Hip Fracture

Definition/Description

A hip fracture occurs when the proximal end of the femur, near the hip joint, is broken.About one-third of elderly people living independently fall every year, with 10% of these falls resulting in a hip fracture.[1]  Such a fracture is a serious injury that occurs mostly in elderly people over 65 years and complications can be life-threatening.[2](level of evidence 1A) The femur is the largest and strongest bone in the body, so it requires a large or high impact force to break. Most femur fractures are the result of a high energy trauma, such as a motor accident, gunshot wound, or jump/fall from a height.[2]However, in an older population, a simple fall may cause a femoral fracture due to reduced bone mineral density. A femoral fracture is a very serious injury and needs 3-6 months to heal.[2] High mortality, long-term disability and huge socio-economic burden are the main consequences of a hip fracture. The biggest risk factors for running up a hip fracture are osteoporosis and cognitive impairment.[2]

Clinically Relevant Anatomy

The hip joint is a ball and socket joint, formed by the head of the femur and the acetabulum of the pelvis.
Figure1 hip fracture.jpeg
The head of the femur is almost ( for ¾ ) shaped like a sphere. The acetabulum is formed by the three parts of the os Coxae. It is a fusion of illium, ischium and pubis. Through this fusion, the acetabulum is shaped like a hemisphere (the inner section of a sphere) thereby the acetabulum is not covering the entire head of the femur.The convex head fits perfectly in the concave socket of the acetabulum forming a synovial joint. From an osteological viewpoint, the proximal end of the femur in four major parts, namely: femoral head, femoral neck, greater trochanter and the lesser trochanter. These parts are most often and most closely involved with hip fractures. The hip joint is a very sturdy joint, due to the tight fitting of the bones and the strong surrounding ligaments and muscles so a hip luxation will less likely take place. ce. ☃☃Hip fractures can be classified into intracapsular (femoral neck) fractures and extracapsular fractures. The intracapsular fractures are contained within the hip capsule itself. Those fractures are subcapital neck fracture and transcervical neck fracture. The extracapsular fractures are intertrochantericic and subtrochanteric fracture. You also have a greater and lesser trochantefracturees[3] (figure1)

Click Hip Anatomy for more details

Epidemiology


In 1990 there were estimated to be 1.66 million hip fractures around the world, and it’s also estimated that this number will rise to 6.26 million in 2050.
It is known that there will be more old people in 2050 than in 1990, this is the biggest cause of the big raise.[4]
Most of the hip fractures occur in North Europe and in the USA, the regions with the least hip fractures are Latin America and Africa. In Asia there is an immediate number of hip fractures. But it’s estimated that most of the hip fractures will occur in Asia by 2050.[5]

Age-standardized hip fracture rates (per 100 000 population) across different continents[5]

Continent

Country

Men

Women

Africa





Rabat

57.7

79.9


Cameroon

43.7

52.1

Asia





Beijing

87

97


Shenyang

101.3

80.9


Korea

137

262


Iran

127.3

164.6


Malaysia

87.4

212.5


Tottori

107.3

297.3


Japan

99.6

368


Kuwait

216.6

316


Singapore

152

402


Hong Kong

193

484.3


Hong Kong

50

110


Taiwan

233.4

496.8

South America





Mexico

98

169


Sobral, Brazil

59.3

168.4


Argentina

137

405


Venezuela

37

98

Europe





Switzeland

137.8

346


Former East Germany

137.8

354.7


Former West Germany

154.5

399.4


England

143.6

418.2


Greece

201.7

469.9


Sweden

302.7

709.5


Norway

352

763.6


Oslo

399.3

920.7


Austria

567

759


Hungary

223

430


The Nederlands

308

669

North America





Minnesota

201.6

511.6


United States

197

516

Oceania





Maori, New Zealand

197

516


Non-Maori

288

827


New South Wales

191.8

475.1


Australia

187.8

504.2


Classification of Hip Fractures

Hip fracture.jpeg

Hip fractures can be classified into intracapsular and extracapsular fractures[6] (figure2).

