Hip Fracture: Diagnosis, Treatment, and Secondary Prevention

HERBERT Fifty. MUNCIE JR., MD, Louisiana Land University School of Medicine, New Orleans, Louisiana

LEANNE L. LeBLANC, Medico, Temple University, Philadelphia, Pennsylvania

Am Fam Physician. 2014 Jun 15;89(12):945-951.

Patient information: See related handout on hip fractures, written by the authors of this article.

This clinical content conforms to AAFP criteria for standing medical education (CME). Run across CME Quiz Questions.

Article Sections

  • Abstract
  • Epidemiology
  • Risk Factors
  • History
  • Physical Test
  • Diagnostic Testing
  • Management
  • Prophylaxis
  • Long-Term Care
  • References

Hip fractures cause significant morbidity and are associated with increased mortality. Women experience 80% of hip fractures, and the average age of persons who accept a hip fracture is 80 years. Most hip fractures are associated with a fall, although other risk factors include decreased bone mineral density, reduced level of activeness, and chronic medication use. Patients with hip fractures have pain in the groin and are unable to bear weight on the affected extremity. During the physical examination, displaced fractures present with external rotation and abduction, and the leg volition announced shortened. Plain radiography with cantankerous-table lateral view of the hip and anteroposterior view of the pelvis normally confirms the diagnosis. If an occult hip fracture is suspected and plain radiography is normal, magnetic resonance imaging should be ordered. Virtually fractures are treated surgically unless the patient has significant comorbidities or reduced life expectancy. The consulting orthopedic surgeon will cull the surgical procedure. Patients should receive condom antibiotics, particularly against Staphylococcus aureus, before surgery. In addition, patients should receive thromboembolic prophylaxis, preferably with depression-molecular-weight heparin. Rehabilitation is critical to long-term recovery. Unless contraindicated, bisphosphonate therapy should exist used to reduce the risk of another hip fracture. Some patients may benefit from a fall-prevention cess.

Older patients commonly experience hip fractures, which cause significant morbidity and are associated with increased bloodshed. The family dr.'south role involves multiple objectives: identify patients at increased risk of a hip fracture, promptly diagnose a hip fracture, facilitate long-term rehabilitation, reduce the risk of another hip fracture, and manage comorbid atmospheric condition.1–4

SORT: Cardinal RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Bear witness rating References

Plain radiography should be the initial diagnostic test in patients with suspected hip fracture.

C

5

Hip fracture surgery should be performed 24 to 48 hours after a fracture unless a filibuster is needed to stabilize comorbidities.

C

34

Patients undergoing hip fracture surgery should receive thromboembolic and antibiotic prophylaxis.

A

46–48, 50

Following a hip fracture, patients should commonly be treated with a bisphosphonate, regardless of their bone mineral density, unless contraindicated.

C

53

Following a hip fracture, nigh patients should have a formal fall-prevention cess.

C

55

Patients should receive post-fracture rehabilitation to help restore functional capability.

B

56

Epidemiology

  • Abstract
  • Epidemiology
  • Risk Factors
  • History
  • Concrete Examination
  • Diagnostic Testing
  • Management
  • Prophylaxis
  • Long-Term Care
  • References

Women experience 80% of all hip fractures.5 The average age at the fourth dimension of the fracture is 80 years, and nearly all patients are older than 65 years.5 The lifetime prevalence of a hip fracture is 20% for women and 10% for men.1 The project of annual new hip fractures past 2050 ranges from 500,000 to 1 million.vi The estimated annual cost in the U.s.a. is approximately $10.3 to $15.ii billion.7

Hip fractures are associated with increased mortality; 12% to 17% of patients with a hip fracture die inside the start twelvemonth, and the long-term increased run a risk of death is twofold.viii,ix Of the patients who survive, only one-half walk independently again, and 20% must move to a long-term care facility.1 With regard to functional independence, 50% of patients recover prefracture capability of activities of daily living, and 25% recover total capability of their instrumental activities of daily living.10

Take chances Factors

  • Abstract
  • Epidemiology
  • Risk Factors
  • History
  • Physical Examination
  • Diagnostic Testing
  • Management
  • Prophylaxis
  • Long-Term Intendance
  • References

Sexual activity and age are nonmodifiable risk factors that are highly associated with an increased risk of hip fracture (Table 111–23). Women older than 85 years are 10 times more likely to sustain a hip fracture than those 60 to 69 years of age.xi A previous hip fracture, a family history of hip fracture, and low socioeconomic status are also associated with an increased take chances.12–fifteen,24 Hip fracture clinical risk scores have been developed to identify high-take a chance patients in the primary care setting (run across i example at https://world wide web.aafp.org/afp/2007/0715/p273.html).3

Table 1.

