation or hardware, bone death due to lack of blood supply, and the fracture not healing properly.
Patients can also experience health complications after a hip fracture. It’s important to recognize and treat these problems early to decrease the risk of death. Here are some medical complications that are common after a hip fracture, along with their rates:
- Delirium: 13.5% to 33%
- Pulmonary embolism (a blood clot in the lungs): 1.4% to 7.5%
- Deep venous thrombosis (a blood clot in the leg): 27%
- Pneumonia: 7%
- Myocardial infarction or heart failure (heart issues): 35% to 42%
- Urinary retention or infection: 12% to 61%
- Acute kidney injury: 11%
- Anemia (low red blood cell count): 24% to 44%
- Skin pressure damage: 7% to 9%
Recovery from Hip Fracture Overview
Preventing blood clots after surgery, or venous thromboembolism, with medicine is usually suggested, unless there are reasons why the patient shouldn’t take these drugs. Transfusing additional blood after surgery is only recommended if a patient’s hemoglobin level is below 8 g/dL or if they are showing symptoms of severe anemia.
Following surgery, it’s equally important to focus on post-operative rehabilitation. The goal of the procedure is to improve mobility, so it’s crucial to get moving as soon as possible. After undergoing joint replacement surgery or fracture repair outside of the joint capsule, patients can generally start moving around right away without any weight restrictions. However, for repairs inside the joint capsule, it’s often suggested to limit weight-bearing activities to lower the risk of any further fracture.
To quickly regain mobility and restore original movement capabilities, regular and intense physiotherapy is typically needed. It’s also crucial to manage any other medical conditions to decrease the likelihood of complications. Unfortunately, not all patients are able to regain their previous level of mobility and independence, and thus might need assistance from social care providers.
Preventing Hip Fracture Overview
There are two main ways to lower the chances of hip fractures particularly in older people. The first is by preventing falls, which is not so straightforward as there are many factors that contribute to falls. Some of these factors can’t be changed at all. It’s important for health care professionals to know what these fall risk factors are. They should do their best to find and manage these risks.
The second way to lower the chances of hip fractures is by diagnosing and managing osteoporosis, a disease that weakens the bones. A tool to determine the risk of bone fracture due to osteoporosis over the next 10 years is used. Both a personal history of fractures and having a parent who had a hip fracture can increase a patient’s risk score. All people over the age of 50 who come in with any type of bone fracture should be checked for osteoporosis. This can help reduce the chance of them getting another fracture.
