Hip Fracture: Diagnosis and Treatment

Hip fracture is a very common type of fracture that I see in my clinical practice. Patients say that they sustained trauma following which they have hip pain and are unable to walk or move the affected limb. Commonly this fracture is a complication of osteoporosis. Therefore it is more common in elderly people.

You should immediately consult your doctor if after a fall

• you have pain in the hip region
• you can not lift your limb straight in the air

If the above two conditions are present together there is a high probability that you have fractured your hip.

In young people this fracture is caused by high velocity trauma (road traffic accidents, industrial accidents, fall from height). With the global increase in the elderly population patients of hip fracture are going to increase. Therefore it is important to know about this injury.

On reaching the hospital you will be

• questioned and gently examined
• given a pain killer to reduce pain
• your limb will be splinted (by traction)
• if your blood pressure is low IV fluids will be given

1. Fracture Neck Femur

2. Intertrochanteric Fracture

First we will learn about Fracture Neck Femur. As the name suggests it is a fracture of the neck of the femur. By neck I mean the part of the femur bone that is located just below the head of femur. This fracture is also called the "Unsolved fracture" as it is very challenging to treat.

The challenge in treating this fracture is caused by the unique surgical anatomy of this part of the femur bone.

• Blood supply to the head of the femur goes through the neck. Fracture neck femur disrupts this blood supply. This can result in avascular necrosis of the head if all blood vessels are disrupted.
• The neck of femur is located within the hip joint. Synovial fluid in the joint washes away the fracture haematoma, preventing the callus (soft bone that unites fractures) formation.
• Fracture produces two pieces of bone, one very small ( head and part of neck of femur) and one very large ( part of neck, shaft and lower end of femur). This difference poses a problem in proper fracture alignment.

Diagnosis is by history and physical examination of the patient.

• History of trauma is present
• Patient will complain of hip pain that is increased by movement of the limb
• Inability to stand and walk may be present.
• On examination there is mild shortening and leg is rotated outwards
• Inability to lift the leg straight in the air
• Patients of impacted fractures (incomplete fracture in which bone ends are pushed into each other)may come walking

Type 1 - Impacted fractures. In these fractures both the fracture fragments are crushed into each other. If the fracture fragments separate later on then the fracture is treated as displaced fracture.

Type 2 - Undisplaced fractures. In these fractures the alignment of the fracture fragments is not disturbed.

Type 3 - Displaced fractures. In these fractures the alignment of the fracture fragments is disturbed.

This is a x ray of a impacted hip fracture in a 19 year male. When the patient came to me he was walking and had sustained the injury about 20 days back. The red arrows show the extent of the fracture line. This fracture was treated by bed rest for a month.

Treatment of fracture neck femur depends on the age of the patient

• In children below the age of 16 years undisplaced and impacted fractures can be treated by plaster cast or traction. To detect displacement, follow up with check x rays is essential on a weekly basis for one month. If the fracture displaces then it has to be fixed surgically with pins or screws.

All displaced fractures have to be fixed surgically with pins or screws.

• Between 16 to 60 years (active people with good bone stock) all undisplaced and displaced neck fractures are fixed with devices such as dynamic hip screw (Compression screw with side plate) or multiple screws.

Impacted fractures may be treated by bed rest and traction for few weeks followed by gentle exercises. If the fracture parts separate then surgery is done.

• Beyond 60 years age (less active people with poor bone stock) all undisplaced and displaced neck fractures are treated with removal of the femoral head and replacement with a prosthesis (artificial upper end of femur bone) such as Austin Moore or Bipolar.

Impacted fractures are treated same as above.

The above mentioned age limits are arbitrary. If 70 year old person who is active and has good bone stock comes with a fracture, then he can be treated by stabilization of the fracture rather than prosthetic replacement.

Walking on the limb is usually allowed from the second or third post-operative day when prosthetic replacement is done.

The following x rays show a fracture neck femur in a 13 year old male child. The first x ray was taken 20 days after he sustained the fracture. You can see the displaced fracture. The next x ray was taken 1 day after surgically fixing his fracture with screws. The lower most x ray show the united fracture after 2 months.

The following x rays are of a 35 year old male patient who came to me 1 month after sustaining a displaced fracture neck femur. The first x ray shows the fracture. He was managed surgically by valgus osteotomy (wedge shaped cut in bone) and fixation of the fracture with a side plate and screws. The second x ray was taken 2 months after. I now allowed him to walk with partial weight bearing on his operated limb. The third x ray taken five months after operation. He was now allowed full weight bearing as the fracture had united satisfactorily.

Complications include

1. Nonunion

2. Avascular Necrosis. This can be reduced by

• fixing the fracture surgically by plate and screws within 12 hours of injury
• maintaining exact alignment of the fracture fragments during surgery

3. Deep vein thrombosis. Prophylaxis with anticoagulant drugs (reduce the clotting of blood) can minimise this complication.

Nonunion and avascular necrosis can be avoided altogether by initial prosthetic replacement.

This fracture can take a long time to unite. Sometimes on the x ray the fracture may appear united, still nonunion may be present.

Intertrochanteric Fractures are caused by fall on the hip and high velocity accidents. They are more common in osteoporotic bone. As compared to fracture neck femur these patients are

• of more age
• have more deformity
• more shortening of the limb
• more pain

But these fractures heal faster than neck fractures.

Diagnosis can be confirmed by x rays of the hip.

Treatment is by surgery. Plaster and traction have no role in the definitive treatment of this fracture. Fracture is aligned and fixed with a Dynamic Hip Screw device. The fracture usually takes 6 to 8 weeks to unite.

Intertrochanteric Hip Fracture fixed with Compression Screw and Plate

Complications of intertrochanteric hip fracture include

1. Malunion. This complication can be avoided with strong and stable fixation of the fracture.

2. Nonunion is rare. It can occur with implant failure. (breakage or cut through of the screw).

3. Deep vein thrombosis. Prophylaxis with anticoagulant drugs is done to minimise this complication.

This is a x ray of patient who developed nonunion of the intertrochanteric fracture after taking treatment from a quack for a few months.

Below is the x ray after surgical stabilization of the fracture nonunion. The nonunion healed soundly and now he is walking normally.

Frequently Asked Questions

How long is the hospital stay after surgery for hip fracture?

It can be as less as 3 days (good general condition, no complications) to many weeks (poor general condition, complications present).

When will I be able to walk on my limb?

If prosthetic replacement is done then you would be allowed to walk from the second day of surgery. If compression screws and a plate is used to fix the fracture then using the limb will depend on

• stability of the bone plate unit
• presence of osteoporosis and other complications
• rate of progression to fracture union

Will the screws and plate have to be removed?

In young people they should always be removed after 3 to 5 years. In people above the age of sixty they can be left if they are causing no problems.

Can a second operation be required?

If you develop avascular necrosis or your hip fracture does not unite then you may require a second operation.

How can I prevent a hip fracture?

Hip fracture can be prevented by

1. Preventing or treating osteoporosis (opens a new window)

2. Preventing injury (fall) by

• using a walking stick or cane
• using slippers in the bathroom
• no electrical cables running across the rooms or galleries
• using extra hand grips in the bathroom
• proper lighting
• using hand rails on both side of stairs

I hope the information provided was helpful. If you have any query about hip fracture, you can ask me at the contact me page.

This page was last updated on 2nd March 2011.

Other causes of hip pain...

Hip Osteoarthritis

Congenital Dislocation of Hip

Avascular Necrosis

Perthes Disease

Hip Replacement

Hip Joint Anatomy

Go back to Hip Pain from Hip Fracture