Femoral Neck Hip Fracture: Difference between revisions

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== Introduction ==
== Definition/Description ==
[[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.


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.<ref>Tinetti ME, Kumar C. The patient who falls: “It's always a trade-off. ''JAMA''. 2010 Jan 20;303(3):258–266.</ref> &nbsp;Such a fracture is a serious injury that occurs mostly in elderly people over 65 years and complications can be life-threatening.<ref>Marks R. [https://www.researchgate.net/profile/Ray_Marks/publication/340793491_VITAMIN_C_AND_HIP_FRACTURES/links/5e9e058c299bf13079ad8850/VITAMIN-C-AND-HIP-FRACTURES.pdf Vitamin C and Hip Fractures-Review.] EC Orthopaedics. 2020;11:33-41.</ref><ref name=":0">Antapur et al. Fractures in the elderly: when is a hip replacement a necessity? Clinical Interventions in Aging. 2011</ref>(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.<ref name=":0" />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.<ref name=":0" /> 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.<ref name=":0" />
# The terms hip fracture and femoral neck fracture both relate to the same type of injury.
== Clinically Relevant Anatomy  ==
# 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>


The hip joint is a ball and socket joint, formed by the head of the femur and the acetabulum of the pelvis. [[Image:Figure1 hip fracture.jpeg|thumb|right]]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<ref name=":5">Bateman, Laura, et al. "Medical management in the acute hip fracture patient: a comprehensive review for the internist." The Ochsner Journal 12.2 (2012): 101-110.</ref> (figure1) <div>
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 


Click [[Hip Anatomy]] for more details
== Etiology ==
</div>
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]].


==Epidemiology ==
==Epidemiology ==
<br>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. <br>It is known that there will be more old people in 2050 than in 1990, this is the biggest cause of the big raise.<ref>Kannus, P., et al. "Epidemiology of hip fractures." Bone 18.1 (1996): S57-S63. </ref><br>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.<ref name=":1">Dhanwal, Dinesh K., et al. "Epidemiology of hip fracture: Worldwide geographic variation." Indian journal of orthopaedics 45.1 (2011): 15.</ref>  
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>  


Age-standardized hip fracture rates (per 100 000 population) across different continents<ref name=":1" /><br>
* 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>
{| class="wikitable" width="200" cellspacing="1" cellpadding="1" border="1"
|-
|
'''Continent'''
|
'''Country'''
|
'''Men'''
|
'''Women'''
|-
|
'''''Africa'''''
|
<br>
|
<br>
|
<br>
|-
|
<br>
|
Rabat
|
57.7
|
79.9
|-
|
<br>
|
Cameroon
|
43.7
|
52.1  
|-
|
'''''Asia'''''
|
<br>
 
|
<br>
|
<br>
|-
|
<br>
|
Beijing
|
87
|
97
|-
|
<br>
|
Shenyang
|
101.3
|
80.9
|-
|
<br>
|
Korea
|
137
|
262
|-
|
<br>
|
Iran
|
127.3
 
|
164.6
|-
|
<br>
|
Malaysia
|
87.4
|
212.5
|-
|
<br>
|
Tottori
|
107.3
 
|
297.3
|-
|
<br>
|
Japan
|
99.6
|
368
|-
|
<br>
|
Kuwait
|
216.6  
|
316
|-
|
<br>
|
Singapore
|
152
|
402
|-
|
<br>
|
Hong Kong
|
193
|
484.3
|-
|
<br>
|
Hong Kong
|
50
|
110
|-
|
<br>
|
Taiwan
|
233.4
|
496.8
|-
|
'''''South America'''''
|
<br>
|
<br>
|
<br>
|-
|
<br>
|
Mexico
|
98
|
169
|-
|
<br>
 
