Femoral Neck Hip Fracture: Difference between revisions

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== Introduction ==
== Search Strategy ==
[[File:Fig5.png|thumb|Garden classification, NOF]]
Hip fractures are one of the most frequent fractures presenting to the emergency department and orthopedic trauma teams.


Databases searched: Pubmed, PEDro, eMedicine, Medscape,Handbook of fractures, Prometheus, Kapandji<br><br>Keywords searched: hip fracture, incidence femoral neck fracture, osteoporotic hip fracture, treatment hip fractures …<br>  
# The terms hip fracture and femoral neck fracture both relate to the same type of injury.
# Both terms describe a fracture of the proximal femur between the femoral head and 5 cm distal to the lesser trochanter.<ref name=":2">Emmerson BR, Varacallo M, Inman D. Hip Fracture Overview. InStatPearls [Internet] 2022 Feb 12. StatPearls Publishing.Available;https://www.statpearls.com/articlelibrary/viewarticle/22890/ (accessed 9.12.2022)</ref>


== Definition/Description ==
A hip fracture occurs just below the head of femur (HOF), the region of the femur called the femoral neck. A femoral neck fracture disconnects the HOF from the rest of the femur. Click [[Hip Anatomy]] for more details  


A hip fracture is a condition in which the proximal end of the femur, near the hip joint, is broken.It’s also possible to have a fracture in the pelvis or acetabulum. Such a fracture is a serious injury that occurs mostly in elderly people over 65 years and complications can be life threatening. <ref name="bron vier">ANTAPUR ET AL. Fractures in the elderly: when is a hip replacement a necessity? Clinical Interventions in Aging. 2011</ref> ''(level of evidence A1)''  
== Etiology ==
Most commonly:
* Falls in the elderly: Account for the majority of hip fractures. Risk factors for falls in the elderly population are many, those strongly associated with these fractures are a previous history of falls, gait abnormalities, the use of walking aids, vertigo, Parkinson disease, and antiepileptic medications. A lot of patients have multiple risk factors, and this, combined with age-associated reduced bone quality, is the underpinning cause of most hip fractures.<ref name=":2" /> The majority of fragility hip fractures occurred inside the home<ref name=":3">Dhibar DP, Gogate Y, Aggarwal S, Garg S, Bhansali A, Bhadada SK. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6683687/ Predictors and outcome of fragility hip fracture: a prospective study from North India]. Indian Journal of Endocrinology and Metabolism. 2019 May;23(3):282.</ref>
* Significant trauma (e.g. motor vehicle collisions) in younger patients
* About 3% of hip fractures are related to localized bone weakness at the fracture site, secondary to tumour, followed by bone cysts, or [[Paget's Disease|Paget’s disease]].


== Clinically Relevant Anatomy  ==
==Epidemiology ==
The incidence of femoral neck fractures is increasing as the proportion of the elderly population in many countries increases. Between 1990 and 2000, there was nearly a 25% increase in hip fractures worldwide.<ref name=":0">Radiopedia Neck of femur fracture Available:https://radiopaedia.org/articles/neck-of-femur-fracture-1?lang=us (accessed 9.12.2022)</ref>


The hip joint is a ball and socket joint, formed by the head of the femur and the acetabulum of the pelvis. 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, trochanter major and the minor 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. <ref name="kapandji">KAPANDJI I.A. Bewegingsleer Deel II De Onderste Extremiteit. Bohn Stafleu Van Loghum. Houtem/Diegem 1986</ref>  
* The peak number of hip fractures occurred at 75-79 years of age for both sexes, with most occuring in women. In white women, the lifetime risk of hip fracture is 1 in 6.
* Up to 20% of patients die in the first year following hip fractures, mostly due to pre-existing medical conditions. Less than half of  those who survive the hip fracture regain their previous level of function<ref>IOF [https://www.iofbonehealth.org/facts-statistics#category-16 Facts and stats] Available from:https://www.iofbonehealth.org/facts-statistics#category-16 (last accessed 14.10.2020)</ref>


== Classification of Hip Fractures ==
[[File:Hip fracture classification.png|350x350px|alt=|thumb|Hip fracture classification]]
Hip fractures is classified into intracapsular and extracapsular fractures<ref name=":7">Zuckerman JD. [https://www.nejm.org/doi/full/10.1056/NEJM199606063342307 Hip fracture]. New England journal of medicine. 1996 Jun 6;334(23):1519-25.</ref>


# '''Intracapsular fractures''' (femoral neck fractures): Occurs within the hip capsule; accounts for 45% of all acute hip fractures in the elderly<ref>Canale ST. ''Campbell's Operative Orthopaedics''. St. Louis, MO: Mosby;; 1998. pp. 2181–2223.</ref>; susceptible to malunion/[https://physio-pedia.com/Avascular_Necrosis avascular necrosis] of the HOF because of the limited blood supply to the area. The [[Femoral Neck Fractures, Garden Classification]] is the most commonly classification system. This splits into four categories depending on the severity of the fracture and the degree of displacement.   
# '''Extracapsular fractures''': Intertrochanteric fracture: occurs between the greater and the lesser trochanter<ref name=":7" />, intertrochanteric region has a good blood supply, [https://physio-pedia.com/Avascular_Necrosis avascular necrosis] or nonunion is rare; Subtronchanteric fracture: occurs below the lesser trochanter, approximately 2.5 inches below.


