A hip fracture is a

break Break or Breaks or The Break may refer to: Time off from duties * Recess (break), time in which a group of people is temporarily dismissed from its duties * Break (work), time off during a shift/recess ** Coffee break, a short mid-morning res ...

that occurs in the upper part of the

femur The femur (; ), or thigh bone, is the proximal bone of the hindlimb in tetrapod vertebrates. The head of the femur articulates with the acetabulum in the pelvic bone forming the hip joint, while the distal part of the femur articulates with ...

(thigh bone). Symptoms may include pain around the hip, particularly with movement, and shortening of the leg. Usually the person cannot walk. They most often occur as a result of a fall. (

Femoral head fracture Femoral head fractures are very rare fractures of the upper end (femoral head) of the thigh bone (femur). They are a very rare kind of hip fracture that may be the result of a fall like most hip fractures but are more commonly caused by more violen ...

s are a rare kind of hip fracture that may also be the result of a fall but are more commonly caused by more violent incidents such as traffic accidents.) Risk factors include

osteoporosis Osteoporosis is a systemic skeletal disorder characterized by low bone mass, micro-architectural deterioration of bone tissue leading to bone fragility, and consequent increase in fracture risk. It is the most common reason for a broken bone ...

, taking many medications,

alcohol use An alcoholic beverage (also called an alcoholic drink, adult beverage, or a drink) is a drink that contains ethanol, a type of Alcohol (chemistry), alcohol that acts Alcohol (drug), as a drug and is produced by Ethanol fermentation, fermentat ...

, and

metastatic cancer Metastasis is a pathogenic agent's spread from an initial or primary site to a different or secondary site within the host's body; the term is typically used when referring to metastasis by a cancerous tumor. The newly pathological sites, then, ...

. Diagnosis is generally by

X-ray An X-ray, or, much less commonly, X-radiation, is a penetrating form of high-energy electromagnetic radiation. Most X-rays have a wavelength ranging from 10 picometers to 10 nanometers, corresponding to frequencies in the range 30&nb ...

Magnetic resonance imaging Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body. MRI scanners use strong magnetic fields, magnetic field gradients, and radio wave ...

, a CT scan, or a

bone scan A bone scan or bone scintigraphy is a nuclear medicine imaging technique of the bone. It can help diagnose a number of bone conditions, including cancer of the bone or metastasis, location of bone inflammation and fractures (that may not be visi ...

may occasionally be required to make the diagnosis. Pain management may involve

opioids Opioids are substances that act on opioid receptors to produce morphine-like effects. Medically they are primarily used for pain relief, including anesthesia. Other medical uses include suppression of diarrhea, replacement therapy for opioid use ...

or a

nerve block Nerve block or regional nerve blockade is any deliberate interruption of signals traveling along a nerve, often for the purpose of pain relief. Local anesthetic nerve block (sometimes referred to as simply "nerve block") is a short-term block, u ...

. If the person's health allows, surgery is generally recommended within two days. Options for surgery may include a

total hip replacement Hip replacement is a surgical procedure in which the hip joint is replaced by a prosthetic implant, that is, a hip prosthesis. Hip replacement surgery can be performed as a total replacement or a hemi (half) replacement. Such joint replacement or ...

or stabilizing the fracture with screws. Treatment to prevent blood clots following surgery is recommended. About 15% of women break their hip at some point in life; women are more often affected than men. Hip fractures become more common with age. The risk of death in the year following a fracture is about 20% in older people.

Signs and symptoms

$Heupfractuur$ The classic

clinical presentation In a physical examination, medical examination, or clinical examination, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the patient ...

of a hip fracture is an elderly patient who sustained a low-energy fall and now has

groin In human anatomy, the groin (the adjective is ''inguinal'', as in inguinal canal) is the junctional area (also known as the inguinal region) between the abdomen and the thigh on either side of the pubic bone. This is also known as the medial comp ...

pain and is unable to bear weight. Pain may be referred to the supracondylar

knee In humans and other primates, the knee joins the thigh with the leg and consists of two joints: one between the femur and tibia (tibiofemoral joint), and one between the femur and patella (patellofemoral joint). It is the largest joint in the hu ...