|
Sobral, Brazil
|
59.3
|
168.4
|-
|
<br>
|
Argentina
|
137
|
405
|-
|
<br>
|
Venezuela
|
37
|
98
|-
|
'''''Europe'''''
|
<br>
|
<br>
|
<br>
|-
|
<br>
|
Switzeland
|
137.8
|
346
|-
|
<br>  
|
Former East Germany
|
137.8
|
354.7
|-
|
<br>
|
Former West Germany
|
154.5
|
399.4
|-
|
<br>
|
England
|
143.6
|
418.2
|-
|
<br>
|
Greece
|
201.7
|
469.9
|-
|
<br>
|
Sweden
|
302.7
|
709.5
|-
|
<br>
|
Norway
|
352
|
763.6
|-
|
<br>
|
Oslo
|
399.3
|
920.7
|-
|
<br>
|
Austria
|
567
|
759
|-
|
<br>
|
Hungary
|
223
|
430
|-
|
<br>
|
The Nederlands
|
308
|
669
|-
|
'''''North America'''''
|
<br>
|
<br>
|
<br>
|-
|
<br>
|
Minnesota
|
201.6
|
511.6
|-
|
<br>
|
United States
|
197
|
516
 
|-
|
'''''Oceania'''''
|
<br>
|
<br>
|
<br>
|-
|
<br>
|
Maori, New Zealand
 
|
197
|
516
|-
|
<br>
|
Non-Maori
|
288
|
827
|-
|
<br>
|
New South Wales
|
191.8
|
475.1
|-
|
<br>
|
Australia
|
187.8
|
504.2
|}<br>


== Classification of Hip Fractures ==
== Classification of Hip Fractures ==
[[Image:Hip fracture.jpeg|frame|right]]  
[[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>


Hip fractures can be classified into intracapsular and extracapsular fractures<ref name=":7">Zuckerman JD. Hip fracture. ''N Engl J Med''. 1996 Jun 6;334(23):1519–1525. </ref> (figure2). 
# '''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.
'''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.<ref>Canale ST. ''Campbell's Operative Orthopaedics''. St. Louis, MO: Mosby;; 1998. pp. 2181–2223.</ref> It mostly results from a low-impact fall from a standing position or from twisting on a planted foot.<ref>Christodoulou NA, Dretakis EK. Significance of muscular disturbances in the localization of fractures of the proximal femur. ''Clin Orthop Relat Res''. 1984. pp. 215–217. Jul-Aug. (187)</ref> 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<ref>Garden RS. The structure and function of the proximal end of the femur. ''J Bone Joint Surg Br''. 1961 Aug;43B(3):576–589.</ref> (figure 3).  [[Image:Fig5.png|thumb|right]]
 
*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.<ref name=":7" /> 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<ref name=":8">Rao, Shobha S., and Manjula Cherukuri. "Management of hip fracture: the family physician’s role." Am Fam Physician 73.12 (2006): 2195-2200. </ref>
 
== Etiology ==
 
A substantial portion of the population is at risk of hip fracture by virtue of low bone mass and frequent falls.<ref name=":3">Melton, LJd. "Hip fractures: a worldwide problem today and tomorrow." Bone 14 (1993): 1-8. </ref> 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.<ref name=":3" />
*Trauma or lesion in the femur ( around 10% )<ref>Melton, LJd. "Hip fractures: a worldwide problem today and tomorrow." Bone 14 (1993): 1-8. </ref>
*Local pathologies ( 1% ); metastatic malignancy 
*Fall 
*Hip fractures without injuries ( &lt; 5% )
*Osteoporosis: Osteoporosis is a multifactorial, chronic disease that may progress silently for decades until characteristic fractures occur late in life. &nbsp; 


