Hip Fractures: Evaluation and Management
Hip Fractures: Evaluation and Management
Authors: Robert Corder, MD, Assistant Professor, University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, MD; and Michael K. Abraham, MD, Chief Resident, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD.
Peer reviewer: Jonathan Singer, MD, FAAP, FACEP, Professor of Emergency Medicine and Pediatrics, Boonshoft School of Medicine, Wright State University, Dayton, OH.
Emergency department physicians frequently assess and manage patients with potential hip fractures. Fractures of the hip may have devastating consequences and are associated with substantial morbidity and mortality, approximately 15% of patients die within one year of fracture and patients who survive may suffer from limited physical mobility. The mechanism of injury for sustaining a hip fracture are divergent; elderly patients may have minimal trauma and younger patients typically have high-velocity injuries. This article focuses on a discussion and review of proximal femur fractures including classification systems, radiographic evaluation, and ED management.
— The Editor
Introduction
Hip fractures are a commonly encountered problem in the emergency department (ED). The majority of hip fractures in elderly patients occur with minimal trauma, such as a fall. In contrast, younger healthy adults do not typically sustain a hip fracture without a high-velocity injury, such as a motor vehicle collision or falls from very significant heights. Hip fractures may result in significant consequences for an afflicted individual, including an approximate mortality rate of 15% within one year of fracture. Morbidity associated with hip fractures include persistent pain, decreased physical mobility, and protracted recoveries.
The goal of the emergency physician (EP) is to stabilize the patient and then identify any potential fractures. Following fracture identification the physician must then stabilize the fracture, provide patient comfort, and perform appropriate diagnostic studies. Timely and appropriate referral to the orthopedic consultants also assist in preserving or restoring function and preventing complications. Potential areas of liability for the practicing clinician include: failure to keep a patient with a stress or incomplete femoral neck fracture non-ambulatory, failure to diagnose a stress femoral neck fracture in a young patient with hip or knee pain, and failure to consider an incomplete femoral neck fracture in an older patient.
This article will focus on fractures of the hip limited to the proximal femur, from the femoral head to the greater and lesser trochanters. An overview of the anatomy, epidemiology, classification systems for proximal femur fractures, radiographic evaluation and ED management will be presented.
Anatomy
The hip joint is comprised of the pelvic acetabulum articulating with the proximal femur from its head to approximately 2-3 inches below the lesser trochanter, forming a ball and socket. (See Figure 1.) It is surrounded by a strong fibrous capsule that attaches proximally around the acetabulum and inserts distally to the intertrochanteric line anteriorly, and posteriorly onto the neck of the femur proximal to the intertrochanteric crest. (See Figure 1.) Fractures occurring on that part of the femur, which lie within the capsule, are known as intracapsular fractures of the hip. They involve the femoral head and neck. Extracapsular hip fractures involve the trochanteric, intertrochanteric, and subtrochanteric regions. The bone of the femoral head, neck, and intertrochanteric regions is primarily cancellous. Bone distal to the intertrochanteric region is primarily cortical.
| Figure 1. Hip Anatomy |
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| Reproduced with permission from Southern California Orthopedic Institute (www.scoi.com) |
The vascular supply to the femoral head is derived primarily from epiphyseal or retinacular arteries off branches of the obturator, medial femoral circumflex, lateral femoral circumflex, and superior and inferior gluteal arteries. These course beneath the capsular reflection on the femoral neck and along the ligamentum teres. The artery of ligamentum teres is another source of blood supply to the femoral head and neck. This is significant since displaced intracapsular fractures carry with them higher rates of avascular necrosis, nonunion, and malunion compared to nondisplaced intracapsular and most extracapsular fractures.
