Hip Fracture

Disease/Disorder

Introduction

Hip fractures are a significant problem in the US, characterized by high annual admissions, substantial medical costs, and severe health complications frequently requiring inpatient rehabilitation facility (IRF) admission following surgical treatment. From 2008-2018, the yearly incidence per 100,000 for hip fractures in the U.S. Medicare population was estimated to be 321 for males and 624 for females.¹ By 2050, the annual incidence globally is anticipated to be 4.5 million.2 Hip fractures have been designated as meeting the eligibility threshold for inpatient rehabilitation facility (IRF) admission according to the CMS 60% rule restricting medical condition admissions. Although IRF level of rehabilitation is more costly than skilled nursing facility (SNF) level of care when evaluating cost of stay itself, inpatient rehabilitation was shown to incur lower overall costs of care at 18 months follow up. This finding may be due to lower rate of readmission to acute care facilities, shorter length of stay at IRF, or higher functional status at discharge from IRF, which may decrease costs by decreased need for home care. In a retrospective cohort study in Australia, in-hospital rehabilitation was associated with lower mortality at 90 day and 2 year follow-up compared to those who did not receive hospital-based rehabilitation following hip fracture.³

Definition

Hip fractures are fractures which occur at the proximal femur, and can be classified as either intracapsular or extracapsular. Femoral head and neck fractures are intracapsular fractures, whereas intertrochanteric and subtrochanteric fractures are extracapsular.

Etiology

Most hip fractures are due to falls. Elderly people are at higher risk of hip fractures due to decreased bone resilience and increased risk of falls, especially to the side due to slower gait speed with decreased forward momentum. Postmenopausal women are at a particularly high risk due to estrogen deficiency elevating risk of osteoporosis, which contributes to the higher incidence of female hip fractures. There is also a smaller but steadily growing population of young patients presenting with hip fractures due to high energy trauma such as motor vehicle collisions. Up to 5% of hip fractures are non-traumatic, stemming from etiologies such as malignancy.⁴

Risk factors

Hip fracture risk factors can be classified into two broad categories: those negatively influencing bone mineral density (BMD), and those increasing risk of falls. Among the most significant non-modifiable risk factors which influence BMD are female sex and older age, which are also risk factors for osteoporosis. Common factors influencing BMD considered to be modifiable include vitamin deficiencies (e.g., calcium, vitamin D), inflammatory processes, medications (e.g., corticosteroids, loop diuretics, or proton pump inhibitors), excess caffeine or alcohol intake, smoking, and low body mass index.⁵

Factors increasing the chance of falls can be viewed as environmental (e.g., loose rugs or cords, slippery floor) or directly related to the individual. The latter may include factors such as muscular weakness, sensory or cognitive impairment, polypharmacy or substance abuse, and orthostatic hypotension.

Epidemiology

Hip fractures are likely to rise significantly due to the aging population and are already considered one of the top ten causes of loss of disability-adjusted life years in individuals aged 65 years and older. From a global perspective, an estimated 4.5 million people suffer disability from hip fractures annually and this is expected to increase to 21 million living persons with disability by 2040.⁶

Primary prevention

First-line prevention of fractures includes fall prevention, smoking cessation, moderation of alcohol intake, and management of osteoporosis.

The CDC has developed the STEADI (Stopping Elderly Accidents, Deaths & Injuries) Initiative for Health Care Providers to reduce an individual’s risk of falling. This initiative utilizes an algorithm to identify patients at varying levels of risk for fall, as well as identify modifiable risk factors and provide effective interventions.⁷ The U.S. Preventive Services Task Force (USPSTF) recommends exercise interventions as a Grade B recommendation for fall prevention.⁸

Osteoporosis is a common disease, with over 2 million osteoporotic fractures occurring annually.⁹ The U.S. Preventive Services Task Force recommends using dual energy x-ray absorptiometry to screen all women 65 years and older, and younger women who have an increased fracture risk as determined by the World Health Organization’s FRAX Fracture Risk Assessment Tool.¹⁰ First-line treatment of osteoporosis is typically bisphosphonate therapy.

Patho-anatomy/physiology

The hip is a ball and socket joint. The femoral head, a ball-like structure, connects to the acetabulum, which functions as a socket. This connected structure is covered by a fibrous tissue making up the hip joint capsule.