. On examination, the affected extremity is often shortened and externally rotated compared to the unaffected leg.

Complications

Nonunion Nonunion is permanent failure of healing following a broken bone unless intervention (such as surgery) is performed. A fracture with nonunion generally forms a structural resemblance to a fibrous joint, and is therefore often called a "false joi ...

, 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 Avascular necrosis (AVN), also called osteonecrosis or bone infarction, is death of bone tissue due to interruption of the blood supply. Early on, there may be no symptoms. Gradually joint pain may develop which may limit the ability to move. Co ...

of the femoral head occurs frequently (20%) in intracapsular hip fractures, because the blood supply is interrupted.

Malunion A malunion is when a fractured bone does not heal properly. Some ways that it shows is by having the bone being twisted, shorter, or bent. Malunions can occur by having the bones improperly aligned when immobilized, having the cast taken off to ...

, 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 Varus may refer to: * Var River or Varus, a river in France * Stura di Lanzo or Varus, a river in Italy * Varus deformity, a medical term for the inward angulation of the distal segment of a bone or joint ** Coxa vara, affecting the hip ** Genu varu ...

valgus deformity A valgus deformity is a condition in which the bone segment distal Standard anatomical terms of location are used to unambiguously describe the anatomy of animals, including humans. The terms, typically derived from Latin or Greek roots, des ...

, 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. Hip fractures rarely result in

neurological Neurology (from el, νεῦρον (neûron), "string, nerve" and the suffix -logia, "study of") is the branch of medicine dealing with the diagnosis and treatment of all categories of conditions and disease involving the brain, the spinal ...

vascular The blood vessels are the components of the circulatory system that transport blood throughout the human body. These vessels transport blood cells, nutrients, and oxygen to the tissues of the body. They also take waste and carbon dioxide away f ...

injury.

Medical

Many people are unwell before breaking a hip; it is common for the break to have been caused by a

fall Autumn, also known as fall in American English and Canadian English, is one of the four temperate seasons on Earth. Outside the tropics, autumn marks the transition from summer to winter, in September (Northern Hemisphere) or March ( Southe ...

due to some illness, especially in the elderly. Nevertheless, the stress of the injury, and a likely surgery, increases the risk of medical illness including

heart attack A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops to the coronary artery of the heart, causing damage to the heart muscle. The most common symptom is chest pain or discomfort which may tr ...

stroke A stroke is a medical condition in which poor blood flow to the brain causes cell death. There are two main types of stroke: ischemic, due to lack of blood flow, and hemorrhagic, due to bleeding. Both cause parts of the brain to stop functionin ...

, and chest infection. Hip fracture patients are at considerable risk for thromboemoblism, blood clots that dislodge and travel in the bloodstream.

Deep venous thrombosis Deep vein thrombosis (DVT) is a type of venous thrombosis involving the formation of a blood clot in a deep vein, most commonly in the legs or pelvis. A minority of DVTs occur in the arms. Symptoms can include pain, swelling, redness, and enla ...

(DVT) is when the blood in the leg veins clots and causes pain and swelling. This is very common after hip fracture as the circulation is stagnant and the blood is hypercoagulable as a response to injury. DVT can occur without causing symptoms. A

pulmonary embolism Pulmonary embolism (PE) is a blockage of an pulmonary artery, artery in the lungs by a substance that has moved from elsewhere in the body through the bloodstream (embolism). Symptoms of a PE may include dyspnea, shortness of breath, chest pain p ...

(PE) occurs when clotted blood from a DVT comes loose from the leg veins and passes up to the lungs. Circulation to parts of the lungs is cut off which can be very dangerous. Fatal PE may have an incidence of 2% after hip fracture and may contribute to illness and mortality in other cases.