1) Intracapsular fractures: also known as femoral neck fractures. It occurs within the hip capsule and accounts for 45% of all acute hip fractures in the elderly.[7] It mostly results from a low-impact fall from a standing position or from twisting on a planted foot.[8] Femoral neck fractures are susceptible to malunion and avascular necrosis of the femoral head because of the limited blood supply to the area. Intracapsular fractures are further classified as nondisplaced or displaced based on radiographic findings[9] (figure 3).
Fig5.png
  • Type 1: undisplaced and incomplete fracture
  • Type 2: undisplaced complete fracture
  • Type 3: complete fracture but incompletely displaced
  • Type 4: complete fracture and completely displaced

2) Extracapsular fractures: could be an intertrochanteric fracture or subtronchanteric fracture.

    • Intertrochanteric fracture: occurs between the greater and the lesser trochanter.[6] Majorly occurs in the osteoporotic geriatric population and result from a fall from a standing height with direct contact of the lateral thigh or torsion of the lower extremity. The intertrochanteric region has a good blood supply, avascular necrosis or nonunion is rare.
    • Subtronchanteric fracture: occurs below the lesser trochanter, approximately 2.5 inches below

About 3% of hip fractures are related to localized bone weakness at the fracture site, secondary to tumor, followed by bone cysts, or Paget’s disease. More than half of the remaining patients have osteoporosis, and nearly all are osteopenia[10]

Etiology

A substantial portion of the population is at risk of hip fracture by virtue of low bone mass and frequent falls.[11] Fracture incidence rates rise dramatically with age, and populations are aging rapidly around the world. Due to the sheer size of the affected population, control programs for osteoporosis are likely to be expensive, but effective and efficient prevention efforts have great potential promise.The incidence rates themselves are rising in some regions, and any further improvements in life expectancy will compound the problem.[11]

  • Trauma or lesion in the femur ( around 10% )[12]
  • Local pathologies ( 1% ); metastatic malignancy
  • Fall
  • Hip fractures without injuries ( < 5% )
  • Osteoporosis: Osteoporosis is a multifactorial, chronic disease that may progress silently for decades until characteristic fractures occur late in life.  

Risk factors

Risk factors for hip fracture include[13][14]:

  • Gender: prevalent in women; postmenopausal twice as likely as premenopausal to have hip fracture[15]
  • Reduced Bone density[16]
  • Fall
  • Medications: Some medications can cause a decrease in bone density like cortisone.
  • Nutrition: It is well known that calcium and vitamin D increase bone mass, so a lack of it can cause several fractures, including hip fractures. Some eating disorders like anorexia and bulimia can weaken your bones, zo you become more fragile to have a hip fracture.
  • Age: the older you get, the higher the risk is for hip fractures. 90% of these fractures occur in persons over 70 years old.
  • Alcohol and tobacco: These products can reduce the bone mass, causing a higher risk to have a hip fracture
  • Medical problems: Endocrine disorders can cause fragility of the bones
  • Physical inactivity: Physical activity is very important for the muscle mass and the bone mass, so if you practice enough sports you will have less risk to have hip fractures.
  • Stroke disease increases risk factor for falls which can cause a hip fracture.
  • Parkinson’s disease increases risk factor for falls which can cause a hip fracture.

Risk factors other than low bone mineral density (BMD), defined by the National Osteoporosis Foundation (National Osteoporosis Foundation, 1998) are previous history of fracture as an adult, history of fracture in a first-degree relative, low body weight, and current cigarette smoking.[17]Another risk factor that is frequently discussed for the last years is the proximal femoral geometry, it is suggested as an important marker for the hip fracture risks.[17]

Characteristics/Clinical Presentation

  • Dull ache in the groin and/or hip region[10]
  • Inability to put weight on the injured leg causing immobility right after the fall[18]
  • Shorter leg on the side of the injured hip
  • External rotation of the injured leg[18]
  • Stiffness, bruising and swelling in and around the hip

Differential Diagnosis

  • Femoral Head Avascular Necrosis
  • Femoral Neck Fracture
  • Femoral Neck Stress Fracture
  • Femur Injuries and Fractures
  • Hip Pointer
  • Hip Tendonitis and Bursitis
  • Iliopsoas Tendinitis
  • Slipped Capital Femoral Epiphysis
  • Hip dislocation
  • Pelvic fracture

