Hip Fractures

The most common hip fracture involves the proximal (upper) part of the femur (upper leg bone), either the femoral neck or intertrochanteric area. Fractures can be from trauma or pathologic. Hip fractures are more common in elderly patients following a fall, with the average age being 80.¹ Due to the strength of the femur bone, hip fractures in younger patients require significant force/trauma. Pathologic fractures occur in 5% of hip fractures and are from a disease process.¹

To understand hip fractures, we need to know the anatomy of the hip joint. The pelvic bone is connected to the head of the femur with a ball and socket joint. At the base of the head is the neck of the femur. Between the neck and shaft of the femur is the intertrochanteric area. The proximal shaft of the femur is called the subtrochanteric area. The surfaces of the ball and socket are covered in articular cartilage, which can be damaged during a traumatic fracture. In these cases, it is not uncommon for patients to develop post-traumatic arthritis later.

Causes

Most hip fractures are caused by a traumatic injury. More fragile bones, such as those in the elderly or from certain chronic illnesses, are more likely to fracture with a simple falling mechanism. Healthy, strong bones require more force, such as a fall from a significant height or a vehicular accident. Pathologic fractures happen as a secondary result of an underlying condition. Stress fractures are caused by repeated stress, often in the femoral neck, and are most common in long-distance runners. A femoral head fracture is uncommon and often the cause of a high-impact force or hip dislocation.

Symptoms

If you cannot put weight on your leg due to hip pain and have experienced a traumatic injury (such as a fall), it is crucial to visit a qualified orthopedic specialist. A proper diagnosis can prevent further damage and allow for the best outcome. The most common symptoms of a hip fracture include the following:

Pain usually in the groin and upper thigh
Inability to bear weight
Inability to twist the upper leg in or out

Diagnosing

Most patients cannot bear weight following a hip fracture and end up in the emergency room via ambulance. The diagnostic process begins with a physical examination and medical history. X-rays are often the definitive diagnostic imaging test to diagnose a hip fracture. MRI scans can detect small or incomplete fractures not visible on X-rays. A CT scan may be ordered to provide a more detailed image of the fracture, allowing your orthopedic surgeon to better plan your treatment.

Treatments

Hip fracture treatment depends on the fracture location and the patient’s medical background and personal preferences. To restore ambulation more quickly, surgical repair of the fracture is most common. For patients unfit for surgery, conservative treatment is an option.

Conservative Treatment Options

Conservative treatment does not offer the best outcomes, so it is reserved for patients at high surgical risk or who can ambulate reasonably pain-free. Fractures that can be treated conservatively:

Nondisplaced intracapsular fracture
Greater trochanter fracture
Nondisplaced femoral head fracture

Surgical Treatment

Arthroplasty: total hip replacement or hemiarthroplasty
Intracapsular fracture
Femoral head fracture with large fragment (in elderly patient)
Intramedullary nails
Intertrochanteric fractures
Subtrochanteric fracture
Sliding hip screws
Intertrochanteric fractures
Open reduction and internal fixation (ORIF)
Femoral head fracture with a large fragment

Complications

All surgical procedures have risks: pain, bleeding, nerve damage, and wound problems. Your orthopedic surgeon will discuss risks and possible complications before surgery. Complications following arthroplasty include hip dislocation, hardware loosening, leg length discrepancy, and peri-prosthetic fractures (fractures above/below the hardware). Hip fractures also have a risk of medical complications, including delirium, pulmonary embolism (blood clot in the lung), deep venous thrombosis (blood clot in the leg), pneumonia, myocardial infarction (heart attack), heart failure, urinary infection, acute kidney injury, anemia, and skin pressure ulcers.

References:

Emmerson BR, Varacallo M, Inman D. Hip Fracture Overview. PubMed. Published 2020. https://www.ncbi.nlm.nih.gov/books/NBK557514/
Fischer S, Gray J. Hip Fractures – OrthoInfo – AAOS. Aaos.org. Published November 2020. https://orthoinfo.aaos.org/en/diseases–conditions/hip-fractures/