Mental confusion In medicine, confusion is the quality or state of being bewildered or unclear. The term "acute mental confusion"

is extremely common following a hip fracture. It usually clears completely, but the disorienting experience of pain, immobility, loss of independence, moving to a strange place, surgery, and drugs combine to cause

delirium Delirium (also known as acute confusional state) is an organically caused decline from a previous baseline of mental function that develops over a short period of time, typically hours to days. Delirium is a syndrome encompassing disturbances in ...

or accentuate pre-existing

dementia Dementia is a disorder which manifests as a set of related symptoms, which usually surfaces when the brain is damaged by injury or disease. The symptoms involve progressive impairments in memory, thinking, and behavior, which negatively affe ...

Urinary tract infection A urinary tract infection (UTI) is an infection that affects part of the urinary tract. When it affects the lower urinary tract it is known as a bladder infection (cystitis) and when it affects the upper urinary tract it is known as a kidney ...

(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

pressure sores Pressure ulcers, also known as pressure sores, bed sores or pressure injuries, are localised damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in combi ...

on the sacrum and heels of patients with hip fractures. Whenever possible, early mobilization is advocated; otherwise, alternating pressure mattresses should be used.

Risk factors

Hip fracture following a fall is likely to be a

pathological fracture A pathologic fracture is a bone fracture caused by weakness of the bone structure that leads to decrease mechanical resistance to normal mechanical loads. This process is most commonly due to osteoporosis, but may also be due to other pathologies ...

. The most common causes of weakness in bone are: *

Osteoporosis Osteoporosis is a systemic skeletal disorder characterized by low bone mass, micro-architectural deterioration of bone tissue leading to bone fragility, and consequent increase in fracture risk. It is the most common reason for a broken bone ...

. * Other

metabolic bone disease Metabolic bone disease is an abnormality of bones caused by a broad spectrum of disorders. Most commonly these disorders are caused by deficiencies of minerals such as calcium, phosphorus, magnesium or vitamin D leading to dramatic clinical disord ...

s such as Paget's disease,

osteomalacia Osteomalacia is a disease characterized by the softening of the bones caused by impaired bone metabolism primarily due to inadequate levels of available phosphate, calcium, and vitamin D, or because of resorption of calcium. The impairment of bone ...

osteopetrosis Osteopetrosis, literally "stone bone", also known as marble bone disease or Albers-Schönberg disease, is an extremely rare Biological inheritance, inherited disease, disorder whereby the bones harden, becoming Density, denser, in contrast to mor ...

and

osteogenesis imperfecta Osteogenesis imperfecta (; OI), colloquially known as brittle bone disease, is a group of genetic disorders that all result in bones that break easily. The range of symptoms—on the skeleton as well as on the body's other organs—may be mi ...

Stress fracture A stress fracture is a fatigue-induced bone fracture caused by repeated stress over time. Instead of resulting from a single severe impact, stress fractures are the result of accumulated injury from repeated submaximal loading, such as running or ...

s may occur in the hip region with metabolic bone disease. * Elevated levels of homocysteine, a toxic 'natural' amino acid. * Benign or malignant primary

bone tumor A bone tumor is an abnormal growth of tissue in bone, traditionally classified as noncancerous (benign) or cancerous (malignant). Cancerous bone tumors usually originate from a cancer in another part of the body such as from lung, breast, thyroi ...

s are rare causes of hip fractures. *

Metastatic Metastasis is a pathogenic agent's spread from an initial or primary site to a different or secondary site within the host's body; the term is typically used when referring to metastasis by a cancerous tumor. The newly pathological sites, then, ...

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 Tobacco smoking is the practice of burning tobacco and ingesting the resulting smoke. The smoke may be inhaled, as is done with cigarettes, or simply released from the mouth, as is generally done with pipes and cigars. The practice is believed ...

(associated with osteoporosis).

Mechanism

Functional anatomy

The

hip joint In vertebrate anatomy, hip (or "coxa"Latin ''coxa'' was used by Celsus in the sense "hip", but by Pliny the Elder in the sense "hip bone" (Diab, p 77) in medical terminology) refers to either an anatomical region or a joint. The hip region is ...

is a

ball-and-socket joint The ball-and-socket joint (or spheroid joint) is a type of synovial joint in which the ball-shaped surface of one rounded bone fits into the cup-like depression of another bone. The distal bone is capable of motion around an indefinite number of ...

