History

Fact Explanation
History of a fall in elderly ( in young adults history of motor vehicle accident or a fall from height) Poor bone density, multiple medical problems and propensity to fall are major risk factors for femoral neck fracture in elderly. Also called 'fragility’ fracture', when it is caused by a fall (from standing height or less) in an an older person with osteoporosis or osteopenia. In young adults, the mechanism of injury is often high-energy trauma, such as motor vehicle accident or fall from height because fractures that occur in this normal bone density population require substantial axial load.[1][2]
Inability to move immediately after the fall Pain limits voluntary movement. There is also stiffness due to muscle spasms.[1][2][3]
Severe pain in hip and/or groin When there is a break in the bone, the pain sensitive nerve fibers which supply that area get disrupted and also stretched due distortion of the anatomy. This stimulates these nerve endings to send impulses to brain, so that we feel pain.[1][2][3]
Inability to walk or put weight on the affected leg This is partly due to pain and partly due to the discontinuation in bone, so that it can no longer to bear the weight and transmit the force to ground effectively.[1][2]3]
Pain in thigh and/or knee area Sometimes the pain that comes from one region is referred to another region that is supplied by the same spinal level. This is because brain mistakes the stimulus to be coming from an area that is more commonly involved with pain than the area which is originally causing pain.[1][2][3]
References
  1. The management of hip fracture in adults.National Institute for Health and Care Excellence, Clinical guidelines, CG124, [online] 2011.[viewed 18 April 2014] Available from: http://guidance.nice.org.uk/CG124
  2. THUAN V.L, MARC F.S. Management of femoral neck fractures in young adults. Indian J Orthop. [online]. Jan-Mar 2008; vol 42(1): 3–12. [viewed on 18 April 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2759588/
  3. SHOBA S. R, MANJULA C. Management of Hip Fracture. The Family Physician’s Role. Am Fam Physician. [online] Jun 2006 15;73(12):2195-2200. [viewed on 18 April 2014] Available from: http://www.aafp.org/afp/2006/0615/p2195.html

Examination

Fact Explanation
Shortening of affected leg Pull of muscles on the broken bone leads the broken distal segment to overlap and malalign.[2][3][4]
Affected leg is externally rotated and abducted Separation of the body and head of the femur change the axis of the limb. The unopposed action of the lateral rotators (mainly psoas and iliacus musceles) and abductors, on the distal segment of bone lead to this position. [2][3][4]
Tenderness in the hip area This is due to increased sensitivity and stimulation of pain sensitive nerve fibers in the area[2][3][5]
Bruising around hip area Due to blood vessel rupture causing bleeding into soft tissue.[2][3][4]
Swelling in and around hip area Due to local edema which is a feature of inflammation[2][3]
References
  1. The management of hip fracture in adults.National Institute for Health and Care Excellence, Clinical guidelines, CG124, 2011.[viewed 18 April 2014] Available from: http://guidance.nice.org.uk/CG124
  2. HAMEDAN A.l, MAQBALI M.A. History and physical examination of hip injuries in elderly adults. Orthop Nurs. [online] Mar-Apr 2014, vol 33(2):86-92. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24651140
  3. Hip fractures: American academy of orthopedic surgeons. [online]. [viewed April 7 2014]. Available from: http://orthoinfo.aaos.org/topic.cfm?topic=A00392
  4. THUAN V.L, MARC F.S. Management of femoral neck fractures in young adults. Indian J Orthop. [online]. Jan-Mar 2008; vol 42(1): 3–12. [viewed on 18 April 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2759588/
  5. PERL Edward R. Pain Mechanisms: A Commentary on Concepts and Issues.Prog Neurobiol. [online] Jun 2011; 94(1): 20–38.[viewed 18 April 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3138063/