The pelvic ring is composed of the sacrum. The hip bone is formed at maturity by the fusion of three ossification centers:<br> The ilium<br> The ischium<br> The pubis<br>
== Risk factors ==
 
Risk factors for hip fracture include<ref>Grisso JA, Kelsey JL, Strom BL, Ghiu GY, Maislin G, O'Brien LA, Hoffman S, Kaplan F. [https://www.nejm.org/doi/full/10.1056/NEJM199105093241905 Risk factors for falls as a cause of hip fracture in women]. New England journal of medicine. 1991 May 9;324(19):1326-31. </ref><ref>http://www.mayoclinic.com/health/hip-fracture/DS00185/DSECTION=risk-factors (visited on april 2016)</ref>:
The transversely placed ligaments withstand rotational forces and incorporate the short posterior sacroiliac. The vertically placed ligaments withstand vertical shear and incorporate the long posterior sacroiliac, sacrotuberous and lateral lumbosacral ligaments. <br>
*Gender: prevalent in women; post[[Menopause|menopausal]] twice as likely as premenopausal to have hip fracture<ref>Banks E, Reeves GK, Beral V, Balkwill A, Liu B, Roddam A, [https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000181 Million Women Study Collaborators. Hip fracture incidence in relation to age, menopausal status, and age at menopause: prospective analysis]. PLoS medicine. 2009 Nov 10;6(11):e1000181.</ref>
 
*Reduced Bone density<ref>Angthong C, Suntharapa T, Harnroongroj T. [https://dergipark.org.tr/en/pub/aott/issue/18213/191450 Major risk factors for the second contralateral hip fracture in the elderly.] Acta orthopaedica et traumatologica turcica. 2009 May 1;43(3):193-8.</ref>
Muscles (19)<br>The hip joint consist of 27 muscles with each their own function. A few important ones:
*Falls<ref>Yang Y, Komisar V, Shishov N, Lo B, Korall AM, Feldman F, Robinovitch SN. [https://asbmr.onlinelibrary.wiley.com/doi/abs/10.1002/jbmr.4048 The Effect Of Fall Biomechanics On Risk For Hip Fracture In Older Adults: A Cohort Study Of Video‐Captured Falls In Long‐Term Care.] Journal of bone and mineral research. 2020 May 13.</ref>  
 
*[[Medication and Falls|Medications]]: Some medications can cause a decrease in bone density like cortisone.
Posterior<br> M gluteii <br> M gluteus maximus<br> M gluteus medius<br> M gluteus minimus <br> powerful muscles<br> stabililzation<br> stabilize the femoral head in the acetabulum<br> accelerate the standing position<br> strong hip extensors<br> external rotators<br> hip abductors
*[[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.
 
*Age: the older you get, the higher the risk is for hip fractures. 90% of these fractures occur in persons over 70 years old.  
 M piriformis<br> external rotator <br> weak abductor<br> weak flexor of the hip<br> provide postural stability while walking or standing
*[[Alcoholism|Alcohol]] and tobacco: These products can reduce bone mass, causing a higher risk to have a hip fracture  
 
*Medical problems: Endocrine disorders can cause fragility of the bones
Anterior<br> M iliopsoas<br> M iliacus<br> M psoas major<br> M psoas minor<br> most powerful hip flexors<br>
*[[Physical Inactivity|Physical inactivity]]: [[Physical Activity|Physical activity]] is very important for muscle mass and bone mass 
 
*[[Stroke]] increases the risk factor for falls which can cause a hip fracture.
[http://www.physio-pedia.com/Hip_Anatomy www.physio-pedia.com/Hip_Anatomy]
*[[Parkinson's|Parkinson’s]] disease increases the risk factor for falls which can cause a hip fracture.  
 
== Characteristics/Clinical Presentation ==
== Epidemiology /Etiology  ==
*Dull ache in the groin and/or hip region<ref name=":8">Rao SS, Cherukuri M. [https://www.aafp.org/afp/2006/0615/p2195.html Management of hip fracture: the family physician's role]. American family physician. 2006 Jun 15;73(12):2195-200. </ref>
 
*Inability to put weight on the injured leg causing immobility right after the fall<ref name=":9" />
Different events can form the basis of a hip fracture.<br>Young adult hip fractures are generally the result of high-energy trauma, and the larger peak seen in the elderly population is low-energy injuries, like a fall caused by gait and/or balance disorders.<ref name="bron vier" />&nbsp;Hip fractures are regarded as the most common type of fall-related injury among elderly because of their high morbidity, mortality and impairment in quality of life.<ref name="bron vijf">TANNER ET AL. Hip fracture types in men and women change differently with age. BMC Geriatrics. 2010, 10:12</ref> ''(level of evidence C)''
*Shorter leg on the side of the injured hip 
High energy trauma is mostly the cause of pelvic fractures: <br> 57% motor vehicle accidents<br> 18% pedestrian injuries<br> 9% motorcycle accidents<br> 9% falls from height<br> 4% crush mechanisms <br>
*External rotation of the injured leg<ref name=":9" />  
 
*Stiffness, bruising and swelling in and around the hip  
[[Osteoporosis|Osteoporosis]] is currently considered a chronic condition characterized by a reduction in bone mass, usually because of aging, leading to a reduction in bone strength and an increase in the risk of fracture. Women are more likely to have a hip fracture than men.<ref name="bron twee">DRAGOI D., POPESCU R. ET AL. A multidisciplinary approach in patients with femoral neck fracture on an osteoporotic basis. Romanian Journal of Morphology and Embryology 2010, 51(4):707–711</ref>&nbsp;A stress injury occurs when abnormal stress, usually in the form of frequent repetition of otherwise normal stress, is exerted on a bone with normal elastic resistance but unaccustomed to that action. Stress fractures, mostly tibia and [[Femoral Fractures|femoral fractures]], are common in athlete and military populations, in which subjects are exposed to a sudden increase in physical training.<ref name="bron twee">NIVA ET AL. Bone Stress Injuries Are Common in Female Military Trainees. Clinical Orthopaedic Related Research (2009) 467:2962–2969</ref> ''(level of evidence B)''
 
 
Causes of Acute fracture:<br>After extreme muscle contraction-&gt; avulsion fracture<br>After extreme sports -&gt; stress fracture due<br>Osteoporosis or hip osteoarthritis often cause complaints in older people.
 