. The femur connects at the

acetabulum The acetabulum (), also called the cotyloid cavity, is a concave surface of the pelvis. The head of the femur meets with the pelvis at the acetabulum, forming the hip joint. Structure There are three bones of the ''os coxae'' (hip bone) that c ...

of the pelvis and projects laterally before angling medially and inferiorly to form the knee. Although this joint has three

degrees of freedom Degrees of freedom (often abbreviated df or DOF) refers to the number of independent variables or parameters of a thermodynamic system. In various scientific fields, the word "freedom" is used to describe the limits to which physical movement or ...

, it is still stable due to the interaction of

ligaments A ligament is the fibrous connective tissue that connects bones to other bones. It is also known as ''articular ligament'', ''articular larua'', ''fibrous ligament'', or ''true ligament''. Other ligaments in the body include the: * Peritoneal li ...

and

cartilage Cartilage is a resilient and smooth type of connective tissue. In tetrapods, it covers and protects the ends of long bones at the joints as articular cartilage, and is a structural component of many body parts including the rib cage, the neck an ...

. The labrum lines the circumference of the acetabulum to provide stability and shock absorption. Articular cartilage covers the concave area of acetabulum, providing more stability and shock absorption. Surrounding the entire joint itself is a capsule secured by the tendon of the

psoas muscle The psoas major ( or ; from grc, ψόᾱ, psóā, muscles of the loins) is a long fusiform muscle located in the lateral lumbar region between the vertebral column and the brim of the lesser pelvis. It joins the iliacus muscle to form the il ...

and three ligaments. The iliofemoral, or Y, ligament is located anteriorly and serves to prevent hip

hyperextension Motion, the process of movement, is described using specific anatomical terms. Motion includes movement of organs, joints, limbs, and specific sections of the body. The terminology used describes this motion according to its direction relative ...

. The

pubofemoral ligament The pubofemoral ligament (pubocapsular ligament) is a ligament on the inferior side of the hip joint. This ligament is attached, above, to the obturator crest and the superior ramus of the pubis; below, it blends with the capsule and with the d ...

is located anteriorly just underneath the

iliofemoral ligament The iliofemoral ligament is a ligament of the hip joint which extends from the ilium to the femur in front of the joint. It is also referred to as the Y-ligament (see below). the ligament of Bigelow, the ligament of Bertin and any combinations ...

and serves primarily to resist abduction,

extension Extension, extend or extended may refer to: Mathematics Logic or set theory * Axiom of extensionality * Extensible cardinal * Extension (model theory) * Extension (predicate logic), the set of tuples of values that satisfy the predicate * E ...

, and some

external rotation Motion, the process of movement, is described using specific anatomical terms. Motion includes movement of organs, joints, limbs, and specific sections of the body. The terminology used describes this motion according to its direction relative ...

. Finally the

ischiofemoral ligament The ischiofemoral ligament (ischiocapsular ligament, ischiocapsular band) consists of a triangular band of strong fibers on the posterior side of the hip joint. Its fibers span from the ischium at a point below and behind the acetabulum to blend wi ...

on the posterior side of the capsule resists

adduction Motion, the process of movement, is described using specific anatomical terms. Motion includes movement of organs, joints, limbs, and specific sections of the body. The terminology used describes this motion according to its direction relative ...

, and

internal rotation Motion, the process of movement, is described using specific anatomical terms. Motion includes movement of organs, joints, limbs, and specific sections of the body. The terminology used describes this motion according to its direction relative ...

. When considering the biomechanics of hip fractures, it is important to examine the mechanical loads the hip experiences during low energy falls.

Biomechanics

The hip joint is unique in that it experiences combined mechanical loads. An axial load along the shaft of the

results in

compressive stress In long, slender structural elements — such as columns or truss bars — an increase of compressive force ''F'' leads to structural failure due to buckling at lower stress than the compressive strength. Compressive stress has stress units (fo ...