Gamble Factors for Hip Fracture

Nonmodifiable

Historic period > 65 years11

Family history of hip fracture12

Female sex13

Low socioeconomic status14,15

Prior hip fracture12

Modifiable

Chronic medications16–19

Levothyroxine (decreases bone density)

Loop diuretics (impair calcium absorption in kidneys)

Proton pump inhibitors (reduce calcium absorption)

Selective serotonin reuptake inhibitors/sedatives (increase adventure of falls acquired by sedation, postural hypotension)

Decreased os mineral density (osteoporosis)20

Falls21

Reduced level of activity 22

Vitamin D deficiency 23

The modifiable chance factors for hip fracture include falls, decreased bone mineral density, reduced level of activeness, and chronic medication utilise. A fall is the almost pregnant risk factor for hip fracture, with 90% of fractures associated with a fall.21 Falls ordinarily occur from a standing position and are associated with reduced protective reactions, slower reaction times, and reduced overall strength.25 A fall may create a fear of future falls, which leads to decreased activity and mobility, and increased tension and tightening of the muscles.26,27 Many older persons become less active every bit they historic period, which increases their take a chance of a fracture.22

A bone mineral density T-score less than –two.five, as measured past dual energy x-ray absorptiometry, is associated with an increased gamble of fractures.twenty Low os mineral density scores are associated with inadequate calcium intake, vitamin D deficiency, and a family history of osteoporosis. Vitamin D levels less than 20 ng per mL (50 nmol per 50) are associated with an increased adventure of falls.23

Several medications are associated with an increased take chances of falls or fractures.16 Psychoactive medications, including selective serotonin reuptake inhibitors and benzodiazepines, are about consistently associated with an increased take chances of falls.16,17 Long-term use of proton pump inhibitors18 and higher dosages of levothyroxine are associated with an increased risk of fractures.19

History

  • Abstract
  • Epidemiology
  • Risk Factors
  • History
  • Physical Examination
  • Diagnostic Testing
  • Management
  • Prophylaxis
  • Long-Term Care
  • References

Patients with hip fracture have pain in the groin and are unable to bear weight on the afflicted extremity. Pain may exist referred to the distal femur or upper knee. Rarely, a patient may be able to walk with a cane, crutches, or a walker. If the patient is able to walk, there is typically worsening pain in the buttock or groin with weight begetting and ambulation. When an older person presents with hip pain afterward a fall, he or she should be treated as if a hip fracture has occurred, until proven otherwise.

Physical Examination

  • Abstract
  • Epidemiology
  • Risk Factors
  • History
  • Concrete Examination
  • Diagnostic Testing
  • Management
  • Prophylaxis
  • Long-Term Intendance
  • References

A stress fracture or a nondisplaced fracture may have no obvious deformity. Nevertheless, most patients accept some fracture displacement. Equally a result, when the patient lies in the supine position, the leg is held in external rotation and abduction, and appears shortened. Pain is elicited with rotation, such as with the log whorl maneuver, which involves gentle internal and external rotation of the lower leg and thigh in the supine position. In addition, a fracture may exist suspected if groin pain is elicited when applying an axial load to the affected extremity. Considering of the pain and instability, patients are unable to perform an active directly leg raise. Ecchymosis is rarely present initially. Distal pulses and awareness should be assessed and documented. Patients should be examined for any additional associated injuries.

Diagnostic Testing

  • Abstract
  • Epidemiology
  • Adventure Factors
  • History
  • Physical Exam
  • Diagnostic Testing
  • Management
  • Prophylaxis
  • Long-Term Care
  • References

Plain radiography is the initial diagnostic test for hip fracture5 (Figures 1 through 5). A cross-table lateral view of the hip and an anteroposterior view of the pelvis are appropriate. The frog-leg view should exist avoided; positioning the limb for this view results in severe pain and tin cause displacement of a nondisplaced fracture or worsen a displaced fracture.28 If radiography is negative and a hip fracture is still suspected, magnetic resonance imaging or a bone scan should be performed.29 The imaging study should be evaluated for other possibilities, such every bit pelvic, stress, or pathologic fractures. Computed tomography may be used, although it may not discover trabecular bone injuries in osteoporotic fractures or reveal bone marrow edema surrounding the fracture line.28

Effigy one.

Left intertrochanteric fracture (minimally displaced; arrows).

Figure 2.

Open up reduction and internal fixation following left intertrochanteric fracture.

Figure iii.

Left subtrochanteric femur fracture with intertrochanteric extension (arrows).

Figure 4.

Right femoral cervix fracture.

Effigy 5.

Hemiarthroplasty following femoral neck fracture.

