Hip Fractures in Elderly

By Shanojan Thiyagalingam, MS3, SGU SOM

Orthopedic Surgery Rotation, NBIMC

Outline

Intro
Epidemiology
Risk Factors
Anatomy
Types of Fractures
Initial Management
Prognosis
!

Femoral Neck Fractures

Intertrochanteric Fractures
Trochanteric Fractures
Subtrochanteric Fractures

Intro

increasing elderly population leading to more hip fx

risk factors in elderly:
poorer balance, medication side effects, difficulty
maneuvering around environmental hazards

Epidemiology

By 2050: 6 million hip fx in world

In 2003: 310 000 hip fx in USA
30% of all hospitalized pts
!

cost: $10.3-$15.2 billion/year

Epidemiology

increases risk of death and major morbidity

risk highest among:
nursing home residents, men, >90 y/o, cognitive impairment and other
co-morbidities, treated non-operatively, cannot ambulate independently
50% of pts dont regain ability to live independently
!

Overall 1 yr mortality rate: 12-37%

In-hospital 1 yr mortality rate: 1-10%

Epidemiology

Femoral neck fractures (intracapsular)

mostly age 65-99
F to M = 3:1
!

Intertrochanteric (extracapsular)
mostly age 65-99
F to M = 3:1
!

Subtrochanteric
bimodal distribution: 20s-40s and >60s
!

Isolated trochanteric fracture

mostly young active adult age 14-25

Risk Factors

Major: osteoporosis, falls

90% hip fx in elderly due to fall from standing position
Female>Male
d/t higher rate of osteoporosis
lifetime risk :17.5% vs 6% respectively
average age: 77 vs 72 respectively
!

Other:
low socioeconomic status, CVD, some endocrine disorder (ie:
thyroid, diabetes,etc)

Anatomy

hip joint: ball and socket

ball (femoral head)
socket (acetabulum)

Anatomy

femoral neck connects

femoral head to proximal
femoral shaft and attaches to
intertrochanteric region

Hip Fracture: refers to fx at any

of the above described
locations

Types of Fractures

Types of Fractures

Femoral neck/head fractures (intracapsular)

!
!
!
!

Intertrochanteric/subtrochanteric
(extracapsular)

Initial Management

pain management
IV (faster relief), IM, PO, regional nerve blocks
orthopedic surgery consult
obtain blood for type and screen if risk for hemorrhage:
age >75 , Hb <12g/dL, peritrochanteric fx
DVT and wound infection prophylaxis
!
if elderly pt:
identify cause of fall (ie: syncope, etc) by taking good hx
identify sites of injury by physical exam

Prognosis

Varies by anatomic location !

!

Intertrochanteric fx:
heals well relatively
high amt cancellous bone, good blood supply
!

Femoral neck fx:

heals not as well relatively
less amt cancellous bone, thin periosteum, poor
blood supply
higher incidence of complication
avascular necrosis, degenerative femoral head
changes

Femoral Neck Fractures

Overview:!
! ! subcapital: femoral head/neck junction!

!
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!
!
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! !

transcervical: midportion of femoral neck!

basicervical: base of femoral neck!

Mechanism:!
elderly fall!
directly onto lateral hip!
twisting mechanism: foot planted, body rotates!
sudden spontaneous completion of fatigue fx causing a fall!
younger adult fall!
major trauma!

Symptoms:!
sudden onset of hip pain following a fall; may/may not bear weight!
groin pain, leg externally rotated and shortened!
little bruising since its intracapsular!
if insufficient (fatigue) fx: vague knee, buttock, groin or thigh pain

Femoral Neck Fractures

Radiograph:!
AP view w/ max lateral rotation; lateral view!
abnormal trabecular pattern !
defects in the cortex !
shortening or angulation of the femoral neck!
normal b/w femoral neck and femoral shaft on an AP
radiograph is 45 degrees !
normal b/w medial femoral shaft and trabecular lines running
through the shaft to the femoral head is 160 to 170 degrees!
Alterations in these angles suggest a fracture.!
!

MRI or bone scan (up to 72 hrs post-fx to see changes) if xray

unremarkable but clinical suspicion

!
!

Femoral Neck Fractures

Management:!
Orthopedic surgical consult for surgical fixation OR if pt
minimal symptoms/poor surgical candidate then PMD comanage with Orthopedic surgeon!
Surgery: Open reduction, internal fixation (lower
morbidity) vs. arthroplasty (lower reoperation rate)

Intertrochanteric Fracture

Overview:!
Stable vs unstable!
Stable: lesser trochanter not displaced, no comminution, medial cortices
of prox/distal fragments aligned!
Unstable: displacement occurs, comminution, multiple fracture lines
exist!
!

Mechanism:!
elderly!
fall!
younger adult!
rarer; seen in major trauma!
!

Symptoms!
hip pain, joint swelling, ecchymosis (d/t extracapsular)!
injured leg shortened, externally rotated if fx displaced!
trochanteric tenderness!
look for other injuries d/t high association with concomitant injuries

Intertrochanteric Fracture

Radiograph:!
AP view w/ max lat rotation!
lat view!
!

MRI or bone scan (up to 72

hrs post-fx) if xray
unremarkable but clinical
suspicion !
!

Intertrochanteric Fracture

Management:!
Orthopedic surgery consult: !
open reduction, internal fixation (vs. arthroplasty)!
no evidence to support one over the other!
ambulatory pt are good surgical candidates!
!

non-ambulatory pt, significant uncorrected

comorbididity/terminal illness managed with pain
control

Trochanteric Fractures

Overview:!
due to forceful muscle contraction of a fixed limb!
most often in young active adult!
if elderly if no trauma cause then look for pathologic causes mainly
metastasis!
!
Mechanism:!
isolated avulsion fx of greater or lesser trochanter via forceful muscle
contraction!
greater trochanter fx: resister hip flexion leads to strong contraction of
iliopsoas muscle!
lesser trochanter fx: forceful contraction of hip abductors!
!
Symptoms:!
greater trochanter fx:!
hip pain that increases with abduction and tenderness over greater
trochanter!
lesser trochanter fx: !
groin pain!
knee or posterior thigh pain that worsens with hip flexion and rotation

Trochanteric Fractures

Radiograph!
greater trochanter!
standard AP view!
lesser trochanter!
AP view with leg in ext rotation!
!

Management:!
Most heal well with nonoperative management unless displaced
>1cm!
pt must remain non-weight bearing for 3-4 weeks!
full activity in 2-3 months !
Orthopedic surgery consult!
if displaced >1cm then open reduction internal fixation

Subtrochanteric Fracture

Overview:!
increased need for implanted devices (ie: intramedullary
rods/nails!
higher rate of implant failures d/t increased stress on this
part of femur

The end

Reference

UpToDate

Medscape

PubMed