. Bending load at the neck of the femur causes

tensile stress In continuum mechanics, stress is a physical quantity. It is a quantity that describes the magnitude of forces that cause deformation. Stress is defined as ''force per unit area''. When an object is pulled apart by a force it will cause elonga ...

along the upper part of the neck and

along the lower part of the neck. While

osteoarthritis Osteoarthritis (OA) is a type of degenerative joint disease that results from breakdown of joint cartilage and underlying bone which affects 1 in 7 adults in the United States. It is believed to be the fourth leading cause of disability in the w ...

and

are associated with

bone fracture A bone fracture (abbreviated FRX or Fx, Fx, or #) is a medical condition in which there is a partial or complete break in the continuity of any bone in the body. In more severe cases, the bone may be broken into several fragments, known as a '' ...

as we age, these diseases are not the cause of the fracture alone. Low energy falls from standing are responsible for the majority of fractures in the elderly, but fall direction is also a key factor. Elderly tend to fall to the side as instead of forward, and the lateral hip and strikes the ground first. During a sideways fall, the chances of hip fracture see a 15-fold and 12-fold increase in elderly males and females, respectively.

Neurological factors

Elderly individuals are also predisposed to hip fractures due to many factors that can compromise

proprioception Proprioception ( ), also referred to as kinaesthesia (or kinesthesia), is the sense of self-movement, force, and body position. It is sometimes described as the "sixth sense". Proprioception is mediated by proprioceptors, mechanosensory neurons ...

and

balance Balance or balancing may refer to: Common meanings * Balance (ability) in biomechanics * Balance (accounting) * Balance or weighing scale * Balance as in equality or equilibrium Arts and entertainment Film * ''Balance'' (1983 film), a Bulgarian ...

, including medications,

vertigo Vertigo is a condition where a person has the sensation of movement or of surrounding objects moving when they are not. Often it feels like a spinning or swaying movement. This may be associated with nausea, vomiting, sweating, or difficulties w ...

, and

peripheral neuropathy Peripheral neuropathy, often shortened to neuropathy, is a general term describing disease affecting the peripheral nerves, meaning nerves beyond the brain and spinal cord. Damage to peripheral nerves may impair sensation, movement, gland, or or ...

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.

Imaging

Typically,

radiographs Radiography is an imaging technology, imaging technique using X-rays, gamma rays, or similar ionizing radiation and non-ionizing radiation to view the internal form of an object. Applications of radiography include medical radiography ("diagnos ...

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. 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. A case demonstrating a possible order of imaging in initially subtle findings: File:X-ray of subtle compressive hip fracture, labeled.jpg, X-ray showing a suspected compressive subcapital fracture as a radiodense line File:CT of subtle compressive hip fracture.jpg, CT scan shows the same, atypical for a fracture since the cortex is coherent File:T1 TSE MRI of hip fracture.jpg, T1-weighted,

turbo spin echo An MRI sequence in magnetic resonance imaging (MRI) is a particular setting of pulse sequences and pulsed field gradients, resulting in a particular image appearance. A multiparametric MRI is a combination of two or more sequences, and/or includ ...

MRI Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body. MRI scanners use strong magnetic fields, magnetic field gradients, and radio waves ...

confirms 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

$Hip fracture classification$ X-rays of the affected hip usually make the diagnosis obvious; AP (anteroposterior) and lateral views should be obtained. Trochanteric fractures are subdivided into either intertrochanteric (between the greater and

lesser trochanter The lesser trochanter is a conical posteromedial bony projection of the femoral shaft. it serves as the principal insertion site of the iliopsoas muscle. Structure The lesser trochanter is a conical posteromedial projection of the shaft of the fe ...

) or pertrochanteric (through the trochanters) by the

Müller AO Classification of fractures The Müller AO Classification of fractures is a system for classifying bone fractures initially published in 1987 by the AO Foundation The AO Foundation is a nonprofit organization dedicated to improving the care of patients with musculoskeletal i ...

