A hip fracture is a break that occurs at the top of the femur (thigh bone). Symptoms may include pain around the hip especially with movement and shortening of the legs. Usually that person can not walk.
They occur most often as a result of falling. Risk factors include osteoporosis, taking a lot of drugs, alcohol use, and metastatic cancer. Diagnosis is generally done with X-rays. Magnetic resonance imaging, CT scan, or bone scan are sometimes necessary to make the diagnosis.
Pain management may occur with opioids or nerve blocks. If a person's health is sufficient, surgery is generally recommended within two days. Options for surgery may include total hip replacement or screws. Efforts to prevent deep vein thrombosis following surgery are recommended.
About 15% of women break their hips at some point in their lives. Women are more often affected than men. Hip fractures become more common with age. The risk of death in the next year after the fracture is about 20% in the elderly.
Video Hip fracture
Signs and symptoms
The classical clinical presentation of a hip fracture is an elderly patient who suffers from a low energy drop and now has groin pain and is unable to withstand weight. Pain can be referred to the supracondylary knee. On examination, the affected extremity is often shortened and unnatural, externally rotated compared to the unaffected foot.
Maps Hip fracture
Risk factors
Hip fractures after fall tend to be pathological fractures. The most common causes of weakness in bone are:
- Osteoporosis.
- Homocysteine, a "natural" toxic amino acid associated with the cause of heart disease.
- Other metabolic bone diseases such as Paget's disease, osteomalacia, osteopetrosis and osteogenesis imperfecta. Stress fractures can occur in the hip area with metabolic bone disease.
- Benign or malignant primary bone tumors are a cause of a rare pelvic fracture.
- Metastatic cancer deposits in the proximal femur may weaken bones and cause pathologic pelvic fractures.
- Bone infection is a cause of a rare pelvic fracture.
- Smoking (related to osteoporosis).
Mechanism
Functional anatomy
Hip joints, enarthrodial joints, can be described as balls and socket joints. The femur connects on the pelvic acetabulum and the lateral project before tilting the medial and inferior to form the knee. Although this joint has three degrees of freedom, it is still stable because of the interaction of the ligaments and cartilage. Acetabulum circular labrum line to provide stability and shock absorption. The articular cartilage conceals the acetabulum concave area, providing more stability and shock absorption. Surrounding the whole joint itself is a capsule that is secured by psoas muscle tendons and three ligaments. The iliofemoral ligament, or Y, lies anteriorly and serves to prevent hip hypresectence. The pubophoral ligament lies anteriorly just below the iliofemoral ligament and serves primarily to withstand abduction, extension, and some external rotation. Eventually the ischiofemoral ligament on the posterior side of the capsule rejects extension, adduction, and internal rotation. When considering the biomechanics of hip fractures, it is important to check the mechanical loads experienced by the hip when low energy drops.
Biomechanics
The hip joint is unique because it has a combined mechanical load. Axial load along the femoral axle produces a compressive stress. Load bending in the thigh neck causes tensile stress along the top of the neck and compressive pressure along the bottom of the neck. While osteoarthritis and osteoporosis are associated with fractures as we get older, the disease is not the cause of the fracture itself. The low energy fall from the stand is responsible for most of the fractures in the elderly, but the falling direction is also a key factor. Elderly tend to fall sideways instead of forward, and the lateral hips and attack the ground first. As long as it falls sideways, the likelihood of a hip fracture sees a 15-fold increase and 12-fold in older men and women, respectively.
Neurological factors
Elderly people also tend to have hip fractures because of many factors that can harm propiosception and balance, including drugs, vertigo, stroke, and peripheral neuropathy.
Diagnosis
Physical Exam
Fractures that disappear from the trochanter or the neck of the femur will usually cause external rotation and shortening of the foot when the patient is lying on his back.