Management

  • Abstract
  • Epidemiology
  • Risk Factors
  • History
  • Concrete Examination
  • Diagnostic Testing
  • Management
  • Prophylaxis
  • Long-Term Care
  • References

Hip fractures are classified past location for prognostic implications. The two categories are extracapsular (intertrochanteric and subtrochanteric) and intracapsular (femoral head and neck); these are summarized in Table 2.xxx The intertrochanteric region contains a big corporeality of cancellous os and an adequate blood supply.30 Equally a consequence, fractures in this region typically heal well with open reduction and internal fixation, which involves surgery to reduce the displaced bone, followed by internal fixation of the fracture with plates or screws. Subtrochanteric fractures, however, have an increased need for intramedullary rods or nails (touch on devices) and have a higher rate of touch failure, mainly because of the high stresses on this role of the femur. The femoral neck region has a sparse periosteum, little cancellous os, and a relatively poor claret supply.30 Consequently, fractures in the intracapsular region have a higher incidence of avascular necrosis, nonunion or malunion, and degenerative changes.

Table 2.

Hip Fracture Classification and Characteristics

Category Characteristic Significance

Extracapsular

Large amount of cancellous os and practiced blood supply

Typically heals well, although subtrochanteric has higher rate of impact device failure

Intertrochanteric

Subtrochanteric

Intracapsular

Little cancellous bone and relatively poor blood supply

College incidence of avascular necrosis, nonunion, malunion, and degenerative changes

Femoral head

Femoral cervix

Initially, care should focus on acceptable analgesia and consultation with an orthopedic surgeon. Surgery is the most viable selection for most patients. Nonsurgical interventions are reserved for patients with severe debilitation, unstable patients with major uncorrectable diseases, nonambulatory patients, or patients at the stop stages of a last illness.31 However, some patients with impacted stable fractures may exist considered for nonsurgical management.32

At initial presentation, the doc should address comorbidities and search for other injuries. When planning for surgery, patients should be assessed for bleeding risk. The presence of two of the following indicates a higher risk of bleeding: peritrochanteric fracture, initial hemoglobin level less than 12 chiliad per dL (120 g per L), and age older than 75 years.33

The timing of surgery may affect the eventual outcome. Early on surgery (within 24 to 48 hours) is prudent. This allows earlier mobilization and rehabilitation, which speeds functional recovery and decreases the chance of pneumonia, skin breakdown, deep venous thrombosis, and urinary tract infections.34 Before surgery is associated with reduced pain and shorter length of stay in the infirmary.34 Patients with comorbidities have an increased adventure of mortality; therefore, surgery may need to be delayed until 48 to 72 hours afterwards the fracture to stabilize these conditions.35,36

Some physicians consider the use of traction, either skin or skeletal, before surgery. Even so, no data suggest a benefit.37 General anesthesia is most mutual for surgery, although spinal anesthesia may exist called for some patients. Regional anesthesia may reduce postoperative confusion, even so no evidence suggests a clinically important difference between the two types of anesthesia.38

The consulting orthopedic surgeon determines the almost advisable surgical procedure. For femoral cervix fractures, there is debate as to whether open reduction and internal fixation or arthroplasty is the amend treatment. Arthroplasty replaces the acetabulum and the head of the femur, whereas hemiarthroplasty replaces only the femoral caput. Internal fixation results in lower morbidity, including decreased blood loss and deep wound infection. However, lower reoperation rates have been noted with arthroplasty. Additionally, arthroplasty has a reduced chance of avascular necrosis and nonunion, and allows for before recovery.39,40 Intertrochanteric fractures may exist treated with open up reduction and internal fixation or with arthroplasty. In that location is bereft evidence to determine which method is best.40,41

Trochanteric fractures (greater or lesser) are usually isolated avulsion fractures that typically occur in younger, agile patients.42 These often heal with conservative, nonoperative management, unless meaning displacement (greater than 1 cm) is noted, in which instance an orthopedic surgeon should be consulted.43 Patients with nondisplaced fractures should non bear weight for three to four weeks, and are usually able to render to total activity within three to 4 months.

There is business organization about the safety of metal-on-metal implants because of a higher failure charge per unit compared with other bearings. Implants typically last the residual of patients' lives; however, they take a failure rate of 12% (twice the industry average), resulting in corrective procedures (revision surgery) within five years.44 Recent data suggest that metal-on-metal bearing surfaces were not associated with an increased adventure of cancer diagnoses in patients who were followed for seven years postoperatively, just the biologic effects of these metals is non fully known.44,45

Prophylaxis

  • Abstruse
  • Epidemiology
  • Risk Factors
  • History
  • Physical Examination
  • Diagnostic Testing
  • Direction
  • Prophylaxis
  • Long-Term Care
  • References

