Hip fractures are a common emergency among the geriatric population, with 90% of these occurring in people over 65 years old.  In the last decade, there were only an estimated 250,000 fractures per year in the United States, with an upward trend because of aging people . Classically, these injuries are caused by low-energy falls from one’s own height, but they can also occur in younger people as a result of high-energy accidents. The burden to society remains high despite available options to prevent hip fractures: an 8-36% excess in mortality within 1 year (higher in women) , problems to the family and the people around the patient, and high costs to the healthcare system (estimated to be 17-20 billion per year) .
The purpose of this article is to explore the different types of fractures in the hip joint emphasising femoral neck and trochanteric fractures, how to perform an uneventful diagnostic, the initial clinical management and briefly outline the different surgical treatment options.
The hip joint, or coxofemoral joint, is a ball and socket joint, the articulation between the proximal epiphysis of the femur (the femoral head) and the acetabulum in the pelvis. However, when we talk about Hip Fractures, we refer to fractures involving any part of this proximal epiphysis or metaphysis of the femur, which includes the femoral head, the femoral neck, and the trochanters. Figure 1.
Case example: A 75-year-old female presents to the emergency department after a mechanical fall in the grocery store parking lot. Her leg is shortened and externally rotated. She can not bear weight nor sit without pain. Radiographs demonstrate a displaced femoral neck fracture. Upon further questioning, she states she is active, plays golf twice a week, and does not use assistive devices. She denies antecedent hip pain. Radiographs and CT scans are obtained, shown in Figure 2. The patient is admitted to the hospital and will be taken tomorrow to the OR to perform a Total Hip Arthroplasty.
Approximately 1.6 million hip fractures occur worldwide yearly, by 2050, this number could reach between 4.5 million and 6.3 million. Countries with the higher incidence are the United States and Scandinavian countries .
Age is the leading risk factor for hip fractures; the incidence of hip fractures increases exponentially with age: 52% of hip fractures occur after the age of 80 years and 90% after the age of 65 years .
Femoral neck and Pertrochanteric fractures are the most common among all hip fractures, and they occur mainly in the elderly with a similar overall incidence. Women are more prone to suffer a hip fracture (some studies show more than double the incidence), and Caucasians are at higher risk. In caucasian women, the lifetime risk of hip fracture is 1 in 6. A 50-year-old woman has a 2.8% risk of death related to hip fracture during her remaining lifetime. Moreover, up to 20% of patients die in the first year following hip fractures, mainly due to pre-existing medical conditions. Less than half of those who survive the hip fracture regain their previous level of function .
On the other hand, femoral head fractures are rare traumatic injuries that are usually associated with hip dislocations and high mortality and disability rate, occurring primarily at younger ages and caused by high-energy trauma.
The decline in bone mineral density and the increase in the frequency of falls in elderly people are mainly responsible for this high incidence. Only 1% of falls lead to a hip fracture, but 90% of these fractures are related to a fall from a standing height or less.
In contrast, young people are prone to suffer high-energy accidents resulting in hip fractures and dislocations.
Hip fractures can be divided into Intracapsular or medial (within the limits of the capsule insertion), which are femoral head and femoral neck fractures, or Extracapsular or lateral (pertrochanteric/intertrochanteric fractures).
Femoral neck fractures can be classified with Pauwel’s classification , which describes the horizontality of the fracture line or more commonly classified with Garden’s classification, which is based on the displacement of the fracture on an AP x-ray image  (Table 1) (Figure 2).
Table 1. Garden classification for femoral neck fractures.
|1||Incomplete fracture (or valgus impacted)|
|2||Complete fracture, not displaced|
|3||Complete fracture, partially displaced|
|4||Complete fracture, fully displaced|
For lateral fractures there are many classifications (Evans, Tronzo, AO, among other classifications), but the AO Classification  (which corresponds to the 31A type fractures) demonstrated better reliability among physicians  (Table 2).
Table 2. AO classification for femoral intertrochanteric/pertrochanteric fractures.
|31-A1||simple (two-part) fractures, with the typical oblique fracture line extending from the greater trochanter to the medial cortex; the lateral cortex of the greater trochanter remains intact.|
|31-A2||fractures are comminuted with a posteromedial fragment; the lateral cortex of the greater trochanter, however, remains intact. Fractures in this group are generally unstable, depending on the size of the medial fragment
|31-A3||fractures are those in which the fracture line extends across both the medial and lateral cortices; this group includes the reverse obliquity pattern or subtrochanteric extensions.|
And lastly, femoral head fractures are classified using the classic Pipkin’s classification . Table 3. Figure 3.
Table 3. Pipkin classification for femoral head fractures.
|Type 1||Fracture is below the fovea/ligamentum. Does not involve the weight-bearing portion of the femoral head.|
|Type 2||Fracture is above the fovea/ligamentum, and involves the weight-bearing portion of the femoral head.|
|Type 3||Type 1 or 2 fracture associated with a femoral neck fracture. It has a high incidence of avascular necrosis.|
|Type 4||Type 1 or 2 fracture associated with an acetabulum fracture, usually the posterior wall.|
Patients with hip fractures will have pain in the hip or groin region, which can be referred to the medial side of the thigh or the knee. They are unable to walk or bear weight on the affected leg and sitting or logrolling elicits pain.
Classically, in the patient with a fractured hip, the affected leg will be shorter and externally rotated. There can be bruises or edema around the hip too.
Otherwise, when a femoral head fracture is associated with a hip dislocation, the affected hip and leg will be in slight flexion, adduction, and internal rotation. Testing of neurovascular structures is essential since hip dislocations are associated with sciatic nerve injuries in 10-20%.