The hip is one of the strongest and most mobile joints in the body. The major ligaments that help to assure stability and function are the iliofemoral, pubofemoral, and ischiofemoral ligaments. The muscle groups allow the hip to move powerfully in flexion, extension, rotation, adduction, and abduction. The most powerful hip flexor is the iliopsoas muscle, which gets assistance from the rectus femoris, pectineus, adductor longus, gracilis, tensor fascia lata, and sartorius muscles. The gluteus maximus and hamstring muscles (biceps femoris, semitendinosus, and semimembranosus muscles) provide for hip extension. Medial rotation is achieved using the tensor fascia lata, gluteus medius, gluteus minimus, and gracilis muscles. The piriformis, obturator internus, obturator externus, superior and inferior gemelli, and quadratus femorus muscles work to provide lateral rotation. Hip adduction uses the gracilis, pectineus, adductor magnus, adductor brevis, adductor longus, and hamstring muscles. The muscles involved with hip abduction include sartorius, tensor fascia lata, gluteus minimus, and gluteus medius.
The nerve innervation of the hip primarily is provided by branches of the femoral and sciatic nerves arising from the second through fourth lumbar nerve roots and the fourth lumbar through third sacral nerve roots, respectively. (See Figure 2.) Familiarity with the anatomy of the hip will assist the EP in considering specific injuries and possible neurovascular complications and to anticipate diagnostic testing.
| Figure 2. Sciatic Nerve Relationship to the Hip |
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Epidemiology
Hip fractures are a significant individual, familial, and public health concern in most industrialized countries. They account for more than 300,000 hospitalizations and 60,000 nursing home admissions in the Unites States annually.1 According to Popovic, most patients with hip fractures are hospitalized for approximately one week.2 However, institutionalization of at least a year is needed for almost 25% of older adults who sustain a hip fracture and were previously living in the community.3 According to the Centers for Disease Control and Prevention (CDC), Medicare costs in 1991 were estimated to be $2.9 billion.4 The estimated cost of medical treatment for this injury in 1995 was $8.86 billion.5 Patients older than 50 years of age account for an estimated 90% of proximal femur fractures.6 The U.S. Bureau of the Census estimates an increase of people ages 65 and older from 34.8 million to 77.2 million in the years 2000 to 2040.7 The fastest growing segment of the population is the 85 year old and older age group. Given the aging population of the United States, the incidence of hip fracture is estimated to exceed more than 500,000 cases by the year 2004.8
In addition to the financial costs, there are high costs with regard to morbidity and mortality. In their Position Statement on hip fractures in the elderly in 1999, the American Academy of Orthopaedic Surgeons and American Association of Orthopaedic Surgeons reported a mortality rate of 4% during a patient's initial hospitalization, and that 24% of patients die within the first year of injury.9 Morbidity associated with hip fracture is vast.
Complications associated with immobility include the development of pneumonia, deep vein thrombosis, pulmonary embolism, and general deconditioning. The multisystem trauma patient with hip fracture and concurrent intra-abdominal, intrathoracic, soft tissue, or other skeletal injuries suffers the additive effects of morbidity from those medical conditions.
There also are complications inherent to corrective surgical procedures, including intolerance to anesthesia, postoperative infection, malunion, and nonunion of fracture sites. Loss of independence due to the inability to return to a pre-injury level of ambulation is another significant morbidity factor effecting a patient's quality of life. In fact, losing the ability to walk after hip fracture has been reported to be as high as 50% in a study by Wolinsky and colleagues.10
Due to the higher rate of osteoporosis in whites, there is a 2 to 3 times greater incidence of hip fractures in Caucasians when compared to non-Caucasians. With regard to a person's sex, females have a 2 to 3 times greater fracture rate than males; this results in 75-80% of all hip fractures occurring in females. There is an approximate 15% and 5% lifetime risk of hip fracture in white females and males, respectively.11 Risk factors associated with the probability of suffering a hip fracture in ones' lifetime are presented in Table 1.
