Femoral Neck Hip Fracture

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Search Strategy

Databases searched: Pubmed, PEDro, eMedicine, Medscape
Keywords searched: hip fracture, incidence femoral neck fracture, osteoporotic hip fracture, treatment hip fractures …

Definition/Description

A hip fracture is a condition in which the proximal end of the femur, near the hip joint, is broken. Such a fracture is a serious injury that occurs mostly in elderly people over 65 years and complications can be life threatening. (level of evidence A1)

Clinically Relevant Anatomy

The hip joint is a ball and socket joint, formed by the head of the femur and the acetabulum of the pelvis. The convex head fits perfectly in the concave socket of the acetabulum forming a synovial joint. From an osteological viewpoint, the proximal end of the femur in four major parts, namely: femoral head, femoral neck, trochanter major and the minor trochanter. These parts are most often and most closely involved with hip fractures. The hip joint is a very sturdy joint, due to the tight fitting of the bones and the strong surrounding ligaments and muscles.

Epidemiology /Etiology

Different events can form the basis of a hip fracture.
Young adult hip fractures are generally the result of high-energy trauma, and the larger peak seen in the elderly population is low-energy injuries, like a fall caused by gait and/or balance disorders. Hip fractures are regarded as the most common type of fall-related injury among elderly because of their high morbidity, mortality and impairment in quality of life. (level of evidence C)

Osteoporosis is currently considered a chronic condition characterized by a reduction in bone mass, usually because of aging, leading to a reduction in bone strength and an increase in the risk of fracture. Women are more likely to have a hip fracture than men. A stress injury occurs when abnormal stress, usually in the form of frequent repetition of otherwise normal stress, is exerted on a bone with normal elastic resistance but unaccustomed to that action. Stress fractures, mostly tibia and femoral fractures, are common in athlete and military populations, in which subjects are exposed to a sudden increase in physical training. (level of evidence B)

Risk factors for hip fracture include:

• Osteoporosis
• Low Bone Marrow Density (level of evidence A1)
• Age> 65 years = risk group
• Gender: women have more fractures than men
• Physical inactivity
• and others such as alcohol use, vitamin D and calcium deficiency, smoking, ... (level of evidence A2)

However the evidence that calcium supplements reduce fracture risk is lacking. (level of evidence A1)

Characteristics/Clinical Presentation

Specific features for patients with hip fracture include:

• Dull ache in the groin and/or hip region (level of evidence B)
• Inability to put weight on the injured leg causing immobility right after the fall (level of evidence A1)
• If the femur bone is completely broken the injured leg might be shorter compared to the other leg
• Severe pain
• The patient tends to keep the injured hip as still as possible, positioning it in external rotation  
• A swelling might occur

Differential Diagnosis

Certain types of hip fracture are associated with an increased risk of avascular necrosis of the femoral head.
Other lower body fractures must be excluded:
- Stress fractures
- Fracture of acetabulum
- Fracture of ramus pubis

Diagnostic Procedures

The diagnosis of a hip fracture is established based on patient history, physical examination and radiography.

On a MRI one can see that a proximal hip fracture consists many kinds:

•  Subcapital neck fracture: right below the femoral head
•  Femoral neck fracture (intracapsular fracture)  (level of evidence B)
•  Intertrochanteric fracture: between the greater and the small trochanter (extracapsular fracture)
•  Subtrochanteric fracture: 2 ½ inch below the small trochanter (extracapsular fracture)
•  Fracture of the greater trochanter
•  Fracture of the small trochanter
  

Outcome Measures

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Examination

On physical examination, the injured leg is shortened, externally rotated, and abducted in the supine position. Plain radiographs of the hip usually confirm the diagnosis.

Medical Management

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Physical Therapy Management

Prolonged bed rust can increase the risk of pressure sores en deconditioning. Therefore it’s important to start rehabilitation on the first post-operative day (on patients with a total hip replacement). This includes quadriceps strengthening exercises, isometric exercises, and flexion and extension mobilizations in the hip joint …

On the second and third post-operative day the patient can start with walking between parallel bars, and later on they can walk with a walker or a cane.

Weight-bearing exercises are very important for mobility, balance, activities of daily living and quality of life (level of evidence B), examples:

• stepping in different directions
• standing up and sitting down
• tapping the foot and stepping onto and off a block. 

Prevention is also a part of the rehabilitation process to prevent fractures. Prevention of hip fractures should focus on preventing falls and osteoporosis.

Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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