Hip Fracture
Orthopedic, Trauma
First 5 Minutes
- Perform and document neurovascular assessment of lower limbs.
- Determine mechanism of injury and assess for any other injuries.
Context
- High morbidity and mortality even with effective treatment
- Nearly 10% mortality within 30 days post-op.
- 80% use gait at one year post injury.
- 3 different fracture patterns
- Femoral neck fracture
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- Intracapsular fracture.
- Higher risk of avascular necrosis, non-union than other hip fracture types.
- Common hip fracture pattern.
- Intertrochanteric fracture
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- Extracapsular fracture.
- Common hip fracture pattern.
- Subtrochanteric fracture
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- Extracapsular fracture.
- Less common hip fracture pattern.
- Consider possible pathological femoral fracture secondary to bisphosphonates, denosumab or cancer.
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Diagnostic Process
- Older patients typically present with a low energy mechanism, such as a history of fall, and sudden onset hip pain.
- Consider a pathological fracture if pain preceded fall.
- Younger patients typically high energy trauma.
- Physical exam findings may include:
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- Inability to ambulate and pain on palpation.
- Affected limb shortened, abducted, externally rotated (if fracture is displaced).
- NB: If impacted femoral neck or incomplete fracture may present with mild discomfort with active and passive hip ROM.
- Patients have been known to walk on fractured hips.
- Imaging
- Plain x-ray
- AP hip (maximum possible internal rotation is ideal), AP pelvis, cross table lateral, full length femur if significant mechanism.
- If high clinical suspicion, no fracture on x-ray – CT or MRI may be used to rule out occult fracture
- MRI is preferred, but usually CT ordered initially.
- Plain x-ray
Recommended Treatment
- Early referral to orthopedic surgery is indicated.
- Analgesia
- IV opioids appropriate for management.
- Ex: Hydromorphone 0.1- 0.5 mg IV Q 1 -2 hours prn (in ED). Rarely are cases managed non-surgically;
- Patient high risk for surgery/cannot tolerate surgery (i.e., highly comorbid).
- Non-ambulatory at baseline.
Criteria For Hospital Admission
- All patients require admission.
Criteria For Transfer To Another Facility
- Patients require transport to a facility with an orthopedic surgery service.
Criteria For Close Observation And/or Consult
- Orthopedic surgery consult is required.
Quality Of Evidence?
High
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
Moderate
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
Low
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Justification
Hip fractures are well studied, resources cited trials, and systematic reviews for assessment and management, though the specific surgical techniques are still debatable.
Related Information
OTHER RELEVANT INFORMATION
Reference List
Bhandari M, Swiontkowski M. Management of Acute Hip Fracture. Solomon CG, editor. N Engl J Med. 2017 Nov 23;377(21):2053–62.
Blomberg J. Femoral Neck Fractures – Trauma – Orthobullets [Internet]. [cited 2023 Sep 23]. Available from: https://www.orthobullets.com/trauma/1037/femoral-neck-fractures
Foster KW. Overview of common hip fractures in adults – UpToDate [Internet]. [cited 2023 Aug 6]. Available from: https://www.uptodate.com/contents/overview-of-common-hip-fractures-in-adults?search=hip%20fracture&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
Karadesh M, Tarazona D. Intertrochanteric Fractures – Trauma – Orthobullets [Internet]. [cited 2023 Sep 23]. Available from: https://www.orthobullets.com/trauma/1038/intertrochanteric-fractures
Weatherford B. Subtrochanteric Fractures – Trauma – Orthobullets [Internet]. [cited 2023 Sep 23]. Available from: https://www.orthobullets.com/trauma/1039/subtrochanteric-fractures
RESOURCE AUTHOR(S)
DISCLAIMER
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by Emergency Care BC (formerly the BC Emergency Medicine Network) and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. Emergency Care BC is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. Emergency Care BC also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Dec 21, 2023
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