| Table 1. Risk Factors for Hip Fractures |
| • Osteoporosis • Smoking • Visual impairment • Excessive alcohol consumption • Physical inactivity • Institutional living • Maternal history of hip fracture • Dementia • High caffeine intake • Use of medications that decrease bone mass or contribute to unsteady ambulation • Low body weight • Tall stature • Previous fracture of hip, wrist, or vertebrae |
Many risk factors are modifiable and have been the focus of several efforts toward hip fracture prevention. The elderly are not the only ones affected by fractures of the hip. High energy physical trauma is the usual cause of proximal femur fractures in younger patients, with a higher incidence of concurrent injury to multiple body systems. However, younger children and adolescents presenting with limp or hip pain should be evaluated for either Legg-Calvé-Perthes disease or slipped capital femoral epiphysis (SCFE). Legg-Calvé-Perthes disease is an ischemic condition affecting the proximal femur leading to infarction, necrosis, and often fracture of the femoral head. It is more common in females and in children ages 4 to 9 years. (See Figure 3.) SCFE typically is a gradual, chronic process, but acute presentations may occur. It is more common in males; African-Americans; and obese adolescents, ages 11 to 15 years. SCFE is a Salter-Harris type 1 fracture through the proximal femoral physis typically resulting when stress around the hip causes a shear force to be applied at the growth plate. Obesity is a predisposing factor in the development of SCFE and hormones are believed to play a role. The fracture occurs at the hypertrophic zone of the physeal cartilage secondary to stress on the hip causing the epiphysis to move posteriorly and medially. The clinical presentation may be challenging, with only 50% of patients presenting with hip pain and 25% presenting with knee pain. Diagnostic errors are common, and approximately 25% of patients experience delay in treatment. The outcome of SCFE is related directly to the severity of the slip at the time of treatment. An anterioposterior (AP) pelvis and lateral frog-leg radiographs are usually all that is needed to make the diagnosis. (See Figure 4.) CT scan is a sensitive method of measuring the degree of tilt and detecting early disease, but is rarely indicated. MRI may be used to detect the slippage earliest, and MRI can demonstrate early marrow edema and slippage. (See Figure 5.) The treatment of SCFE entails stabilizing the hip, through the use of pins, screws, and wires to cross the physis and fix the epiphysis. Both entities need proper diagnosis and orthopedic referral for proper management. Diligent pursuit of the etiology of a patient's hip pain, while keeping in mind these epidemiologic facts, will assist the EP in the assessment and management of hip fractures.
| Figure 3. Legg-Calvé-Perthes Disease |
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| Courtesy of Dr. Ann Dietrich |
| Figure 4. Slipped Capital Femoral Epiphysis (SCFE) |
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| Courtesy of Dr. Howie Werman, Ohio State University College of Medicine and Public Health |
| Figure 5. MRI of Slipped Capital Femoral Epiphysis (SCFE) |
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| Courtesy of Dr. Howie Werman, Ohio State University College of Medicine and Public Health |
Initial Emergent Care
Evaluation and recognition of possible hip fractures in the ED can be challenging. Presentations vary from a hemodynamically unstable, multisystem trauma patient to an elderly patient with hip pain and difficulty ambulating for several days. From an emergency medicine perspective, the approach to all varieties of hip fractures is the same. Anatomic findings may differ, but the EP must approach each entity equipped with a broad knowledge base and with attention to detail.
The initial evaluation by both emergency medical services (EMS) and EP's is the same: a primary assessment of airway, breathing, and circulation. Typical EMS pathways for patients suspected of having significant life threatening injuries include securing a patient's airway via endotracheal intubation, use of airway adjuncts, or less invasive oxygen supplementation. For patients who are hypotensive or tachycardic, resuscitation is started using large bore intravenous catheters and initial crystalloid fluid boluses. For patients with possible intertrochanteric and subtrochanteric fractures, the potential for significant blood loss exists and patients must be carefully assessed and monitored. The neck and spine are frequently immobilized using rigid cervical collars and backboards if the EMS provider determines there is a possibility for associated spinal injuries based on mechanism of injury, and brief physical and neurologic exams.
Injuries with bleeding are addressed by using direct pressure dressings and elevation if possible. The affected extremity is immobilized and a splint is applied with traction unless there is concern for sciatic nerve injury or the fracture is open.12 A recent survey of trauma physicians, in accordance with Advanced Trauma Life Support (ATLS) protocol, recommended pneumatic anti-shock garments (PASG) in patients with an identifiable pelvic fracture and hypotension. This has been shown to decrease mortality.
Consultation within the EMS communication network with regard to administering intravenous analgesics and other resuscitative medications is performed. Transporting patients to a facility offering the appropriate Level I or II trauma care also is discussed and initiated based on local EMS protocols.