. Practically, the difference between these types is minor. The terms are often used synonymously. 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.Page 303
in: Yet, an ''isolated trochanteric fracture'' may not be regarded as a true hip fracture because it is not cross-sectional.

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. These can include environmental factors and medical factors (such as postural hypotension or co-existing disabilities from disease such as

Stroke A stroke is a medical condition in which poor blood flow to the brain causes cell death. There are two main types of stroke: ischemic, due to lack of blood flow, and hemorrhagic, due to bleeding. Both cause parts of the brain to stop functionin ...

Parkinson's disease Parkinson's disease (PD), or simply Parkinson's, is a long-term degenerative disorder of the central nervous system that mainly affects the motor system. The symptoms usually emerge slowly, and as the disease worsens, non-motor symptoms becom ...

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. This is relatively unrecognised consequent of CSM. Additionally, there is some evidence to systems designed to offer protection in the case of a fall.

Hip protectors A hip protector is a specialized form of pants or underwear containing pads (either hard or soft) along the outside of each hip/leg, designed to prevent hip fractures following a fall. Recent developments include the use of double-sided adhesive fi ...

, for example appear to decrease the number of hip fractures among the elderly, but they are often not used.

Management

Most hip fractures are treated surgically by implanting a

prosthesis In medicine, a prosthesis (plural: prostheses; from grc, πρόσθεσις, prósthesis, addition, application, attachment), or a prosthetic implant, is an artificial device that replaces a missing body part, which may be lost through trau ...

. Surgical treatment outweighs the risks of nonsurgical treatment which requires extensive bedrest. Prolonged immobilization increases risk of thromboembolism, pneumonia, deconditioning, and decubitus ulcers. Regardless, the surgery is a major stress, particularly in the elderly. Pain is also significant, and can also result in immobilization, so patients are encouraged to become mobile as soon as possible, often with the assistance of

physical therapy Physical therapy (PT), also known as physiotherapy, is one of the allied health professions. It is provided by physical therapists who promote, maintain, or restore health through physical examination, diagnosis, management, prognosis, patient ...

. Skeletal traction pending surgery is not supported by the evidence.

Regional nerve block Nerve block or regional nerve blockade is any deliberate interruption of signals traveling along a nerve, often for the purpose of pain relief. Local anesthetic nerve block (sometimes referred to as simply "nerve block") is a short-term block, u ...

s are useful for pain management in hip fractures. Peripheral nerve blocks may reduce pain on movement and acute confusional state, may improve time to first mobilisation, and may reduce the risk of postoperative lower respiratory tract infection. Surgery can be performed under general anaesthesia or with neuraxial techniques – choice is based on surgical and patient factors, as outcomes such as mortality and post-procedure complications including pneumonia, MI, stroke or confusion, are not affected by anaesthetic technique.

Red blood cell transfusion Blood transfusion is the process of transferring blood products into a person's circulation intravenously. Transfusions are used for various medical conditions to replace lost components of the blood. Early transfusions used whole blood, but mo ...

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. Waiting until the hemoglobin was less than 8 g/dL or the person had symptoms may increase the risk of heart problems. 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

physiotherapy Physical therapy (PT), also known as physiotherapy, is one of the allied health professions. It is provided by physical therapists who promote, maintain, or restore health through physical examination, diagnosis, management, prognosis, patient ...

is needed to reduce the risk of

pneumonia Pneumonia is an inflammatory condition of the lung primarily affecting the small air sacs known as alveoli. Symptoms typically include some combination of productive or dry cough, chest pain, fever, and difficulty breathing. The severity ...

and skilled rehabilitation and nursing to avoid

and

DVT Deep vein thrombosis (DVT) is a type of venous thrombosis involving the formation of a blood clot in a deep vein, most commonly in the legs or pelvis. A minority of DVTs occur in the arms. Symptoms can include pain, swelling, redness, and enla ...

Most people will be bedbound for several months. Non-operative treatment is now limited to only the most medically unstable or demented patients or those who are nonambulatory at baseline with minimal pain during transfers. Surgery on the same day or day following the break is estimated to reduce postoperative mortality in people who are medically stable.