Differential Diagnoses

Fact Explanation
Intracapsular subcapital femoral neck fractures These are the femoral neck fractures that occur within the capsule that surrounds the hip joint. The blood supply to the femoral head is entirely dependent upon a series of arteries that pass through the femoral neck region. Intracapsular fractures of the femoral neck can entirely disrupt the blood supply to the femoral head, leading to major healing complications such as fracture nonunion and avascular necrosis of the head of the femur.[1][2][3]
Extracapsular intertrochanteric fractures These occur more laterally than femoral neck fractures, in the area between the greater and lesser trochanters outside of the joint capsule and are therefore extracapsular. The bony area involved in these fractures have a good local blood supply. But these fractures can also get complicated by the pull of the hip muscles on the fractured bony fragments pulling them out of alignment, leading to shortening of the length of the femur or malunion. [1][2][3]
Extracapsular Subtrochanteric fractures These type of fractures occur distal to the lesser trochanter in the proximal femur. The blood supply to the bone of the subtrochanteric region is not as good as the blood supply to the bone of the intertrochanteric region. Therefore these fractures heal more slowly. These are also subject to muscular pull that tend to pull the fractured fragments out of alignment leading to malunion.[1][2][3]
Osteitis pubis This is an inflammation of the pubis and surrounding muscle insertions, seen following invasive procedures about the pelvis and in athletes.[4]
Slipped capital femoral epiphysis A relatively uncommon but important differential diagnosis in the pediatric and adolescent age group.[5]
References
  1. BUTLER M, FORTE M, KANE RL, et al. Treatment of Common Hip Fractures. Rockville (MD): Agency for Healthcare Research and Quality (US). [online] 2009 Aug. (Evidence Reports/Technology Assessments, No. 184.) 1, Introduction. [viewed 18 April 2014] Available from: http://www.ncbi.nlm.nih.gov/books/NBK32595/
  2. The management of hip fracture in adults.National Institute for Health and Care Excellence, Clinical guidelines, CG124, 2011.[viewed 18 April 2014] Available from: http://guidance.nice.org.uk/CG124
  3. THUAN V.L, MARC F.S. Management of femoral neck fractures in young adults. Indian J Orthop. [online]. Jan-Mar 2008; vol 42(1): 3–12. [viewed on 18 April 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2759588/
  4. HENNING P.T. The running athlete: stress fractures, osteitis pubis, and snapping hips. Sports Health. [online] 2014 Mar; vol 6(2):122-7. [viewed on 18 Apri 2014]. Available from:http://www.researchgate.net/publication/260449129_The_running_athlete_stress_fractures_osteitis_pubis_and_snapping_hips
  5. NOVAIS E.N. MILLIS M.B. Slipped capital femoral epiphysis: prevalence, pathogenesis, and natural history. Clin Orthop Relat Res. [online]2012 Dec; 470(12):3432-8. [viewed 18 April 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3492592/

Investigations - for Diagnosis

Fact Explanation
X-ray hip anteroposterior view Can confirm the presence of a fracture which was clinically suspected.The estimated sensitivity of hip radiographs of good quality is 90% and 98%. A fracture which is not obviously evident on radiographs is likely to be undisplaced or an occult fracture. (occult hip fractures become visible if radiographs are repeated after a few days due to bone resorption occurring along the fracture line making obvious)[1][2]
X-ray hip and femur lateral view Can visualize a fracture which was not shown on the anteroposterior view. But some studies suggest that one view is adequate and safe for the majority of hip fractures and lateral radiograph need not be performed routinely [1][2][3]
Magnetic resonance imaging (MRI) of hip Used for early detection of occult fractures. Done when clinical suspicion of a fracture is high but radiographs appear normal. (MRI has the highest accuracy i.e.100% sensitivity and 93%-100% specificity)[1][2]
Computed tomography (CT) of hip Done to for early detection of occult fractures when MRI is not available.[1]
Radionuclide scan (RNS) of hip If MRI is contraindicated, a bone scan may be useful in diagnosing fracture. (but results may appear normal up to 72 hours after the injury)[1][2]
Ultrasound scanning (US) Not widely used as it is highly operator-dependent. Can detect bone surface changes, effusions or hemorrhage in patients with fractures but the results are non-specific and usually require confirmation by MRI or CT.[1]
References
  1. The management of hip fracture in adults.National Institute for Health and Care Excellence, Clinical guidelines, CG124, [online] 2011.[viewed 18 April 2014] Available from: http://guidance.nice.org.uk/CG124
  2. SHOBA S. R, MANJULA C. Management of Hip Fracture. The Family Physician’s Role. Am Fam Physician. [online] Jun 2006 15;73(12):2195-2200. [viewed on 18 April 2014] Available from: http://www.aafp.org/afp/2006/0615/p2195.html
  3. B ALMAZEDI, SMITH C D, MORGAN D, THOMAS G, PEREIRA G. Another fractured neck of femur: do we need a lateral X-ray? Br J Radiol.[online] 2011 May; vol 84(1001): 413–417.[viewed 18 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3473646/