Once the patient is under the care of the EP, stabilization continues. As with every patient being treated in the ED, ensuring respiratory, ventilatory and hemodynamic competence is a primary concern. Intertrochanteric fractures generally require fluid resuscitation and subtrochanteric fractures frequently require large volumes of fluid resuscitation. Thorough histories and physical examinations are completed to the degree the medical situation allows. This is supplemented by family recall, ancillary medical personnel reports, and from other individuals having firsthand knowledge of the circumstances. The EP will acquire lab data, diagnostic imaging and orthopedic consultation; administer medications to support adequate physiologic requirements and provide patient comfort; anticipate further needs associated with both operative and non-operative interventions; and provide proper disposition communication and documentation.
Unless the fracture has a complication requiring emergent intervention, trauma protocols will call for a prioritized approach for the patient with multisystem trauma. One major area the EP should focus is on analgesia, since pain management may significantly improve the physical exam.
Compounding matters are the comorbid conditions of the patient and the clinical scenario. Parenteral analgesia or nerve blockade can be used for pain control. Nerve blockade may be preferred in the setting of hypotension, thereby mitigating some of the systemic effects of opiates. However, a thorough neurological examination must be performed prior to the blockade. The EP must evaluate for contributory medical conditions such as myocardial ischemia, cerebrovascular accidents, and arrhythmias as events that could have lead to a fall in the elderly patient. Subsequent sections in this article will address more specific evaluation and treatment approaches based on the anatomic location of the hip fracture.
Case 1
A 30-year-old male involved in a head-on motor vehicle collision is brought to the ED by EMS. On initial examination, the patient has multiple lacerations on his face. His breath sounds are clear; his abdomen is soft; and his left leg is shortened, internally rotated, and adducted.
- What is the first step in his evaluation?
- What type of dislocation does the exam correlate with?
- What type of fracture is he at risk for?
Femoral Head Fractures
Shearing forces from hip dislocations are the most common cause of femoral head fractures. Isolated femoral head fractures are unusual. Posterior hip dislocations comprise 70-80% of all hip dislocations. They generally result from forces applied to a flexed knee with hip flexed, adducted, and internally rotated. (See Figure 6.) In this scenario, there is a 10-16% association with fracture of the posteroinferior and inferomedial aspect of the femoral head.13 Anterior hip dislocations result when strong forces are applied with the hip flexed, and leg abducted, and externally rotated. (See Figure 7.) This accounts for 20-30% of hip dislocations and carries with it a 22-77% rate of fracture to the posterosuperior and lateral aspects of the femoral head.14 The cause of the majority of these injuries is motor vehicle collisions involving younger patients, and carries with it a significant rate of associated major injuries to the other extremities, skull, face, thorax, and abdomen. Older patients involved in similar incidences are more likely to sustain femoral neck fractures, in addition to the other associated injuries. (See Table 2.)
| Figure 6. Posterior Hip Dislocation |
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| Courtesy of Dr. Ann Dietrich |
| Figure 7. Anterior and Posterior Hip Dislocations |
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| Courtesy of Dr. Ann Dietrich |
| Table 2. Fracture Site, Mechanism, and Physical Findings |
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The patient will typically complain of severe pain and hold the hip joint immobile in positions characteristic of the position of dislocation. The leg is shortened, internally rotated, and adducted when posteriorly dislocated. The affected leg appears flexed, externally rotated, and abducted with the inferior type of anterior dislocations; and extended and externally rotated in the superior type. Other common ipsilateral injuries to consider associated with hip dislocations include acetabular and femoral neck fractures, sciatic nerve injury, arterial injury, venous thrombosis, hematoma, and knee ligamentous tears and fractures.
Orthopedic consultation should be obtained in the ED. The treatment focus for patients with dislocations is reduction of femoral head and fracture fragment as soon as possible to avoid avascular necrosis. Small fracture fragments, if present, may need to be removed. If a single attempt at closed reduction fails, then open reduction and internal fixation are indicated.
Case 2
An 85-year-old white female was brought in by ambulance from an assisted living facility after a fall. The patient is awake and alert, and her vital signs are stable. The patient is complaining of mild pain in her hip region but she is unable to ambulate.