Causes of Stress fracture:<br>As a result of fatigue fracture of the bone because of repeated stress <br>Athletes have an increased vulnerability due to high training load <br>In endurance runners/ athletes the pelvic region is frequently affected (incidence greater in women)<br>by decrease in bone density<br>A fracture at the femoral neck is hard to determine<br>-&gt; A femoral neck fracture by fatigue may be due to lower shock absorption of the muscles and a lower load limit.<br>
 
<u>Risk factors for hip fracture include:<br></u>  
 
*<u></u>Osteoporosis
*Low Bone Marrow Density <ref name="riskfactor">CAULEY A. J. Risk Factors for Severity and Type of the Hip Fracture. Journal of Bone and Mineral Research. Volume 24, Number 5, 2009</ref> ''(level of evidence A1)''
*Age&gt; 65 years = risk group
*Gender: women have more fractures than men
*Physical inactivity
*and others such as alcohol use, vitamin D and calcium deficiency, smoking, ...<ref name="bron zeven">LEYTIN and BEAUDION. Reducing hip fractures in the elderly. Clinical Interventions in Aging 2011:6</ref><ref name="mayo">http://www.mayoclinic.com/health/hip-fracture/DS00185/DSECTION=risk-factors (visited on april 2011)</ref> ''(level of evidence A2)''
 
However the evidence that calcium supplements reduce fracture risk is lacking.<ref name="calcium">SEEMAN E. Evidence that Calcium Supplements Reduce Fracture Risk Is Lacking. Clinical Journal of the American Society of Nephrology 5: S3–S11, 2010</ref> ''(level of evidence A1)''
 
== Characteristics/Clinical Presentation ==
 
Specific features for patients with hip fracture include:<ref name="mayo" /> <ref name="ortho">http://orthoinfo.aaos.org/topic.cfm?topic=A00392 (visited on april 2011)</ref>
 
*Dull ache in the groin and/or hip region <ref name="doffe pijn">DORNE and LANDER. Spontaneous Stress Fractures of the Femor Neck. AJA 144:343-347, February 1985</ref> ''(level of evidence B)''
*Inability to put weight on the injured leg causing immobility right after the fall <ref name="symp en diag">SHOBHA S. RAO, M.D., and MANJULA CHERUKURI, M.D. Management of Hip Fracture: The Family Physician’s Role. www.aafp.org/afp Volume 73, Number 12, June 15, 2006</ref> ''(level of evidence A1)''
*If the femur bone is completely broken the injured leg might be shorter compared to the other leg
*Severe pain
*The patient tends to keep the injured hip as still as possible, positioning it in external rotation <ref name="symp en diag" />&nbsp;
*A swelling might occur
* Patients may not be able to achieve the same level of functional recovery as their cognitively intact counterparts do (18)
 
Intra capsular = femoral neck / cervical<br>Extra capsular = intertrochanteric / pertrochanteric / subtrochanteric<br>
 
== Differential Diagnosis  ==
 
Certain types of hip fracture are associated with an increased risk of[http://www.physio-pedia.com/Avascular_Necrosis avascular necrosis] of the femoral head.<br>Other lower body fractures must be excluded:<ref name="bron zes">LANCE C. BRUNNER,M.D., and LIZA ESHILIAN-OATES,M.D. Hip Fractures in Adults. www.aafp.org/afp February 1, 2003 Volume 67, Number 3</ref><br>- Stress fractures<br>- Fracture of acetabulum<br>- Fracture of ramus pubis <br>


== Diagnostic Procedures  ==
== Diagnostic Procedures  ==


The diagnosis of a hip fracture is established based on patient history, physical examination and radiography. <ref name="symp en diag" />
The diagnosis of a hip fracture is established based on patient history, physical examination, and radiography.<ref name=":9">Dinçel VE, Şengelen M, Sepici V, Çavuşoğlu T, Sepici B. [https://onlinelibrary.wiley.com/doi/abs/10.1002/ca.20680 The association of proximal femur geometry with hip fracture risk]. Clinical Anatomy: The Official Journal of the American Association of Clinical Anatomists and the British Association of Clinical Anatomists. 2008 Sep;21(6):575-80.
 
</ref> 
On a MRI one can see that a proximal hip fracture consists many kinds:  
* Plain [[X-Rays|radiograph]]<nowiki/>s (sensitivity 93-98%) is the first-line investigation for suspected Neck of Femur(NOF) fractures.
 
* In patients with a suspected occult NOF fracture, [[MRI Scans|MRI]] (sensitivity 99-100%) is recommended by many institutions as the second-line test if available within 24 hours, with CT or nuclear medicine bone scan third-line<ref name=":1">Radiopedia [https://radiopaedia.org/articles/femoral-neck-fracture NOF fractures] Available from:https://radiopaedia.org/articles/femoral-neck-fracture (last accessed 14.10.2020)</ref>
*&nbsp;Subcapital neck fracture: right below the femoral head
*&nbsp;Femoral neck fracture (intracapsular fracture) <ref name="bron zes" />&nbsp;''(level of evidence B)''
*&nbsp;Intertrochanteric fracture: between the greater and the small trochanter (extracapsular fracture) <ref name="bron zes" /><ref name="ortho" />
*&nbsp;Subtrochanteric fracture: 2 ½ inch below the small trochanter (extracapsular fracture) <ref name="ortho" />
*&nbsp;Fracture of the greater trochanter
*&nbsp;Fracture of the small trochanter<br>
* intracapsular fracture (non-unions and avascalar necrosis) (17)
* Extracapsular fracture (screw cut out, femur fracture and implant failure) (17)
* To determine surgery, partial or complete hip replacement: take into account different criteria: age, sports, bone density / bone osteoporosis
 
 
 
 


== Outcome Measures  ==
== Outcome Measures  ==
* [https://physio-pedia.com/Functional_Independence_Measure_(FIM) Functional Independence Measure]
* [[Berg Balance Scale|Berg Balance Scale]]
* [https://physio-pedia.com/Timed_Up_and_Go_Test_(TUG) Timed Up and Go Test (TUG)]
* [[Patient Specific Functional Scale]]
* [[Falls Risk Assessment Tool (FRAT): An Overview to Assist Understanding and Conduction|Falls Risk Assessment Tool]]


add links to outcome measures here (also see [[Outcome Measures|Outcome Measures Database]])  
== Treatment ==
Serious complications (for example avascular necrosis and non-union) are very common without surgical intervention.
In general, Garden stage I and II are stable fractures and can be treated with internal fixation (head-preservation) eg dymanic hip screw, and stage III and IV are unstable fractures and hence treated with arthroplasty (either hemi- or total arthroplasty. Internal fixation can be performed with multiple pins, intramedullary hip screw, crossed screw-nails or compression with a dynamic screw and plate.


