Thursday, March 30, 2023

Hip Fracture


Although sports injuries to the knee, ankle, and shoulder have been well documented, injuries to the pelvis, hip, and thigh get little attention because of their low prevalence. Unfortunately, severe consequences may result if these injuries are improperly managed.

Femoral neck stress fractures were mainly seen in military recruits due to a triad of activity that is new, strenuous, and highly repetitive. However, as a result of self-imposed fitness regimens of recreational athletes, over the last 20 years the number of these injuries has been increasing in nonmilitary populations. In contrast, contact sports such as football, rugby, and soccer are usually the cause of most fractures of the hip. Stress fractures occur in normal bone undergoing repeated submaximal stress. As the bone attempts to remodel, osteoclastic activity occurs at a greater rate than osteoblastic activity. When these cumulative forces exceed the structural strength of bone, stress fractures occur.

Stress fractures occur mainly at the femoral neck and are classified as either tension (at the superior aspect of the femoral neck) or compression (at the inferior aspect of the femoral neck). See the images below.

A subcapital femoral neck fracture. Slight compres

A subcapital femoral neck fracture. Slight compression of the femoral head onto the femoral neck can be seen. Note the cortical break medially. This fracture could be missed if not closely evaluated.

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A view of the contralateral hip for comparison.

A view of the contralateral hip for comparison.

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Hip fractures are classified as intracapsular, which includes femoral head and neck fractures, or extracapsular, which includes trochanteric, intertrochanteric, and subtrochanteric fractures. The location of the fracture and the amount of angulation and comminution play integral roles in the overall morbidity of the patient, as does the preexisting physical condition of the individual. Fractures of the proximal femur are extremely rare in young athletes and are usually caused by high-energy motor vehicle accidents or significant trauma during athletic activity. Other causes may be an underlying disease process such as Gaucher disease, fibrous dysplasia, or bone cysts.

Identification and initiation of treatment is imperative in attempts to avoid complications, such as avascular necrosis (AVN). AVN is more common in patients in the pediatric and adolescent age groups. This outcome is due to the precarious nature of the blood supply to the subchondral region of the femoral head, which does not stabilize until years after skeletal maturity, after which collateral flow develops.

For excellent patient education resources, visit eMedicineHealth’s First Aid and Injuries Center. Also, see eMedicineHealth’s patient education article Total Hip Replacement.

New guidelines for management of hip fracture in the elderly released

The American Academy of Orthopaedic Surgeons released new guidelines on the management of hip fractures in patients over the age of 65. Recommendations supported by strong evidence include the following:

Regional analgesia can be used to improve preoperative pain control in patients with hip fracture.

In patients undergoing hip fracture surgery, similar outcomes can be achieved with general or spinal anesthesia.

Arthroplasty should be used for patients with unstable (displaced) femoral neck fractures.

Use of a cephalomedullary device is recommended for the treatment of patients with subtrochanteric or reverse obliquity fractures.

In asymptomatic postoperative hip fracture patients, a blood transfusion threshold of no higher than 8g/dl should be used.

Intensive post-discharge physical therapy improves functional outcomes.

Use of an interdisciplinary care program in hip fracture patients with mild to moderate dementia improves functional outcomes.

Multimodal pain management should be used after hip fracture surgery.

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