== Risk factors ==
== Risk factors ==
Risk factors for hip fracture include<ref>Grisso, Jeane Ann, et al. "Risk factors for falls as a cause of hip fracture in women." New England Journal of Medicine 324.19 (1991) </ref><ref>http://www.mayoclinic.com/health/hip-fracture/DS00185/DSECTION=risk-factors (visited on april 2016)</ref>:
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>:
*'''Gender''': prevalent in women; postmenopausal twice as likely as premenopausal to have hip fracture<ref>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 Med''. 2009 Nov;6(11) e1000181. Epub 2009 Nov 1. </ref>  
*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. [Major risk factors for the second contralateral hip fracture in the elderly] ''Acta Orthop Traumatol Turc''. 2009 May-Jul;43(3):193–198. Turkish.</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>
*'''Fall'''<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>  
*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>  
*'''Medications''': Some medications can cause a decrease in bone density like cortisone.  
*[[Medication and Falls|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.
*[[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.  
*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  
*[[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  
*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.
*[[Physical Inactivity|Physical inactivity]]: [[Physical Activity|Physical activity]] is very important for muscle mass and bone mass
*'''Stroke disease''' increases risk factor for falls which can cause a hip fracture.  
*[[Stroke]] increases the risk factor for falls which can cause a hip fracture.  
*'''Parkinson’s disease''' increases risk factor for falls which can cause a hip fracture.  
*[[Parkinson's|Parkinson’s]] disease increases the 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.<ref name=":2">Parker, Martyn, and Antony Johansen. "Hip fracture." British Medical Journal 7557 (2006): 27. (Level of Evidence A3)</ref>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.<ref name=":2" />
 
== Characteristics/Clinical Presentation ==
== Characteristics/Clinical Presentation ==
*Dull ache in the groin and/or hip region<ref name=":8" />
*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" />   
*Inability to put weight on the injured leg causing immobility right after the fall<ref name=":9" />   
*Shorter leg on the side of the injured hip   
*Shorter leg on the side of the injured hip   
*External rotation of the injured leg<ref name=":9" />  
*External rotation of the injured leg<ref name=":9" />  
*Stiffness, bruising and swelling in and around the hip  
*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  ==
== Diagnostic Procedures  ==


The diagnosis of a hip fracture is established based on patient history, physical examination, and radiography.<ref name=":9">Dinçel, V. Ercan, et al. "The association of proximal femur geometry with hip fracture risk." Clinical Anatomy 21.6 (2008): 575-580.
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> 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%.<ref>Dominguez S, Liu P, Roberts C, Mandell M, Richman PB. Prevalence of traumatic hip and pelvic fractures in patients with suspected hip fracture and negative initial standard radiographs—a study of emergency department patients. ''Acad Emerg Med''. 2005 Apr;12(4):366–369.</ref><ref>Lee YP, Griffith JF, Antonio GE, Tang N, Leung KS. Early magnetic resonance imaging of radiographically occult osteoporotic fractures of the femoral neck. ''Hong Kong Med J''. 2004 Aug;10(4):271–275.</ref><ref>Lim KB, Eng AK, Chng SM, Tan AG, Thoo FL, Low CO. Limited magnetic resonance imaging (MRI) and the occult hip fracture. ''Ann Acad Med Singapore''. 2002 Sep;31(5):607–610. </ref><ref>Kirby MW, Spritzer C. Radiographic detection of hip and pelvic fractures in the emergency department. ''AJR Am J Roentgenol''. 2010 Apr;194(4):1054–1060</ref> 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.
</ref>
 
* Plain [[X-Rays|radiograph]]<nowiki/>s (sensitivity 93-98%) is the first-line investigation for suspected Neck of Femur(NOF) fractures.
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.<ref>Holder LE, Schwarz C, Wernicke PG, Michael RH. Radionuclide bone imaging in the early detection of fractures of the proximal femur (hip): multifactorial analysis. ''Radiology''. 1990 Feb;174(2):509–515.</ref>CT scan is another modality that can be used to diagnose occult hip fractures, although its efficacy has been proven by few studies.<ref>Cannon J, Silvestri S, Munro M. Imaging choices in occult hip fracture. ''J Emerg Med''. 2009 Aug;37(2):144–152. Epub 2008 Oct 28. </ref>  
* 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>


== Outcome Measures  ==
== 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<ref>Edward l Hannan et al., Mortality and Locomotion 6 Months After Hospitalization for Hip FractureRisk Factors and Risk-Adjusted Hospital Outcomes
* [https://physio-pedia.com/Functional_Independence_Measure_(FIM) Functional Independence Measure]
 
* [[Berg Balance Scale|Berg Balance Scale]]
(Level of Evidence A2)
* [https://physio-pedia.com/Timed_Up_and_Go_Test_(TUG) Timed Up and Go Test (TUG)]
</ref>). (Level of evidence A2)  
* [[Patient Specific Functional Scale]]
 
* [[Falls Risk Assessment Tool (FRAT): An Overview to Assist Understanding and Conduction|Falls Risk Assessment Tool]]
* '''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.<br>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.<br>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.<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. 


