From the Guidelines
The management of subcapital hip fractures typically involves surgical intervention, with the specific approach determined by patient factors and fracture characteristics, and should be performed within 24-48 hours of injury to reduce mortality and complication rates. For non-displaced fractures in younger patients, internal fixation with multiple screws or a sliding hip screw is often preferred to preserve the native femoral head, as it reduces the risk of subsequent displacement, which can be as high as 30-50% with conservative treatment 1. For displaced fractures or in elderly patients, arthroplasty is generally recommended, either hemiarthroplasty for less active patients or total hip arthroplasty for more active individuals with good bone quality, as it improves hip function and reduces the risk of long-term arthritis and avascular necrosis of the bone 1.
Key Considerations
- Preoperatively, patients require pain management, DVT prophylaxis, and optimization of medical comorbidities.
- Postoperatively, early mobilization within 24 hours is crucial, along with continued DVT prophylaxis for 4-6 weeks, pain management, and physical therapy.
- Long-term care includes osteoporosis treatment, calcium and vitamin D supplementation, and fall prevention strategies.
Surgical Approach
- The choice of surgical approach depends on the patient's age, activity level, and bone quality, as well as the fracture characteristics.
- Cemented arthroplasty is preferred over uncemented arthroplasty, as it improves hip function and reduces residual pain postoperatively 1.
Anaesthetic Management
- The optimal anaesthetic technique for patients undergoing hip fracture surgery is not well established, but regional anaesthesia may reduce the incidence of postoperative confusion 1.
- The use of peripheral nerve blockade as an adjunct to spinal or general anaesthesia can extend the period of postoperative non-opioid analgesia and reduce the risk of respiratory depression and postoperative confusion 1.
From the Research
Management of Subcapital Hip Fractures
The management of subcapital hip fractures can be categorized into two main options: internal fixation or arthroplasty (either hemiarthroplasty or total hip arthroplasty) 2. The choice of treatment depends on various factors, including:
- Patient's age
- Functional demands
- Individual risk profile
- Presence of cognitive dysfunction
Treatment Options
For non-displaced fractures, closed reduction and internal fixation is the recommended treatment, regardless of the patient's age 2. For displaced femoral neck fractures:
- In younger patients, urgent open reduction and internal fixation (ORIF) with the goal of anatomic reduction is recommended 2.
- In elderly patients with cognitive function, total hip arthroplasty is considered the best option 2, 3, 4.
- In elderly patients with cognitive dysfunction, bipolar hemiarthroplasty or total hip arthroplasty with larger heads (32 mm or 36 mm) and/or constrained sockets may be considered 2.
Comparison of Treatment Options
Studies have compared the outcomes of different treatment options for subcapital hip fractures:
- A prospective randomized trial found that total hip replacement resulted in the least pain and most mobility at 1 year, while hemiarthroplasty was worst in these respects 3.
- Another study found that primary total hip replacement for displaced subcapital fractures in elderly patients resulted in excellent or good results in 62% of patients, with a low revision rate 4.
- A review of recent literature concluded that total hip arthroplasty provides early mobilization, long-term pain relief, and little additional morbidity at surgery, making it a cost-effective option 5.
Additional Considerations
Other factors to consider in the management of subcapital hip fractures include: