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Fractures of the Hip and Femur
Introduction
- Correctly chosen and performed surgical treatment of the fracture, early mobilization, and good management of the patient's general diseases are essential - remaining permanently in institutional care is a threat Comprehensive Geriatric Assessment for Older People Admitted to a Surgical Service.
- Non-displaced fracture of the femoral neck may pass unnoticed (relatively painless, the patient may be able to put weight on the limb, poorly visible on x-ray). Always carefully examine the hips of an elderly patient after a fall accident, even if he/she only complains of e.g. the knee.
Fracture of the hip
- Typically in an elderly patient, often following a low-energy injury (slipping, falling, falling out of bed).
- In younger patients usually a high-energy accident (falling from height, traffic accident)
- In a displaced fracture, shortening and external rotation of the limb is usually evident.
- A non-displaced fracture of the femoral neck may be relatively painless (the patient may be able to put weight on the limb and walk to the surgery).
- Fracture of the proximal femur may be felt as referred knee pain, which may delay the diagnosis as attention is paid to the knee only.
Classification and imaging
- The fractures are divided into fractures of the femoral neck, trochanteric fractures, and subtrochanteric fractures.
- Anteroposterior pelvic and lateral hip radiographs should always be taken. The fractured hip is compared with the healthy one.
- An MRI is carried out if the clinical suspicion of a fracture is strong (painful patient who is not able to put weight on the hip) but x-ray is normal. The MRI may reveal an impacted, non-displaced fracture.
- Previous mobility, pharmacotherapies and other co-existing illnesses should be evaluated before surgery.
- Surgery should usually be performed soon, preferably within 24 h of the injury.
- Antithrombotic prophylaxis Prophylaxis Against Deep Vein Thrombosis and Pulmonary Embolism in Hip Fracture Surgery (usually low-molecular-weight heparin continued for 3-4 weeks postoperatively).
- Non-displaced femoral neck fracture
- Primarily surgical treatment
- Osteosynthesis using screw fixation that prevents the development of a displacement
- Hemiarthroplasty or total prosthesis in an eldery person, if the bone is of low quality and the stability of the osteosynthesis is likely to be poor.
- As an exception, conservative treatment may be considered for a relatively pain-free, permanently bedridden patient.
- Displaced femoral neck fracture
- In young patients, closed reduction and screw fixation of the fracture
- In elderly patients usually hemiarthroplasty. Total hip arthroplasty may be considered for active and healthy patients and, on the other hand, for patients whose hip joint is in poor condition due to e.g. osteoarthritis or rheumatoid arthritis.
- Trochanteric fractures are treated with osteosynthesis using either plate-sliding screw or intra-medullary nail system.
- Unstable intertrochanteric and subtrochanteric fractures are fixed with intra-medullary nail-sliding screw osteosynthesis.
Weight bearing after operation
- Osteosynthesis (plate-sliding screw, intra-medullary nail-sliding screw) should be so stable that it allows immediate mobilisation of the patient with full weight-bearing. In comminuted subtrochanteric fractures, touch-down weight-bearing (also known as toe-touch weight bearing) for a period of 6-12 weeks may be necessary (foot may touch the floor, but no weight should be put on the affected limb).
- After hemiarthroplasty and total hip arthroplasty, full weight bearing is allowed immediately.
- Mobilization with partial weight bearing or non-weight bearing is not always possible to achieve with an elderly patient. On the other hand, an elderly person does not tolerate well a long period of bed rest, and therefore an assisted early mobilization should be pursued Interventions for Improving Mobility after Hip Fracture Surgery. When mobilizing starts, crutches, a wheeled walker (rollator) or a Zimmer frame is used for an appropriate length of time.
- Active exercise therapy is essential; first sitting, then standing, followed by walking. Mobilization should start as soon as possible, preferably on the first postoperative day. Early training of the activities of daily living is important.
- Physiotherapy with mechanical devices provides no particular benefit.
- Medication for osteoporosis Osteoporosis in the elderly should be considered if the patient is capable of moving when returning to a care institution or to his/her own home.
- Hip protectors may reduce the risk of femoral fractures in elderly persons who are in institutional care provided that the regular use of the protectors is ensured Hip Protectors for Preventing Hip Fractures in Older People.
- X-ray controls
- Control radiographs are taken after the surgery.
- The stability of the osteosynthesis is controlled clinically and by follow-up radiograph at 6-8 weeks after surgery.
- Follow-up x-rays are usually not needed in patients who have been treated with hemiarthroplasty.
Complications
- Common complications after femoral fractures include shortening of the limb, deformities as well as infections associated with the operation. For complications after joint replacement surgery, see Complications of Prosthetic Joints.
Fracture of the femoral shaft
- Usually high-energy injuries, in the elderly also low-energy falls
Examination and findings
- The thigh is shortened and swollen.
- Check distal pulses and sensation.
- Diagnosis is confirmed by radiography.
Treatment and follow-up
- The thigh should be splinted well during transport. Intravenous infusion is often warranted (the patient may bleed up to 2 000 ml).
- Tibial traction may be applied whilst waiting for surgery, in a fracture of the femoral shaft 1:10 of the patient's weight.
- The fracture is stabilized with locking intra-medullary nail fixation or with a locking plate.
- Postoperatively, the knee and hip are freely mobilized without forgetting the strengthening and stretching exercises of the thigh muscles.
- Usually, limb weight-bearing during the first 6 weeks and after that a gradual increase in the load. Full weight-bearing is usually allowed after 10-12 weeks.
- Bone union may be slow and may require reoperations (dynamization of the intra-medullary nail, bone-grafting operation).
- In young patients, the intra-medullary nail is removed 1.5-2 years after the surgery at the earliest.
Distal femoral fracture
- In healthy bone requires a high-energy injury (traffic accident, falling from height, etc.)
- Typical fracture of the osteoporotic bone in elderly people, occurring when the patient falls over and the knee is twisted into forceful flexion or extension.
Examination and findings
- The fracture site is swollen, remarkably tender, unstable
- Diagnosis is confirmed by radiography.
Treatment and follow-up
- As a rule, operative treatment by internal fixation with a locking plate or by nailing.
- A stable non-displaced fracture in an elderly patient may be treated by casting.
- A plain radiograph right after the surgery, as well as 6 and 12 weeks after the surgery.
- Mobilization without weight-bearing may be allowed immediately, often with a hinged brace.
- Full weight-bearing usually 10-12 weeks after the surgery
- Plates or screws are not removed routinely.
References
- Lewis SR, Macey R, Eardley WG ym. Internal fixation implants for intracapsular hip fractures in older adults. Cochrane Database Syst Rev 2021;(3):CD013409. [PubMed]
- HEALTH Investigators., Bhandari M, Einhorn TA ym. Total Hip Arthroplasty or Hemiarthroplasty for Hip Fracture. N Engl J Med 2019;381(23):2199-2208. [PubMed]
Evidence Summaries ⬆