Patients should receive prophylactic antibiotics within one to two hours before surgery, particularly against Staphylococcus aureus, the major pathogen of concern. Cefazolin, 1 to ii g intravenously every eight hours, is typically used and recommended within one hour of surgery.46,47 If the patient is allergic, so 1 yard of intravenous vancomycin should exist administered every 12 hours and started within two hours of surgery. Antibiotics should be provided for 24 hours.48

Patients should receive thromboembolic prophylaxis, preferably with low-molecular-weight heparin, although studies comparing it with unfractionated heparin found no difference in bleeding rates.49 A guideline from the American College of Chest Physicians recommends starting low-molecular-weight heparin 12 hours or more preoperatively or postoperatively, rather than inside four hours of surgery, to reduce the risk of haemorrhage.50 The guideline also recommends extending prophylaxis up to 35 days, rather than ten to 14 days, to prevent 9 additional venous thromboembolic events per 1,000 persons. Aspirin may exist used, but is suboptimal and not preferred for protection against thromboembolic events.fifty

The use of intermittent pneumatic compression devices is suggested with anticoagulation until the patient is ambulatory on a regular basis.51 Routine utilise of graduated compression stockings is not recommended in patients who are able to tolerate anticoagulation.52

Long-Term Care

  • Abstract
  • Epidemiology
  • Risk Factors
  • History
  • Concrete Exam
  • Diagnostic Testing
  • Direction
  • Prophylaxis
  • Long-Term Care
  • References

Because a previous hip fracture is a take chances factor for another hip fracture and because bisphosphonates reduce that risk,22 patients should receive bisphosphonate therapy, regardless of os mineral density results, unless contraindicated.53 Calcium (1,000 mg per day) and vitamin D (at least 800 IU per twenty-four hour period) supplements are usually combined with bisphosphonate therapy. Risks associated with bisphosphonate therapy may increase after 5 years of use.54 Nigh patients benefit from a fall-prevention assessment, which includes removing habitation environmental hazards, reviewing medications, and assessing muscle strength, residue, and gait.55

All patients crave rehabilitation therapy after hospital discharge, but the all-time strategies to ameliorate mobility are non fully known.4,56 The location of the therapy (habitation, outpatient, or skilled nursing facility) depends on the patient'due south capabilities and motivation. Outpatient therapy may lead to improved functional status.57 The optimal duration of therapy is unclear. Early ambulation improves patient outcomes and may embark with unrestricted weight bearing. Any nutritional concerns should be addressed. In malnourished patients, protein supplements reduced medical complications.58

Displaced fractures have an increased hazard of avascular necrosis.59 Therefore, periodic radiography should be performed following surgery. Depending on the wellness of the patient, the frequency of imaging should exist individualized and discussed with the orthopedic surgeon. If avascular necrosis is suspected, magnetic resonance imaging may be necessary because plain radiography may non bear witness changes for half dozen months afterward avascular necrosis develops. Long-term care is essential to return the patient to the nearly functional state as soon as possible, ideally to prefracture level of activity.60

BEST PRACTICES IN PREVENTIVE MEDICINE: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

Recommendation Sponsoring organisation

Exercise not use DEXA to screen for osteoporosis in women younger than 65 years or men younger than 70 years with no run a risk factors.

American Academy of Family unit Physicians

Practise not routinely echo DEXA scans more than often than once every 2 years.

American College of Rheumatology

Information Sources: A search of Essential Evidence Plus and the U.S. Preventive Services Chore Force was completed for the following keywords: femoral diaphysis fracture, femoral neck fractures, and hip fractures. A literature search of PubMed was completed using the keyword hip fractures (classification, drug therapy, epidemiology, history, bloodshed, prevention and control, radiography). The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Search dates: February xix and 20, 2012, and March half dozen, 2014.

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The Authors

prove all author info

KIM EDWARD LeBLANC, Doc, PhD, FAAFP, FACSM, CAQSM, is the executive director of the Clinical Skills Evaluation Collaboration in Philadelphia, Pa. At the fourth dimension the article was written, Dr. LeBlanc was the Bernard and Marie Lahasky Professor and caput of the Department of Family unit Medicine at Louisiana State University School of Medicine, New Orleans....

HERBERT L. MUNCIE JR., Physician, is a professor in the Department of Family unit Medicine at Louisiana Land Academy School of Medicine.

LEANNE L. LeBLANC, MD, FAAFP, is in clinical exercise affiliated with Temple Academy in Philadelphia.

Author disclosure: No relevant financial affiliations.

Address correspondence to Kim Edward LeBlanc, MD, 3750 Marketplace St., Philadelphia, PA 19104. Reprints are not available from the authors.

The authors thank Christine 50. Manalla for her editorial aid in the writing and preparation of the manuscript.

Figures 1 through 5 courtesy of Drs. Michael 50. Maristany, William Shaffer, and Michael Hanemann, Louisiana State University School of Medicine, New Orleans.

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