• Refers to fractures of the proximal femur
• 60,000 hip fractures occur per year in the United Kingdom
• Mean age of patient is 80 years
• Incidence increases exponentially above the age of 65 years
• Main risk factors are female sex and osteoporosis

Clinical features

• Usually occurs following a fall
• Patient usually has other significant co-morbidity
• Main symptom is hip pain and inability to weight bear
• The leg is shortened and externally rotated
• Diagnosis confirmed by AP and lateral x-ray
• Impacted undisplaced fractures may present diagnostic difficulty

Garden classification

• Stage 1 - incomplete or impacted fracture
• Stage 2 - complete fracture with no displacement
• Stage 3 - complete fracture with partial displacement
• Stage 4 - complete fracture with full displacement

'Practical' classification

• Fractures best separated into intracapsular and extracapsular fractures
• Intracapsular fractures reduce the blood supply to femoral head
• At high risk of delayed union, non-union or avascular necrosis
• If head is to be preserved they need anatomical reduction
• Extracapsular fractures do not interfere with femoral head blood supply
• Do not require anatomical reduction

Management

• All patients require surgery if fit for an operation
• Early mobilisation is associated with improved long-term prognosis
• Ideally surgery should be performed within 24 hours
• Postoperative rehabilitation should be by a multidisciplinary team

Intracapsular fractures

• The two treatment options are:
  • Reduction and internal fixation
  • Femoral head replacement
• Internal fixation indicated in:
  • Undisplaced fractures
  • Displaced fractures in young patients (<70 years)
• Usually achieved with the use of three cancellous screws
• Complications include non-union and avascular necrosis
• Femoral head replacement indicated in:
  • Displaced fractures
  • Pathological fractures
• Options available include:
  • Cemented Thompson prosthesis
  • Uncemented Austin Moore prosthesis
  • Bipolar prosthesis
  • Total hip replacement
• Complications include dislocation, loosening and peri-prosthetic femoral fracture

Extracapsular fractures

• Usually repaired with a dynamic hip screw
• Allows impaction and stabilisation of fracture
• Prognosis related to the number of bone fragments
• 90% of fractures proceed to uncomplicated fracture union

Prognosis

• 40% of patients with a hip fracture die within a year
• 50% of survivors are less independent than before the injury
• Most morbidity is related to coexisting medical conditions

Bibliography

Lane J M,  Russell L,  Khan S N.  Osteoporosis.  Clin Orthop 2000;  372:  139-150.

Parker M J,  Handoll H H.  Conservative versus operative treatment of extracapsular hip fractures.  Cochrane Database Syst Rev 2000 (2):  CD000337.

Parker M.  Diagnosis and immediate care of fractured neck of femur.  Hosp Med 2002;  63:  42-43.

Schmidt A H,  Swiontkowski M F.  Femoral neck fractures.  Orthop Clin North Am 2002;  33:  97-111.