Hip Fractures: Current Review of Treatment and Management

Daniel C. Kim, MD, MS; Michael W. Honeycutt, MD; John T. Riehl, MD

Disclosures

Curr Orthop Pract. 2019;30(4):385-394. 

In This Article

Abstract and Introduction

Abstract

Hip fractures are one of the most common major orthopaedic injuries in the United States, with an incidence that is growing with the aging population. These fractures vary significantly in anatomy, pathogenesis, and treatment. Orthopaedists must be able to carefully distinguish between femoral neck, intertrochanteric, and subtrochanteric femoral fractures because diagnosis is essential in guiding treatment. The extent of complex decision-making and management is often underappreciated in this diverse group of fractures. In this review, the relevant background, anatomy, and current treatment considerations essential to optimize management of these common and significant injuries are discussed.

Introduction

The term "hip fracture" is a misnomer that is often used to refer to any fracture of the proximal femur extending from the distal extent of the femoral head to the proximal aspect of the femoral shaft. Acetabular fractures are not usually included in this terminology despite being a part of the hip joint and have separate diagnostic and treatment considerations. The fractures referred to in this anatomic region are classically divided into femoral neck (FN), intertrochanteric (IT), and subtrochanteric (ST) fractures, from proximal to distal, respectively. Proper diagnosis is an essential first step in understanding treatment options because they vary regionally along the "hip".

Hip fractures are one of the most common major orthopaedic injuries in the United States, with an incidence of 1.66 million worldwide in 1999, projected to rise above 6 million per year in 2050.[1] Management of hip fractures cost roughly $20 billion in 2010, and this diagnosis is consistently one of Medicare's top expenses.[2] In addition to the increase in hip fracture incidence over time, the diagnosis carries with it significant morbidity and mortality. Hip fractures carry a 20% to 30% 1-year mortality rate in elderly patients;[3] therefore carefully integrated care with a multidisciplinary approach is essential to improve outcomes.[4,5] It is important to keep in mind that the diagnosis of a low-energy hip fracture is more than just an orthopaedic diagnosis. It can be an indicator of systemic disease as well. In other words, people who are otherwise healthy do not often fall from ground level and break their hip. The goal of treatment in these fractures is early medical optimization and surgical stabilization to allow for quicker mobilization and recovery.

Because hip fractures are so common, the extent of complex decision making and management often is underappreciated in this diverse group of fractures. This review covers the relevant background, anatomy, and treatment considerations essential for an orthopaedic practitioner to optimize management of these common and significant injuries.

Clinical Evaluation

By the time the orthopaedic surgery team has been consulted, the diagnosis of a hip fracture often has already been determined. The clinical evaluation is similar among all hip fracture subtypes. For most displaced hip fractures, patients will have pain surrounding the entire hip region, and any movement of the affected limb generates significant pain. On visual examination, patients often have a resting lower extremity position of flexion, external rotation, abduction, and shortening. Patients with nondisplaced FN or IT fractures may complain only of mild pain in the groin and may be able to bear weight on the fractured extremity. On physical examination, nondisplaced fractures will not cause obvious clinical deformity, and patients will have moderate discomfort with hip range of motion.

As with all comprehensive orthopaedic trauma clinical evaluations, the patient should undergo a complete secondary survey to evaluate for other injuries in the setting of a distracting hip fracture. A thorough history is important for low-energy fracture mechanisms in determining treatment and disposition. This history should include a complete medical history, preinjury functional and ambulatory status, presence of prior hip pain, which could be indicative of a pathologic fracture and/or preexisting arthritis, and any loss of consciousness or history of syncope.[6]

Radiographic Evaluation

The radiographic evaluation of hip fractures is critical to appropriate fracture management. It includes similar requirements for all hip fracture subtypes with a few notable differences. Recommended radiographs include an anteroposterior pelvis, cross-table lateral, and full-length femur radiographs of the affected side. Obtaining a frog-leg lateral view is less desirable because it can potentially cause displacement of a nondisplaced FN fracture.[6] Some surgeons prefer dedicated imaging of the uninjured hip to use as a preoperative template. The most valuable radiograph for specifically defining the FN or IT fracture pattern is a traction-internal rotation anteroposterior view of the hip, which accounts for normal FN anteversion and assists in preoperative planning.[7] A CT scan of the pelvis can be beneficial in characterizing the fracture pattern as well; however, CT scan is not the standard of care and is not routinely obtained in the radiographic workup of hip fractures. MRI or a bone scan can be used for evaluation of occult hip fractures. In the setting of a delayed presentation to the hospital, duplex ultrasound can be used to rule out deep venous thrombosis.

The initial treatment goal of hip fracture surgery is to allow early mobilization and weight bearing. It is not uncommon for post-injury functional status to decrease in elderly patients after hip fracture from the pre-injury state. Additionally, patients should be routinely screened for osteoporosis, and treatment should be provided as indicated.

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