Investigations - Fitness for Management

Fact Explanation
Complete blood cell (CBC) count To detect the presence of anemia, undetected infection before planing surgery.[1][2]
Serum electrolyte levels Done to asses renal functions before planing surgery.[1][2]
Serum creatinine level Done to asses baseline renal function prior to planing surgery.[1][2]
Fasting/random blood glucose level Done prior to planing surgery as blood sugar levels affect outcome of surgery.[1][2]
Urine analysis To detect urinary infections.[1][2]
Prothrombin time (PT) To assess the need for and adjust dose of anti-coagulation treatment. Done in patients given Warfarin.[1][2]
Activated partial thromboplastin time (APTT) To assess the need for and adjust dose of anti-coagulation treatment. Done in patients given Heparin.[1][2]
Arterial blood gas (ABG) To assess the respiratory function before planing surgery. Done if there is a cardio-respiratory problem or when prolonged ventilation is needed.[1][2]
Lung function tests To assess the cardio-respiratory reserve prior to anesthesia. Also done in patients with cardio-respiratory problems.[1][2]
Electrocardiogram To assess the cardiac function prior to anesthesia. Done in older patients and those with a history of ischemic heart disease only.[1][2]
References
  1. The management of hip fracture in adults.National Institute for Health and Care Excellence, Clinical guidelines, CG124, [online] 2011.[viewed 18 April 2014] Available from: http://guidance.nice.org.uk/CG124
  2. ADITYA K, UMA S.Role of routine laboratory investigations in preoperative evaluation. J Anaesthesiol Clin Pharmacol. [online] 2011 Apr-Jun. [viewed on18 April 2014] vol27(2): 174–179. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3127294/

Investigations - Followup

Fact Explanation
X-ray hip anteroposterior/lateral To assess alignment after reduction and to asses the healing process.[1]
References
  1. The management of hip fracture in adults.National Institute for Health and Care Excellence, Clinical guidelines, CG124, [online] 2011.[viewed 18 April 2014] Available from: http://guidance.nice.org.uk/CG124