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. Fractures managed by

closed reduction Reduction is a surgical procedure to repair a Fracture (bone), fracture or Dislocation (medicine), dislocation to the correct alignment. Description When a bone fractures, the fragments lose their alignment in the form of Displacement (Orthopedic ...

can possibly be treated by percutaneously inserted screws. In elderly patients with displaced or intracapsular fractures many surgeons prefer to undertake a

hemiarthroplasty Hip replacement is a surgical procedure in which the hip joint is replaced by a prosthetic implant, that is, a hip prosthesis. Hip replacement surgery can be performed as a total replacement or a hemi (half) replacement. Such joint replacement or ...

, replacing the broken part of the bone with a metal implant. However, in elderly people who are medically well and still active, a

may be indicated. Independently mobile older adults with hip fractures may benefit from a total hip replacement instead of hemiarthroplasty. Traction is contraindicated in femoral neck fractures due to it affecting blood flow to the head of the femur. 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. 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 Reduction is a surgical procedure to repair a Fracture (bone), fracture or Dislocation (medicine), dislocation to the correct alignment. Description When a bone fractures, the fragments lose their alignment in the form of Displacement (Orthopedic ...

may not be satisfactory and open reduction then becomes necessary.Subtypes of trochanteric fractures: The use of open reduction has been reported as 8-13% among pertrochanteric fractures, and 52% among intertrochanteric fractures. * This study cites the following primary source:
Both intertrochanteric and pertrochanteric fractures may be treated by a

dynamic hip screw Dynamic hip screw (DHS) or Sliding Screw Fixation is a type of orthopaedic implant designed for fixation of certain types of hip fractures which allows controlled dynamic sliding of the femoral head component along the construct. It is the most c ...

and plate, or an intramedullary rod. The fracture typically takes 3–6 months to heal. As it is only common in elderly, removal of the

is usually not recommended to avoid unnecessary risk of second operation and the increased risk of re-fracture after implant removal. The most common cause for hip fractures in the elderly is osteoporosis; if this is the case, treatment of the osteoporosis can well reduce the risk of further fracture. Only young patients tend to consider having it removed; the implant may function as a stress riser, increasing the risk of a break if another accident occurs.

Subtrochanteric fractures

Subtrochanteric fractures may be treated with an intramedullary nail or a screw-plate construction and may require traction pre-operatively, though this practice is uncommon. It is unclear if any specific type of nail results in different outcomes than any other type of nail. 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.

Rehabilitation

Rehabilitation has been proven to increase daily functional status. Forty percent of individuals with hip fractures are also diagnosed with

mild cognitive impairment Mild cognitive impairment (MCI) is a neurocognitive disorder which involves cognitive impairments beyond those expected based on an individual's age and education but which are not significant enough to interfere with instrumental activities of ...

which often results in poorer post-surgical outcomes. In such cases enhanced rehabilitation and care models have been shown to have limited positive effects in reducing delirium and hospital length of stay. It is unclear if the use of

anabolic steroid Anabolic steroids, also known more properly as anabolic–androgenic steroids (AAS), are steroidal androgens that include natural androgens like testosterone (medication), testosterone as well as synthetic androgens that are structurally related ...

s effects recovery. 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. 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.

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.

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

. Mal-positioning: The fracture can be fixed and subsequently heal in an incorrect position; especially rotation. This may not be a severe problem or may require subsequent

osteotomy An osteotomy is a surgical operation whereby a bone is cut to shorten or lengthen it or to change its alignment. It is sometimes performed to correct a hallux valgus, or to straighten a bone that has healed crookedly following a fracture. It is ...

surgery for correction.

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 10%. At one year after fracture, this may reach 30%. If the condition is untreated the pain and immobility imposed on the patient increase that risk. Problems such as

and chest infections are all increased by immobility. The prognosis of untreated hip fractures is very poor.