Imaging
Typically, radiographs are taken from the hips from the front (AP view), and the sides (lateral view). The frog's toe view should be avoided, as it can cause severe pain and subsequently replace the fracture. In situations where hip fractures are suspected but not clear on x-rays, MRI is the next choice test. If MRI is not available or the patient can not be placed onto the scanner, CT can be used instead. The sensitivity of MRI to radiographic occult fractures is greater than that of CT. Bone scanning is another useful alternative, but substantial losses include decreased sensitivity, preliminary false negative results, and decreased age-related conspiracy findings due to metabolic changes in the elderly.
Since patients most often require surgery, a full pre-operative investigation is required. This usually includes blood tests, ECG and chest x-rays.
Type
X-rays from affected hips usually make the diagnosis clear; AP (anteroposterior) and lateral views should be obtained.
The trochanteric fracture is divided into intertrochanteric (between larger and smaller trochanters) or pertrochanteric (via trochanters) by MÃÆ'¼ller AO Classification of fractures. Practically, the difference between these types is small. This term is often used synonymously. An isolated trochanter fracture involves one trokanter without going through the anatomical axis of the femur, and can occur in young individuals due to strong muscle contraction. However, isolated trochanter fractures may not be considered a true hip fracture because they are not cross-sectional.
Prevention
Most hip fractures are the result of a fall, especially in the elderly. Therefore, identifying why a fall occurs, and applying care or change, is the key to reducing hip fractures. Many contributing factors are often identified. These may include environmental factors and medical factors (such as postural hypotension or joint disability from diseases such as Stroke or Parkinson's Disease that cause visual and/or balance disorders). A recent study has identified a high incidence of undiagnosed spondylotic myelopathy (CSM) among patients with hip fractures. This is a relatively unrecognized consequence of CSM.
In addition, there is some evidence for systems designed to offer protection in case of collapse. Hip protectors, for example, appear to reduce the number of hip fractures among the elderly. They; However, it is not often used.
Management
Most pelvic fractures are treated with orthotic surgery. Surgical treatment is greater than the risk of non-surgical treatment requiring a wide berth. Prolonged immobilization increases the risk of thromboembolism, pneumonia, decondition, and decubitus ulcers. Regardless, surgery is a major stress, especially in the elderly. Pain is also significant, and may also lead to immobilization, so patients are encouraged to become mobile phones as soon as possible, often with the help of physical therapy. Skeletal traction awaiting surgery is not supported by evidence. Regional nerve blocks are useful for pain management of pelvic fractures. Surgery may be performed under general anesthesia or with neuraxial techniques - the choice is based on surgical and patient factors, as results such as death and post-procedure complications including pneumonia, MI, stroke or confusion are not affected by anesthesia techniques.
Red blood cell transfusion is common for people who undergo hip fracture surgery due to sustained blood loss during surgery and from injury. Undesirable effects of blood transfusions can occur and are avoided by the use of limited blood transfusions rather than free use. Restrictive blood transfusion is based on symptoms of anemia and a lower threshold of 10 g/dL of hemoglobin used for liberal blood transfusion.
If operative treatment is rejected or the risk of surgery is considered too high, the main emphasis of treatment is to relieve pain. Skeletal traction may be considered for long-term treatment. Aggressive chest physiotherapy is needed to reduce the risk of pneumonia and rehabilitation and skilled nursing to avoid pressure sores and lung DVT/embolism Most people will lie in bed for several months. Non-operative treatments are currently limited to the most medically unhealthy or unhealthy patients, or those who are disorganized at baseline with minimal pain during transfer.
Intracapsular fracture
For low grade fractures (Garden types 1 and 2), standard treatment is the fixation of in situ fractures with screws or screw/shear devices. This treatment can also be offered for fracture displaced after the fracture has been reduced.
Closures managed by closed reduction may be handled with screws inserted percutaneously.
In elderly patients with displaced or intracapsular fractures, many surgeons prefer to perform hemiarthroplasty, replacing broken bone parts with metal implants. The advantage is that patients can mobilize without having to wait for healing.
In elderly patients who are medically healthy and still active, total hip replacement may be indicated.
Contraindicated traction on the femoral neck fracture therefore affects the blood flow to the femoral head.
Trochanteric fracture
A trochanteric fracture, under the thigh neck, has a good chance of healing.
