Hip fractures
Hip fracture is a fragility fracture of the femoral neck, intertrochanteric, or shaft region that presents with a shortened, externally rotated leg after a fall in an older adult, confirmed by radiograph or MRI, and requires operative fixation within 24 hours plus VTE prophylaxis and osteoporosis treatment.
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What this article covers
- Overview
A fragility fracture of the proximal femur: hip fracture is the most devastating consequence of low bone mineral density and osteoporosis, typically occurring after a low-energy fall in an older adult.
- Epidemiology
A leading cause of disability in older adults: more than 50% of patients with hip fracture do not return to independent living.
- Risk factors
Osteoporosis: the dominant underlying risk factor, with risk further stratified by bone mineral density T-score and clinical risk factors.
- Pathophysiology
Osteoporotic bone fragility lowers the force threshold for fracture, so that a simple fall from standing height, which would not fracture normal bone, is sufficient to fracture the femoral neck or intertrochanteric region.
- Clinical features
A shortened, externally rotated leg is the hallmark finding in a patient, typically elderly, after a fall, and by itself should trigger urgent hip fracture workup.
- Differential diagnosis
Hip dislocation: unlike a fracture, the leg is flexed, adducted, and internally rotated in a posterior dislocation, not merely shortened and externally rotated as in a fracture; see hip-dislocations.
- Diagnosis
Hip fracture is confirmed by imaging showing a fracture line through the femoral neck, intertrochanteric region, or femoral shaft, correlated with the classic shortened, externally rotated limb exam…
- Management
First, provide analgesia and assess the patient for surgical candidacy while arranging same-admission orthopedic surgery, since surgery should be performed within 24 hours of admission.
- Complications
Avascular necrosis of the femoral head: the dominant complication of displaced femoral neck fracture, from disruption of the medial femoral circumflex artery supply.
- Prognosis
Mortality is substantially elevated: women have a 12-20% increased mortality for the 2 years following hip fracture.
- Prevention
Screen for osteoporosis with dual-energy x-ray absorptiometry (DEXA) bone density testing in all women aged 65 years or older, and in younger women at increased risk by a formal risk assessment tool…
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