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Hip Fracture

Epidemiology: Osteoporosis related
1. U.S. Incidence of hip Fracture at age 65
  1. Overall: 250,000 per year
  2. Men: 4-5 per 1,000
  3. Women: 8-10 per 1,000
2. Worldwide gender distribution of hip Fracture
  1. Men: 30%
  2. Women: 70%
3. Morbidity and Mortality
  1. Mortality 20% within 1 year hip Fracture
    1. Men: 31% mortality in 1 year
    2. Women: 17% mortality in 1 year
  2. ADL assistance needed in 50% of hip Fractures
  3. Long term care needed in 25% of hip Fractures
4. References
  1. Cooper (1992) Osteoporos Int 2:285
  2. Forsen (1999) Osteoporos Int 10:73
Risk Factors
1. Osteoporosis
Hip Fracture Types
1. Intracapsular Fracture: Femoral Neck Fracture
  1. Subcapital Femur Fracture (proximal neck Fracture)
  2. Transcervical neck Fracture (mid-neck Fracture)
2. Extracapsular Fracture
  1. Intertrochanteric Fracture
  2. Subtrochanteric Fracture
  3. Femoral Shaft Fracture
  4. Trochanteric Fracture (Hip Avulsion Fracture)
    1. Greater trochanteric Fracture
    2. Lesser trochanteric Fracture
3. Stress Fractures
Symptoms
1. Severe Hip Pain
2. Unable to ambulate (or painful gait)
Signs
1. Shortened limb on Fracture side
2. Hip externally rotated and abducted
3. Tenderness to palpation over injured hip
4. Limited range of motion
  1. Do not test ROM unless XRay normal
  2. Resisted passive range of motion
Imaging
1. Hip Xray
  1. Usually identifies Fracture
2. Hip MRI (T1-weighted)
  1. Indicated for high suspicion despite normal XRay
  2. Test Sensitivity: 100%
  3. Does not require delay after injury
3. Hip Bone Scan with Technetium Tc99m Polyphosphate
  1. Test Sensitivity: 98%
  2. Delay scan at least 72 hours after time of injury
Differential Diagnosis
1. See Hip Pain
Management: General
1. See specific Fracture management
2. Early surgery within 48 hours lowers risk
  1. Lowers 1 year mortality and Pulmonary Embolism risk
  2. Stabilize comorbidities within 72 hours if unstable
3. Thromboembolic Prevention
  1. See DVT Prevention in Perioperative Period
4. Prevention of infection
  1. See Surgical Antibiotic Prophylaxis
  2. Remove Foley Catheter within 24 hours of surgery
5. Prevention of Delirium
  1. Observe for medical causes
    1. Electrolyte abnormalities
    2. Inadequate pain control
    3. Occult infection
  2. Avoid medications predisposing to Delirium
    1. Avoid Polypharmacy
    2. Avoid anticholinergics
  3. Consider treatment if no cause identified
    1. Low dose Haloperidol, Risperidone, Olanzapine
6. Surgical care is appropriate even at end of life
  1. Pain control is significantly improved after repair
  2. Actual intraoperative risk is low
    1. Complications are typically post-operative
Management: Rehabilitation
1. Evaluate for skilled nursing facility on day 1 post-op
  1. Prefracture functionality poor (e.g. ADLs difficult)
  2. Impaired cognitive function
  3. Patient can perform therapy 2-3 hours daily
2. Protocol
  1. Day 1: Quadriceps contractions, Gentle hip ROM
  2. Day 2-3: Parallel bars
  3. Day 3-5: Advance to weight bearing with walker/cane
3. Assistive Devices
  1. See Canes
  2. See Walkers
Prevention
1. See Osteoporosis Prevention
2. See Fall Prevention in the Elderly
3. Physical Activity reduces hip Fracture risk
  1. Walking 4 hours per week or more (55% reduction)
  2. Dose dependent effect: 6% reduction per MET-hour/week
  3. Standing 10 hours per week also reduced risk
  4. Feskanich (2002) JAMA 288:2300
References
1. Gurr in Marx (2002) Rosen's Emergency Med, p. 655-60
2. Huddleston (2001) Mayo Clin Proc 76:295
3. Brunner (2003) Am Fam Physician 67(3):537
4. Rao (2006) Am Fam Physician 73(12):2195

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This page was written by Scott Moses, MD. This page was last revised before 5/10/08, prior to consistent tracking of revision date. This page was last published on 6/1/2008. Please send comments and questions to the editor. Contact information may be found on the page About the Family Practice Notebook. These pages are best viewed with Microsoft Internet Explorer 6.0.