Management - General Measures

Fact Explanation
Pain relief Prompt and adequate relief of pain is a major priority in the management of hip fracture. Treatment depends on severity of pain. Can give simple analgesics such as paracetamol to a wide range of opioids. Nerve blocks (injecting local anesthetic around the femoral nerve to block pain perception) are administered to patients if simple analgesics and opioids are not adequate to relieve pain.[1][2]
Thromboprophylaxis Important because there is increased risk of deep vein thrombosis and pulmonary embolism. [1][3][4][5]
Rehabilitation Early mobilization with help of a physiotherapist reduces complications, improves functional status, mortality, pain, quality of life and help regain muscle strength and the ability to walk.[1][3][6][7] Occupational therapist helps to learn techniques for independence in daily life[1][3]
Osteoporosis prevention To reduce future risk of fractures. Postmenopausal women are at higher risk of osteoporotic fractures. they should participate in regular weight-bearing exercise, quit smoking, limit alcohol intake, and take adequate amount of elemental calcium and vitamin D daily.[3][8] Dose of calcium for women age 50 and younger and men age 70 and younger is 1000 mg/day. Women age 51 & older and men age 71 & older should take 1200 mg/day of calcium.[8] Men and women under age 50 should take 400-800 IU of vitamin D daily. Those age 50 and older needs 800-1,000 IU daily. (safe upper limit of vitamin D for most adults is 4,000 IU per day)[8]
References
  1. The management of hip fracture in adults.National Institute for Health and Care Excellence, Clinical guidelines, CG124, [online] 2011.[viewed 18 April 2014] Available from: http://guidance.nice.org.uk/CG124
  2. BUTLER M, FORTE M, KANE R.L, et al. Treatment of Common Hip Fractures. Rockville (MD): Agency for Healthcare Research and Quality (US); [online] 2009 Aug. (Evidence Reports/Technology Assessments, No. 184.) 1, Introduction. [viewed on 18 April 2014]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK32595/
  3. SHOBA S. R, MANJULA C. Management of Hip Fracture. The Family Physician’s Role. Am Fam Physician. [online] Jun 2006 15;73(12):2195-2200. [viewed on 18 April 2014] Available from: http://www.aafp.org/afp/2006/0615/p2195.html
  4. GEERTS W.H, PINEO G.F, HEIT J.A, BERGQVIST D, LASSEN M.R, COLWELL C.W, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004.[online] 126:S338–400. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15383478
  5. GEERTS W.H, PINEO G.F, HEIT J.A, BERGQVIST D, LASSEN M.R, COLWELL C.W. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).American College of Chest Physicians.Chest.[online] 2008 Jun; 133(6 Suppl):381S-453S. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18574271
  6. TAY Y.W, HONG C.C, MURPHY D.Functional outcome and mortality in nonagenarians following hip fracture surgery. Arch Orthop Trauma Surg. [online] 2014 Mar 30. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24682524
  7. OVERGAARD J, KRISTENSEN M.T.Feasibility of progressive strength training shortly after hip fracture surgery.World J Orthop. [online] 2013 Oct 18;4(4):248-58. Available from: http://www.ncbi.nlm.nih.gov/pubmed/?term=.Feasibility+of+progressive+strength+training+shortly+after+hip+fracture+surgery.
  8. Calcium and Vitamin D: What You Need to Know. National osteoporosis foundation.[online].[viewed 18April 2014] Available from:http://nof.org/articles/10#howmuchvitamind

Management - Specific Treatments

Fact Explanation
Replacement arthroplasty Early surgery is the most effective form of pain relief, potentially quickening the rehabilitation and reducing complications that occur due to immobilization. Indicated in theelderly either as hemiarthroplasty (replacement of the femoral head with a prosthesis but acetabulum is not replaced) or a total hip arthroplasty (prosthetic replacement of both the femoral head and the acetabulum within the pelvis)
Internal fixation Open reduction and internal fixation is done in fractures of young adults with the use of screws, plates or nails to keep the bone in place while healing takes place. Also done for extracapsular fractures unless the entire hip joint is severely deformed due to advanced degenerative changes, or the fracture extends more proximally.[1][2][3][5] Dynamic hip screw is a minimal invasive treatment option for elderly patients, allowing early activity and weight-bearing and avoid complications seen in artificial joint replacement.[4]
References
  1. BUTLER M, FORTE M, KANE RL, et al. Treatment of Common Hip Fractures. Rockville (MD): Agency for Healthcare Research and Quality (US); 2009 Aug. (Evidence Reports/Technology Assessments, No. 184.) 1, Introduction. Available from: http://www.ncbi.nlm.nih.gov/books/NBK32595/
  2. The management of hip fracture in adults: National Institute for Health and Care Excellence; Clinical guidelines, CG124: Issued: June 2011. Available at http://guidance.nice.org.uk/CG124
  3. THUAN V.L, MARC F.S. Management of femoral neck fractures in young adults. Indian J Orthop. [online]. Jan-Mar 2008; vol 42(1): 3–12. [viewed on 18 April 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2759588/
  4. ZHAO W.B, LIU L, ZHANG H, FANG Y, PEI F.X, YANG T.F.Effect of dynamic hip screw on the treatment of femoral neck fracture in the elderly.Chin J Traumatol. [online] 2014 Apr 1;17(2):69-72. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24698573
  5. CHAMMOUT G.K, MUKKA S.S, CARLSSON T, NEANDER G.F, STARK A.W, SKOLDENBERG O.G. Total hip replacement versus open reduction and internal fixation of displaced femoral neck fractures: a randomized long-term follow-up study.J Bone Joint Surg Am.[online] 2012 Nov 7;94(21):1921-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23014835