Fractures within the joint capsule most commonly involve the femoral neck. This is also the most common location for hip fractures overall and is often compromised in women. Femoral neck fractures can be classified using the Garden Classification, which has four categories. Stage I and II are stable, or non-displaced, while Stage III and IV are unstable, either partially or completely displaced. Stable femoral neck fractures are generally best treated with surgical stabilization and immediate mobilization due to a high risk of secondary displacement. Treatment is by operative pinning with three parallel cannulated screws placed adjacent to the femoral neck. Unstable or displaced fractures in young patients are similarly treated with fixation by cannulated screws, but in the elderly joint replacement procedures yield better results than fixation due to reduced occurrence of post-operative arthritis. The elderly often require hemi- or total joint arthroplasty. In hemiarthroplasty, the acetabular cartilage is left intact and the implant articulates with the acetabulum. Hemiarthroplasty requires less surgery and carries a smaller risk of dislocation, but total joint replacement is preferred in young active patients who would wear down the pelvic bone cartilage with overuse.

Intertrochanteric fractures are the second most common type of hip fractures. The Evan Classification takes into consideration the number of fractured fragments. Fractures where the femur is broken in only two or three parts are stable, while those broken into four or more parts or have oblique fractures are unstable. Stable fractures are treated with a sliding screw and a side plate screwed onto the femoral shaft. An intramedullary nail and a sliding hip screw are often used for unstable fractures.

Subtrochanteric fractures are the least stable and least common type of hip fractures, accounting for approximately 3%. They are treated with an intramedullary hip screw only.

Prognosis of hip fractures

A negative impact on morbidity and mortality can be expected after operative management of hip fractures.⁴ Seniors with impaired ADLs prior to hip fracture had higher risk of ADL decline 6 months after surgery. Intertrochanteric fractures had also been associated with delayed recovery of pre-fracture mobility and increased mortality.

Mortality rates observed in this population have been estimated as 10% at 1 month after hip fracture and up to 36% within 1 year after hip fracture.⁶ Many of the deaths due to falls are associated with hip fractures. Roughly, the one year mortality after a hip fracture has been observed to be 32.5% for men and 21.9% for women.³

A prospective cohort study of 728 patients aged 65 years or older from three Italian public hospitals from October 2013 to October 2015 found predictive factors such as older age, comorbidities, higher pre-fracture dependence in ADL’s, hospital-acquired pressure injuries and lack of recovery ambulation had higher one-year mortality rates.¹¹ Many of these predictive factors relate to frailty and it can be generalized that extent of frailty plays a role in prognosis of hip fracture.

Specific Secondary or Associated Conditions and Complications

• DVT
• Hardware failures
• Wound infection
• Delirium
• Pain
• Leg length discrepancy
• Immobility
• Falls
• Neuropathy

Essentials of Assessment

History

Age and gender are predisposing factors for this injury. Other factors to take into consideration are history of chemo- or radiation therapy, steroid use, polypharmacy, or comorbidities including metabolic disorders, cardiovascular disease, and substance abuse. Pain location is important; true hip pain typically radiates to the groin.

Physical examination

A suspected hip fracture should first be evaluated with visual inspection of the limb. Asymmetry or deformity of the leg may be indicative of fracture. The limb should also be inspected for ecchymosis, abrasions, or other open wounds.

Limb positioning at presentation may also suggest a fracture. In a displaced femoral neck fracture or intertrochanteric fracture, external rotation and shortening of the affected extremity may be observed. Limb shortening or rotation is uncommon in non-displaced fracture. Range of motion testing should be deferred in cases with evident deformities until imaging is completed.

Femoral, popliteal, dorsalis pedis, and posterior tibial pulses should be assessed, with ABI if necessary, due to risk of neurovascular compromise. Sensation in the affected limb should also be assessed. The femoral nerve and/or artery can be injured with subtrochanteric and femoral shaft fractures, while the sciatic nerve can be injured with more proximal hip fractures.

Diagnosis

Radiographic assessment

Imaging evaluation should begin with anterior-posterior (AP) and cross-table lateral projections of the hip. MRI is typically reserved for cases in which plain films are unrevealing, but fracture remains suspected. In younger patients, CT imaging can be useful for preoperative planning due to the typically high-energy nature of these fractures.

Early prediction outcomes

Hip fractures are associated with significant morbidity and mortality, with mortality rates at one month post-operatively as high as 10%. After one month, survivors of hip fracture may face significant morbidity including temporary to permanent immobility, placement in a long term care facility, use of walking aids, and inability to carry out previous ADLs.⁶ It has also been shown that women with a hip fracture have a five-fold increase whereas men have an eight-fold increase in relative likelihood of death within the first 3 months.

