Hip Fractures - Orthopaedic Trauma - Lecture Slides, Slides of Orthopedics

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• General principles
  • With the aging of the American population the

incidence of hip fractures is projected to increase

from 250,000 in 1990 to 650,000 by 2040

• Cost approximately $8.7 billion annually
• 20% higher incidence in urban areas
• 15% lifetime risk for white females who live to age

80

• Epidemiology
  • Incidence increases after age 50
  • Female: Male ratio is 2:
  • Femoral neck and intertrochanteric fractures

seen with equal frequency

• Radiographic

evaluation

• Anterior-posterior view
• Cross table lateral
• Internal rotation view will help delineate fracture pattern

• Radiographic evaluation
  • Occult hip fracture
    • Technetium bone scanning is a sensitive indicator, but may take 2-3 days to become positive
    • Magnetic resonance imaging has been shown to be as sensitive as bone scanning and can be reliably performed within 24 hours

• Management
  • Prompt operative stabilization
    • Operative delay of > 24-48 hours increases one-year mortality rates
    • However, important to balance medical optimization and expeditious fixation
  • Early mobilization
    • Decrease incidence of decubiti, UTI, atelectasis/respiratory infections
  • DVT prophylaxis

• Outcomes
  • Fracture related outcomes
    • Healing
    • Quality of reduction
  • Functional outcomes
    • Ambulatory ability
    • Mortality (25% at one year)
    • Return to pre-fracture activities of daily living

• Femoral neck fractures
  • Intracapsular location
  • Vascular Supply
    • Medial and lateral circumflex vessels anastamose at the base of the neck
    • blood supply predominately from ascending arteries (90%)
    • Artery of ligamentum teres (10%)

• Femoral neck fractures
• Treatment
  • Non-displaced/ valgus impacted fractures
    • Non-operative 8-15% displacement rate
    • Operative with cannulated screws
    • Non-union 5% and osteonecrosis is approximately 8%

• Femoral neck fractures
  • Displaced fractures should be treated operatively
  • Treatment: Open vs. Closed Reduction and Internal

fixation

• 30% non-union and 25%-30% osteonecrosis rate
• Non-union requires reoperation 75% of the time while osteonecrosis leads to reoperation in 25% of cases

• Femoral neck fractures
• Treatment: Hemiarthroplasty
  • Unipolar Vs Bipolar
  • Can lead to acetabular erosion, dislocation,

infection

• Femoral neck fractures
• Treatment
  • Displaced fractures can be treated non -

operatively in certain situations

• Demented, non-ambulatory patient
• Mobilize early
• Accept resulting non or malunion

• Intertrochanteric fractures
  • Extracapsular (well vascularized)
  • Region distal to the neck between the trochanters
  • Calcar femorale
  • Posteromedial cortex
  • Important muscular insertions

• Intertrochanteric fractures
  • Treatment
    • Usually treated surgically
    • Implant of choice is a hip compression screw that slides in a barrel attached to a sideplate
    • The implant allows for controlled impaction upon weightbearing

• Intertrochanteric fractures
  • Treatment
    • Primary prosthetic replacement can be considered
    • For cases with significant comminution

• Subtrochanteric Fractures
  • Begin at or below the level of the lesser trochanter
  • Typically higher energy injuries seen in younger patients
  • far less common in the elderly

• Subtrochanteric Fractures
  • Treatment
    • Intramedullary nail (high rates of union)
    • Plates and screws