- What type of fracture is this population at risk for?
- What are some of the main complications from this type of fracture?
- What type of imaging may be necessary?
Femoral Neck Fractures
Femoral neck fractures are more common in older adults with underlying osteoporosis or osteomalacia. They typically result from minor trauma or torsional mechanisms associated with falls. (See Table 2.) This fracture is not as common in younger patients, but when present, is a result of high energy impact and is associated with other significant concurrent injuries. Potential complications are similar to those in adults, in addition to premature growth plate closure, leg length inequality, and coxa vara.15 These fractures are intracapsular and occur between the end of the articular surface of the femoral head and the intertrochanteric region.
Femoral neck fractures are classified by the amount of displacement. The most commonly cited system is the Garden system. There are four grades of fracture which are based on appearance of initial x-rays prior to reduction. A Garden I fracture is an incomplete, impacted fracture with intact trabeculae in the inferior femoral neck. The patient may complain of only minor pain, often of the medial aspect of the knee or groin, and may be ambulatory. On inspection, the affected leg may appear slightly shortened, with possible induration and swelling at the anterior hip. There may be tenderness on palpation of the anterior hip and reported discomfort with passive movement of the hip in flexion and internal rotation.
There are both operative and non-operative approaches to management. However, advocates of internal fixation report a lower incidence of avascular necrosis, and fewer complications from immobilization compared with longer immobilization times when a non-surgical approach is chosen.16 There is up to a 20% incidence of avascular necrosis regardless of the approach chosen.
Garden II fractures are complete but non-displaced. The symptoms and signs are similar to those of the Garden I fracture. These fractures are prone to displacement due to the loss of structural integrity; therefore, they are routinely internally fixated. Garden II fractures have outcomes and incidences of avascular necrosis similar to Garden I fractures. A CT scan, focused MRI, or bone scan are possible adjuncts in patients whose x-rays are not diagnostic.
Garden III fractures involve the complete femoral neck and are partially displaced. (See Figure 8.) Garden IV fractures are complete and appear totally displaced, with no continuity between bone fragments.
| Figure 8. Type III Garden Fracture |
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| Courtesy of Dr. Ann Dietrich |
Displaced fractures are more noticeable on anteroposterior (AP) views of the hip; however, a standard, lateral view for exact position should be obtained. The patient with a displaced femoral neck fracture is unable to walk. Inspection may show a shortened leg, abducted and in external rotation. Complaint of pain in the entire region is common. Varying degrees of edema, erythema and ecchymosis will be present.
Surgical treatment should be initiated as soon as possible. Complications of femoral neck fractures are significant, but can be decreased if the patient has surgical intervention within a 6 to 12 hour time frame, barring other traumatic or medical concerns that require intervention prior to correcting the hip pathology. In this case, external reduction and traction will be employed until the patient is ready for their orthopedic procedure.
Trochanteric Fractures
Greater trochanter fractures (see Figure 9) typically result from avulsion injuries at the site of insertion of the gluteus medius. It is usually not an isolated injury and most commonly is a component of an intertrochanteric fracture. Orthopedic consultation in the ED is appropriate. If displacement is less than 1 cm and there is no tendency to further displacement, treatment may be bedrest with the affected extremity in balanced suspension until the acute pain subsides. In these patients activity is encouraged as rapidly as symptoms permit, with full weight bearing permitted as soon as healing is apparent. If displacement is greater than 1 cm, these fractures typically are managed with reduction and internal fixation unless the patient is older or debilitated. If that is the case, conservative therapy may be used.
| Figure 9. Greater Trochanter Fracture |
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| Courtesy of Dr. Howie Werman, Ohio State University College of Medicine and Public Health |
Lesser trochanter fractures may be caused by avulsion injuries of the iliopsoas secondary to forceful contraction. This type of injury typically occurs in children and young athletes. Lesser trochanteric fractures commonly occur as a component of an intertrochanteric fracture. (See Figure 10.) Fracture of the lesser trochanter, along with a subtrochlear or intertrochlear fracture, is by definition unstable. Orthopedic consultation in the ED is appropriate. If displacement is less than 1 cm and there is no tendency to further displacement, treatment may be conservative. If displacement is greater than 1 cm, these fractures are typically managed with reduction and internal fixation unless the patient is older or debilitated. If that is the case, conservative therapy may be used.
