Authors

Dr Keran Sundaraj MBBS MSc (Trauma) FRACS FAOA

A hip fracture refers to a break in the upper part of the femur (thighbone). This commonly occurs in elderly patients whose bones are weakened by osteoporosis. In younger patients, a fractured hip is generally caused by high-energy trauma, such as motor vehicle accidents. Occasionally, hip fractures may occur due to repetitive impact injury causing a stress fracture.

Anatomy

The hip is a ball and socket joint. The socket is formed by the acetabulum (part of the pelvis), and the ball is formed by the femoral head (upper end of the thigh bone).

Fractures in the hip refer to one of four areas:

• Femoral neck

• Intertrochanteric area

• Subtrochanteric area

• Femoral head

Treatment

Hip fracture treatment is based on several factors:

• Age

• Pre-injury mobility

• Medical health issues

• Region of hip fracture

• Fracture configuration

Hip fractures are very painful, and prompt treatment is recommended to allow for early mobilisation. Treating the fracture and allowing for early mobility will decrease the risk of complications. These complications can include:

• Deep vein thrombosis (DVT/blood clots in the legs)

• Pulmonary embolism (PE/blood clots in the lungs)

• Pneumonia

• Bedsores

In general, nearly all patients will require surgery for a hip fracture. All but the most unwell patients will be offered surgery. Unlike a wrist fracture, a cast alone is insufficient treatment for these fractures to heal.

To keep patients safe there are several steps taken before, and following, surgery:

• Anaesthetic clearance - patients are generally seen or discussed with the doctors providing the anaesthetic. Further tests are sometimes required to ensure the heart and lungs are functioning optimally.

• Geriatricians - if elderly, patients are sometimes seen before the operation to optimise their medical function. Elderly patients are usually seen as a routine after the procedure to ensure they have a smooth recovery.

• Blood tests - are performed as a routine before and after surgery to address any imbalances in the blood.

• Urinary catheters - are placed before surgery to help patients who cannot mobilise for hygiene purposes. The catheter also helps to monitor hydration levels.

• Urine cultures - are performed to ensure the bladder is clear of infection. Urinary tract infections are a common cause of falls that leads to hip fracture.

• Chest X-rays - are performed to help guide anaesthetic treatment and minimise risk to the heart and lungs during surgery.

• ECG - is performed to detect underlying heart abnormalities or whether a heart attack has caused or occurred during the fall.

Surgery

Femoral Neck Fracture

This is referred to as a subcaptial or intracapsular fracture. This region can be thought of as an ice cream on a cone.

If undisplaced (ice cream remains on the cone), the bones can be pinned to prevent them from moving. If displaced (ice cream falling off the cone), the blood supply to the femoral head (ice cream) is compromised. For younger patients, this can be placed back on and pinned. There is a risk of developing avascular necrosis in the future. This risk is generally acceptable for younger patients as it's best to maintain their own hip rather than an artificial one. For elderly patients, a hip replacement (total or partial) may be recommended.

Intertrochanteric Fracture

Intertrochanteric fractures are those outside the hip capsule where the blood supply runs. These do not have the same risk of avascular necrosis as femoral neck fractures. As such, these are treated differently. Generally, a sliding pin and plate or an intramedullary nail (rod inside the bone) are used. These allow for compression of the fracture as a patient put weight through their leg. This also aids in the bone healing.

Subtrochanteric Fractures

These are fractures of the upper shaft of the femur. To allow for healing, an intramedullary nail (rod inside the bone) is used. This is locked in place with interlocking screws (cross-bolts) near the knee to prevent the bone from rotating. Healing in this area can be slower than in other fractures. Occasionally, fractures in this area are caused by osteoporosis medications (bisphosphonate stress fractures). This is a rare side-effect of this medication which makes the bones brittle. Healing in these fractures is impaired even despite surgical treatment and can make for challenging cases to manage.

Femoral Head Fractures

Femoral head fractures are rare and usually only occur with very high energy injuries such as high-speed motor vehicle accidents. If the fracture is not displaced or involves a small region below the weight-bearing portion of the femoral head, surgery may not be necessary. If the fracture is displaced, involves a significant weight-bearing amount of the femoral head, or the hip joint is unstable, surgery may be required. Sometimes despite the best medical care, arthritis can develop. If this does occur, a hip replacement may be necessary.

Recovery

The majority of patients begin mobilising the day after surgery. Early mobilising is key to reducing medical complications after surgery, such as blood clots and pneumonia. For elderly patients confusion and deconditioning is a serious concern. To prevent this, a multidisciplinary (combined) team approach is taken between orthopaedic surgeon, geriatrician, physiotherapist, occupational therapist and nursing staff.

Patients may be transferred to a rehabilitation unit after surgery. Here the goal is to return patients back to their pre-injury condition. Given that hip fractures generally occur in the elderly and that these patients may already have chronic medical issues, this is not always possible. For patients who sustain a hip fracture, some will return to their pre-injury function, some may require assistance with mobility (walking aids), and others will require increased levels of care (independent living to nursing home).

What to Discuss with Dr Sundaraj

• How long can I expect off work?

• When can I start driving?

• Do I need to be screened for osteoporosis (weak bones)?

• When can I start physiotherapy?

• What is the likely outcome from this treatment?

• When do I need to come back?