A closed reduction may be unsatisfactory and open reduction then becomes necessary. The use of open reduction has been reported as 8-13% among pertrochanteric fractures, and 52% among intertrochanteric fractures. Intertrochanteric and pertrochanteric fractures can be treated with dynamic screw and pelvic plate, or intramedullary bar.
Fractures usually take 3-6 months to heal. Because it is only common in the elderly, removal of a dynamic hip screw is usually not advisable to avoid unnecessary risks from a second surgery and increased risk of fracture after implant removal. The most common cause for hip fractures in the elderly is osteoporosis; if this is the case, the treatment of osteoporosis may also reduce the risk of further fractures. Only young patients tend to consider it removed; the implant may serve as a stressor, increasing the risk of rest if another accident occurs.
Subtrochanteric fractures
Subtrochanteric fractures may be treated with intramedullary spikes or screw-plate constructions and may require preoperative traction, although this practice is rare. It is unclear whether certain types of nails produce different results than other nail types.
Rehabilitation
Rehabilitation has been shown to improve daily functional status. It is unclear whether the use of anabolic steroid recovery effects.
There is not enough evidence to ascertain what the best strategy to promote goes after hip fracture surgery.
Nutritional supplements
Oral supplements with non-protein, protein, vitamin and mineral energies starting before or earlier after surgery can prevent complications during the first year after hip fractures in older adults; without effect on death.
Complications
Nonunion, the failure of the fracture to heal, often occurs in the femoral neck fracture, but is much less frequent with other pelvic fractures. Femoral head avascular necrosis is common (20%) in intracapsular hip fractures, because the blood supply is impaired.
Malunion, healing fractures in a distorted position, is very common. Thigh muscles tend to attract bone fragments, causing them to overlap and recombine incorrectly. Shortening, varus deformity, valgus deformity, and malunion rotation all occur frequently because the fracture may be unstable and collapse before healing. This may not be of much concern to patients with independence and limited mobility.
Hip fractures rarely cause neurological or vascular injury.
Surgery
Inside or superficial wound infections have an estimated 2% incidence. This is a serious problem because superficial infections can cause deep infection. It can cause bone healing infections and implant contamination. It is difficult to remove the infection in the presence of foreign objects of metal such as implants. Bacteria inside the implant can not be accessed by the body's defense system and antibiotics. Management tries to suppress infection with drainage and antibiotics until bone is healed. Then the implants should be removed, after which the infection can be lost.
Implant damage may occur; screws and metal plates can be broken, back out, or cut off superior and into the joint. This occurs either through inaccurate placement of implants or if fixation does not occur in weak and fragile bones. In the event of a failure, surgery may be repeated, or converted into total hip replacement.
Mal-positioning: Fractures can be repaired and then healed in the wrong position; especially rotation. This may not be a severe problem or may require subsequent osteotomy surgery for correction.
Medical
Many people are unhealthy before a hip fracture; it is common to break caused by falling due to some illness, especially in the elderly. However, stress injury, and possible surgery, increases the risk of medical illnesses including heart attacks, strokes, and chest infections.
Patients with hip fractures are at great risk for thromboemoblism, blood clots that secrete and travel in the bloodstream. Deep venous thrombosis (DVT) is when the blood in the feet freezes and causes pain and swelling. This is very common after hip fractures due to stagnant circulation and blood hypercoagulation in response to injury. DVT can occur without causing symptoms. Pulmonary embolus (PE) occurs when the frozen blood of the DVT is released from the leg veins and passes through it to the lungs. Circulation to the lung part is cut off which can be very dangerous. Fatal PE may have a 2% incidence after hip fracture and may cause illness and death in other cases.
Mental confusion is very common after hip fracture. It's usually completely clean, but the experience of disorientation of pain, immobility, loss of independence, moving to strange places, surgery, and medication combine to cause delirium or accentuate pre-existing dementia.
Urinary tract infection (UTI) may occur. Patients immobilized and in bed for several days; they are often catheterized, usually causing the infection.
Prolonged immobilization and difficulty moving make it difficult to avoid pressure injuries on the sacrum and heel of patients with hip fractures. Whenever possible, early mobilization is encouraged; otherwise, an alternating pressure mattress should be used.
