Proximal femoral fracture

A fracture of the proximal femur also named hip fracture, consists in the break of the upper segment of the femur bone in proximity of the pelvic socket, the acetabulum. ;

A proximal femur fracture is a serious condition that requires immediate management in the Emergency Department. It is a serious injury because it frequently occurs in elderly people and may lead to life threatening complications, like pneumonia or deep venous thrombosis. Nowadays, the incidence of proximal femur fractures is increasing as a consequence of prolonged life expectancy. In the elderly the loss of bone calcium or osteoporosis, which reduces bone density, combined with a higher risk of falls are a major medical concern. In the younger population a proximal femur fracture requires a high energy traumatic impact.

Proximal femur fractures can occur in different locations and are generally divided into: Intra-capsular (fracture of the femur within the joint capsule) Extra-capsular (fracture of the femur outside the joint capsule). There are three types of proximal femur fractures:Femoral neck fracture ;or trans-cervical fracture, proximal to the trochantersTrochanteric femur fracture ;or inter-trochanteric fracture, between the greater trochanter and the lesser trochanterFemoral neck or sub-trochanteric fracture ;located distally, beneath the trochanters The fracture to the proximal femur is displaced when the bone extremities have lost their anatomical alignment or non-displaced when the break does not separate the femur bone segments. A displaced fracture requires a reduction into the correct position whereas in a non-displaced fracture, reduction is not necessary.

In older individuals a fall is the most frequent cause for a proximal femur fracture (approximately of 90% of all hip fractures). Even a fall from a standing position can lead to a proximal femur fracture in this patient group. A fall can be the consequence of medical conditions including limited vision, balance problems, sudden loss in blood pressure and heart arrhythmia causing people to faint.A stress fracture of the proximal femur in the elderly is due to bone weakening by osteoporosis. This type of fractures does not require a traumatic impact or a fall to occur. Women with an average age of 80 years are particularly vulnerable to a proximal femur fracture having an 8 to 10 ratio of incidence compared to men. In the younger population a proximal femur fracture is rare and arises from high energy trauma such as car accidents or falls from a significant height.

Leading risk factors for a proximal femur fracture include:Elderly ageFemale gender: women lose bone density after menopauseOsteoporosisChronic medical conditions (hyper-/hypotension, stroke, heart arrhythmia, thyroid dysfunction)Medications e.g. steroids weaken bone density or relaxants facilitating fallsLack of physical fitnessUse of tobacco and alcoholCar accidentsWorking at height (carpenters, electricians, builders, painters)

A fractured proximal femur causes an immediate, severe pain. The patient is likely unable to move, stand up and walk. As a result of a proximal femur fracture the leg of the side affected is positioned at a different angle directed outwards and may appear shorter. On the hip side of the fall the patient may present a bruise, swelling and stiffness.

Given the serious nature of a proximal femur fracture the first diagnosis is normally executed at the Emergency Department. Following admittance to the hospital, the patient is firstly treated with pain killers (analgesics) and fluid replacement, prior to begin radiologic evaluation with X-rays. Often a CT scan or an MRI is performed to characterise the fracture type and the potential involvement of the cartilage and ligaments of the hip joint. After image assessment, the orthopaedic surgeon will opt for the best treatment appropriate to the type of fracture and the general condition of the patient.

A non-displaced, intracapsular proximal femur fracture is normally treated conservatively but requires a longer hospitalisation period. Nonoperative treatment of a proximal femur fracture increases the risk of delayed bone displacement and involves frequent monitoring by X-ray. In complex proximal femur fractures, surgery is avoided only if the patient has medical conditions that pose a high risk of complications. ;

The guidelines from the National Institute for Health and Clinical Excellence (NICE) recommend that surgery for a proximal femur fracture is carried out within one or two days from the accident. Prior to surgery the patient is treated with analgesic drugs for pain relief. Non-displaced fractures “ Surgery via internal fixation may necessary for the treatment of non-displaced intra-capsular proximal femur fracture to consolidate the bone fragments. A number of metal devices are available for this surgery such as screws, nails, plates and rods. This procedure ensures a superior healing by maintaining a proper bone alignment with the advantage to accelerate the general recovery of the patient allowing early mobilisation.

Avascular necrosis - ; in case of an intra-capsular hip fracture the bone break may injure the vessels supplying the femoral head causing the death of the bone tissue. Avascular necrosis of the femoral head can lead to chronic pain of the hip region.Pressure ulcers - due to extended immobilisation and the fragile skin in the elderly, the pressure of the weight on specific areas of the body can form skin ulcers. This can be prevented using specific bed characteristics, massage and frequent reposition of the patient. When pressure ulcers become infected they need immediate antibiotic treatment Pneumonia - used to be the main cause of death in older patient that were immobilised for several weeks. Nowadays surgical treatment is more often delivered to aged patients accelerating their mobility and reducing the risk of infections Urinary tract infection - is another complication due to immobilisation, hygiene and insufficient hydration

Particularly in elderly patients it is critical to begin rehabilitation immediately after surgery through gradual and assisted walking to prevent medical complications. This phase may require the patient to be admitted to a cared facility or receive regular in-home visits by an occupational therapist to return to independent daily living activities. A wheelchair, crutches, walking stick, or a walker may be necessary to support the patient during the first weeks up to 12 months after a proximal femur fracture while recovering in function. Physiotherapy during the first 6-12 weeks post surgery include:Ice/heat treatmentAntiinflammatory therapyExercise to strengthen quadriceps, hamstrings and gluteal musclesHydrotherapyMassageJoint mobilisationGuided return to activityUse of high chairs and walking devicesWeight loss in overweighed patients

A proximal femur fracture poses a higher risk for a second such a fracture. Therefore prevention is key to avoid recidivism. In osteoporotic patients treatment includes the administration of the bisphosphonate group of drugs with additional supplements of calcium and vitamin D.Other preventive measures include:Exercise and maintenance of muscular strength in the elderly (walking, swimming)Use of supporting walking devices in the elderlyWearing of hip protectorsAdherence to occupational health and safety procedures and road traffic safety equipment (seatbelt, ;harness, balustrades)Monitoring of chronic diseases and pharmacological use (blood pressure medications)Alcohol and drug rehabilitationQuit smoking (impairing bone healing)Removal of carpets or other items facilitating fallsModify habits (use laced shoes, illuminate house at night, install railings, non-skid tiles in bathroom). ;