Femoral Neck Hip Fracture

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

Search Strategy

Databases searched: Pubmed, PEDro, eMedicine, Medscape,Handbook of fractures, Prometheus, Kapandji

Keywords searched: hip fracture, incidence femoral neck fracture, osteoporotic hip fracture, treatment hip fractures …

Definition/Description

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. (level of evidence A1)

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. 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.

The pelvic ring is composed of the sacrum. The hip bone is formed at maturity by the fusion of three ossification centers:
 The ilium
 The ischium
 The pubis

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.

Muscles (19)
The hip joint consist of 27 muscles with each their own function. A few important ones:

Posterior
 M gluteii
 M gluteus maximus
 M gluteus medius
 M gluteus minimus
 powerful muscles
 stabililzation
 stabilize the femoral head in the acetabulum
 accelerate the standing position
 strong hip extensors
 external rotators
 hip abductors

 M piriformis
 external rotator
 weak abductor
 weak flexor of the hip
 provide postural stability while walking or standing

Anterior
 M iliopsoas
 M iliacus
 M psoas major
 M psoas minor
 most powerful hip flexors

www.physio-pedia.com/Hip_Anatomy

Epidemiology /Etiology

Different events can form the basis of a hip fracture.
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. 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. (level of evidence C) High energy trauma is mostly the cause of pelvic fractures:
 57% motor vehicle accidents
 18% pedestrian injuries
 9% motorcycle accidents
 9% falls from height
 4% crush mechanisms

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. 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, are common in athlete and military populations, in which subjects are exposed to a sudden increase in physical training. (level of evidence B)

Causes of Acute fracture:
After extreme muscle contraction-> avulsion fracture
After extreme sports -> stress fracture due
Osteoporosis or hip osteoarthritis often cause complaints in older people.

Causes of Stress fracture:
As a result of fatigue fracture of the bone because of repeated stress
Athletes have an increased vulnerability due to high training load
In endurance runners/ athletes the pelvic region is frequently affected (incidence greater in women)
by decrease in bone density
A fracture at the femoral neck is hard to determine
-> A femoral neck fracture by fatigue may be due to lower shock absorption of the muscles and a lower load limit.

Risk factors for hip fracture include:

• Osteoporosis
• Low Bone Marrow Density (level of evidence A1)
• Age> 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, ... (level of evidence A2)

However the evidence that calcium supplements reduce fracture risk is lacking. (level of evidence A1)

Characteristics/Clinical Presentation

Specific features for patients with hip fracture include:

• Dull ache in the groin and/or hip region (level of evidence B)
• Inability to put weight on the injured leg causing immobility right after the fall (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  
• 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
Extra capsular = intertrochanteric / pertrochanteric / subtrochanteric

Differential Diagnosis

Certain types of hip fracture are associated with an increased risk ofavascular necrosis of the femoral head.
Other lower body fractures must be excluded:
- Stress fractures
- Fracture of acetabulum
- Fracture of ramus pubis

Diagnostic Procedures

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

On a MRI one can see that a proximal hip fracture consists many kinds:

•  Subcapital neck fracture: right below the femoral head
•  Femoral neck fracture (intracapsular fracture)  (level of evidence B)
•  Intertrochanteric fracture: between the greater and the small trochanter (extracapsular fracture)
•  Subtrochanteric fracture: 2 ½ inch below the small trochanter (extracapsular fracture)
•  Fracture of the greater trochanter
•  Fracture of the small trochanter
  
•  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

add links to outcome measures here (also see Outcome Measures Database)

www.physio-pedia.com/International_Hip_Outcome_Tool_(iHOT)

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

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.

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.

Timed Up and Go Test (TUGT) is used to test the functional mobility level. (23)
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.
www.physio-pedia.com/Timed_Up_and_Go_Test_(TUG)

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.
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.

Examination

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.

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.

Anteroposterior radiograph of the pelvis:

•  anterior lesions
•  iliac fractures
•  L5 transverse process fractures

Obturator and iliac oblique views:
• May be used for (suspected) acetabular fractures
Inlet radiograph:
• 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.

Outlet radiograph:
• Taken in de supine position. Useful for determination of vertical displacement of the hemipelvis.
• Computed tomography
• Magnetic resonance imaging
• Stress view

Medical Management

The recommended treatment of pelvic fractures depends from institution to institution:
General treatment options:

•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:
Lateral compression: external fixation for 3 to 6 weeks is advised. With mobilization depending on the comorbid injuries
Anteroposterior compression: external fixation for 8-12 weeks, depending on the principle of the posterior sacroiliac ligaments.
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.

•Internal fixation – this significantly rises the forces resisted by the pelvic ring when compared to external fixation. Biomechanical studies suggest the following treatments:
Iliac wing fractures: open reduction and internal fixation
Diastasis of the pubic symphysis: plate fixation if undergoing laparotomy
Sacral fractures: transiliac bar fixation, but may cause compressive neurologic injury
Unilateral sacroiliac dislocation: internal fixation with cancellous screws fixation can be indicated
Bilateral posterior unstable disruptions: fixation of the displaced part of the pelvis to the sacral body may be accomplished by posterior screw fixation.
• Open fractures: priority should be given to the evaluation of the anus, rectum, vagina and genitourinary system.
• Postoperative plan: Generally, early mobilization is desired

Physical Therapy Management

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). First post-operative day (OR = 3.3) (p values: 0.009-<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 …

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
  

Weight-bearing exercises are very important for mobility, balance, activities of daily living and quality of life (level of evidence B), examples:

• stepping in different directions
• standing up and sitting down
• tapping the foot and stepping onto and off a block. 

Prevention is also a part of the rehabilitation process to prevent fractures. Prevention of hip fractures should focus on preventing falls and osteoporosis.

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

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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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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16. KENNETH J. KOVAL, and JOSEPH D. ZUCKERMAN, Handbook of fractures, second edition, 2002 ( level of evindence: 5 )
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
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 )
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)
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 )
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.
(level of evidence: 2C)
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.
(level of evidence 1 B)
Physiopedia Link: http://www.physio-pedia.com/International_Hip_Outcome_Tool_(iHOT)
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 December 2009 vol. 23 no. 12 1116-1123
(level of evidence 2B)

9. Kristensen MT, Jakobsen TL, Nielsen JW, Jørgensen LM, Nienhuis RJ, Jønsson LR. “Cumulated Ambulation Score to evaluate mobility is feasible in geriatric patients and in patients with hip fracture.” Dan Med J. 2012 July;59 (7)
(level of evidence 2B)
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
(level of evidence 3B)
11. Boyd K, Peirce N, Batt M. Common hip injuries in sport. Sports med 24(4): 273-88, 1997.
(level of evidence 1A)