Environmental 

The home environment can have many hazards which may place an individual at risk for a hip fracture. The CDC recommends the following to minimize fall hazard

• Remove tripping hazards such as small throw rugs or use adhesives to keep rugs from slipping
• Add grab bars inside and outside the shower or tub, and next to the toilet
• Add railings on both sides of the stairs
• Utilize bright lights in the home
• Non-slip mats in bathtub and shower floors
• Wear appropriate fitting shoes with good support inside and outside the home

Rehabilitation Management and Treatments

Indications for inpatient rehabilitation for hip fractures

IRFs optimize hip fracture rehabilitation by ensuring 3 hours of therapy a day for 5 days a week or at least 15 hours of therapy weekly, to provide a concentrated rehab effort. Patients are provided with around-the-clock medical and nursing care. Given the multidisciplinary care, patients must meet additional criteria that warrants medical supervision while completing rehabilitation. Factors which have been shown to increase likelihood of discharge from the acute hospital to IRF compared to home include older age, lower pre-operative functional status, and ORIF surgery type, as well as medical comorbidities such as hypertension, diabetes, congestive heart failure, or cognitive impairment.¹²

Superiority of inpatient rehabilitation 

Although hip fracture rehabilitation can be undertaken at an SNF, outpatient, or home levels, there is strong evidence supporting the superiority of IRF-based rehabilitation.

IRF patients have the lowest rate of inpatient re-hospitalization compared to SNF, home discharge (with and without home health care) at 180 days after discharge. Also, patients discharged from IRFs require less home care than those from SNF. Hip fracture patients undergoing rehabilitation in IRFs are more likely to be discharged home and less likely to be re-institutionalized after rehabilitation than patients undergoing rehabilitation in SNF. Patients in IRF also had shorter lengths of stay than those at SNF. Herbold et al reported that “matched for age, gender, operative diagnosis, [morbidity] severity index, and admission ambulation FIM score, those who received rehabilitation in the IRF had shorter length of stay and superior functional outcomes than those in the SNF setting.”¹³

Restore function 

Until 2019, IRFs tracked patients’ functional status from admission to discharge by using the FIM (Functional Independence Measure), as a standardized method to measure function. After adjusting for baseline characteristics and participation in rehabilitation, subjects in the IRF group were eight times more likely to regain 95% of their pre-fracture FIM motor score at 12 weeks, as compared to subjects in the SNF group.

Peer support

IRFs often provide peer support groups both during IRF stay and as an adjunct treatment following IRF stay for their patients. Peer support groups allow for better adjustment to the consequences of hip fractures and easier community reintegration. It has been shown that peer support groups provide advocacy, resources, community and relationship building, mentoring/goal setting, and socialization/self-esteem building as well as assist with education and awareness. Group learning was shown to decrease the number of ADL items perceived to be performed with difficulties and increase perceived ability to participate in social life after hip fracture.

Mental health

Depression, apathy, and cognitive impairments affect hip fracture patients’ participation in therapy. Depressed patients are not motivated to participate in therapy and due to lack of participation normally have less functional improvement. Evidence supports improved outcomes in patients with dementia undergoing rehabilitation in IRFs. In select patients with mood disorders, this can also correlate with their perception on pain and predispose them to opioid use disorder post-operatively. Inpatient rehabilitation can mitigate this through therapy, psychological and medical interventions.

Patients at higher risk 

Obesity is a common comorbidity found among hip fracture patients. Nailing fixation of hip fractures in morbidly obese population resulted in increased incidence of wound infections, greater trochanter fractures, and pulmonary emboli.

Diabetes may have profound effects on hip fracture patients, including increased mortality rate.

Cardiovascular disease is another important comorbidity in this patient population. A significant increase in proportion of hip fracture patients admitted with comorbid cardiovascular disease has been documented.

Hip fracture primary complications 

Femoral neck fractures

Since repair of these fractures often affects the fibrous capsular tissue in addition to bone tissue, intra-capsular fractures have a higher incidence of complications, including nonunion (failure of bone fragments to join together after the surgery) and avascular necrosis (compromise of blood flow causing bone tissue death) of the femoral head, than extracapsular fractures. Osteonecrosis is the most common complication of femoral neck fractures (23%), followed by nonunion (8%). Unstable fractures have a 27% rate of necrosis. These complications may require a repeat surgery with hip replacement.

Intertrochanteric fractures

Inter-trochanteric fractures may be complicated by nonunion, screw cut-out, nail breakage, malunion, or limp, most of which may be treated by total joint replacement.

Total or hemiarthroplasty 

Patients with total or hemiarthroplasty may complain of hip pain and present with acetabular erosion (in hemiarthroplasty), prosthetic loosening, hip dislocation, fracture, or infection. All of these complications may need a repeat surgery with total hip replacement.

Hip precautions are specific mobility restrictions placed on the patient during rehabilitation to help prevent dislocation. These restrictions may include use of an abduction pillow between the legs while in bed to keep the hip 15 degrees away from the midline, avoiding reaching forward by flexing at the hip, using adaptive equipment including reachers, sock-aids and dressing sticks for lower extremity care, and raised toilet-seats/commodes and tub benches for toileting and hygiene. Patients at particularly high risk for dislocation are those with prior history of dislocation, poor compliance, impulsivity, altered mental status, and revision arthroplasty. These patients may benefit from a restrictive abduction hip brace.