| Figure 10. Intertrochanteric and Lesser Trochanter Fractures |
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| Courtesy of Dr. Ann Dietrich |
Intertrochanteric Fractures
Intertrochanteric fractures affect an estimated 150,000 patients in the United States every year. These patients are usually elderly, most often women with deficits of bone quality, and the fractures frequently occur as a result of a fall. These fractures are defined as extracapsular, with the affected bone having a relative abundant blood supply. As a result, rates of avascular necrosis are reduced with this fracture; however, significant morbidity and mortality still exists. Mortality rates of 18% have been reported after surgical correction, with rates of 34% if it is treated non-operatively. Corrective surgery for this type of fracture is the most commonly performed surgical procedure for the orthopedic surgeon.
Patients will be nonambulatory and complain of significant pain if medically able. The affected leg will appear shortened. (See Table 2.) Owing to the strong rotational force of the iliopsoas muscle, the leg will be in marked external rotation. A thorough primary and secondary survey of the patient should be performed, as well as a complete physical exam, paying particular attention to joints distal and proximal to the primary injury, and the neurovascular status of the affected extremity. Many classification systems exist with the primary purpose of stratifying fractures based on stability, surgical approaches, and probable outcomes. However, almost all intertrochanteric fractures are surgically reduced and fixed unless medical circumstances or premorbid conditions prohibit surgical intervention.
Stable fractures are two-part fractures running from lateral and cephalad to medial and caudad. (See Figures 11 and 12.) Unstable fractures involve posteromedial comminution, reverse obliquity, or subtrochanteric extension. (See Figure 13.)
| Figure 11. AP of Two-part Intertrochanteric Fracture |
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| Source: http://www.gentili.net |
| Figure 12. Lateral of Two-part Intertrochanteric Fracture |
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| Source: http://www.gentili.net |
| Figure 13. Unstable Intertrochanter Fracture |
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| Courtesy of Dr. Ann Dietrich |
The EP's approach to patient stabilization and evaluation is the same for intertrochanteric fractures as it is for the other hip fracture varieties. Demographically, this patient is older, has comorbid medical considerations, and generally has better outcomes if there is prompt surgical intervention. Prognosis for intertrochanteric fractures is predicated on approach to surgical fixation, the extent of any osteoporosis, and the general condition of the patient prior to surgery.
A study on hip fracture outcomes by Eastwood and coworkers showed that 33-37% of patients returned to their previous level of function with regard to self care, transfers, and locomotion by six months, and that only 24% were completely independent in locomotion at six months.17 It has been reported that after an intertrochanteric fracture, only 51% are ever able to regain their premorbid level of ambulation.18 In the pediatric population, non-displaced or minimally displaced fractures (see Figure 14) can be managed with a spica cast for 6-8 weeks, but internal fixation is preferred for displaced fractures.
| Figure 14. Intertrochanteric Fracture |
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| Courtesy of Dr. Ann Dietrich |
Diagnosis
The diagnosis of these fractures should be suspected based on a patient's age, mechanism of injury, and physical examination. AP and lateral radiographs of the affected side will demonstrate most fractures. If there is a high degree of suspicion for a fracture, but it is not radiographically obvious, look for alteration of the Shenton line and compare it to the other hip. In addition, the neck shaft angle should be assessed (measure the angle created by lines drawn through the centers of the femoral shaft and femoral neck) and is normally approximately 120 to 130 degrees. For patients in whom a femoral neck fracture is suspected, but the initial radiographs are negative, an AP view with internal rotation may provide an enhanced view of the femoral neck.
If the standard views on plain radiography prove inadequate, focused CT scan or MRI can be employed. If the situation permits, and a CT scan is indicated for other injuries, the study can be easily extended through the femur as well. Fracture of the femoral head must be considered in all patients with hip dislocations. Initial x-rays to be obtained include AP view of the pelvis, as pelvic fractures are present in approximately 10% of the cases of hip dislocations.19 AP and lateral x-rays of the involved hip should be obtained. The head of the femur is medial and inferior to the acetabulum in anterior dislocation, and lies lateral and superior to the acetabulum in posterior dislocation. (See Figure 7.)
