Hip Fractures

Aetiology

  • Typical mechanism of injury is a low impact fall in the elderly
    • 92% patients are over 60
  • Often assocaited with osteoporosis
    • 73% of patients are female
  • Young adults - caused by high energy trauma

Risk factors

  • Osteoporosis
  • Smoking, alcohol use
  • Malnutrition
  • Neurological impairment
  • Impaired vision
  • Low BMI

Pathophysiology

  • 30% mortality at one year
  • Fractures are classified as either intracapsular or extracapsular
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Intracapsular fractures

  • Occur proximal to the intertrochanteric line
  • Involve the femoral head and neck
  • Subdivided into subcapital and transcervical fractures
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  • Can be displaced or undisplaced
  • Prone to femoral head AVN and non-union
    • Intracapsular fractures can damage the medial femoral circumflex artery
  • Intracapcular fractures are classified using the Garden classification - predicts union and risk of AVN, which influences treatment
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Extracapsular

  • Occur distal to the intertrochanteric line
  • Subdivided into basicervical, intertrochanteric, reverse oblique and subtrochanteric fractures
  • Blood supply to the head of femur is intact, so AVN and non-union is rare
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Clinical presentation

Symptoms

  • Hip/groin pain
  • May be swelling
  • Unable to weight bear

Signs

  • Lower limb on affected side may be shortened and externally rotated
  • Assess neurology and vascuar status of the lower limb
  • Assess for cognitive impairment
  • Assess for any missed injuries
  • Assess for dehydration (some patients may have been on the floor for a long time)

Investigations

X-ray

  • Most are easy to see on x-ray - pelvis and lateral hip
  • Loss of contour of Shenton's line in pelvic x-ray indicates hip fracture
    • Fractures to femoral neck do not always cause loss of Shenton's line
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MRI

  • Some undisplaced fractures are subtle/invisible on x-ray
  • Where clinical suspician persists patients undergo either a repeat x-ray after 10 days or an immediate MRI

Others

  • ECG
  • Bloods

Management

  • Usually by operation followed by early mobilisation to avoid complications of prolonged bedrest
  • Analgesia - local nerve blocks rather than strong opiates

Surgical management

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