Hip fracture

Definition
Fracture of the femur head or neck, usually as the result of a fall. The following classification derives from the vascular anatomy of the head and neck of the femur.


Anatomy

Articulation	between the hemispherical head of the femur and the cup-shaped acetabulum of the hip bone -synovial ball-and-socket joint
Ligaments	Iliofemoral strong inverted Y shaped ligament Pubofemoral triangular in shape- limits extension and abduction Ischiofemoral spiral in shape- limits extension Tranverse acetabular bridges acetabular notch - turns the noth into a tunnel- blood vessels/nerve enter joint Ligament of head of femur Flat and triangular in shape - lies within joint, ensheathed by synovium.
Nerve supply	Femoral, obturator, sciatic nerve and the nerve to the quadratus femoris Hip pain referred to knee because of femoral and obturator nerves supply hip and knee joints
Blood supply	3 sources: 1.  Medial & lateral circumflex femoral arteries Branches of deep femoral artery Form retinacular vessels at capsular margins Capsule is important as it carries a major part of the supply to femoral head in its retinacular fibres 2.  Vessels travelling up from the diaphysis along the cancellous bone 3.  Artery in the ligament teres Neglible source in adults but essential in children when the femoral head is separated form the neck by the cartilage of the epiphyseal line.
Movements	Flexion (120°) – iliopsoas, rectus femoris, sartorius Extension (5°-20°) – gluteus maximus, hamstrings Abduction (40°) – gluteus medius and minimus Adduction (25°) – adductor longus and brevis, adductor magnus External rotation (45°) – piriformis, obturator internus and externus, quadratus femoris, superior and inferior gemelli (assisted by gluteus maximus) Internal rotation (35°) – tensor fascia latae, anterior fibres of gluteus medius and minimus

Classification

Intracapsular	Types: Femoral neck, subcapital or transcervical Intracapsular femoral neck fractures may disrupt the blood supply to the femoral head, resulting in avascular necrosis.
Extracapsular	Intertrochanteric Subtrochanteric

Epidemiology

• Hip fractures common in geriatric age group
• 80% occur in those >60 years old
• F:M=3:1

Risk Factors

• Low bone-mineral density
• Female
• Metastatic cancer
• Neurologic disease with gait impairment
• Severe renal disease with secondary hyperparathyroidism
• Long-acting sedatives or hypnotics in the elderly
• Age
• Propensity to fall
• History of previous fracture

General Prevention

Prophylactic treatment for osteoporosis	Calcium supplementation, 1000–1500 mg PO daily Vitamin D supplementation, 400–800 IU PO daily Bisphosphonates: Alendronate (Fosamax), 35–70 mg PO weekly Risedronate (Actonel), 35 mg PO weekly Ibandronate (Boniva), 150 mg PO monthly Zoledronic acid (Reclast), 5 mg IV yearly Also approved as a fracture preventative after the occurence of a hip fracture
Avoid	Avoid long-acting sedatives and hypnotics in the elderly.
Unsteady gait	walking canes or walkers
General safety	use sturdy rails in showers, bathrooms, stairs, or ramps; avoid throw rugs and slippery surfaces

Presentations

History	Pain in hip. If severe, it usually indicates a displaced fracture. Mild pain usually occurs in nondisplaced fractures. Pain in knee. Pain is referred from hip and may occur in absence of hip pain
Physical Exam	External rotation of leg Shortening of leg

Investigation

Routine preoperative lab

FBC, chemical profile, electrolytes

Radiographs

Anteroposterior and “frog leg” lateral of hip. Classified using Garden Classification:  Anteroposterior pelvis to rule out pelvic fracture as cause of pain. Remainder of femur to include knee. The Shenton line is an imaginary line drawn along the inferior border of the superior pubic ramus (superior border of the obturator foramen) and along the inferomedial border of the neck of femur. This line should be continuous and smooth.   Interruption of Shenton's line can indicate (in the correct clinical scenario) developmental dysplasia of the hip (DDH) fractured neck of femur

Management

Analgesics	morphine sulfate 2–10 mg q3h as needed with change to oral opioids as soon as possible
Prophylactic anticoagulation	UFH 5,000 U SC q8–12h or low molecular weight heparin (Lovenox) 30 mg SC q12h
Prophylactic antibiotics	Ceftriaxone 2 g IV or IM for 1 dose
Surgery	All patients require surgery if fit for an operation Early mobilisation is associated with improved long-term prognosis Ideally surgery should be performed within 24 hours. Based on types of fracture. Described below:
Follow-up	Physiotherapy Radiographs of the hip taken prior to discharge from the hospital and every 8–12 weeks afterward until healed Monitor postoperative physical therapy for full recovery.

Surgery

Intracapsular fractures

2 Options: Reduction and internal fixation Femoral head replacement (preferred) Reduction and internal fixation Indication Undisplaced fractures Displaced fractures in young patients (<70 years) Media achieved with the use of three cancellous screws(percutaneous pinning) Complications non-union and avascular necrosis Femoral head replacement Indication Displaced fractures Pathological fractures Retinacula fibre are torn, and blood supply to the femoral head is disrupted Options Cemented Thompson prosthesis Uncemented Austin Moore prosthesis Bipolar prosthesis Total hip replacement Media Hemiarthroplasty is a type of hip replacement in which only the "ball" of the hip is replaced A total hip replacement replaces both the hip socket and ball Complications dislocation, loosening and peri-prosthetic femoral fracture

Extracapsular fractures

Usually repaired with a dynamic hip screw Allows impaction and stabilisation of fracture Prognosis related to the number of bone fragments 90% of fractures proceed to uncomplicated fracture union Dynamic hip screw

Complications

Mental deterioration:	Present in 90% of older patients for varying periods of time after surgery Usually subsides, but may persist owing to preexisting cognitive and mood disorders.
Infection	More common in comminuted fractures and patients with diabetes Surgical implants should be left in place and antibiotics given as indicated by culture and sensitivity. Some require the wound to be opened and drained.
Avascular necrosis of femoral head	Occurs in 25–30% of femoral neck fractures Treatment requires a prosthetic replacement in older patients.
Phlebitis	Prophylaxis with warfarin (Coumadin) to keep INR 2.0–2.5 or prothrombin time 15–18 seconds, for at least 4 weeks, OR Enoxaparin (Lovenox) 30 mg SC q12h beginning 12 hours after surgery and continuing until patient is mobile
Nonunion	In case of neck fractures, a prosthetic replacement is indicated. In the intertrochanteric fracture, a bone graft, usually with replacement of the nail and plate, is indicated.

Prognosis

• Hip fractures remain a serious injury in older people: 15–20% 3-month mortality in trochanteric fractures; 10% in neck fractures.
• 65% can be expected to return to their former state of health.
• An interdisciplinary team approach implemented both pre- and postoperatively appears to result in better outcomes with fewer complications.
• The overall risk of repeat hip fracture ranges from 2–10% and is greatest during the 12-month period following the 1st hip fracture.