Hip Fracture (elderly)

Anatomy

A ‘hip fracture’ is actually a break in the upper quarter of the femur.  An injury to the acetabulum itself is not considered to be a hip fracture.  There are 3 types of hip fracture classified anatomically by where the fracture is.  Each has a different prognosis and requires different management.

  • Intracapsular hip fractures
    • occur at the level of the neck and head of the femur (i.e. within the capsule)
    • If there is damage to the the medial femoral circumflex artery, then there is a risk of avascular necrosis to the femoral head.
  • Trochanteric hip fractures
    • Can be intertrochanteric (i.e. runs between the greater and lesser trochanters of the femur) or pertrochanteric (i.e. the fracture involves both the trochanters, one or both of which may be fractured/separated.  It is more likely to be a comminuted fracture).
    • There is little risk of avascular necrosis in trochanteric fractures which are, effectively, extracapsular.
  • Subtrochanteric hip fracture
    • Occurs below the lesser trochanter (but remains within the upper 1/4 of the femur)

Risk factors/Assessment of risk

  • Age 80+
  • Maternal History of hip fracture
  • Osteoporosis (and its risk factors)
  • Likewise, a history and/or risk factors for Falls
  • Cognitive impairment

Morbidity/Mortality

  • Extremely high rates of morbidity/mortality
    • Mortality of up to 30% within a year (most have contributions from other comorbidities)
    • Up to 20% of patients admitted from home will have to enter institutionalised care
    • Most elderly patients won’t regain the degree of function present prior to the fracture.

Presentation

  • Pain over the hip joint, particularly on weight bearing, which can often radiate to the knee
    • Pain in the knee can be the presenting complaint without any hip pain
  • There may or may not be a history of injury.  More commonly, in the elderly, there can be a history of a simple (fragility) fall.
    • There may also be a history of other (fragility) fractures e.g. Colles fracture, vertebral fracture.
  • On examination, the affected leg is classically shorted, abducted and externally rotated (NB the only exception would be in the case of femoral head fracture with hip dislocation, more commonly the leg is dislocated posteriorly and is found adducted and internally rotated)
    • Testing range of movement will be extremely painful and proceeding with the examination is not really necessary

Investigation

  • A plain film x-ray of the hip is usually diagnostic
  • Note that it is important also to investigate other systems, particularly in elderly patients, in order for surgery and a more detailed prognosis
    • FBC and cross match; Renal assessment (U&Es); LFTs; clotting
    • ECG (definitely) and CXR (dependent on patient)

Management

  • Analgesia should be prescribed early
  • Ideally, surgery should be on the same (or next) day as the presentation
  • NB Traction is NOT recommended prior to surgery
  • For intracapsular fractures
    • If the fracture is displaced (I.e. the head and neck of the femur are not aligned), then hemi-arthroplasty (hip replacement) is recommended
      • NB In younger, fit patients- closed reduction and internal fixation is more appropriate
      • NB in older patients with pre-existing joint disease, reasonable pre-injury mobility and reasonable life-expectancy – a total arthroplasty may be more suitable
    • If the fracture is nondisplaced (i.e. the head and neck are aligned), then internal fixation is the first choice
  • For trochanteric fractures/extracapsular fractures
    • NICE & SIGN recommend using extramedullary internal fixation e.g. sliding hip screw (rather than intramedullary nail fixation)
  • Subtrochanteric fractures should probably be treated using an intramedullary nail

All patients should be closely monitored post-surgery and mobilised as early as possible (as long as they are medically stable).  Post-op physiotherapy rehab should be offered to all patients.

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