Diagnostic Procedures

The diagnosis of a hip fracture is established based on patient history, physical examination, and radiography.[18] The majority of hip fractures are found by plain radiography, the initial imaging modality used in the diagnosis of hip fracture, which has a sensitivity ranging from 90%-95%.[19][20][21][22] Occult hip fractures are not detectable by radiography, MRI has been shown to have 100% sensitivity and 100% specificity in diagnosing occult hip fractures. Standard x-ray examination of the hip includes an anteroposterior (AP) view of the pelvis and an AP and cross-table lateral view of the involved hip. Plain x-rays without evidence of fracture do not exclude the diagnosis of hip fracture.

If MRI is contraindicated,a bone scan is an alternative imaging option.  Bone scans have a sensitivity of 93% and specificity of 95% in detecting occult hip fractures.[23]CT scan is another modality that can be used to diagnose occult hip fractures, although its efficacy has been proven by few studies.[24]

Outcome Measures

  • Functional Independence Measure: ability to walk and to climb stairs can be measured with a subscale of the FIM. It is a predictor for locomotion This test rates the patient's independence in traveling 45 m (150 ft) walking or in a wheelchair and in going up and down 12 to 14 stairs. A higher score on the test represents a better locomotion. Age and prefracture residence at a nursing home were significant predictors of locomotion (P = .02 for both[25]). (Level of evidence A2)
  • International Hip Outcome Tool (iHOT): The test consists of 33 questions that relate to Symptoms and Functional Limitations, Sports and Recreational Activities, Job-Related Concerns, Social, Emotional, and Lifestyle Concerns.
    iHOT is one of the most carefully and comprehensively validated outcome measures in orthopaedic surgery. Each question has a Visual Analogue Scale (VAS) line where the patient has to put on a marker. The total score is a calculation of the mean of all VAS scores measured in millimeters.
  • Cumulated Ambulation Score (CAS) is a valid tool to evaluate the basic mobility from patients with hip fracture. The test is highly recommended after hip fractures to test the basic mobility. Certainly recommended for hospital treatments.
  • Timed Up and Go Test (TUGT) is used to test the functional mobility level.The test consists in rising from a chair, walk 3 meters on a straight line, turn around and go back to the chair and sit down. When the time is less than 10 seconds, it indicates a normal mobility. Between 11-20 seconds are normal limits for frail elderly and disabled patients but for others it’s an indication for examination and has a higher fall risk. Greater than 20 seconds, there is need to further examination and intervention.
    http://www.physio-pedia.com/Timed_Up_and_Go_Test_(TUG)
  • Chair Stand- Test The amount of time it takes to rise and sit back from a chair or the number of times someone can rise from a chair in 30 seconds.
    The test was performed with the person sitting on a chair (height 45 cm) without arms, but a chair with arms was used if the patient was unable to stand without the use of the armrests. The patient was instructed to stand and sit from a seated position as many times as possible within 30 seconds.

Prognosis

Hip fractures carry an approximately 30% risk of mortality at 1 year,[26]and 25% to 75% of community-dwelling adults may not regain their pre-fracture level of function.[27][28][28] Predictors of mortality include significant comorbid disease, low pre-injury cognitive function, abnormal preoperative ECG, age >85 years, and decreased pre-fracture mobility. Early surgery was not associated with improved function and increased mortality though it was associated with reduced pain and length of stay. Early surgery also resulted in fewer complications. These conclusions were obtained by comparing patients having surgery within 24 hours with those having surgery after 24 hours on the following outcomes[29]: (Level of Evidence A2)

  1. Mean pain scores over the first 5 hospital days
  2. Number of days of severe and very severe pain over hospital days 1 to 5 (assessed by asking patients if they were experiencing no pain, or mild, moderate, or severe pain)
  3. Major postoperative complications
  4. Length of hospital stay
  5. Mortality through 6 months
  6. FIM locomotion (a 2-item subscale focusing on walking and climbing stairs) score at 6 months
  7. FIM self-care (a 6-item scale of self-care activities including bathing and dressing)
  8. FIM transferring (a 3-item scale focusing on transfers from the bed, toilet, and tub).[29]