The high morbidity and mortality assoc<span class="reference" id="cite_ref-11"></span>iated with hip and pelvic fractures after trauma is well reported.
Prognosis varies but is complicated by older age, as hip fractures increase the risk of death and major morbidity in the elderly.<ref name=":0" />


== Rehabilitation ==
[[Image:Figure4.jpg|right|frameless|400x400px]]The postoperative rehabilitation is as important as the initial surgery. Surgery aims to restore mobility, and commence early mobilization. Patients who have undergone arthroplasty or fixation of an extracapsular fracture can usually mobilize immediately after surgery without weight restrictions. Following fixation of an intracapsular fracture protected weight bearing is often recommended to reduce the risk of subsequent fracture displacement.


[http://www.physio-pedia.com/International_Hip_Outcome_Tool_(iHOT) www.physio-pedia.com/International_Hip_Outcome_Tool_(iHOT)]
Regular intensive physiotherapy is needed to encourage the rapid progression of mobility, aiming to restore the patient’s pre-morbid mobility status. Sadly, many patients do not regain their previous level of mobility or independence and therefore require social care input<ref name=":2" />.


'''International Hip Outcome Tool''' (iHOT) (20,21) 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
== 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 details, Click [[Hip Examination]]
== Physical Therapy Management  ==
[[File:Hip exercise 6.png|right|frameless]]
Rehabilitation begins promptly.


'''Two to three days postoperative'''
* Instruct patient in deep breathing and cough. '''Goal:''' Prevent postoperative pneumonia and [[atelectasis]].
* Initiate isometrics and ankle pumps with involved extremity. '''Goal:''' Prepare patient for active exercise program.
* Initiate bedside sitting once physician has cleared patient for this activity. '''Goal:''' Prepare patient to begin transfer and progressive gait training processes.<ref>Luciani D, Cadossi M, Mazzotti A, Chiarello E, Giannini S. [https://link.springer.com/article/10.1007/s40520-013-0079-9 The importance of rehabilitation after lower limb fractures in elderly osteoporotic patients.] Aging clinical and experimental research. 2013 Oct;25(1):113-5.
</ref>
'''Three to five days postoperative'''
* Gait train patient, observing weight-bearing precautions. Progress to walker or crutches. '''Goal:''' Establish independent gait with assistive device, using proper gait pattern on all surfaces and stairs.
* Initiate training in activities of daily living, including bed mobility and transfers to and from bed and toilet. '''Goal:''' Achieve independence with all transfers.
* Initiate active range of motion/strengthening program. Individualize exercise programs according to each patient's needs, but generally include the following. '''Goals:''' Increase strength of involved extremity; increase independence with exercise program.
** Supine: hip abduction and adduction, gluteal sets, quadriceps sets, straight leg raise, hip and knee flexion, short arc quadriceps, internal and external rotation.
** Sitting: Long arc quadriceps, hip flexion, ankle pumps<ref>Physio treatment Hip Protocol Available from:https://www.physiotherapy-treatment.com/Femoral-Neck-Fracture-Physiotherapy.html (last accessed 15.10.2020)</ref>.


iHOT is one of the most carefully and comprehensively validated outcome measures in orthopaedic surgery. Each question has a Visual Analoge 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.
* 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.
* The patient can also begin strengthening exercises based on the surgeon's orders (typically six weeks post-op).
Patients should also undergo [[Balance Training|balance]] and [[Proprioception|proprioceptive]] rehab and these abilities are quickly lost with inactivity. Rehabilitation classes for balance and [[Falls and Exercise|falls prevention]] are recommended.


'''Cumulated Ambulation Score (CAS)''' is a valid tool to evaluate the basic mobility from patients with hip fracture. (22,23) The test is highly recommended after hip fractures to test the basic mobility. Certainly recommended for hospital treatments.
Weight-bearing exercises are very important for mobility, balance, activities of daily living and quality of life<ref>LeBlanc KE, Muncie Jr HL, LeBlanc LL. [https://www.aafp.org/afp/2014/0615/p945 Hip fracture: diagnosis, treatment, and secondary prevention]. American family physician. 2014 Jun 15;89(12):945-51.  
 
</ref>, examples: stepping in different directions, standing up and sitting down, tapping the foot and stepping onto and off a block.
 
[[File:Hip Abduction with IR.JPG|right|frameless]]
 
For patients who underwent a prosthetic replacement have to avoid the following for approximately 12 weeks:
'''Timed Up and Go Test (TUGT)''' is used to test the functional mobility level. (23)<br>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.<br>[http://www.physio-pedia.com/Timed_Up_and_Go_Test_(TUG) www.physio-pedia.com/Timed_Up_and_Go_Test_(TUG)]
*Hip flexion greater than 70–90°
 
*External rotation of the leg
<br>'''Chair Stand- Test (23)''' 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.<br>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. <br>
*Adduction of the leg past midline
 
*Should not bend forward from the waist more than 90°
== Examination  ==
'''Rehabilitation program components'''<ref>Latham NK, Harris BA, Bean JF, Heeren T, Goodyear C, Zawacki S, Heislein DM, Mustafa J, Pardasaney P, Giorgetti M, Holt N. [https://jamanetwork.com/journals/jama/article-abstract/1829991 Effect of a home-based exercise program on functional recovery following rehabilitation after hip fracture: a randomized clinical trial]. Jama. 2014 Feb 19;311(7):700-8.
 