If there is concern for moving the affected hip, a Johnson lateral view taken from the opposite side with the contralateral thigh flexed can be performed. The oblique or Judet view also is useful in cases where the AP pelvis view is indeterminate. However, it may be technically difficult in the setting of trauma, further highlighting the utility of the CT scan in the patient's management. There is evidence that MRI may soon be the primary modality for the diagnosis and classification if the plain films are initially negative but the clinical picture is concerning.
A thorough physical examination should note the passive position of the extremity, presence of open wounds and foreign bodies, active bleeding, and expanding ecchymoses and hematomas. Apart from observing a pale, cold extremity, arterial competency can be assessed by palpation or use of a Doppler device in the femoral, popliteal, posterior tibial, and dorsalis pedis arterial positions.
Traumatic nerve injuries are more common in penetrating trauma, but may occur as a result of a fracture-dislocation of the hip. Deficits can result from direct nerve injury and from extraneural pressure exerted from displaced bone or a hematoma. Sciatic and femoral nerve injury have been well documented in cases of proximal hip injury. It is imperative that a complete sensory and motor examination be performed to rule out traumatic neuropathies.
Sciatic nerve injury has a higher incidence in posterior hip fracture-dislocations, and typically manifests as a partial neuropathy. The most sensitive and common neurologic finding in this event is weakness in the extensor hallucis longus muscle, signifying a sciatic nerve injury in its common peroneal nerve distribution. If the sciatic nerve is completely compromised, there will be paralysis of all muscles below the knee and of the hamstrings above the knee. The deep tendon reflex at the ankle will be absent or diminished. Femoral nerve injury will manifest as knee extension weakness, diminished or absent patellar deep tendon reflex, and a sensory deficit superior and medial to the patella.
The presence of neurovascular deficits will require the EP to involve orthopedic and/or neurosurgical consultation on an emergent basis. Laboratory screening decisions are based on the stability of the patient, associated injuries, comorbid medical problems, anticipated diagnostic imaging studies, and the need for surgical or non-surgical intervention. The blood work is sent upon the patient's arrival in the ED and typically does not delay or interfere with obtaining initial screening radiographs and subsequent evaluation.
Patients sustaining proximal femur fractures require hospitalization and most undergo surgical repair. A large amount of literature regarding the timing of surgery has been written, with a general consensus that surgical intervention within hours of injury will result in less morbidity and mortality than if surgery is delayed several hours to days.20 Complications associated with operative delay include recurrent hip dislocations, post-traumatic arthritis, myositis ossificans and aseptic necrosis (8% in anterior fracture dislocations, and 10-20% in posterior fracture dislocations). Preoperative labs generally include a CBC, chemistries, coagulation studies, and type and screen/cross depending on the clinical situation. Consideration for reversing effects of anticoagulants prior to surgery also must be made in certain patients. Anesthesiology typically requires a screening ECG and chest x-ray.
Definitive Therapy and Ongoing Management
After the patient is stabilized and the pathology is identified and classified, the definitive treatment can begin. As discussed earlier, analgesia should be attained immediately allowing for proper examination. Dislocations are true emergencies and must be reduced. Closed reduction of the dislocation is usually achieved with the assistance of the orthopedic consultant. If the clinical situation allows, adequate analgesia can be obtained through conscious sedation. This allows for both analgesia and muscle relaxation which may increase the effectiveness of the reduction.
Appropriate monitoring should include continuous pulse oximetry, cardiac rhythm monitoring, and serial vital signs. Several methods for closed reduction have been described including the Allis, Stimson, reverse Bigelow and leg crossing maneuvers, Whistler technique, and longitudinal traction. Incidence of avascular necrosis increases with repeated, unsuccessful attempts at closed reduction with some recommendations limiting attempts to three before open reduction should be considered.
