[ Up ] [ Fractures & joint injuries ] [ Delayed union ] [ Common & eponymous fractures ] [ Hip fractures ] [ Peripheral nerve injuries ] [ Paediatric fractures ] [ Bone graft ] [ Degenerative and rheumatoid arthritis ] [ Osteoporosis ] [ Metabolic bone disease ] [ Paget's disease of bone ] [ Hip replacement surgery ] [ Infected joint replacement ] [ The shoulder ] [ Upper limb disorders ] [ The hand ] [ Lower limb ] [ The knee ] [ The foot ] [ Acute osteomyelitis ] [ Septic arthritis ] [ Other bone infections ] [ Low back pain ] [ Spinal cord compression ] [ Scoliosis ] [ Thoracic outlet compression syndrome ] [ Primary bone tumours ] [ Bone metastases ] [ Multiple myeloma ]

Hip fractures

  • 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

A displaced intracapsular hip fracture (Garden IV)

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.

Parker M,  Johansen A.  Hip fracture.  BMJ 2006:  333:  27-30.

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

 

 
 

Last updated: 05 January 2008

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