Secondary precautions  

Pain is common after hip surgery and associated with poor functional outcomes. Pain management with opioid protocol has shown 9% risk reduction of chronic pain incidence and improved physical function at 6 months. Since opioids are commonly used to treat post-operative hip pain, hip fracture patients must be closely monitored for a common opioid side effect of constipation. Additionally, physicians should be cognizant of patients developing dependency on narcotic medications after their procedure, which has been documented in several studies.¹⁴ A multidisciplinary approach should be utilized to attempt weaning of opioid use medications. Clinicians should review the latest 2022 CDC guidelines for prescribing and managing opioids. A slow tapering of opioid medications rather than abrupt cessation leads to better compliance (10% or less decrease monthly in those with opioid use >1 year). Maximizing use of nonopioid therapies is encouraged.¹⁵ Nonopioid therapies can include nonsteroidal anti-inflammatory drugs, exercise or topical agents and have been shown to be at least as effective as opioids for many types of acute pain, but may be inappropriate or impractical in postoperative settings.¹⁵

DVT prevention 

Thromboembolism is a common occurrence in hip fracture patients. Venous thromboembolism prophylaxis in hip fracture patients had been shown to decrease lower extremity blood clots by 40%. Chemoprophylaxis is recommended, though the American Academy of Orthopedic Surgeons does not recommend any specific agent.

Wound healing 

Clinicians should monitor for complications including infection, hematoma or dehiscence at the incision site. A combination of pre-existing health conditions can negatively impact healing. Deep infections after surgery for hip fracture has been reported to be between 1.5% and 7.3% depending on co-morbidities.¹⁶ Malnutrition can delay healing and is commonly observed in the elderly population, which is also the patient population most likely to experience hip fracture.

Nerve palsy 

The following nerve palsies have been described and should be screened for: sciatic, peroneal, femoral, obturator, superior gluteal nerves.

Leg length discrepancy 

Normally, post-operative discrepancy is due to pelvic obliquity from muscle imbalance and hip contractures and may be resolved with therapies. Discrepancy less than half an inch is normally well tolerated, but those more than ¾ of an inch may require a shoe lift that is half of the discrepancy length.

Fall risk 

Fall risk is due to post-operative weakness and mobility impairment. Fall precautions are ordered while inpatient such that patients are instructed not to get out of bed unassisted and nursing staff assists the patient with transfers and mobility until fall risk is cleared. Multifactorial fall risk assessment and intervention had been shown to decrease fall incidence.

Weight bearing precautions 

Weight bearing restrictions (e.g., non–weight bearing, toe-touch, or partial weight bearing) may sometimes be utilized after surgery. These restrictions may be difficult for some patients to comply with due to lack of comprehension, arm strength, or coordination. Furthermore, the restrictions may hinder rehabilitative efforts in patients unable to comply, as therapy treatments need to be halted until proper weight bearing is learned. Fortunately, studies show that after hip surgery, weight bearing as tolerated is well tolerated and therefore encouraged except for in displaced femoral neck fractures fixed with cannulated screws where partial or toe-touch weight bearing is recommended.

Impaired mobility 

Impaired mobility is a relative reduction in ability to ambulate and transfer from surfaces and commonly occurs after hip fracture and subsequent surgery.

Non-progression with therapy

Non-progression with therapy is an unfortunate occurrence in rehab facilities. Etiologies for non-progression include: 1) poor patient cooperation due to personality traits, psychological or cognitive issues; 2) reaching maximum currently achievable functional state; 3) worsening medical condition; 4) pain; 5) insomnia; 6) fatigue; and 7) patient’s family factors. These underlying etiologies need to be investigated to facilitate patients’ rehabilitative course and to assess if there is an underlying subclinical medical condition that is emerging. If non-progression etiologies have been sufficiently investigated and patients persistently fail to improve from therapies, it becomes difficult to justify the patient’s IRF stay. Without measurable functional gain it may be time to consider continuing rehabilitative services at a different level of care, transfer to subacute rehabilitation or home with outpatient therapy regimen.

Cutting Edge/Emerging and Unique Concepts and Practice

N/A

Gaps in the Evidence-Based Knowledge

N/A

References

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Original Version of the Topic

Michael T. Daniels, MD. Hip Fracture. 1/24/2013.

Previous Revision(s) of the Topic

Levan Atanelov, MD, Nicholas Dabai, MD. Hip Fracture. 4/30/2017.

Ajai Sambasivan, MD, Vishal Bansal, MD, Peter Vu, MD. Hip Fracture. 4/20/2023

Author Disclosure

James Begley, MD
Nothing to Disclose

Bailey Urbach, MD
Nothing to Disclose