</ref>:
On physical examination, the injured leg is shortened, externally rotated, and abducted in the supine position. Plain radiographs of the hip usually confirm the diagnosis. <ref name="symp en diag" />
*Hip extension (theraband and manual exercise)
 
*Heel raises onto toes (theraband and manual exercise)
Radiographic evaluation: standard trauma radiographics withstand an anteroposterior view of the chest, a lateral view of the cervical spine, an anteroposterior view of the abdomen and an anteroposterior view of the pelvis.
*Resisted rowing (double arm lifting) (theraband and manual exercise)
 
*Standing diagonal reach (theraband and manual exercise)
Anteroposterior radiograph of the pelvis:
*Modified get up and go (theraband and manual exercise)
 
*Overhead arm extensions (theraband and manual exercise)
* anterior lesions
*Repeated chair stands (vest and manual exercise)
* iliac fractures
*Lunges - forward and back (vest and manual exercise)
* L5 transverse process fractures
*Stepping up and down step (vest, manual exercise and plyometric step)
 
*Calf raises - both legs and one leg (manual exercise)
Obturator and iliac oblique views:<br>• May be used for (suspected) acetabular fractures <br>Inlet radiograph:<br>• Taken in the suspine position. Useful for determining anterior or posterior displacement of the sacroiliac joint, sacrum or iliac wing. And may also determine internal rotation deformities of the ilium and sacral impaction injuries.<br>
'''Importance of rehabilitation/home exercise program''':
 
* 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<ref>Mangione KK, Craik RL, Palombaro KM, Tomlinson SS, Hofmann MT. [https://agsjournals.onlinelibrary.wiley.com/doi/abs/10.1111/j.1532-5415.2010.03076.x Home‐based leg‐strengthening exercise improves function 1 year after hip fracture: a randomized controlled study]. Journal of the American Geriatrics Society. 2010 Oct;58(10):1911-7.</ref>
Outlet radiograph:<br>• Taken in de supine position. Useful for determination of vertical displacement of the hemipelvis.<br>• Computed tomography<br>• Magnetic resonance imaging<br>• Stress view<br>
* A meta-analysis, showed that balance training within 6 months improves a person with hip fracture's physical functioning, gait, lower limb strength, performance task, and activity of daily living.<ref>Wu JQ, Mao LB, Wu J. [https://josr-online.biomedcentral.com/articles/10.1186/s13018-019-1125-x Efficacy of balance training for hip fracture patients: a meta-analysis of randomized controlled trials]. Journal of orthopaedic surgery and research. 2019 Dec;14(1):1-1.</ref>
 
* 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.<ref>Latham NK, Harris BA, Bean JF, Heeren T, Goodyear C, Zawacki S, Heislein DM, Mustafa J, Pardasaney P, Giorgetti M, Holt N. [https://jamanetwork.com/journals/jama/article-abstract/1829991 Effect of a home-based exercise program on functional recovery following rehabilitation after hip fracture: a randomized clinical trial]. Jama. 2014 Feb 19;311(7):700-8.
== Medical Management <br>  ==
</ref>
 
Education and prevention are also important issues to address.
The recommended treatment of pelvic fractures depends from institution to institution:<br>General treatment options:
 
<br>•'''External fixation '''– An external frame design is a rectangular construct mounted on two to three pins, 1cm distance from each other along the anterior iliac crest.
 
Postoperative plan for immobilization: <br>Lateral compression: external fixation for 3 to 6 weeks is advised. With mobilization depending on the comorbid injuries<br>Anteroposterior compression: external fixation for 8-12 weeks, depending on the principle of the posterior sacroiliac ligaments.<br>Vertical shear: external fixation for 12 weeks with mobilization leaded by radiographic evidence of healing. This may require combination with open reduction and internal fixation for adequate stabilization.<br><br>
 
•'''Internal fixation '''– this significantly rises the forces resisted by the pelvic ring when compared to external fixation. Biomechanical studies suggest the following treatments:<br>Iliac wing fractures: open reduction and internal fixation<br>Diastasis of the pubic symphysis: plate fixation if undergoing laparotomy <br>Sacral fractures: transiliac bar fixation, but may cause compressive neurologic injury<br>Unilateral sacroiliac dislocation: internal fixation with cancellous screws fixation can be indicated<br>Bilateral posterior unstable disruptions: fixation of the displaced part of the pelvis to the sacral body may be accomplished by posterior screw fixation.<br>• '''Open fractures''': priority should be given to the evaluation of the anus, rectum, vagina and genitourinary system.<br>• '''Postoperative pla'''n: Generally, early mobilization is desired<br>
 
== Physical Therapy Management <br>  ==
 
Prolonged bed rust can increase the risk of pressure sores en deconditioning. Therefore it’s important to start rehabilitation on the first post-operative day (on patients with a [[Total Hip Replacement|total hip replacement).]]&nbsp;First post-operative day (OR = 3.3) (p values: 0.009-&lt;0.0001). A study shows that patients undergoing hip fracture surgery, who are not able to complete physiotherapy on first post-operative day, are at a greater risk of not regaining basic mobility during hospitalization.(14) The therapy includes quadriceps strengthening exercises, isometric exercises, and flexion and extension mobilizations in the hip joint … <ref name="symp en diag" />  
 
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.
 
