Understanding Hip Fractures: Diagnosis and Treatment

Hip fractures are common, especially in older adults, and require timely medical and surgical intervention. These injuries can significantly impact a patient’s mobility, quality of life, and overall health. Hip fractures are a medical emergency, and delayed treatment can lead to severe consequences. Elderly patients are particularly vulnerable to complications from prolonged immobility, such as pressure sores, muscle atrophy, and infections. 

The mortality after hip fracture in an elderly patient remains high. This ranges between 15% to 35% within the first year. Prompt surgical intervention, within 24 hours, reduces the risk of these complications and improves outcomes. Delays may occur for patients requiring further cardiac workup prior to surgery, however unnecessary delays should be avoided. For younger patients, especially those with high-energy trauma, swift repair helps prevent long-term functional deficits and chronic pain. 

Understanding the types of hip fractures and the various treatment options available is essential for guiding patients through their recovery.

Hip Fractures Categories:

1. Femoral Neck Fractures: Occurring just below the ball of the hip joint (femoral head), this type of fracture is common in elderly patients with osteoporosis in which bone density and strength are eroded over time. In conjunction with the fracture, the blood supply to the femoral head is often compromised leading to a diagnosis of avascular necrosis (AVN). This leads to collapse of the spherical head leading to deformity, degenerative changes and pain often requiring a hip replacement procedure. These injuries can occur anywhere along the neck – subcapital, transcervical or basicervical. Nondisplaced injuries can be managed with fixation with either screws or screw and side plate type of construct. Displaced fractures require either hemiarthroplasty (partial hip replacement – femoral side) or a total hip arthroplasty. This is determined by the patient’s pre-injury functional status, pre-existing arthritis, and other co-morbidities. 
2. Intertrochanteric Fractures: This fracture occurs between the neck of the femur and the lesser trochanter, a bony prominence lower down on the femur. These fractures often have a better blood supply and therefore a better healing prognosis compared to femoral neck fractures. These are treated with internal fixation using either a screw and side-plate construct or a cephalomedullary nail.
3. Subtrochanteric Fractures: This type occurs below the lesser trochanter and is typically seen in younger patients or those with high-energy trauma. These fractures can be more complex to treat due to the location and the forces acting on the femur. These require stabilization most often with an intramedullary nail.

Treatment Options for Hip Fractures

Treatment of hip fractures is influenced by the patient’s age, overall health, and the type of fracture. Surgery is the most common treatment for hip fractures to restore mobility, functional alignment, and reduce the risk of complications.

Open reduction and Internal Fixation (ORIF-Surgical Repair)

Internal fixation involves stabilizing the fractured bone with devices such as a long rod (nail), or a large hip screw with a side plate construct.

• Screws: Metal screws can be inserted into the bone to hold it in place while it heals. This technique is commonly used for impacted non-displaced femoral neck fractures.
• Intramedullary Nails: This method involves inserting a rod through the canal of the femur, helping to stabilize the bone from within. Screw fixation through the nail and up into the femoral head (cephalomedullary fixation) is required for intertrochanteric and subtrochanteric hip fractures.
• Dynamic Hip Screws: This device includes a hip screw with a metal side plate system designed to allow compression while maintaining stability, promoting natural healing. This is most often used for stable intertrochanteric hip fractures and basicervical fractures.

Joint Replacement (Hip Arthroplasty)

In displaced femoral neck fractures, a joint replacement may be the preferred option. This can involve either a partial hip replacement or a total hip replacement:

• Partial Hip Replacement: The damaged or fractured femoral head is replaced with a metal prosthesis. This is often recommended for older patients with limited functional status or those with co-morbidities making surgery riskier necessitating a quicker operation. If the patient has pre-existing hip arthritis, then total hip arthroplasty may be preferred. 
• Total Hip Replacement: In this procedure, both the femoral head and the hip socket are replaced with prosthetic components. This is usually chosen for patients with arthritis or a severely damaged joint due to the fracture. Additionally, in very active elderly patients without pre-existing arthritis, a total hip arthroplasty would be preferred to allow the patient to get back to pre-injury functional status. 

Joint replacement offers benefits such as immediate stability and the ability to bear weight sooner, which can aid in quicker rehabilitation. 

Recovery from Hip Fracture Surgery

Recovery time varies based on the type of surgery performed, the patient’s health, and adherence to rehabilitation protocols. Most patients with intertrochanteric fractures, basicervical fractures and subtrochanteric fractures treated with internal fixation can be allowed to weight bear as tolerated immediately after surgery. Patient with femoral neck fractures treated with joint replacement (partial or total) are usually allowed to weight bear as tolerated as well. Nondisplaced femoral neck fractures treated with fixation are usually restricted to toe-touch weight bearing. Typically, patients spend 4-6 weeks with decreased mobility, gradually transitioning to walking with support (e.g., walkers or crutches). Full recovery may take anywhere from 3 to 6 months.

• Rehabilitation: Physical therapy is critical for regaining strength, balance, and mobility. Rehabilitation usually begins in the hospital and continues to an outpatient basis once the patient is discharged.
• Weight-Bearing: Depending on the type of repair, patients may be able to start full weight-bearing activities sooner. 
• Potential Complications: Outcomes such as infection, blood clots, fracture non-union, delayed wound healing, avascular necrosis or implant failure may occur. Early mobilization and following a proper rehab plan help reduce these risks. Additionally, most patients are prescribed a medication for the prevention of blood clots if the patient was not already on a blood thinner for other reasons prior to surgery. Most common chemoprophylaxis now is the use of a baby aspirin twice a day for 6-12 weeks.

Wound Healing After Hip Fracture Surgery

Wound healing can be significantly slower in elderly patients due to the natural aging process, which decreases the body’s ability to produce wound healing factors. Combined with other factors such as impaired circulation and a weakened immune response, complications such as delayed wound healing, infections, and prolonged recovery times can be exhibited. As a result, elderly patients, especially those undergoing orthopedic surgeries like hip fracture repair, are at a higher risk of poor outcomes. Additional dressing support to improve wound healing is standard of care to managing surgical site incisions. While many options are available, one practice that is becoming more predominant is the use of hydrolyzed collagen powder. Hydrolyzed collagen powder added to the surgical wound can be beneficial for elderly patients because it helps improve wound inflammation, perfusion and breaking strength of repaired tissue (Kumar Advances in Wound Care 2023). By providing a soluble form of collagen, initiation and support to healing of surgical wounds is more effective.

Conclusion

Hip fractures are complex injuries that require individualized but prompt treatment approaches. Whether it’s through internal fixation or joint replacement, the goal is to restore mobility, minimize pain, and improve quality of life for patients. Understanding the types of fractures and the available treatments will empower healthcare professionals to guide patients through the process of recovery and rehabilitation. By doing so, we can enhance patient outcomes and reduce the long-term impact of these potentially life-altering injuries.

References

• Chatha, H., Cheung, Z., et al. (2022). Advances in Hip Fracture Management. Journal of Orthopedic Surgery and Research.
• Smith, T., Pellicci, P., et al. (2020). Current Trends in Hip Arthroplasty. The Hip Journal.
• Kumar M, Banerjee P, Das A, Singh K, Guith T, Kacar S, Gourishetti K, Sen CK, Roy S, Khanna S. Hydrolyzed Collagen Powder Dressing Improves Wound Inflammation, Perfusion, and Breaking Strength of Repaired Tissue. Adv Wound Care (New Rochelle). 2023 Sep 13. Doi: I 0.1089/ wound.2023.0065.

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