In the study of Diamond TH et al. the main prognostic factors such as pre-existing illness and osteoporotic risk factor; outcome data such as fracture-related complications, mortality, and level of function as measured by the Barthel index of activities of daily living at 6 and 12 months postfracture.
The results of these outcome measures are that fracture-related complications affected similar proportions of men and women (30% v. 32%), and mean length of hospital stay was similar. Fourteen percent of men died in hospital compared with only 6% of women (P = 0.06). Men had more risk factors for osteoporosis (P < 0.01).[30]
Physical functioning (measured by the Barthel index) deteriorated significantly in men from 14.9 at baseline to 13.4 at six months (P < 0.05) and 12.4 at 12 months (P < 0.05) after fracture.[30]

Jay Magaziner et al. investigated eight areas of function after hip fracture. This eight areas of function include upper and lower extremity physical and instrumental activities of daily living, gait and balance, social, cognitive, and affective function. They were measured by personal interview and direct observation during hospitalization at 2, 6, 12, 18, and 24 months. Levels of recovery are described in each area, and time to reach maximal recovery was estimated using Generalized Estimating Equations and longitudinal data. Most areas of functioning showed progressive lessening of dependence over the first postfracture year, with different levels of recovery and time to maximum levels observed for each area. New dependency in physical and instrumental tasks for those not requiring equipment or human assistance prefracture ranged from as low as 20.3% for putting on pants to as high as 89.9% for climbing five stairs. Recuperation times were specific to area of function, ranging from approximately 4 months for depressive symptoms (3.9 months), upper extremity function (4.3 months), and cognition (4.4 months) to almost a year for lower extremity function[31]

Physical Examination

On physical examination, findings on the patient with a hip fracture may include the following:

  • limited and painful hip range of motion, especially in internal rotation.
  • the injured leg is shortened, externally rotated, and abducted in the supine position
  • Pain is noted upon attempted passive hip motion.
  • Ecchymosis may or may not be present.
  • An antalgic gait pattern may be present.
  • Tenderness to palpation around the inguinal area, over the femoral neck. This area may also be swollen.
  • Increased pain on the extremes of hip rotation, an abduction lurch, and an inability to stand on the involved leg

For more on Hip examination, click www.physio-pedia.com/Hip_Examination

Medical Management

Figure4.jpg
The management of hip fracture is usually a combination of surgery and rehabilitation. It also depends on the location of the fracture and whether it is displaced. In comparison to conservative management (bed rest and traction), operative management results in a reduced length of hospital stay and improved rehabilitation.[32] Surgery <48 hours after admission may be associated with lower morbidity and may decrease hospital stay.[33][34] It is associated with a 29% risk reduction in mortality as well as a significant reduction in in-hospital pneumonia (relative risk reduction 41%) and pressure sores (relative risk reduction 52%).[35][36]
Intracapsular Fractures
  • Undisplaced: internal fixation with a dynamic hip screw, or multiple cannulated screws[37]
  • Displaced
    • For patients < 60 years of age, most surgeons favor early (<12-24 hours from injury) open reduction and internal fixation partly due to a potential increased risk of avascular necrosis to the femoral head. However, the evidence is conflicting regarding rates of avascular necrosis and timing of surgery.[38][39]
    • For patients 60 to 80 years of age, management is controversial. Evidence from meta-analyses suggests that arthroplasty significantly reduces the risk of revision surgery at 1 year, does not increase the risk of mortality at 1 year, but significantly increases the risk of infection and blood loss, and increases operating time as compared with internal fixation. [40][41][42]
    • For patients > 80 years of age, most surgeons favor arthroplasty[43][38]. Total hip arthroplasty may reduce pain and functional limitation more than hemiarthroplasty. [44][41][44]

Extracapsular Fractures
Surgical stabilization is standard treatment, and non-operative measures are only considered for patients who are at very high surgical risk or who have a limited life expectancy. The goal of surgery is to achieve a stable fracture reduction and fixation, allowing early weight bearing and mobilization of the patient. Non-operative management is only considered for non-ambulatory patients with minimal pain and for medically unstable patients with a major un-correctable comorbid disease or terminal illness.[3]For displaced intertronchanteric fractures, operative management includes internal fixation with either a dynamic hip screw,[45]  or a cephalomedullary nail. [46] Dynamic hip screw is preferred because of decreased complication rate and reoperation rate.[47] [48]

Physical Therapy Management

In a study by Mangione et al, moderate to large improvements in physical performance and quality of life was found in patients who had a 10- week home-based progressive resistance exercise program[49] (Level of evidence: 1b) Also, among patients who had completed standard rehabilitation after hip fracture, the use of a home-based functionally oriented exercise program resulted in modest improvement in physical function at 6 months after randomization.[50] (Level of evidence: 1b)

The patient training begins the day after surgery from a sitting position, with abducted hip during transfer from bed to chair.[51] (Level of evidence: 5) On the second and third post-operative day the patient can start with walking between parallel bars, and later on, they can walk with a walker or a cane. A warming up on a stationary bicycle for 10 to 15 minutes is recommended.[52] (Level of evidence: 2a) Progressive weight-bearing as tolerated till full weight-bearing should start soon after surgery according to general physical status. When internal fixation is performed, partial weight-bearing is recommended for a period of 8–10 weeks (according to the radiological evaluation of fracture healing), and after 3 months full weight-bearing should be allowed. Range of motion exercises for the hip, knee and ankle. The patient can also begin strengthening exercises based on the surgeon's orders (typically six weeks post-op). Patients should also undergo balance and proprioceptive rehab and these abilities are quickly lost with inactivity.

Prolonged bed rest can increase the risk of pressure sores, atelectasis, pneumonia, deconditioning, and thromboembolic complications. Weight-bearing immediately after hip fracture surgery is safe in most patients.[53] (Level of evidence: 2a). Complications following hip surgery involve blood clots, pneumonia, wound infections, and more, all of which can be reduced with activity[54] (Level of evidence: 2a)

Another key component of rehabilitation following hip fracture is education on its prevention. Home safety to prevent falls, regular moderate exercise can slow bone loss and maintain muscle strength, also improve balance and coordination.

There are some important rules postoperative:

  •  internal rotation from hip flexion is very stressful for the joint
  • impact activities should be avoided for six weeks postoperative
  • depending on the surgical procedure is unloaded or partially loaded mobilize postoperatively crucial to the joint
  • Avoid straight leg raise for 4 weeks postoperatively to not provoke irritation of the nerve
  • Cardiovascular training is important

Weight-bearing exercises are very important for mobility, balance, activities of daily living and quality of life[55][5](Level of evidence: 1a), examples: stepping in different directions, standing up and sitting down, tapping the foot and stepping onto and off a block.
Figure6.png
For patients who underwent a prosthetic replacement have to avoid for approximately 12 weeks:
  • Hip flexion greater than 70–90°
  • External rotation of the leg
  • Adduction of the leg past midline
  • Should not bend forward from the waist more than 90

Rehabilitation program components[56](Level of evidence: 1b):

  • Hip extension (theraband and manual exercise)
  • Heel raises onto toes (theraband and manual exercise)
  • Resisted rowing (double arm lifting) (theraband and manual exercise)
  • Standing diagonal reach (theraband and manual exercise)
  • Modified get up and go (theraband and manual exercise)
  • Overhead arm extensions (theraband and manual exercise)
  • Repeated chair stands (vest and manual exercise)
  • Lunges - forward and back (vest and manual exercise)
  • Stepping up and down step (vest, manual exercise and plyometric step)
  • Calf raises - both legs and one leg (manual exercise)

Clinical Bottom Line

The number of hip fractures worldwide will increase up to 7-21 million incidences each year in 2050.[57] Mortality associated with a hip fracture is about 5-10% after one month. One year after fracture, about a third of patients will have died, compared with an expected annual mortality of about 10% in this age group.[57]Thus, only a third of the deaths are directly attributable to the hip fracture itself, but patients and relatives often think that the fracture has played a crucial part in the final illness. More than 10% of survivors will be unable to return to their previous residence. Most of the remainder will have some residual pain or disability. Most people who sustain the injury require surgery followed by a period of rehabilitation.Treatment is generally surgical to replace or repair the broken bone. Some loss of function is to be expected in most patients.

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