 
 
There are some important rules postoperative:15
 
* 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<br>
 
Weight-bearing exercises are very important for mobility, balance, activities of daily living and quality of life<ref name="bron een">ANNE M. MOSELEY, CATHERINE SHERRINGTON, STEPHEN R. LORD, ELIZABETH BARRACLOUGH, REBECCA J. ST GEORGE, IAN D. CAMERON. Mobility training after hip fracture: a randomized controlled trial. Age and Ageing 2009; 38: 74–80</ref>&nbsp;''(level of evidence B)'', examples:
 
*stepping in different directions
*standing up and sitting down
*tapping the foot and stepping onto and off a block.&nbsp;
 
Prevention is also a part of the rehabilitation process to prevent fractures. Prevention of hip fractures should focus on preventing falls and osteoporosis.<ref name="bron zeven" />  
 
It is crucial in postoperative rehabilitation to recruit the stabilizers of the hip joint and to train them. This is to improve the neuromuscular coordination. Weakness of the m. Gluteus Medius causes significant abnormalities in the gait pattern. This is associated with problems of the hip and knee regions. After surgery you can start with isometric contractions of the gluteal and thigh muscles. Recent studies have shown that the gluteal muscles are strongly recruited by the following exercises in open chain: lying on your side, hip abduction; lying on your side, hip abduction from 30 ° hip flexion ; lying on your side, hip abduction from 60°, hip flexion in closed chain: bridging exercises.  
 
There can be a change in the length of the femoral neck due to the placement of a hip prosthesis and changes arise in the biomechanics of the hip. A physiotherapist need to look into this.15<br>
 
Prevention is also a part of the rehabilitation process to prevent fractures. Prevention of hip fractures should focus on preventing falls and osteoporosis.[6]
 
== Key Research  ==
 
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== Clinical Bottom Line  ==
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== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
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== References  ==
== References  ==
 
<references /> <br>
see [[Adding References|adding references tutorial]].
[[Category:Vrije_Universiteit_Brussel_Project]]
 
[[Category:Primary Contact]]
 
[[Category:Older People/Geriatrics]]
 
[[Category:Acute Care]]
<references />  
[[Category:Older People/Geriatrics - Conditions]]
 
[[Category:Fractures]]
16. KENNETH J. KOVAL, and JOSEPH D. ZUCKERMAN, Handbook of fractures, second edition, 2002 ( level of evindence: 5 )<br>17. Lane N, Hochberg M, Pressman A, Scott J, Nevitt M. Recreational physical activity and the risk of osteoarthritis of the hip in elderly women. J Rheumatol 26(4): 849-854, 1999<br>18 Mikko Määttä etal., Lifestyle factors and site-specific risk of, hip fractures in community dwelling older women-a 13 year prospective population-based cohort study, Muscoskeletal disorder, 2012 ( level of evidence 1A )<br>19. Korpelainen R, Korpelainen J, Heikkinen J, Väänänen K, Keinänen-Kiukaanniemi S: Lifestyle factors are associated with osteoporosis in leanwomen but not in normal and overweight women: a population-based cohort study of 1222 women. Osteoporos Int 2003, 14(1):34–43. (level of evidence 2B)<br>20. Rajesh Adhau et al., Multiple muscle tears after fall on buttock-role of conservative management and exercise for early recovery and return to play, Muscles ligaments tendosn, April-June 2014 ( level of evidence 1C )<br>21. Mohtadi NG, Griffin DR, Pedersen ME, Chan D, Safran MR, Parsons N, Sekiya JK, Kelly BT, Werle JR, Leunig M, McCarthy JC, Martin HD, Byrd JW, Philippon MJ, Martin RL, Guanche CA, Clohisy JC, Sampson TG, Kocher MS, Larson CM. The development and validation of a self-administered quality-of-life outcome measure for young, active patients with symptomatic hip disease: The International Hip Outcome Tool (iHOT-33). Arthroscopy. 2012. 28(5): 595-610.<br>(level of evidence: 2C)<br>22.. Griffin DR, Parsons N, Mohtadi NG, Safran MR. A short version of the International Hip Outcome Tool (iHOT-12) for use in routine clinical practice. Arthroscopy. 2012, 28(5):611-6. <br>(level of evidence 1 B)<br>Physiopedia Link: http://www.physio-pedia.com/International_Hip_Outcome_Tool_(iHOT) <br>23. Morten Tange Kristensen. “High intertester reliability of the Cumulated Ambulation Score for the evaluation of basic mobility in patients with hip fracture” Clin Rehabil&nbsp;December 2009&nbsp;vol. 23 no. 12&nbsp;1116-1123 <br>(level of evidence 2B)
[[Category:Conditions]]
 
9. Kristensen MT,&nbsp;Jakobsen TL,&nbsp;Nielsen JW,&nbsp;Jørgensen LM,&nbsp;Nienhuis RJ,&nbsp;Jønsson LR. “Cumulated Ambulation Score to evaluate mobility is feasible in geriatric patients and in patients with hip fracture.” Dan Med J.&nbsp;2012 July;59 (7) <br>(level of evidence 2B)<br>10. Cline A, Jansen G, Melby C. Stress fractures in female army recruits: implications of bone density, calcium intake and exercise. J Am Coll Nutr 17(2): 128- 135, 1998<br>(level of evidence 3B)<br>11. Boyd K, Peirce N, Batt M. Common hip injuries in sport. Sports med 24(4): 273-88, 1997.<br>(level of evidence 1A)<br>
 
[[Category:Vrije_Universiteit_Brussel_Project|Template:VUB]]

Latest revision as of 08:32, 14 December 2022

Original Editor - Delmoitie Giovanni Top Contributors - Delmoitie Giovanni, Lucinda hampton, Simisola Ajeyalemi, Jessie Tourwe, Joyce De Gelas, Kim Jackson, Admin, Tolulope Adeniji, Aminat Abolade, Debontridder Jordy, Annelies Beckers, Sara Evenepoel, Yarne Leuckx, Vidya Acharya, Lauren Lopez, Elien Lebuf, Karen Wilson and Claire Knott

Introduction[edit | edit source]

Garden classification, NOF

Hip fractures are one of the most frequent fractures presenting to the emergency department and orthopedic trauma teams.

