HIP FRACTURES
*P.  Lecorps MD, FAANOS, FICS
** M. J-M Coles MD, FAANOS, FICS, FRCS, 2011

* Popular Bluff Regional Medical Center, Poplar
Bluff, Missouri USA
** Coffeyville Regional Medical Center,
Coffeyville KS

Fig. 1: Hip fracture

Introduction

A hip fracture (fig.1) is a serious injury, particular among the elderly  and complications can be   life-threatening.   Fortunately,   surgery   to repair a hip fracture is usually very effective, although recovery often requires time and patience.

The mortality following a fractured neck of the femur is between 20% and 35% within one year in patients aged 82, +/-7 years, of which 80% were women

I- Causes

In older adults, a hip fracture is most often a result of:

Fig. 2: Falling

1- Fainting,      slipping,     missing    steps,    foot caught in a curve or foreign object (Fig.2).
2- Sustaining a blow to the hip joint. With he- marthrosis bruising of the trochanteric area increasing the patient’s pain symptoms.
3- Osteoporosis.  This  is  the  most  common cause of fracture of the hip.  It is found in post  menopausal  women  explaining  why this fracture is much more common in elderly women.

II-  Symptoms
Signs and symptoms of a hip fracture include:
1-   Immobility after a fall
2-   Severe pain in the hip or groin
3-   Inability to put weight on the leg of the side of the injury
4-   Stiffness,   bruising   and   swelling   in   and around the hip area
5-   Shorter leg on the side of the injury
6-  Turning outward of the leg on the side of injury

III- Risk Factors
1- Osteoporosis
2- Homocysteine, a toxic “natural” amino acid linked to cause heart disease. Other metabolic bone diseases such as Paget’s disease, osteomalacia, osteogenesis imperfecta.  Stress  fractures  may  occur  in the hip region with metabolic bone disease
3- Benign or malignant primary bone tumors are rare causes of hip fractures
4- Metastatic cancer deposits in the proximal femur may weaken the bone and cause a pathological hip
5- Fracture  Infection  in  the  bone  is  a  rare cause of hip fracture
6- Age: After menopause and andropause the chances are greater although it can happen at  any  age  due  to  trauma  from  motor vehicle accident, motorcycle accident, sport related injuries, and fall from height.
7- Sex: Hip fractures are much more common in women to the rate of 2 to 3 for one man due to the fact that osteoporosis is much more common in women than men and generally have less muscle and bony mass.
8- Chronic medical conditions: Due to hyper- tension, diabetes, congestive heart failure, chronic obstructive pulmonary disease, pre- vious stroke, fracture, or chronic anemia.
9- Certain medications: For the treatment of senile dementia, Alzheimer’s disease, anti- hypertensive, anti-depressive, sleeping pills, and medication for most psychotic disor- ders.
10- Nutritional  problems:  Avitaminosis,  hypo- proteinemia, Crohn’s disease, malabsortion, and cancer of the gastro-intestinal tract.
11- Physical inactivity: Decrease physical acti- vity  due  to  obesity,  previous  injuries  to upper and lower limbs, general weakness, dementia, depression, other psychiatric disorders, previous stoke or paralysis.
12- Tobacco and alcohol use: Nicotine is known to decrease blood supply to the bone and increase its weakness. Alcohol is known to cause  avascular  necrosis  of  the  bone making it more brittle and susceptible to fracture.

 IV-  Complications

Fig. 3: Plantar ulcer

1-  Serious  injury:  Most  of  the  patients  with hip fracture have other medical conditions that have to be taken care of or stabilized in the next 48 hours prior the surgery to avoid further complications.
2- Life  threatening:  Deep  Vein  Thrombosis and pulmonary embolism may cause death before or shortly after surgery.
3- An associated illness: Because of their age many have senile dementia and Alzheimer’s disease  making  post  op  physical  therapy and rehabilitation difficult and prolonged.
4- Blood clots: Any patient undergoing hip surgery  for  fracture  should  be  taken  off their  anti-cogulants  to  decrease  bleeding during   surgery   and   resume   after   the surgery.
5- Superficial thrombophlebitis: This happens very  often  after  surgery  on  the  side involved (fig.3)
6- DVT: Check for calf pain and Homan’s sign often.
7- Pulmonary embolism: If diagnosed the patient should be fully heparinized.
8- Death: This risk is present for every patient undergoing hip fracture surgery.

V-  Test and Diagnosis

Fig. 4: RMI show an hidden fracture

An incomplete fracture may not be seen on a regular X-ray. In that case, an MRI may be requi- red, The MRI (fig. 4) will usually show a hidden fracture. If the patient is unable to have an MRI be- cause of an associated medical condition a CT may be obtained instead. However it is not as sensitive as an MRI.

