HIP FRACTURES

BY: RANDY BONNELL

BACKGROUND Fractures of the hip are relatively common in

adults and often lead to devastating consequences

Disability frequently results from persistent pain and limited physical mobility. Hip fractures are associated with substantial morbidity and mortality; approximately 15-20% of patients die within 1 year of fracture.

Most hip fractures occur in elderly individuals as a result of minimal trauma, such as a fall from standing height

PATHOPHYSIOLOGY The hip joint is a large

multiaxial ball-and-socket synovial joint, enclosed by a thick articular capsule

During standing, the entire weight of the upper body is transmitted to the heads and necks of the femurs.

The hip joint is further supported by the femur and the muscles that cross the joint; this bone and these muscles are the largest and most powerful in the human body.

Classifying fractures Femoral head fractures Isolated femoral head

fractures are rare and are usually associated with hip dislocations. Superior femoral head fractures normally are associated with anterior dislocations, while inferior femoral head fractures are associated with posterior dislocations.

Femoral neck fractures These are rare among

younger patients but are commonly seen in older adults, most often secondary to osteoporosis or osteomalacia. These fractures usually result from minor trauma with falls accounting for 90%, or torsion.

Type 1 - Stress fractures or incomplete fractures

Type 2 - Impacted fractures

Type 3 - Partially displaced fractures

Type 4 - Completely displaced or comminuted fractures

Femoral neck fracturesPICTURES

                         

Trochanteric fractures Greater trochanteric

fractures usually result from avulsion injuries at the insertion of the gluteus medius. Lesser trochanteric fractures may be caused by avulsion injuries of the iliopsoas secondary to forceful contraction. These are most common in children and young athletes (eg, dancers, gymnasts).

Type 1 - Nondisplaced fractures

                         

Intertrochanteric fractures These extracapsular

fractures occur in a line between the greater and lesser trochanters, generally in elderly patients and women secondary to osteoporosis.

Type 1 - Single fracture line without displacement;

Frequency In the US: In the United States, hip fracture

occurs in approximately 80 per 100,000 persons or approximately 250,000 persons each year. The rate of hip fracture increases with age, doubling each decade after age 50 years. Nearly half of all hip fractures occur in adults older than 80 years. Hip fracture at a young age is rare and is usually the result of a high-velocity injury or, rarely, secondary to bone pathology.

Mortality/Morbidity Reported overall mortality rate of hip

fractures is 15-20%, yet in older persons this can increase to 36% over the year following hip fracture. Rate of mortality is greatest in the first few months following injury but remains high for up to 1 year.

Morbidity associated with hip fracture is staggering, especially in older persons. Morbidity from immobilization includes development of deep vein thrombosis, pulmonary embolism, pneumonia, and muscular deconditioning. Morbidity from surgical procedures includes complications of anesthesia, postoperative infection, loss of fixation, malunion or nonunion, as well as the complications associated with immobilization as outlined above

Hip fracture resulting from major trauma often is associated with other bone and soft-tissue injuries, intra-abdominal and intrapelvic injuries, major blood loss, head and neck injuries, and other extremity injuries. Morbidity associated with an inability to return to a prefracture level of mobility results in a loss of independence, reduction in quality of life, and depression, particularly in older persons.

Race /Sex The incidence of hip fracture is 2-3 times

greater in whites than in nonwhites, primarily because of the increased rate of osteoporosis in whites.

Rate of hip fracture is 2-3 times greater in women than in men. At least 75% of all hip fractures occur in women.

History In elderly patients, hip

fracture most often results from a simple fall; in a small percentage, it occurs spontaneously, in the absence of any trauma.

Patient complains of pain and inability to move the hip

With stress fractures in young athletes and nondisplaced fractures, patient may complain of pain in hip or knee and may be ambulatory.

Patient may have a history of other osteoporotic fractures, such as Colles or vertebral compression fractures

Physical Pay particular attention to vital

signs and secondary manifestations of shock such as changes in skin, mental status, and urine output. Hip fractures are associated with blood volume losses of up to 1500 mL.

Inspect and palpate for deformity, hematoma formation, laceration, and asymmetry

Observe the anatomical position of the extremity because this alone provides useful clues to the type of injury the patient has sustained.

If the patient is a trauma victim, assess for pelvic fractures by stressing the pelvis anteriorly to posteriorly through iliac crests and symphysis pubis, and laterally to medially through iliac crests.

Causes Neurological impairment

Caucasian race

Cigarette smoking

Institutional living

Maternal history of hip fracture

Previous hip fracture

Physical inactivity

Tall stature Alcohol abuse

Low body weight

Impaired vision

Prolonged corticosteroid use

Use of medications that decrease bone mass, including furosemide, thyroid hormone,

THE NUMBER 1 REASON IS…..

TREATMENT patient who complains of hip

pain should include immobilization on a stretcher

If fracture or deformity of the femur is obvious, apply a traction splint and place an intravenous (IV) line for hydration

If the patient is hypotensive or tachycardic, initiate crystalloid fluid bolus and place patient on supplemental oxygen

Initiate appropriate parenteral analgesia as soon as possible

Properly evaluate the entire patient to rule out associated severe injuries.

Stable and unstable fractures usually are treated with ORIF unless the patient is not an operative candidate for other reasons

Orthopedic surgery; vascular surgery or neurology, if necessary

MEDICATION /Analgesics Morphine sulfate Fentanyl citrate

(Duragesic, Sublimaze

Antibiotics Cefazolin (Ancef, Kefzol, Zolicef Gentamicin (Gentacidin, Garamycin Ampicillin (Omnipen, Marcillin) Vancomycin (Vancocin) --

Complications Infection Nonunion Avascular necrosis Chronic pain Gait disturbance

Patient Education Gear patient education

toward identification of avoidable risk factors in the patient's life.

In young persons, stress avoidance of tobacco and alcohol abuse and safe, responsible use of motorized vehicles

Counsel older persons on ways to make their home environment safe from falls. Encourage them to consult with their primary physician regarding medications or supplements for the prevention and treatment of osteoporosis.

Teach hip percautions

Hip Precautions