  1. The terms hip fracture and femoral neck fracture both relate to the same type of injury.
  2. Both terms describe a fracture of the proximal femur between the femoral head and 5 cm distal to the lesser trochanter.[1]

A hip fracture occurs just below the head of femur (HOF), the region of the femur called the femoral neck. A femoral neck fracture disconnects the HOF from the rest of the femur. Click Hip Anatomy for more details

Etiology[edit | edit source]

Most commonly:

  • Falls in the elderly: Account for the majority of hip fractures. Risk factors for falls in the elderly population are many, those strongly associated with these fractures are a previous history of falls, gait abnormalities, the use of walking aids, vertigo, Parkinson disease, and antiepileptic medications. A lot of patients have multiple risk factors, and this, combined with age-associated reduced bone quality, is the underpinning cause of most hip fractures.[1] The majority of fragility hip fractures occurred inside the home[2]
  • Significant trauma (e.g. motor vehicle collisions) in younger patients
  • About 3% of hip fractures are related to localized bone weakness at the fracture site, secondary to tumour, followed by bone cysts, or Paget’s disease.

Epidemiology[edit | edit source]

The incidence of femoral neck fractures is increasing as the proportion of the elderly population in many countries increases. Between 1990 and 2000, there was nearly a 25% increase in hip fractures worldwide.[3]

  • The peak number of hip fractures occurred at 75-79 years of age for both sexes, with most occuring in women. In white women, the lifetime risk of hip fracture is 1 in 6.
  • Up to 20% of patients die in the first year following hip fractures, mostly due to pre-existing medical conditions. Less than half of those who survive the hip fracture regain their previous level of function[4]

Classification of Hip Fractures[edit | edit source]

Hip fracture classification

Hip fractures is classified into intracapsular and extracapsular fractures[5]

  1. Intracapsular fractures (femoral neck fractures): Occurs within the hip capsule; accounts for 45% of all acute hip fractures in the elderly[6]; susceptible to malunion/avascular necrosis of the HOF because of the limited blood supply to the area. The Femoral Neck Fractures, Garden Classification is the most commonly classification system. This splits into four categories depending on the severity of the fracture and the degree of displacement.
  2. Extracapsular fractures: Intertrochanteric fracture: occurs between the greater and the lesser trochanter[5], 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.

Risk factors[edit | edit source]

Risk factors for hip fracture include[7][8]:

  • Gender: prevalent in women; postmenopausal twice as likely as premenopausal to have hip fracture[9]
  • Reduced Bone density[10]
  • Falls[11]
  • 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.
  • 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 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 muscle mass and bone mass
  • Stroke increases the risk factor for falls which can cause a hip fracture.
  • Parkinson’s disease increases the risk factor for falls which can cause a hip fracture.

Characteristics/Clinical Presentation[edit | edit source]

  • Dull ache in the groin and/or hip region[12]
  • Inability to put weight on the injured leg causing immobility right after the fall[13]
  • Shorter leg on the side of the injured hip
  • External rotation of the injured leg[13]
  • Stiffness, bruising and swelling in and around the hip

Diagnostic Procedures[edit | edit source]

The diagnosis of a hip fracture is established based on patient history, physical examination, and radiography.[13]

  • Plain radiographs (sensitivity 93-98%) is the first-line investigation for suspected Neck of Femur(NOF) fractures.
  • In patients with a suspected occult NOF fracture, MRI (sensitivity 99-100%) is recommended by many institutions as the second-line test if available within 24 hours, with CT or nuclear medicine bone scan third-line[14]

Outcome Measures[edit | edit source]

Treatment[edit | edit source]

Serious complications (for example avascular necrosis and non-union) are very common without surgical intervention. In general, Garden stage I and II are stable fractures and can be treated with internal fixation (head-preservation) eg dymanic hip screw, and stage III and IV are unstable fractures and hence treated with arthroplasty (either hemi- or total arthroplasty. Internal fixation can be performed with multiple pins, intramedullary hip screw, crossed screw-nails or compression with a dynamic screw and plate.

The high morbidity and mortality associated with hip and pelvic fractures after trauma is well reported. Prognosis varies but is complicated by older age, as hip fractures increase the risk of death and major morbidity in the elderly.[3]

Rehabilitation[edit | edit source]

Figure4.jpg

The postoperative rehabilitation is as important as the initial surgery. Surgery aims to restore mobility, and commence early mobilization. Patients who have undergone arthroplasty or fixation of an extracapsular fracture can usually mobilize immediately after surgery without weight restrictions. Following fixation of an intracapsular fracture protected weight bearing is often recommended to reduce the risk of subsequent fracture displacement.

Regular intensive physiotherapy is needed to encourage the rapid progression of mobility, aiming to restore the patient’s pre-morbid mobility status. Sadly, many patients do not regain their previous level of mobility or independence and therefore require social care input[1].

Physical Examination[edit | edit source]

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 details, Click Hip Examination

Physical Therapy Management[edit | edit source]

Hip exercise 6.png

Rehabilitation begins promptly.

Two to three days postoperative

  • Instruct patient in deep breathing and cough. Goal: Prevent postoperative pneumonia and atelectasis.
  • Initiate isometrics and ankle pumps with involved extremity. Goal: Prepare patient for active exercise program.
  • Initiate bedside sitting once physician has cleared patient for this activity. Goal: Prepare patient to begin transfer and progressive gait training processes.[15]

Three to five days postoperative

  • Gait train patient, observing weight-bearing precautions. Progress to walker or crutches. Goal: Establish independent gait with assistive device, using proper gait pattern on all surfaces and stairs.
  • Initiate training in activities of daily living, including bed mobility and transfers to and from bed and toilet. Goal: Achieve independence with all transfers.
  • Initiate active range of motion/strengthening program. Individualize exercise programs according to each patient's needs, but generally include the following. Goals: Increase strength of involved extremity; increase independence with exercise program.
    • Supine: hip abduction and adduction, gluteal sets, quadriceps sets, straight leg raise, hip and knee flexion, short arc quadriceps, internal and external rotation.
    • Sitting: Long arc quadriceps, hip flexion, ankle pumps[16].
  • 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.
  • 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. Rehabilitation classes for balance and falls prevention are recommended.

