*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,
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
In older adults, a hip fracture is most often a result of:
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.
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
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.
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)
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:
-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
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.
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
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
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)
Fig. 17: Short and Long Trochanteric Nails
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)
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. 23 et 24: Fracture Table Positioning with C-arm fluoroscopy machine in the antero-posterior view.
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
The post-op team ideally must include the specialists from Internal medicine, cardiology. A dietician and a physical therapist are very useful.
• Dislocation of prosthesis and Refracture
• Failure of hardware
• DVT and pulmonary embolism
Fig. 28: dislocation of the prosthesis
Follow Up Care
In the follow up care it is recommended to check the wound and remove sutures or skin staples in no less than three weeks after surgery.
X-rays are prescribed every three weeks to assess healing. Additional therapy is applied if needed. The fracture may take up to six months to heal depending on the condition of the bone and the patient’s health status and condition.
Questions and comments email:
Phone: 573-785-5599 Fax: 573-785-9559
And Maxime J-M Coles MD
Phone 203 395 1934
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