A hip fracture is a break that occurs in the upper part of the femur (thigh bone), at the femoral neck or (rarely) the femoral head. Symptoms may include pain around the hip, particularly with movement, and shortening of the leg. Usually the person cannot walk. A hip fracture is usually a femoral neck fracture. Such fractures most often occur as a result of a fall. (Femoral head fractures are a rare kind of hip fracture that may also be the result of a fall but are more commonly caused by more violent incidents such as traffic accidents.) Risk factors include osteoporosis, taking many medications, alcohol use, and metastatic cancer. Diagnosis is generally by X-rays. Magnetic resonance imaging, a CT scan, or a bone scan may occasionally be required to make the diagnosis. Pain management may involve opioids or a nerve block. If the person's health allows, surgery is generally recommended within two days. Options for surgery may include a total hip replacement, hemiarthroplasty (half hip replacement) or stabilizing the fracture with screws. Treatment to prevent blood clots following surgery is recommended. About 15% of women break their hip at some point in life; women are more often affected than men. Hip fractures become more common with age. The risk of death in the year following a fracture is about 20% in older people.
Signs and symptoms
The classic clinical presentation of a hip fracture is an elderly patient who sustained a low-energy fall and now has groin pain and is unable to bear weight. Pain may be referred to the supracondylar knee. On examination, the affected extremity is often shortened and externally rotated compared to the unaffected leg.
Complications Nonunion, failure of the fracture to heal, is common in fractures of the neck of the femur, but much more rare with other types of hip fracture. Avascular necrosis of the femoral head occurs frequently (20%) in intracapsular hip fractures, because the blood supply is interrupted. Malunion, healing of the fracture in a distorted position, is very common. The thigh muscles tend to pull on the bone fragments, causing them to overlap and reunite incorrectly. Shortening, varus deformity, valgus deformity, and rotational malunion all occur often because the fracture may be unstable and collapse before it heals. This may not be as much of a concern in patients with limited independence and mobility. Hip fractures rarely result in neurological or vascular injury.
Medical Most people who have a hip fracture are living with frailty. This means they are at increased risk of developing complications after an injury or surgery. Some people also are unwell before breaking a hip. It is common for the break to have been caused by a fall due to some illness, especially in the elderly. Nevertheless, the stress of the injury, and a likely surgery, increases the risk of medical illness including heart attack, stroke, and chest infection. Hip fracture patients are at considerable risk for thromboemoblism, blood clots that dislodge and travel in the bloodstream. Deep venous thrombosis (DVT) is when the blood in the leg veins clots and causes pain and swelling. This is very common after hip fracture as the circulation is stagnant and the blood is hypercoagulable as a response to injury. DVT can occur without causing symptoms. A pulmonary embolism (PE) occurs when clotted blood from a DVT comes loose from the leg veins and passes up to the lungs. Circulation to parts of the lungs is cut off which can be very dangerous. Fatal PE may have an incidence of 2% after hip fracture and may contribute to illness and mortality in other cases. Delirium is extremely common following a hip fracture. It is most common in the first few days after hip fracture. It usually clears completely. There are multiple causes including inflammation as a result of the fracture and surgery, as well as pain, immobility, moving to a strange place, and drugs and medical complications following hip fracture (such as pneumonia and cardiac issues). Delirium after hip fracture is associated with an increased risk of being diagnosed with dementia. There are currently no drug treatments that have been shown to reduce the risk of developing delirium after hip fracture. Urinary tract infection (UTI) can occur. Patients are immobilized and in bed for many days; they are frequently catheterised, commonly causing infection. Prolonged immobilization and difficulty moving make it hard to avoid pressure sores on the sacrum and heels of patients with hip fractures. Whenever possible, early mobilization is advocated; otherwise, alternating pressure mattresses should be used.
Risk factors Hip fracture following a fall is likely to be a pathological fracture. The most common causes of weakness in bone are:
Osteoporosis. Other metabolic bone diseases such as Paget's disease, osteomalacia, osteopetrosis and osteogenesis imperfecta. Stress fractures may occur in the hip region with metabolic bone disease. Elevated levels of homocysteine, a toxic 'natural' amino acid. Benign or malignant primary bone tumors are rare causes of hip fractures. Metastatic cancer deposits in the proximal femur may weaken the bone and cause a pathological hip fracture. Infection in the bone is a rare cause of hip fracture. Tobacco smoking (associated with osteoporosis).
Mechanism
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