What are the causes and treatment options for a hip fracture?

From the Guidelines

Hip fractures typically require immediate surgical intervention, usually within 24-48 hours of injury to reduce complications and mortality, as recommended by the most recent and highest quality study 1.

Overview of Hip Fractures

Hip fractures are a break in the upper part of the femur (thigh bone) near where it connects to the pelvis. They are serious injuries with significant mortality risk, particularly in older adults, with complications including blood clots, pneumonia, and pressure ulcers.

Treatment and Management

Treatment involves either internal fixation (using screws, plates, or rods) or hip replacement, depending on the fracture location, severity, and patient factors like age and bone quality.

• Surgical timing: The American Academy of Orthopaedic Surgeons recommends surgery within 24 to 48 hours of hospital admission 1.
• Pain management: Patients need pain management with medications like acetaminophen, NSAIDs, or opioids as needed, with gradual weaning as pain improves.
• Physical therapy: Physical therapy should begin as soon as possible after surgery, initially focusing on gentle movement and progressing to weight-bearing exercises as tolerated.

Prevention Strategies

Prevention strategies include:

• Fall prevention measures
• Adequate calcium (1000-1200mg daily) and vitamin D (800-1000 IU daily) intake
• Osteoporosis medications when indicated, such as bisphosphonates or denosumab, which have been shown to reduce the risk of vertebral, non-vertebral, and hip fractures 1

Multidisciplinary Care

Patients with hip fractures require multidisciplinary care, led by orthogeriatricians, to minimize delirium and avoid complications, and to optimize fitness for surgery and early surgery, which seem to improve morbidity and mortality 1. Early mobilisation is a key part of the management of patients with hip fractures, and measures should be taken to prevent secondary falls 1.

From the FDA Drug Label

In the Three-Year Study of FIT, fractures of the hip occurred in 22 (2. 2%) of 1005 patients on placebo and 11 (1.1%) of 1022 patients on alendronate sodium, p=0. 047. Hip fracture 1.1 2.2 1.1 51¶ Hip fracture 1.0 1.4 0.4 29 (NS)#

Hip Fracture Reduction with Alendronate Sodium

• The Three-Year Study of FIT showed a 51% relative reduction in the risk of hip fracture with alendronate sodium compared to placebo.
• The Four-Year Study of FIT showed a 29% relative reduction in the risk of hip fracture, but this result was not statistically significant.
• Alendronate sodium may reduce the risk of hip fracture in postmenopausal women with osteoporosis, particularly those with a history of vertebral fracture 2.

From the Research

Hip Fracture Overview

• Hip fractures are common causes of disability, with mortality rates reaching 30% at one year 3
• Nonmodifiable risk factors include lower socioeconomic status, older age, female sex, prior fracture, metabolic bone disease, and bony malignancy 3
• Modifiable risk factors include low body mass index, having osteoporosis, increased fall risk, medications that increase fall risk or decrease bone mineral density, and substance use 3

Diagnosis and Management

• Hip fractures present with anterior groin pain, inability to bear weight, or a shortened, abducted, externally rotated limb 3
• Plain radiography is usually sufficient for diagnosis, but magnetic resonance imaging should be obtained if suspicion of fracture persists despite normal radiography 3
• Operative management within 24 to 48 hours of the fracture optimizes outcomes 3, 4, 5
• Fractures are usually managed by surgery, with the approach based on fracture type and location; spinal or general anesthesia can be used 3
• Nonsurgical management can be considered for patients who are not good surgical candidates 3

Pain Management

• Pain due to intra- and extracapsular hip fractures is usually treated with opioid medication 6
• Intravenous paracetamol has been shown to have a significant opioid-sparing effect and satisfactory pain relief in preoperative hip fracture patients 6, 7
• Scheduled intravenous acetaminophen can reduce narcotic use, decrease pain levels, and shorten length of hospital stay in geriatric patients with hip fractures 7

Timing of Surgical Intervention

• Surgical delay of ≥2 days is common and confers an increased risk of complications in those undergoing non-total hip arthroplasty procedures 5
• Multivariate analyses identified multiple risk factors for delay of ≥2 days, including congestive heart failure and body mass index ≥40 5
• Operative management within 24 hours of the fracture has been shown to reduce mortality compared to those operated on beyond 24 hours or within 24 to 36 hours 4