Hip Fracture Disease

BASICS

DESCRIPTION

Fracture of the head or neck of the femur, usually as the result of a fall

Types
- Neck, subcapital or transcervical
- Intertrochanteric
- Subtrochanteric; usually caused by more severe trauma and has higher incidence in males than the other types
System(s) affected: Musculoskeletal
Genetics: No known genetic factor
Incidence/Prevalence in USA:
- 200,000 patients per year over the age of 65 have fracture of hips
- In women over age 75, there is a 1% incidence per year
Predominant age: 80% occur in those over age 60
Predominant sex: Female > Male

SIGNS AND SYMPTOMS

Pain in hip. If severe, it usually indicates a displaced fracture. Mild pain usually occurs in non-displaced fractures.
Pain in knee. Pain is referred from hip and may occur in absence of hip pain.
External rotation of leg
Shortening of leg

CAUSES

Falls
Motor vehicle trauma
Spontaneous in pathologic conditions

RISK FACTORS

Osteoporosis, usually post menopausal
Metastatic cancer
Neurological disease
Severe renal disease with secondary hyperparathyroidism
Use of long-acting sedatives and hypnotics in the elderly

DIAGNOSIS

LABORATORY

Routine pre-operative laboratory including CBC, chemical profile, electrolytes

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

Osteoporosis

SPECIAL TESTS

N/A

IMAGING

X-rays - AP and "frog leg" lateral of hip
X-ray AP pelvis to rule out pelvis fracture as cause of pain. Also provides information regarding appearance of opposite side.
X-ray remainder of femur to include knee
X-ray any other tender or painful area as other fractures are common and symptoms may be ignored with severe pain of hip fracture
CT or MRI scans are not routinely indicated as the diagnosis is usually obvious from plain radiographs

DIAGNOSTIC PROCEDURES

N/A

TREATMENT

APPROPRIATE HEALTH CARE

Treat as semi-emergency
During transportation to hospital, gentle traction of the leg, especially Buck's traction 5# will help relieve discomfort. This can be maintained in bed, but requires close observation of circulation and skin changes.

GENERAL MEASURES

Medical evaluation to have patient in best possible condition before surgery
Surgery is almost always indicated. Older patients do not tolerate long periods of bed confinement.
Protect pressure points to avoid decubitus ulcers, especially on the sacrum, heels and malleoli

SURGICAL MEASURES

A hip prosthesis or pins are used in neck fractures. Nails or screws with side plates are used in intertrochanteric fractures. For subtrochanteric fractures, a nail with a long side plate, or intermedullary hip screws, or reconstructive rods may be used.

ACTIVITY

Patients should be up (for toilet, and prevention of deep vein thrombosis and decubiti) as soon as possible after surgery, usually the next day
Ambulate as soon as possible after surgery, e.g., with use of a walker. Close supervision by an experienced therapist necessary.

DIET

No special diet

PATIENT EDUCATION

Refer to physical therapy for walking instructions; usually non-weight bearing for several weeks at least

FOLLOW UP

PREVENTION/AVOIDANCE

Prophylactic treatment for osteoporosis
Avoid long-acting sedatives and hypnotics in the elderly
Use walking canes or walkers if patient has unsteady gait
Have older people use proper chair for sitting. Should not allow hip flexion greater than 90 degrees since rising from this position requires external rotation of the extremity with subsequent torsional forces which can cause fracture.
Use sturdy rails in showers, bathrooms, stairs, or ramps

POSSIBLE COMPLICATIONS

Mental deterioration. Present in 90% of older patients for varying periods of time after surgery. Usually subsides, but may persist due to pre-existing arteriosclerosis.
Infection. More common in comminuted fractures and patients with diabetes. Surgical implants should be left in place and antibiotics given as indicated by culture and sensitivity. Some require the wound to be opened and drained.
Aseptic necrosis of femoral head. Occurs in 25-30% of femoral neck fractures. Treatment requires a prosthetic replacement in older patients.
Phlebitis. Prophylaxis with ´warfarin´ (Coumadin) to keep INR 2.0-2.5 or pro-time 15-18 scc - for at least 4 weeks; or ´enoxaparin´ (Lovenox) 30 mg SQ q12h beginning 12 hours after surgery and continuing until patient is mobile
Nonunion
- In case of neck fractures, a prosthetic replacement is indicated
- In the intertrochanteric fracture, a bone graft, usually with replacement of the nail and plate, is indicated

EXPECTED COURSE AND PROGNOSIS

Hip fractures remain a serious injury in older people. There is a 15-20% three month mortality in trochanteric fractures and 10% in neck fractures.
Sixty-five percent of patients can be expected to return to their former state of health

MISCELLANEOUS

ASSOCIATED CONDITIONS

Osteoporosis
Metastatic malignancy

AGE-RELATED FACTORS

Pediatric: N/A
Geriatric: Hip fractures common in geriatric age group
Others: N/A

PREGNANCY

N/A

OTHER NOTES

None

ABBREVIATIONS

N/A

Clinical Investigations

ROLE OF HOMOEOPATHY

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