Prognosis
Hip fracture is a very dangerous episode especially for elderly and weak patients. The risk of death from surgery stress and injury in the first thirty days is about 10%. At one year after this fracture could reach 30%. If the condition is not treated, the pain and immobility imposed on the patient increase that risk. Problems such as pressure sores and chest infections are all increased due to immobility. The prognosis of untreated pelvic fracture is very poor.
Postal operations
Among those affected over the age of 65, 40% are transferred directly to long-term care facilities, long-term rehabilitation facilities, or nursing homes; most of those affected need some kind of life support from family or home care providers. 50% permanently require pedestrians, sticks, or crutches for mobility; all require some sort of mobility assistance throughout the healing process. Much of the restoration of walking ability and daily life activity occurs within 6 months after fracture. After fractures about half of parents recover their pre-fractured levels of mobility and ability to perform the daily instrumental activities of life, while 40-70% regain their level of independence for basic activities of everyday life.
Among those affected over the age of 50, about 25% die within the next year due to complications such as blood clots (deep venous thrombosis, pulmonary embolism), infections, and pneumonia.
Patients with hip fractures are at high risk for future fractures including the hip, wrist, shoulders, and spine. After treatment of acute fractures, future fracture risk should be addressed. Currently, only 1 in 4 patients after hip fracture receive treatment and work for osteoporosis, the main cause of most fractures. Current treatment standards include starting bisphosphonates to reduce the risk of future fractures by up to 50%.
Epidemiology
Hip fractures are seen globally and are of serious concern at the individual and population levels. By 2050, it is estimated that there will be 6 million cases of hip fractures worldwide. One study published in 2001 found that in the United States alone, 310,000 people were hospitalized for hip fractures, which could account for 30% of Americans hospitalized that year. Another study found that in 2011, femoral neck fracture was one of the most expensive conditions seen in US hospitals, with a combined cost of nearly $ 4.9 billion for 316,000 hospitalized patients. The rate of hip fractures decreased in the United States, probably due to increased use of bisphosphonates and risk management. Falling, poor vision, weight and height are all seen as risk factors. Falling is one of the most common risk factors for hip fracture. Approximately 90% of hip fractures are associated with falling from a standing height.
Given the high morbidity and mortality associated with hip fractures and costs for health systems, in England and Wales, the National Hip Fracture Database is a mandatory national audit of care and treatment of all hip fractures.
Population
All populations have hip fractures but the numbers vary with race, sex, and age. Women suffer hip fractures three times more than men. In a lifetime, men have an estimated 6% risk while postmenopausal women have a 14% risk estimated to suffer hip fractures. These statistics provide insight into the lifespan and conclude that women are twice as likely to suffer hip fractures. Most hip fractures occur in whites while blacks and Hispanics have lower rates of them. This may be due to their larger bone density and also because whites have a longer life span as a whole and are likely to reach advanced age where the risk of hip fracture increases. Deprivation is also a key factor: in the UK it has been found that people in the poorest parts of the country are more likely to fracture their hips and are less likely to recover well than those in the least deprived areas.
Age is the most dominant factor in hip fracture injury, with most cases occurring in people over 75. Increased age is associated with an increased incidence of hip fractures, which is the most frequent cause of hospitalization in centenarians, overcoming congestive heart failure and respiratory infections. Waterfalls are the most common cause of hip fractures, about 30-60% of older adults fall every year. This increases the risk of hip fractures and leads to an increased risk of death in older individuals, a one-year mortality rate seen from 12-37%. For the remaining patients who did not suffer death, half of them needed help and could not live independently. Also, older adults experience hip fractures due to osteoporosis, which is a degenerative disease due to age and decreased bone mass. The median age for suffering hip fractures is 77 years for women and 72 years for men. This shows how closely age is related to hip fracture.
References
External links
- Fracture of the Femoral Neck Wheel Neckline from Orthopedic
- Fracture of Intertrochanteric Wheeless' Textbook of Orthopedics
Source of the article : Wikipedia
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