Hip Fracture

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Hip Fracture

What Is It?

The hip is the joint between the upper end of the thighbone (femur) and its socket in the pelvis. When a hip fractures (breaks), the injury is always in the femur. The upper end of the femur can fracture in any one of three places:

• The head of the femur — The rounded surface at the very end of the bone that fits into a socket in the pelvis.

• The neck of the femur — A somewhat horizontal stretch of bone at the top of the femur that gives this bone the shape of an inverted "L."

• Between or below the greater and lesser trochanters — The femur naturally bends at the lower boundary of the hip, angling toward the knee. At this bend, two bony humps protrude along the outside edge of the femur. These ridges are the greater trochanter and lesser trochanter.

Falling is the most common cause of hip fractures. Usually, this occurs in people older than 50. Older people are at risk of hip fractures because of osteoporosis, a disease that weakens bones and may be age-related. A hip also may be fractured during trauma, such as an automobile accident.

Doctors label fractures according to how far the bone has moved from its original position (its displacement). Fractures can be:

• Nondisplaced, in which the bone has cracked but not separated

• Minimally displaced, in which the bone has shifted slightly along or away from a break

• Displaced, in which a part of the bone has become completely detached

Symptoms

A hip fracture can cause hip pain, swelling or bruising, and the hip may look deformed. It may be difficult to move the hip, especially turning the foot outwards or bending at the hip. The fracture may make the hip seem too weak to lift the leg. People usually have pain in the groin when they put weight on the hip. Walking or even standing can cause the fracture to spread, which may worsen the pain. In severe cases, a person with a hip fracture is in too much pain to move. In rare cases, usually in people who are bed-bound and do not put weight on their hips, a hip fracture may not cause any symptoms.

Diagnosis

If your doctor suspects you have a hip fracture, an X-ray or magnetic resonance imaging (MRI) scan can confirm the diagnosis. Occasionally, additional X-rays are needed to spot small fractures, which become more visible on X-rays after one to two weeks.

Expected Duration

The amount of time it takes to recover from a hip fracture depends on how the fracture is treated. When pins and screws are used to secure the bone, the person should try to resume walking with a walker as soon as possible. It may take six to eight weeks before the person can switch to walking with a cane. Recovering from hip-replacement surgery can take even longer, up to 12 weeks. In as many as two out of three cases, people with a hip fracture require long-term assistance with one or more basic daily activities. In up to 25% of cases, older people with hip fractures are no longer able to live independently even after they recover.

Prevention

There are two main ways to prevent a hip fracture: Maintain bone strength, and prevent falls.

To optimize bone strength, men and women of all ages should exercise regularly and consume enough calcium and vitamin D.

The bones of women are more likely to thin as they age. A special X-ray test, called a bone mineral density test, can identify people with osteoporosis. After menopause, women with risk factors for osteoporosis (including a strong family history of osteoporosis, a bone fracture as an adult, corticosteroid use or smoking) should consider having a bone mineral density test, according to the National Osteoporosis Foundation. Women over age 65, with or without extra risks for osteoporosis, should also have the test.

If bone density testing reveals low bone density, your doctor may recommend medication. A number of medications are available to prevent osteoporosis, including bisphosphonates, including alendronate (Fosamax), risedronate (Actonel), pamidronate (Aredia), teriparatide (Forteo) and hormone replacement therapy. Because hormone-replacement therapy may increase the risk of cardiovascular disease, it is no longer the first choice to prevent osteoporosis.

A doctor should evaluate people who fall frequently. Some causes of falling can be identified and treated. In some cases, improving home safety can help to prevent falls. Grab-bars, non-slip rug liners, adequate lighting and bedside toilet equipment may be helpful for some people. Your doctor can provide additional advice about how to prevent falls, such as exercises to improve strength and balance.

A relatively new strategy can help to prevent hip fractures even when a person falls. If you have osteoporosis or have had hip fracture, you may consider wearing a pair of hip-protector pads. These shields substantially reduce the risk of fracture when falls occur. They are worn daily, inside a specially designed undergarment.

Treatment

Treatment depends on the location of the fracture, the degree of displacement, the number of other fractures and the age of the person. A hip fracture usually is treated with surgery. In recent years, less invasive operations have been developed.

Fracture of the femoral head or neck — If the fracture is not displaced, the bones may be secured with pins and screws during minor surgery. Sometimes metal plates are used. A displaced fracture requires a hip replacement, a major operation. In hip-replacement surgery, the damaged femoral head is replaced with a metal or ceramic ball, which fits into an artificial socket that is cemented in place.

Fracture between the trochanters — Anyone with a fracture between the two trochanters should be treated immediately with traction, which involves the use of weights and pulleys to stretch and extend the muscles around the hip. Traction prevents the muscles that are attached to the trochanters from pulling the two sides of the fractured bone in different directions during the time it takes for the fracture to heal.

For people who participate in regular activity before an injury, traction should be followed by surgery to insert pins and screws into the hip to stabilize the broken bone. These people should begin to move the joint as early as possible after the pins and screws are placed.

This type of surgery may be too traumatic for people who were bedridden before the fracture. In those cases, the fractured bone should be kept immobilized. This immobilization may last four to eight weeks.

Fracture below the trochanters — Surgery involves placing a long metal rod in the shaft of the thighbone to realign the break. In young children, traction and a full leg cast may be all that is needed.

When To Call a Professional

If you experience any hip pain after a fall, call your doctor for an urgent evaluation. If you think you may have fractured a hip, try to stay as still as possible and get help immediately.

Prognosis

Hip fractures are always serious. They are a major source of disability and can result in life-threatening complications. Approximately 4% of people die after a hip fracture because of complications from the fracture, its surgical treatment or from medical consequences from having to be immobilized. Immobility can cause blood clots to form in the leg veins, a problem that can lead to a life-threatening complication called pulmonary embolus. Pneumonia is also common in immobile patients. Immobility can cause bedsores in the buttock or ankle area, and bedsores can develop infections.

A fractured hip can cause sustained disability in many cases. However, in most cases, surgery is successful, and people can walk and resume normal activities with few restrictions.

Fractures of the femoral head can cause an additional complication by injuring the blood vessels that supply blood to the upper part of the femur. This type of injury can impair healing and lead to death of the bone, called osteonecrosis. Osteonecrosis of the femoral head occurs in 15% to 30% of people who fracture a hip.

Additional Info

National Osteoporosis Foundation 1232 22nd St., NW Washington, DC 20037-1292 Phone: 202-223-2226 http://www.nof.org/

National Institutes of Health Osteoporosis and Related Bone Diseases — National Resource Center2 AMS Circle Bethesda, MD 20892-3676 Phone: 202-223-0344 Toll-Free: 1-800-624-2663 Fax: 202-293-2356 TTY: 202-466-4315 http://www.osteo.org/

American Academy of Orthopaedic Surgeons (AAOS) 6300 North River Road Rosemont, IL 60018-4262 Phone: 847-823-7186 Toll-Free: 1-800-346-2267 Fax: 847-823-8125 http://orthoinfo.aaos.org/

National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse National Institutes of Health 1 AMS Circle Bethesda, MD 20892-3675 Phone: 301-495-4484 Toll-Free: 1-877-226-4267 Fax: 301-718-6366 TTY: 301-565-2966 http://www.niams.nih.gov/

Last updated:	August 15, 2008