== Prognosis ==
== Treatment ==
Hip fractures carry an approximately 30% risk of mortality at 1 year,<ref>Magaziner J, Simonsick EM, Kashner TM, et al. Predictors of functional recovery one year following hospital discharge for hip fracture: a prospective study. J Gerontol. 1990;45:M101-M107.</ref>and 25% to 75% of community-dwelling adults may not regain their pre-fracture level of function.<ref>Borgquist L, Ceder L, Thorngren KG. Function and social status 10 years after hip fracture. Prospective follow-up of 103 patients. Acta Orthop Scand. 1990;61:404-410.[A</ref><ref name=":12">Marottoli RA, Berkman LF, Cooney LM Jr. Decline in physical function following hip fracture. J Am Geriatr Soc. 1992;40:861-866</ref><ref name=":12" /> 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<ref name=":10">Gretchen M Orosz et al., Association of Timing of Surgery for Hip Fracture and Patient Outcomes. JAMA. 2004;291(14):1738-1743.</ref>: (Level of Evidence A2)
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.  


#Mean pain scores over the first 5 hospital days
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.
#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)
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" />
#Major postoperative complications
#Length of hospital stay
#Mortality through 6 months
#FIM locomotion (a 2-item subscale focusing on walking and climbing stairs) score at 6 months
#FIM self-care (a 6-item scale of self-care activities including bathing and dressing)
#FIM transferring (a 3-item scale focusing on transfers from the bed, toilet, and tub).<ref name=":10" />


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. <br>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 &lt; 0.01).<ref name=":11">Diamond TH et al., Hip fracture in elderly men: prognostic factors and outcomes. The Medical Journal of Australia [1997, 167(8):412-415]
== 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.


(Level of Evidence C)
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" />.
</ref> <br>Physical functioning (measured by the Barthel index) deteriorated significantly in men from 14.9 at baseline to 13.4 at six months (P &lt; 0.05) and 12.4 at 12 months (P &lt; 0.05) after fracture.<ref name=":11" />  


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<ref>Jay Magaziner et al., Recovery from Hip Fracture in Eight Areas of Function. Journal of Gerontology: Medical Sciences 2000, Vol. 55A, No. 9, M498–M507.</ref>
== Physical Examination  ==
== Physical Examination  ==


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* Tenderness to palpation around the inguinal area, over the femoral neck. This area may also be swollen.
* 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  
* 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 [http://www.physio-pedia.com/Hip_Examination www.physio-pedia.com/Hip_Examination]
For more on details, Click [[Hip Examination]]
 
