What is the optimal approach to managing a hip fracture and dislocation, particularly in an elderly patient with a history of osteoporosis?

Management of Hip Fracture and Dislocation in Elderly Patients with Osteoporosis

Immediate Recognition and Emergency Management

Hip dislocation is an absolute orthopedic emergency requiring reduction within 6-12 hours to prevent avascular necrosis and long-term complications. 1, 2

Initial Assessment and Diagnosis

• Classic presentation: Severe pain, shortening and external rotation of the affected limb, and complete loss of mobility following trauma 3
• Atypical presentation warning: Intracapsular fractures may deceptively maintain some mobility with only moderate pain, leading to delayed diagnosis 3
• Imaging requirements: Obtain AP and lateral pelvis radiographs including both hips; CT scan is mandatory if concentric reduction cannot be confirmed on plain films 1
• Associated injuries: Expect concomitant injuries in 71% of cases, particularly in high-energy trauma 1

Classification System

• Posterior fracture-dislocations (most common, ~90% of cases): Classified by Stewart-Milford system 1, 4
• Anterior-obturator dislocations (less common): Require different reduction techniques 1, 4
• Femoral head fractures: Use Pipkin classification when present 1, 2

Reduction Protocol: Time-Critical Intervention

Reduction must occur within 12 hours of injury—this is the single most important prognostic factor for long-term outcome. 1

Closed Reduction Technique (First-Line)

• Posterior dislocations: Apply longitudinal traction with internal rotation while an assistant stabilizes the pelvis 4
• Anterior dislocations: Use inline traction with external rotation; assistant pushes on femoral head or pulls femur laterally 4
• Sedation requirement: Adequate analgesia and muscle relaxation are essential for successful closed reduction 4
• Multiple attempts contraindicated: Repeated closed reduction attempts increase cartilage damage, particularly in Type V dislocations with femoral head fractures 2

Open Reduction Indications (Immediate Surgery)

• Failed closed reduction after one or two attempts 1, 2
• Non-concentric reduction confirmed on post-reduction radiographs or CT 1, 2
• Femoral head fragment that cannot be reduced anatomically 2
• Sciatic or peroneal nerve paralysis present at time of injury 2
• Irreducible posterior wall fragments blocking concentric reduction 1

Post-Reduction Verification

• Mandatory imaging: AP and lateral pelvis radiographs of both hips immediately after reduction 1, 2
• CT scan indications: Any radiographic abnormality suggesting non-concentric reduction or retained intra-articular fragments 1
• Concentric reduction is non-negotiable: Any deviation requires immediate arthrotomy 2

Surgical Management of Associated Hip Fractures

Femoral Neck Fractures

For displaced femoral neck fractures in healthy, active, independent elderly patients without cognitive dysfunction, total hip replacement arthroplasty is the optimal treatment allowing immediate full weight-bearing. 5, 6

• Non-displaced stable fractures: Percutaneous cannulated screw fixation 5, 6
• Displaced fractures in healthy elderly: Total hip arthroplasty provides superior long-term function 5, 6
• Frail patients or those with dementia: Hemiarthroplasty is preferred due to shorter operative time (mean 54.3 minutes) and significantly lower dislocation risk (0.3% with proper technique) while maintaining acceptable functional outcomes 5, 6, 7

Surgical Approach to Minimize Dislocation

Use short external rotators (SER) preserving posterolateral approach for hemiarthroplasty, which reduces dislocation rates to 0.3% compared to traditional approaches. 7

• Technique advantage: Preserves obturator internus, gemelli, and quadratus femoris muscles 7
• Particularly critical in: Elderly patients with dementia or cognitive impairment who cannot follow hip precautions 7

Intertrochanteric Fractures

For stable intertrochanteric fractures use sliding hip screw; for unstable fractures use cephalomedullary nail—this distinction is critical to prevent fixation failure. 5, 8, 9

• Stable patterns: Sliding hip screw allows controlled fracture impaction with decades of proven reliability 9
• Unstable patterns: Antegrade cephalomedullary nail provides superior biomechanical stability in comminuted or osteoporotic bone 8, 9
• Mandatory cephalomedullary nail indications: Subtrochanteric fractures and reverse oblique fractures 5, 8, 9

Femoral Head Fractures (Pipkin Classification)

Primary open reduction with excision of avulsed head fragments yields better results than closed reduction or delayed surgery. 2

• Surgical approach: Posterior approach only; anterior approaches are contraindicated for Type V fracture-dislocations 2
• Fragment management: Discard small avulsed head fragments rather than attempting fixation 2
• Timing: Immediate arthrotomy if closed reduction fails to reduce the head fragment 2

Perioperative Management Protocol

Timing of Surgery

Surgery must be performed within 48 hours of admission—delays beyond this timeframe significantly increase mortality. 6, 8

• Medical optimization: Perform necessary workup without unnecessarily delaying surgery 6, 8
• Pain management: Multimodal analgesia including preoperative nerve blocks 8, 9
• Tranexamic acid: Administer perioperatively to reduce blood loss (mean 252.4 cc with proper technique) 8, 9, 7

Orthogeriatric Comanagement (Mandatory)

All elderly patients with hip fractures require orthogeriatric comanagement to improve functional outcomes, reduce hospital stay, and decrease mortality. 6, 8

• Multidisciplinary team: Orthopedic surgeon, geriatrician, anesthesiologist, physical therapist 6
• Perioperative monitoring: Regular assessment of cognitive function, nutritional status, renal function, pressure sore risk 5, 6
• Systems-based approach: Routine examinations of cardiovascular, pulmonary, and gastrointestinal systems 5