There should be concern about other clinical symptoms and associated lesions in the elderly or polytrauma patients, especially head trauma and femoral shaft fractures, with are usually associated with hip fractures.
The first and most valuable studies are Radiographs. The protocol should include at least a pelvic AP radiograph and a full-length ipsilateral femur x-ray to exclude associated femoral shaft fractures. Axial hip images or frog leg pelvis AP can be difficult to obtain since pain is usually severe, but cross-table lateral images can be achieved to address the displacement of the neck in the sagittal plane. Lastly, a traction-internal rotation pelvis AP image can show if the fracture is reducible and stable.
CT scan is helpful in determining displacement and degree of comminution in some patients but is mandatory in those patients with a femoral head fracture (intraarticular injury) or after a hip dislocation.
MRI imaging is useful in those cases where a stress fracture or occult fracture is suspected.
- ATLS protocol should be performed in patients with polytrauma (high energy injuries).
- Perform imaging protocol and confirm the diagnosis.
- After confirming the fracture, the patient should be admitted to the hospital (step-down unit) with absolute bed rest.
- Preoperative order set.
- Hip fracture is an independent risk factor for VTE. Start venous thromboembolism prophylaxis, possibly with Heparin.
- This injury should be considered an emergency; early operative treatment is fundamental. Evidence supports that hip fracture surgery within 48 hours of admission is associated with better outcomes. Even in elderly patients, early surgery within 24 hrs of admission is independently associated with fewer pulmonary complications, failure to extubate, reintubation, and shorter length of stay .
- In the case surgery can not be done in the 48 hours window, consider an anti-rotational short cast or boot or bone traction if the hip is severely displaced (moderate evidence is against the use of traction routinely).
Preoperative medical optimization
- Perform a risk assessment for any comorbidities and attempt to maximally optimize each comorbidity perioperatively.
- Orthogeriatics patients should be co-managed by medicine and surgery, and this has demonstrated a shorter time to surgery . There is strong evidence for the use of an interdisciplinary care program in those patients with mild to moderate dementia to improve functional outcomes. Co-managed patients had lower mortality at 1 year .
- Consider regional analgesia to improve preoperative pain control (i.e epidural analgesia) when the patient arrives at the ER.
- Limited evidence supports not delaying hip fracture surgery for patients on aspirin and/or clopidogrel
- Limited evidence supports the preoperative assessment of serum levels of albumin and creatinine for risk assessment of hip fracture patients
- Tranexamic acid (TXA) is used at the beginning of the surgery and in the end to decrease perioperative bleeding and blood transfusion.
Femoral neck fractures
Several options exist for the treatment of femoral neck fractures, ranging from internal fixation to arthroplasty. AAOS recommends the use of internal fixation for stable, non-displaced fractures and arthroplasty for displaced fractures (in the elderly).
Fixation with cannulated screws is indicated in patients with nondisplaced transcervical fractures (Garden I) in physiologically young patients, or displaced transcervical fractures in young patients (Figure 4). The reduction must be anatomic, open reduction may be necessary. A sliding hip screw (SHS) is indicated for basicervical fractures or vertical lines in young patients. SHS is associated with lower reoperation rates compared to cannulated screws .
Moderate evidence supports a benefit to total hip arthroplasty in properly selected patients with unstable (displaced) femoral neck fractures. The use of femoral cemented stems is recommended in femoral neck fractures. Hemiarthroplasty indications are controversial and should be considered in debilitated elderly patients or with metabolic bone disease. Outcomes of unipolar and bipolar hemiarthroplasty for unstable (displaced) femoral neck fractures are similar (Figure 5). Total hip arthroplasty is reserved for older active patients or patients with pre-existing hip osteoarthritis because outcomes include more predictable pain relief and better functional outcomes than hemiarthroplasty .
Femoral intertrochanteric fractures
Rich collateral circulation reduces the risk of non-union and avascular necrosis; therefore, internal fixation is the preferred treatment for lateral hip fractures. In stable intertrochanteric fractures, the use of either a sliding hip screw (SHS) or a cephalomedullary nail (CMN) is recommended. In unstable fractures and reverse obliquity fractures, a cephalomedullary nail (CMN) device is preferred (Figure 6). Arthroplasty indications are rare and include salvage for failed internal fixation, severely comminuted fractures, pre-existing severe hip arthritis, or severely osteoporotic bone that is unlikely to hold internal fixation.
In femoral neck fractures incidence of osteonecrosis is 10-45% and is associated with a non-anatomical reduction and the initial displacement . Non-union incidence is 5-30% and is associated with displaced fractures and varus malreduction. Dislocation after arthroplasty is common, too, with an incidence of 10% approximately. Internal fixation failure can be as high as 46% in the elderly population.
For intertrochanteric fractures, implant failure and cutout occur in 4-20% and are associated with older age, osteoporosis, quality of reduction, and screw positioning. Nonunion is much lower than in femoral neck fractures (<2%). 30% of patients will have hemoglobin lower than 8mg/dl requiring transfusion.
Mortality risk after the first year following fracture is 15-30%. More than 80% of those not treated operatively will die in the first year. Risk factors for high mortality include male gender, intertrochanteric fracture, operative delay of two days or more, older than 85 years, two or more pre-existing medical conditions, and ASA III or ASA IV preoperative score . 41% of patients will maintain pre-injury ambulatory status. Loss of independence will be noted in 40% of patients, who will require assistive devices, 12% become household ambulators, and 8% will not ambulate anymore .
The author does not report any conflict of interest.
This information is for educational purposes and is not intended to treat disease or supplant medical professional judgment. Physicians should follow local policy regarding the diagnosis and management of medical conditions.
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