== Medical Management    ==
[[Image:Figure4.jpg|thumb|right]]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.<ref>Handoll HH, Parker MJ. Conservative versus operative treatment for hip fractures in adults. Cochrane Database Syst Rev. 2008;(3):CD000337</ref> Surgery <48 hours after admission may be associated with lower morbidity and may decrease hospital stay.<ref>Mak JC, Cameron ID, March LM; National Health and Medical Research Council (Australia). Evidence-based guidelines for the management of hip fractures in older persons: an update. Med J Aust. 2010;192:37-41.</ref><ref>Khan SK, Kalra S, Khanna A, et al. Timing of surgery for hip fractures: a systematic review of 52 published studies involving 291,413 patients. Injury. 2009;40:692-697.</ref> 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%).<ref>Simunovic N, Devereaux PJ, Sprague S, et al. Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis. CMAJ. 2010;182:1609-1616</ref><ref>Moja L, Piatti A, Pecoraro V, et al. Timing matters in hip fracture surgery: patients operated within 48 hours have better outcomes. A meta-analysis and meta-regression of over 190,000 patients. PLoS One. 2012;7:e46175</ref><div></div><u>'''Intracapsular Fractures'''</u>
* Undisplaced: internal fixation with a dynamic hip screw, or multiple cannulated screws<ref>Mak JC, Cameron ID, March LM; National Health and Medical Research Council (Australia). Evidence-based guidelines for the management of hip fractures in older persons: an update. Med J Aust. 2010;192:37-41</ref>
* 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.<ref name=":13">Bhandari M, Devereaux PJ, Tornetta P 3rd, et al. Operative management of displaced femoral neck fractures in elderly patients. An international survey. J Bone Joint Surg Am. 2005;87:2122-2130.</ref><ref>Duckworth AD, Bennet SJ, Aderinto J, et al. Fixation of intracapsular fractures of the femoral neck in young patients: risk factors for failure. J Bone Joint Surg Br. 2011;93:811-816</ref>
** 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. <ref>Bhandari M, Devereaux PJ, Swiontkowski MF, et al. Internal fixation compared with arthroplasty for displaced fractures of the femoral neck. A meta-analysis. J Bone Joint Surg Am. 2003;85-A:1673-1681.</ref><ref name=":14">Parker MJ, Gurusamy K. Internal fixation versus arthroplasty for intracapsular proximal femoral fractures in adults. Cochrane Database Syst Rev. 2006;(4):CD001708.</ref><ref>Burgers PT, Van Geene AR, Van den Bekerom MP, et al. Total hip arthroplasty versus hemiarthroplasty for displaced femoral neck fractures in the healthy elderly: a meta-analysis and systematic review of randomized trials. Int Orthop. 2012;36:1549-1560.[</ref>
** For patients > 80 years of age, most surgeons favor arthroplasty<ref>National Institutes of Health (NIH). Osteoporosis prevention, diagnosis, and therapy. NIH Consens Statement. 2000;17:1-45.</ref><ref name=":13" />. Total hip arthroplasty may reduce pain and functional limitation more than hemiarthroplasty. <ref name=":15">Keating JF, Grant A, Masson M, et al. Displaced intracapsular hip fractures in fit, older people: a randomised comparison of reduction and fixation, bipolar hemiarthroplasty and total hip arthroplasty. Health Technol Assess. 2005;9:iii-x, 1-65</ref><ref name=":14" /><ref name=":15" /><br>
 
<u>'''Extracapsular Fractures'''</u><br>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.<ref name=":5" />For displaced intertronchanteric fractures, operative management includes internal fixation with either a dynamic hip screw,<ref>Johnell O, Kanis JA, Oden A, et al. Predictive value of BMD for hip and other fractures. J Bone Miner Res. 2005;20:1185-1194.</ref>  or a cephalomedullary nail. <ref>De Laet C, Kanis JA, Oden A, et al. Body mass index as a predictor of fracture risk: a meta-analysis. Osteoporos Int. 2005;16:1330-1338</ref>  Dynamic hip screw is preferred because of decreased complication rate and reoperation rate.<ref>National Institute for Health and Care Excellence. Hip fracture: management. May 2017. <nowiki>http://www.nice.org.uk/</nowiki> (last accessed 9 August 2017)</ref> <ref>Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev. 2010;(9):CD000093</ref>
== Physical Therapy Management  ==
== 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<ref>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. ''J Am Geriatr Soc''. 2010 Oct. 58(10):1911-7. </ref>  (Level of evidence: 1b). In another study, a meta-analyses, showed that balance training within 6 months improves person with hip fracture physical functioning, gait, lower limb strength, performance task, and activity of daily living.<ref>Wu JQ, Mao LB, Wu J. E[https://josr-online.biomedcentral.com/articles/10.1186/s13018-019-1125-x#Sec2 fficacy of balance training for hip fracture patients: a meta-analysis of randomized controlled trials]. Journal of orthopaedic surgery and research. 2019 Dec 1;14(1):83.</ref>  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.<ref>Latham, Nancy K., et al. "Effect of a home-based exercise program on functional recovery following rehabilitation after hip fracture: a randomized clinical trial." Jama 311.7 (2014): 700-708.
[[File:Hip exercise 6.png|right|frameless]]
</ref> (Level of evidence: 1b)
Rehabilitation begins promptly.
 