Postoperative Care and Rehabilitation

Immediate Postoperative Period

Early mobilization with immediate full weight-bearing is essential to prevent recumbency complications including pneumonia, deep vein thrombosis, and pressure ulcers. 6, 8, 9

• Pain management: Comprehensive multimodal analgesia 6, 8
• Antibiotic prophylaxis: Single-dose perioperative antibiotics 6, 8
• Anemia correction: Transfuse if symptomatic or hemoglobin drops significantly 6, 8
• Bowel and bladder assessment: Regular monitoring and regulation 5
• Wound care: Daily assessment for signs of infection 5

Weight-Bearing Protocol

• Hip arthroplasty (total or hemi): Immediate full weight-bearing 5, 6
• Internal fixation: Resume full weight-bearing between 2-10 weeks (average 8 weeks) depending on fracture stability 1
• Dislocation cases: Earlier mobilization after stable reduction improves outcomes 1

Rehabilitation Program Structure

Initiate early postfracture physical training and muscle strengthening within the first postoperative days, followed by long-term balance training and multidimensional fall prevention. 5, 6, 8

• Phase 1 (Days 1-7): Range-of-motion exercises, transfer training, assisted ambulation 5
• Phase 2 (Weeks 2-12): Progressive resistance training, gait training, balance exercises 5, 6
• Phase 3 (Months 3-12): Long-term balance training, fall prevention strategies, functional independence training 5, 6
• Goal: Regain prefracture level of mobility and independence 5

Secondary Fracture Prevention (Non-Negotiable)

Every patient aged 50 years and over with a hip fracture requires systematic evaluation for subsequent fracture risk using a Fracture Liaison Service (FLS) model—this is the most effective organizational structure for preventing future fractures. 6, 8, 9

Diagnostic Workup

• DEXA scan: Order for outpatient bone mineral density assessment 8, 9
• Laboratory evaluation: Vitamin D level, calcium level, parathyroid hormone level 8, 9
• Spine imaging: Radiographs or MRI to identify asymptomatic vertebral fractures (only 1 in 3 are symptomatic) 5
• Falls risk assessment: Comprehensive evaluation including vision, medications, home safety 8, 9
• Secondary causes: Screen for conditions causing osteoporosis (hyperthyroidism, hyperparathyroidism, malabsorption, medications) 8, 9

Pharmacological Treatment

Use medications demonstrated to reduce vertebral, non-vertebral, and hip fractures, with regular monitoring for tolerance and adherence. 5, 6

• Calcium and vitamin D: 1000-1200 mg calcium daily plus 800 IU vitamin D daily (foundational therapy in all RCTs) 5
• Bisphosphonates, denosumab, or anabolic agents: Based on fracture risk and patient factors 5
• Monitoring: Regular assessment of adherence and side effects 5

Non-Pharmacological Interventions

• Smoking cessation: Mandatory 5
• Alcohol limitation: Reduce to moderate intake or eliminate 5
• Exercise programs: Rigorous exercise improves BMD and muscle strength, reduces fall frequency 5
• Fall prevention: Multidimensional approach including home modifications, vision correction, medication review 5

Long-Term Prognosis and Complications

Expected Outcomes

• Functional results: 71% achieve very good to good outcomes with proper management 1
• Mean Harris Hip Score: 67.5 points at final follow-up after hemiarthroplasty 7
• Mortality: 30% at 12 months reflects high comorbidity burden 3
• New institutionalization: 20% at 12 months 3

Complications to Monitor

Time to reduction and associated injuries are the most important factors determining long-term prognosis. 1

• Avascular necrosis: 9.6% incidence, strongly correlated with delayed reduction beyond 12 hours 1
• Post-traumatic osteoarthritis: 16.1% incidence, expect development in >50% of Type V fracture-dislocations 1, 2
• Dislocation after arthroplasty: 0.3% with SER-preserving technique vs. higher rates with traditional approaches 7
• Periprosthetic fracture: Occurs in small percentage, requires internal fixation or stem revision 7
• Sciatic nerve injury: Requires early surgical intervention if present 2

Long-Term Follow-Up Requirements

• Serial radiographs: Monitor fracture healing, hardware position, development of arthritis 9, 2
• Functional assessment: Regular evaluation of mobility and independence 5, 6
• Osteoporosis treatment monitoring: Ongoing assessment of medication adherence and efficacy 5, 6
• Long-term surveillance: Anticipate arthritic changes in >50% of fracture-dislocations requiring extended follow-up 2

Critical Pitfalls to Avoid

• Delayed reduction beyond 12 hours: Single most preventable cause of poor outcomes and avascular necrosis 1, 2
• Multiple closed reduction attempts: Increases cartilage damage, particularly with femoral head fractures 2
• Failure to confirm concentric reduction: Any abnormality on post-reduction imaging demands immediate arthrotomy 1, 2
• Delaying surgery beyond 48 hours: Significantly increases mortality risk 6, 8
• Omitting orthogeriatric comanagement: Leads to worse functional outcomes and higher mortality 6, 8
• Using sliding hip screw for unstable intertrochanteric fractures: Increases fixation failure; cephalomedullary nails required 8, 9
• Neglecting secondary fracture prevention: Increases risk of subsequent fractures (20% within 2 years without treatment) 6, 8
• Inadequate rehabilitation program: Prevents return to prefracture functional status 5, 6
• Anterior surgical approach for posterior fracture-dislocations: Contraindicated and associated with poor outcomes 2