Other indications for open reduction include, femoral head or shaft fracture, neurovascular deficits subsequent to closed reduction, and persistent joint instability after reduction. Approximately 10% of hip dislocations cannot be reduced using a closed technique.
Post-reduction series of x-rays are required to determine reduction success and presence of fracture. Femoral head fractures can be subtle on post-reduction films. Attention should be directed to the transchondral and lateral posterosuperior areas on the femoral head for lucency, depressions, or flattening. If x-rays are inconclusive and there is continued concern for fracture, a focused CT scan with thin cuts through the acetabulum and proximal femur is needed. Presence of fracture commonly interferes with complete reduction, necessitating surgical reduction and fixation.
If relocation is successful without presence of fracture, the legs should be immobilized in slight abduction using a pad between the legs preventing adduction, until traction can be achieved. Prophylactic antibiotics are indicated for all open fractures and for patients being prepared for immediate internal fixation. Guidelines typically require parenteral administration within 30 minutes of surgery. An IV bolus of 2 grams of a first generation cephalosporin is recommended for closed fractures, as well as for open fractures associated with lacerations of 1 cm or less if there are no contraindications.
If there is moderate contamination, an associated laceration greater than 1 cm, or if soft tissue injury is extensive, a loading dose of an aminoglycoside should be added to the cephalosporin. A penicillin should be added for clostridial coverage if the injury occurs in an environment that is highly contaminated. A meta-analysis of seven studies of prophylactic antibiotic use prior to surgical repair of acute hip fractures showed a 44% risk reduction in post-operative infections.21
Femoral head fractures also occur in the pediatric population but are uncommon and usually result from high energy impacts. The same general approach to stabilization, resuscitation, and evaluation apply, abiding by standard pediatric trauma protocols and algorithms.
Summary
This article has served as a general overview for the EP for the evaluation and treatment of patients sustaining fractures of the hip, from the femoral head to the intertrochanteric region. Emphasis has been placed on the epidemiology associated with hip fractures. Most patients will be elderly and have isolated orthopedic problems. Some will be younger and have significant, multiple trauma concerns. Medical and traumatic comorbidities may complicate the stabilization, evaluation, and treatment of the patient. ATLS and Advanced Cardiac Life Support (ACLS) protocols always should be followed. An organized approach to an appropriately prioritized problem list will facilitate the process. Plain radiography is diagnostic in many cases, but the use of focused CT scan and MRI studies will be definitive in all cases. The EP's primary role is to determine the nature and the extent of the patient's injury, temporize pain and complications, prepare for anticipated treatment, and involve orthopedic consultants early. The EP must recognize femoral head fracture dislocations as emergencies and be familiar with reduction maneuvers of the hip to minimize the incidence of avascular necrosis. In spite of the greatest efforts of the EP and orthopedic surgeon, hip fractures carry with them significant morbidity and mortality. Multidisciplinary approaches have been proposed in an effort to both prevent occurrences and improve outcomes.
References
1. Wolinsky FD, Fitzgerald JF, Stump TE. The effect of hip fracture on mortality, hospitalization and functional status: A prospective study. Am J Public Health 1997;87:398-403.
2. Popovic JR. 1999 National Hospital Discharge Survey: Annual summary with detailed diagnosis and procedure data. National Center for Health Statistics. Vital Health Stat 13 2001; Sep;(151):i-v, 1-206.
3. Magaziner J, Hawkes W, Hebel JR, Zimmerman SI, Fox KM, Dolan M, et al. Recovery from hip fracture in eight areas of function. J Gerontol A Biol Sci Med Sci 2000;55(9):498-507.
4. Centers for Disease Control and Prevention (CDC). Incidence and costs to Medicare of fractures among Medicare beneficiaries aged > or = 65 — United Sates, July 1991-June 1992. MMWR Morb Mortal Wkly Rep 1996;45(41):877-83.
5. Ray NF, Chan JK, Thamer M, Melton LJ 3rd. Medical expenditures for the treatment of osteoporotic fractures in the United States in 1995: report from the National Osteoporosis Foundation. J Bone Miner Res 1997;12:24-35.
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Emergency department physicians frequently assess and manage patients with potential hip fractures.Subscribe Now for Access
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