VI-  Types of Fractures (fig.5)

Fig. 5: Types of fractures

There are:
1- Femoral neck fracture: Any fracture located between  the  head  and  the  greater  and lesser trochanter. It is called sub-capital when it is below the neck and basi-cervical when its at the level of the trochanters.
2- Intertrochanteric fracture: Any fracture between the greater and lesser trochanter is an inter-trochanteric fracture.
3- Subtrochanteric fracture : Any fracture of the trochanteric region extending into the region below the lesser trochanter should be  considered  as  a  sub-trochanteric fracture.

VI-A   Femoral Neck Fractures:

These fractures the narrow neck between the round head of the femur and the shaft. This fracture often disrupts blood supply to the head of the femur. Garden classified this fracture into four types:

Fig.6:

-Type 1 is a stable fracture impaction in valgus
-Type 2 is complete but non-displaced
-Type  3  is  displaced  with  varus  displacement but still has some contact between the two fragments
-Type 4 is completely displaced and there is no contact between the fracture fragments

Fig.7: Type 1

Type 1 and 2 Treatment
Repair of a neck fracture type 1 and type 2 is done with individual screws. Cannulated screws are used for impacted fracture or non-displaced fracture of the femoral neck.

8                                               9

Fig.8: Individual Screws
Fig.9: Single compression Screw can be used femoral neck and inter-trochanteric fracture if the blood supply to the bone is not disturbed.

Type 3 and 4 Treatment
The blood supply is more likely to be disrupted in type 3 and 4

 
10                                                  11

Hemiarthoplasty (Fig. 10, 11) Only the ball is replaced is used in femoral neck fracture with displacement  and comminution.

Total hip replacement of both hip and socket is used  when  osteoarthritis  is  present  with  the neck of the femur.

VI-B Intertrochanteric Fracture (fig.12)

Fig. 12: Intertrochanteric fracture

•   This fracture occurs between the neck and the lesser trochanter
•   Tends to have better blood supply
•   Simple
•   Comminuted

VI-C  Subtrochanteric Fracture (fig. 13)

Fig. 13: Subtrochanteric fracture

•  This   fracture   occurs   below   the   lesser trochanter
•  Account  for  about  10%  to  30%  of  hip fractures
•  Older osteopenic after a low-energy fall
•  Younger patients after high-energy trauma

Subtrochanteric Fracture Treatment
Most fractures are managed with a long intra- medullary nail or together with a large lag screw or screw and plate (fig. 14, 15, 16, 17, 18 19)

14                                   15

Fig.14: Interlocking screws at the end of the nail make the fixation more secur

 

Fig. 18: Plate with Self-Locking Screws

Fig. 19: Screw and plate or locking plate

VII-Reduction of Hip Fracture and Pinning

(fig. 20 et 21)

Fig. 20: pinning

 

Sliding Hip Compression screw

Fig. 21: Slinding hip compression screw

 

VIII-   Fracture Table

This table (fig. 22) is necessary to internally reduce all intertrochanteric and subtrochanteric fractures or fractures of the neck the femur that have good blood supply to the head of the femur.  The foot on the side of the fracture is attached to the fracture boot for traction and reduction of the fracture.  This can be realized even before opening the surgical site.

 
Fig. 22: Fracture table

Fig. 23: C arm

Fig. 23 et 24: Fracture Table Positioning with C-arm fluoroscopy machine in the antero-posterior view.

Post-Op orders

Fig. 25: Sequential compression device

•    Care  include  the  staying  in  recovery room, V.S. q 15mins, Foley catheter, Ice pack and  medication  such  as  IV  –  LR,  Antibiotics (VancomycinR,  Cephalosporin),  Anticoagulants (CoumadinR,  ArixtraR,  LovenoxR,  AspirinR)  and SCD (sequential compression device) (fig. 25). Others drugs could be prescribed as Vitamine C (1000mg), Iron sulfate, CBC or H&H q day x 3 day, Home meds, PCA – Demerol R, Morphine, IV and IM pain meds.
Type and X-match for 2u blood
The patient can have his diet and is out of bed the next day (fig. 26)
P.T.  –  NWB,  FWB,  PWB,  stable  and unstable, Toe Touch are controlled.

Fig.  26:  Out  of the bed the next day

Post-Op Team

Fig. 27: Post op team

The post-op team ideally must include the specialists from Internal medicine, cardiology. A dietician   and   a   physical   therapist   are   very useful.

 

Post-Op Complications

They include:
• Infection
• Dislocation of prosthesis and Refracture
• Failure of hardware
• DVT and pulmonary embolism
• Death.