Post operation

Among those affected over the age of 65, 40% are transferred directly to long-term care facilities, long-term rehabilitation facilities, or

nursing home A nursing home is a facility for the residential care of elderly or disabled people. Nursing homes may also be referred to as skilled nursing facility (SNF) or long-term care facilities. Often, these terms have slightly different meanings to in ...

s; most of those affected require some sort of living assistance from family or home-care providers. 50% permanently require

walker Walker or The Walker may refer to: People *Walker (given name) *Walker (surname) *Walker (Brazilian footballer) (born 1982), Brazilian footballer Places In the United States *Walker, Arizona, in Yavapai County *Walker, Mono County, California * ...

s, canes, or crutches for mobility; all require some sort of mobility assistance throughout the healing process. Most of the recovery of walking ability and activities of daily living occurs within 6 months of the fracture. After the fracture about half of older people recover their pre-fracture level of mobility and ability to perform instrumental activities of daily living, while 40–70% regain their level of independence for basic activities of daily living. Among those affected over the age of 50, approximately 25% die within the next year due to complications such as

blood clots A thrombus (plural thrombi), colloquially called a blood clot, is the final product of the blood coagulation step in hemostasis. There are two components to a thrombus: aggregated platelets and red blood cells that form a plug, and a mesh of cr ...

(

deep venous thrombosis Deep vein thrombosis (DVT) is a type of venous thrombosis involving the formation of a blood clot in a deep vein, most commonly in the legs or pelvis. A minority of DVTs occur in the arms. Symptoms can include pain, swelling, redness, and enla ...

infection An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable dise ...

s, and

. 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 Bisphosphonates are a class of drugs that prevent the loss of bone density, used to treat osteoporosis and similar diseases. They are the most commonly prescribed drugs used to treat osteoporosis. They are called bisphosphonates because they ...

to reduce future fracture risk by up to 50%.

Epidemiology

$Hip fracture incidence world map$ 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. One study published in 2001 found that in the US alone, 310,000 individuals were hospitalized due to hip fractures, which can account for 30% of Americans who were hospitalized that year. Another study found that in 2011, femur neck fractures were among the most expensive conditions seen in US hospitals, with an aggregated cost of nearly $4.9 billion for 316,000 inpatient hospitalizations. Rates of hip fractures are declining in the United States, possibly due to increased use of bisphosphonates and risk management.

Falling Falling or fallin' may refer to: *Falling (physics), movement due to gravity *Falling (accident) *Falling (execution) *Falling (sensation) People * Christine Falling (born 1963), American serial killer who murdered six children Books * ''Fall ...

, poor vision, weight, and height are all seen as

risk factors In epidemiology, a risk factor or determinant is a variable associated with an increased risk of disease or infection. Due to a lack of harmonization across disciplines, determinant, in its more widely accepted scientific meaning, is often use ...

. Falling is one of the most common risk factors for hip fractures. Approximately 90% of hip fractures are attributed to falls from standing height. 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.

Population

All populations experience hip fractures but numbers vary with race, gender, and age. Women have three times as many hip fractures as men. In a lifetime, men have an estimated 6% risk whereas postmenopausal women have an estimated 14% risk of having a hip fracture. 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. 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.

Age related

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, which is the most frequent cause of hospitalization in centenarians, overcoming congestive heart failure and respiratory infection. 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 Mortality is the state of being mortal, or susceptible to death; the opposite of immortality. Mortality may also refer to: * Fish mortality, a parameter used in fisheries population dynamics to account for the loss of fish in a fish stock throug ...

is seen from 12 to 37%. For those remaining patients, half of them need assistance and cannot live independently. Also, older adults sustain hip fractures because of

, 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.Baumgaertner MR, Higgins TF. (2002) "Femoral Neck Fractures." ''Rockwood & Green's Fractures in Adults''. pp. 1579-1586.

References

External links

Fractures of the Femoral Neck
Wheeless Textbook of Orthopaedics
Intertrochanteric Fractures
Wheeless' Textbook of Orthopaedics {{DEFAULTSORT:Hip Fracture Bone fractures Injuries of hip and thigh Wikipedia medicine articles ready to translate