Hip fracture

Medical quality assurance by Dr. Albrecht Nonnenmacher, MD at May 23, 2016
StartDiseasesHip fracture

Hip fractures are a serious and common type of bone fracture, especially among the elderly. These types of fracture are typically the result of a fall or other trauma, but can be spontaneous as well. Hip fractures fall into two major categories: intracapsular and extracapsular.

Contents

Definition & Facts

A hip fracture is a break in the upper part of the femur, or bone of the thigh. While the hip itself is a ball and socket joint, the term hip fracture only refers to a break in the femur, not part of the pelvis that joins with the femoral head. An intracapsular fracture is a break in the femoral head or neck area of the femur, near the pelvis. Extracapsular fractures occur further down the femur and are classified by their proximity to the lesser trochanter, a bony ridge on the femur that acts as a muscle attachment point. 

Symptoms & Complaints

The most common and obvious symptoms of a break in the upper femur are severe pain and the inability to move the hip joint. As most hip fractures are caused by trauma, these symptoms usually appear immediately after a fall. The pain may be localized to the hip itself or spread into the groin and down the thigh.

Dark bruising and intense swelling may also occur at the fracture site. The leg on the affected side may appear shorter and turned outward after suffering a fractured hip.

After a fractured hip has been repaired, long term complications may arise. The most common complaint is chronic arthritis of the hip. Although this can be managed with anti-inflammatory drugs, such as ibuprofen and naproxen, the arthritis may never fully resolve.

If the fracture caused a disruption of the supply of blood to the femur head, then avascular necrosis may be the result. Avascular necrosis is when the bone begins to die from a lack of blood and usually requires the entire upper femur to be replaced with artificial materials.

Causes

The vast majority of hip fractures are caused by a fall, either from slipping, tripping, or fainting. Slipping on icy surfaces is a frequent culprit. An impact from the side, such as being struck by a vehicle, is also a common cause. In many cases, patients with a fractured hip are predisposed to broken bones due to osteoporosis, or weak bones. Osteoporosis is more common among Asians, Caucasians, women and the elderly.

Certain cancers and tumors can also cause the femurs to be weak, leading to a higher chance of fracture. Additionally, some medications, such as proton-pump inhibitors used to prevent heartburn, may leach minerals from bone, resulting in hips more susceptible to breaks. Almost all cases of spontaneous hip fractures, where a break occurs in the absence of a fall or other trauma, are due to brittle bones from one of the causes above.

Diagnosis & Tests

Patients with symptoms of a fractured hip should see a doctor immediately. The doctor will perform an physical examination and will likely perform some basic tests, such as the anvil test. This test consists of tapping the heel and checking for pain in the hip. A positive response indicates a likely break in the femur.

When a hip fracture is suspected, the next step is an X-ray. The doctor will often be able to clearly see the fracture on X-ray and make the diagnosis. In some cases, such as when the break is incomplete, a MRI may be needed. The MRI will more clearly show the fracture and any damage to the surrounding soft tissue. If the patient has metal implants or other factors preventing a MRI from being performed, then a CT scan can be used. 

Treatment & Therapy

The majority of fractured hips require surgery to be repaired. This means the patient will need to see an orthopedic surgeon. The surgeon will assess the fracture and discuss options with the patient. Very rarely, the fracture can be managed without surgery. Also, patients who are not healthy enough to undergo surgery or tolerate anesthesia will receive nonsurgical treatment. This consists of rest, a full leg cast, and refraining from putting weight on the leg.

Surgical treatment almost always involves general anesthesia, meaning the patient is put fully to sleep. Because intracapsular fractures involve the head of the femur (ball) breaking, these fractures are usually treated without hardware, unless the femoral head is completely broken. In those cases the entire femoral head will need to be replaced with a prosthetic.

Extracapsular fractures are also treated with surgery. The fractured femur will be fixated, or held in place, by nails or screws. Blood transfusions during or after surgery are usually not necessary, but are needed in rare instances. Physical therapy commences following discharge from the hospital. This may last several months with the frequency of therapy sessions gradually decreasing over time.

Prevention & Prophylaxis

The best way to prevent hip fractures is to maintain strong bones and joints and manage osteoporosis. Adequate intake of vitamin D and calcium is critical to accomplish this. Smoking also increases the risk of osteoporosis and bone fractures, so patients should consider quitting.

For patients who already have osteoporosis, medications are available to treat the condition. Primary care physicians and orthopedists often prescribe bisphosphonate drugs that prevent bone reabsorption in an effort to reverse or slow osteoporosis.

Other preventative measures can be taken by the patient and their family in the form of fall prevention. Elderly individuals or those prone to falls from fainting, low blood pressure, difficulty walking, or muscle weakness should see their doctors for recommendations about assistive devices. These include canes or walkers.

They should also take all prescribed medications to prevent dizziness or drops in blood pressure. A safe environment should be ensured by removing obstacles around the home and avoiding icy or slippery surfaces. Those prone to falls should move slowly and avoid rising or sitting too rapidly.