Weight-bearing exercises are very important for mobility, balance, activities of daily living and quality of life[17], examples: stepping in different directions, standing up and sitting down, tapping the foot and stepping onto and off a block.

Hip Abduction with IR.JPG

For patients who underwent a prosthetic replacement have to avoid the following 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[18]:

  • 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)

Importance of rehabilitation/home exercise program:

  • 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[19]
  • A meta-analysis, showed that balance training within 6 months improves a person with hip fracture's physical functioning, gait, lower limb strength, performance task, and activity of daily living.[20]
  • 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.[21]

Education and prevention are also important issues to address.

Clinical Bottom Line[edit | edit source]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 Emmerson BR, Varacallo M, Inman D. Hip Fracture Overview. InStatPearls [Internet] 2022 Feb 12. StatPearls Publishing.Available;https://www.statpearls.com/articlelibrary/viewarticle/22890/ (accessed 9.12.2022)
  2. ↑ Dhibar DP, Gogate Y, Aggarwal S, Garg S, Bhansali A, Bhadada SK. Predictors and outcome of fragility hip fracture: a prospective study from North India. Indian Journal of Endocrinology and Metabolism. 2019 May;23(3):282.
  3. ↑ 3.0 3.1 Radiopedia Neck of femur fracture Available:https://radiopaedia.org/articles/neck-of-femur-fracture-1?lang=us (accessed 9.12.2022)
  4. ↑ IOF Facts and stats Available from:https://www.iofbonehealth.org/facts-statistics#category-16 (last accessed 14.10.2020)
  5. ↑ 5.0 5.1 Zuckerman JD. Hip fracture. New England journal of medicine. 1996 Jun 6;334(23):1519-25.
  6. ↑ Canale ST. Campbell's Operative Orthopaedics. St. Louis, MO: Mosby;; 1998. pp. 2181–2223.
  7. ↑ Grisso JA, Kelsey JL, Strom BL, Ghiu GY, Maislin G, O'Brien LA, Hoffman S, Kaplan F. Risk factors for falls as a cause of hip fracture in women. New England journal of medicine. 1991 May 9;324(19):1326-31.
  8. ↑ http://www.mayoclinic.com/health/hip-fracture/DS00185/DSECTION=risk-factors (visited on april 2016)
  9. ↑ Banks E, Reeves GK, Beral V, Balkwill A, Liu B, Roddam A, Million Women Study Collaborators. Hip fracture incidence in relation to age, menopausal status, and age at menopause: prospective analysis. PLoS medicine. 2009 Nov 10;6(11):e1000181.
  10. ↑ Angthong C, Suntharapa T, Harnroongroj T. Major risk factors for the second contralateral hip fracture in the elderly. Acta orthopaedica et traumatologica turcica. 2009 May 1;43(3):193-8.
  11. ↑ Yang Y, Komisar V, Shishov N, Lo B, Korall AM, Feldman F, Robinovitch SN. The Effect Of Fall Biomechanics On Risk For Hip Fracture In Older Adults: A Cohort Study Of Video‐Captured Falls In Long‐Term Care. Journal of bone and mineral research. 2020 May 13.
  12. ↑ Rao SS, Cherukuri M. Management of hip fracture: the family physician's role. American family physician. 2006 Jun 15;73(12):2195-200.
  13. ↑ 13.0 13.1 13.2 Dinçel VE, Şengelen M, Sepici V, Çavuşoğlu T, Sepici B. The association of proximal femur geometry with hip fracture risk. Clinical Anatomy: The Official Journal of the American Association of Clinical Anatomists and the British Association of Clinical Anatomists. 2008 Sep;21(6):575-80.
  14. ↑ Radiopedia NOF fractures Available from:https://radiopaedia.org/articles/femoral-neck-fracture (last accessed 14.10.2020)
  15. ↑ Luciani D, Cadossi M, Mazzotti A, Chiarello E, Giannini S. The importance of rehabilitation after lower limb fractures in elderly osteoporotic patients. Aging clinical and experimental research. 2013 Oct;25(1):113-5.
  16. ↑ Physio treatment Hip Protocol Available from:https://www.physiotherapy-treatment.com/Femoral-Neck-Fracture-Physiotherapy.html (last accessed 15.10.2020)
  17. ↑ LeBlanc KE, Muncie Jr HL, LeBlanc LL. Hip fracture: diagnosis, treatment, and secondary prevention. American family physician. 2014 Jun 15;89(12):945-51.
  18. ↑ Latham NK, Harris BA, Bean JF, Heeren T, Goodyear C, Zawacki S, Heislein DM, Mustafa J, Pardasaney P, Giorgetti M, Holt N. Effect of a home-based exercise program on functional recovery following rehabilitation after hip fracture: a randomized clinical trial. Jama. 2014 Feb 19;311(7):700-8.
  19. ↑ Mangione KK, Craik RL, Palombaro KM, Tomlinson SS, Hofmann MT. Home‐based leg‐strengthening exercise improves function 1 year after hip fracture: a randomized controlled study. Journal of the American Geriatrics Society. 2010 Oct;58(10):1911-7.
  20. ↑ Wu JQ, Mao LB, Wu J. Efficacy of balance training for hip fracture patients: a meta-analysis of randomized controlled trials. Journal of orthopaedic surgery and research. 2019 Dec;14(1):1-1.
  21. ↑ Latham NK, Harris BA, Bean JF, Heeren T, Goodyear C, Zawacki S, Heislein DM, Mustafa J, Pardasaney P, Giorgetti M, Holt N. Effect of a home-based exercise program on functional recovery following rehabilitation after hip fracture: a randomized clinical trial. Jama. 2014 Feb 19;311(7):700-8.


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