The patient training begins the day after surgery from a sitting position, with abducted hip during transfer from bed to chair.<ref>Luciani, D., et al. "The importance of rehabilitation after lower limb fractures in elderly osteoporotic patients." Aging clinical and experimental research 25.1 (2013): 113-115.
</ref> (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.<ref>Sylliaas, Hilde, et al. "Progressive strength training in older patients after hip fracture: a randomized controlled trial." Age and ageing (2011): afq167. </ref> (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.<ref name=":6">Scheerlinck, T., et al. "Hip fracture treatment: outcome and socio-economic aspects: a one-year survey in a Belgian university hospital." Acta orthopaedica belgica 69.2 (2003): 145-156 </ref> (Level of evidence: 2a). Complications following hip surgery involve blood clots, pneumonia, wound infections, and more, all of which can be reduced with activity<ref>Daniel Pendick. ‘’After hip fracture, exercise at home boosts day-to-day function’’ Harvard health publication (2014)  </ref> (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:  
'''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>.


*&nbsp;internal rotation from hip flexion is very stressful for the joint
* 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. 
*impact activities should be avoided for six weeks postoperative
* The patient can also begin strengthening exercises based on the surgeon's orders (typically six weeks post-op). 
*depending on the surgical procedure is unloaded or partially loaded mobilize postoperatively crucial to the joint
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.
*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>Edward Leblanc, k. i. m., and Leanne l. Leblanc. "Hip fracture: diagnosis, treatment, and secondary prevention." American family physician89.12 (2014).  
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>[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.[[Image:Figure6.png|thumb|right]]For patients who underwent a prosthetic replacement have to avoid for approximately 12 weeks:
</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:
*Hip flexion greater than 70–90°  
*Hip flexion greater than 70–90°  
*External rotation of the leg  
*External rotation of the leg  
*Adduction of the leg past midline  
*Adduction of the leg past midline  
*Should not bend forward from the waist more than 90
*Should not bend forward from the waist more than 90°
Rehabilitation program components<ref>Latham, Nancy K., et al. "Effect of a home-based exercise program on functional recovery following rehabilitation after hip fracture: a randomized clinical trial." Jama 311.7 (2014): 700-708.
'''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>(Level of evidence: 1b):
</ref>:
*Hip extension (theraband and manual exercise)  
*Hip extension (theraband and manual exercise)  
*Heel raises onto toes (theraband and manual exercise)  
*Heel raises onto toes (theraband and manual exercise)  
Line 565: Line 127:
*Stepping up and down step (vest, manual exercise and plyometric step)  
*Stepping up and down step (vest, manual exercise and plyometric step)  
*Calf raises - both legs and one leg (manual exercise)
*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<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>
* 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.
</ref>
Education and prevention are also important issues to address.
== Clinical Bottom Line  ==
== Clinical Bottom Line  ==
The number of hip fractures worldwide will increase up to 7-21 million incidences each year in 2050.<ref name=":4">Kannus, P., et al. "Epidemiology of hip fractures." Bone 18.1 (1996): S57-S63. </ref> 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.<ref name=":4" />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.


== References  ==
== References  ==
 
<references />  <br>
<references />  
[[Category:Vrije_Universiteit_Brussel_Project]]
 
[[Category:Primary Contact]]
  <br>
[[Category:Older People/Geriatrics]]
     
[[Category:Acute Care]]
     
[[Category:Older People/Geriatrics - Conditions]]
      [[Category:Vrije_Universiteit_Brussel_Project]]
[[Category:Fractures]]
   
[[Category:Conditions]]
     
      [[Category:Primary Contact]]
   
   
    [[Category:Older People/Geriatrics]]
 
   
    [[Category:Acute Care]]
 
 
  [[Category:Older People/Geriatrics - Conditions]]
 
  [[Category:Fractures]]
 
  [[Category:Conditions]]

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, Claire Knott, Lauren Lopez, Elien Lebuf and Karen Wilson

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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