Hip fractures

The word "hip fracture" can mean many different things.

What's in a name?

A "hip fracture" can be any of the following:

  1. Fractures on the hip socket (acetabulum) side:
    • Acetabulum fractures
    • Pubic rami fractures
  2. Fractures on the ball (femur) side:
    • Femoral neck fractures
    • Intertrochanteric femur fractures
    • Subtrochanteric femur fractures

Of all these different types of "hip fractures," the intertrochanteric fractures are the most common, followed by femoral neck fractures.

What is the typical treatment?

  1. Intertrochanteric hip fractures are the most common type. Typical treatment includes a sliding hip screw connected to either a side plate, or to an intramedullary rod. This type of implant allows the femoral bone to shorten and compress, while keeping the neck angle and rotation stable. Prior to the invention of these implants, intertrochanteric fractures used to be difficult problems. The sliding hip screws now result in high healing rates.
  2. Treatment of femoral neck fractures depends on whether the fracture is displaced, as well as the age of the patient.
    • Displaced femoral neck fractures in elderly patients are treated with a hip replacement operation, either partial, or full replacement.
    • Displaced femoral neck fractures in young patients are treated with osteosynthesis if possible at all, even though the failure rate is high. In young patients every attempt is made to preserve the natural hip joint, so as to delay or avoid a hip replacement.
    • Nondisplaced femoral neck fractures are usually treated with osteosynthesis, typically cannulated screws, in both elderly and young patients
  3. Certain hip fractures can be treated without surgery
    • Pubic rami fractures typically do not require surgery.
    • Isolated trochanter fractures can be treated without surgery, but it is important to make sure that the fracture is indeed isolated.
  4. Subtrochanteric hip fractures are potentially the trickiest of "hip fractures," and are treated with an intramedullary implant.
  5. Last, but not least, treatment of the acetabulum fractures depends on the amount of displacement of fracture fragments, as well as certain other factors. A displaced acetabulum fracture in a young patient can be a life altering injury that causes severe impairment despite the best surgical treatment, whereas a nondisplaced fracture can heal well without surgery.

What are the risks of hip fracture surgery?

  1. Risks of general anesthesia apply, including risk of sudden death, infection, stroke, heart attack, etc.
  2. Infection
  3. Malunion, nonunion, failure of hardware, repeat surgery
  4. DVT, PE

Hip fractures are serious. In the elderly, published mortality rates during the year following a hip fracture range from 11 to 40%. A commonly quoted number is 25%. In other words, when a patient breaks a hip, there is a 1 out of 4 chance that that patient will die during the following year from one reason or another.

Case study: An intertrochanteric fracture, treated with a sliding hip screw

This patient slipped and fell while walking. He was not able to get up and walk due to severe left hip pain. He was brought to the hospital by emergency ambulance.

The ER physicians diagnosed him with a hip fracture, and they called me as the orthopedic surgeon on call. I told the patient that he had a simple intertrochanteric fracture.

I performed his surgery next day using a sliding hip screw and side plate.

Here are his xrays after treatment.

Immediate weight bearing is appropriate after this kind of treatment. Patient healed uneventfully, became able to walk without walker at 2 months after surgery.

Case study: Intertrochanteric fracture, treated with an intramedullary device

This patient was found fallen on the floor of her bathroom, and had probably been there for 2 days. She was found by relatives, and she was then brought to the hospital. After rehydrating and optimizing her medical status, she was prepared for surgery.

Here are her xrays before, and approximately 3 months after treatment.

Weight bearing with walker was allowed immediately after surgery. The patient healed this fracture and eventually her family made arrangements for assisted living.

Unfortunately she fractured the other hip and I saw her again a year later. At that time her right hip fracture had fully healed.

The device I used in this case is generically known as a cephalomedullary nail. After inserting the main titanium intramedullary rod along the length of the femur, the cephalic part of the implant is inserted through the lateral cortical bone, through the main rod, and then into the femoral head. Here is a picture of such an implant:

One important feature of this hardware is the ability of the cephalic part to slide inside the medullary part. The sliding allows for controlled compression and shortening of the fractured area, while keeping angulation and rotational angles stable.

In other words, this implant results in fairly predictable healing, and fairly predictable shortening of the hip.

Case study: A subtrochanteric and neck fracture

This patient was in his 40's, fell from the 3rd floor. Xrays show a fracture that involves the neck of the femur, and extends to the subtrochanteric area. Extension of the fracture to the femoral neck was confirmed by CT.

Subtrochanteric fractures are the more serious and tricky of the peritrochanteric femur fractures. Treatment is only trickier when the femoral neck is involved.

The fracture was treated within hours of arrival. An overnight traction pin was not necessary.

After closed reduction, percutaneous nailing was carried out. In order to help and hold the reduction during the nail insertion, temporary percutaneous K-wires were used. This temporary hardware was removed after the definitive implant was in place. The fracture itself was not exposed.

Below are the fluoroscopy xrays showing reduction and stabilization of the fracture:

Immediate postoperative xrays are routinely done to double check the accuracy of reduction and hardware placement.

This fracture healed in due course. Due to the configuration of this fracture, shortening was very minimal, not enough to measure. Below are xrays done at 6 months: