Imaging

The diagnosis of a hip fracture is generally made by an X-ray of the hip and femur.

In some cases, if the patient falls and complains of hip pain, an incomplete fracture may not be seen on a regular X-ray. In that case, magnetic resonance imaging (MRI) may be recommended. The MRI scan will usually show a hidden fracture.

If the patient is unable to have an MRI scan because of an associated medical condition, computed tomography (CT) may be obtained instead. Computed tomography, however, is not as sensitive as MRI for seeing hidden hip fractures.

Types of Fractures

In general, there are three different types of hip fractures. The type of fracture depends on what area of the upper femur is involved.

Intracapsular Fracture

These fractures occur at the level of the neck and the head of the femur, and are generally within the capsule. The capsule is the soft-tissue envelope that contains the lubricating and nourishing fluid of the hip joint itself.

Intracapsular Fracture. This fracture occurs at the level of the “neck” of the bone and may have loss of blood supply to the bone.

Intertrochanteric Fracture. This occurs further down the bone and tends to have better blood supply to the fracture pieces.

Intertrochanteric Fracture

This fracture occurs between the neck of the femur and a lower bony prominence called the lesser trochanter. The lesser trochanter is an attachment point for one of the major muscles of the hip. Intertrochanteric fractures generally cross in the area between the lesser trochanter and the greater trochanter. The greater trochanter is the bump you can feel under the skin on the outside of the hip. It acts as another muscle attachment point.

Subtrochanteric Fracture

This fracture occurs below the lesser trochanter, in a region that is between the lesser trochanter and an area approximately 2 1/2 inches below .

Subtrochanteric Fracture. This occurs even further down the bone and may be broken into several pieces.

In more complicated cases, the amount of breakage of the bone can involve more than one of these zones. This is taken into consideration when surgical repair is considered.

Considerations

Once the diagnosis of the hip fracture has been made, the patient’s overall health and medical condition will be evaluated. In very rare cases, the patient may be so ill that surgery would not be recommended. In these cases, the patient’s overall comfort and level of pain must be weighed against the risks of anesthesia and surgery.

Most surgeons agree that patients do better if they are operated on fairly quickly. It is, however, important to insure patients’ safety and maximize their overall medical health before surgery. This may mean taking time to do cardiac and other diagnostic studies.

Nonsurgical Treatment

Stable Impacted Fracture. Certain fractures that have not moved (”displaced”) may not require surgery. Because there is a risk that they may move later on, they are often fixed.

Patients who might be considered for nonsurgical treatment include those who are too ill to undergo any form of anesthesia and people who were unable to walk before their injury and may have been confined to a bed or a wheelchair.

Certain types of fractures may be considered stable enough to be managed with nonsurgical treatment. Because there is some risk that these “stable” fractures may instead prove unstable and displace (change position), the doctor will need to follow with periodic X-rays of the area. If patients are confined to bed rest as part of the management for these fractures, they will need to be closely monitored for complications that can occur from prolonged immobilization. These include infections, bed sores, pneumonia, the formation of blood clots, and nutritional wasting.

Surgical Treatment

Before Surgery

Anesthesia for surgery could be either general anesthesia with a breathing tube or spinal anesthesia. In very rare circumstances, where only a few screws are planned for fixation, local anesthesia with heavy sedation can be considered. All patients will receive antibiotics during surgery and for the 24-hours afterward.

Appropriate blood tests, chest X-rays, electrocardiograms, and urine samples will be obtained before surgery. Many elderly patients may have undiagnosed urinary tract infections that could lead to an infection of the hip after surgery.

The surgeon’s decision as to how to best fix a fracture will be based on the area of the hip that is broken and the surgeon’s familiarity with the different systems that are available to manage these injuries.

Intracapsular Fracture

If the head of the femur (”ball”) alone is broken, management will be aimed at fixing the cartilage on the ball that has been injured or displaced. Frequently with these injuries, the socket, or acetabulum, may also be broken. The surgeon will need to take this into consideration as well.

These injuries may be approached either from either the front or back of the hip. In some cases, both approaches are required in order to clearly see and fix the injured bone.

For true intracapsular hip fractures, the surgeon may decide either to fix the fracture with individual screws (percutaneous pinning) or a single larger screw that slides within the barrel of a plate. This compression hip screw will allow the fracture to become more stable by having the broken area impact on itself. Occasionally, a secondary screw may be added for stability.

Repair of an intracapsular fracture with individual screws.

Repair of an intracapsular fracture with a single compression hip screw.

If the intracapsular hip fracture is displaced in a younger patient, a surgical attempt will be made to reduce, or realign, the fracture through a larger incision. The fracture will be held together with either individual screws or with the larger compression hip screw.

In these cases, the blood supply to the ball, or head of the femur, may have been damaged at the time of injury (avascular necrosis). Even though the fracture is realigned and fixed into place, the cartilage and underlying supporting bone may not receive adequate blood. Over a period of time, this may cause the femoral head to flatten out. When this occurs, the joint surface becomes irregular. Ultimately, the hip joint may develop a painful arthritis, despite the surgical repair.

Although the fracture is repaired, the blood supply to the “ball” of the femur is damaged.

In the older patient, the chance that the head of the femur is damaged in this way is higher. It is generally felt that for these displaced fractures, patients will do better if some of the components of the hip are replaced. In some cases, this can mean a replacement of the ball, or head of the femur (hemiarthroplasty). In other cases, this can mean the replacement of both the ball and socket, or head of the femur and acetabulum (total hip replacement).

Hemiarthroplasty is a type of hip replacement in which only the “ball” of the hip is replaced.

A total hip replacement replaces both the hip socket and ball.

Intertrochanteric Fracture

Repair of an intertrochanteric fracture with an intramedullary nail. The nail is in the hollow cavity of the femur (thighbone) rather than on the side of it (as with a plate).

Most intertrochanteric fractures are managed with either a compression hip screw or an intramedullary nail, which also allows for impaction at the fracture site.

The compression hip screw is fixed to the outer side of the bone with bone screws and has a large secondary screw (lag screw) that is placed through the plate into the neck and head of the hip (see compression hip screw figure above). The design of the device allows for impaction and compression at the fracture site. This may increase the stability of the area and promote healing.

The intramedullary nail is placed directly into the marrow canal of the bone through an opening made at the top of the greater trochanter. A lag screw is then placed through the nail and up into the neck and head of the hip. As with the compression hip screw, sliding of the lag screw and impaction of the fracture take place.

There are no definitive studies to show that one device is superior to another. The decision as to which to use is based on the surgeon’s preference and experience.

Subtrochanteric Fracture

At the subtrochanteric level, most fractures are managed with a long intramedullary nail together with a large lag screw or they are managed with screws that capture the neck and head of the femur or the area immediately underneath it, if it has remained intact.

Repair of subtrochanteric fracture with a long intramedullary nail.

Interlocking screws at the end of the nail make the fixation more secure.

In order to keep the bones from rotating around the nail or from shortening (”telescoping”) on the nail, additional screws may be placed at the lower end of the nail in the area of the knee. These are called interlocking screws.

In certain cases, the surgeon may choose to use a plate rather than a nail. The plate will have screws that go into the bone from the lateral, or outer, side of the femur. A single large screw goes into the neck and the head of the femur and appears similar to the compression hip screw, but at a different angle. Secondary screws are then placed through the plate into the bone to hold the fracture in place.

A locking plate may be used for more difficult to treat fractures.

Patients may be discharged from the hospital to their home or find that a stay in a rehabilitation facility is necessary to assist them in regaining their ability to walk.

Initial Exercise Program Ankle Pumps
•Lie on your back.
•Move ankles up and down. Repeat 10 times.
•Repeat 10 times.
Heel Slides
•Lie on your back.
•Slowly bend and straighten knee.
•Repeat 10 times.
Abdominal Contraction
•Lie on your back with knees bent and hands resting below ribs.
•Tighten abdominal muscles to squeeze ribs down toward back.
•Be sure not to hold breath.
•Hold 5 seconds.
•Relax.
•Repeat 10 times.

At the end of the healing time, cleaning twice daily is no longer required, although cleaning once daily is still suggested. At this point, jewelry can safely be changed, but should not be left out of any piercing. Even once the hole becomes permanent, it can still shrink and make jewelry reinsertion more difficult. If you need to hide the piercing or need non-metallic/flexible jewelry for surgery, pregnancy, etc., call the shop. As a general rule, if you like your piercing, keep jewelry in it.

What A BMD Test Can Do
A BMD test is the only way to detect low bone density and diagnose osteoporosis. The lower a person’s bone mineral density, the greater the risk of having a fracture. A BMD test is used to:
• Detect low bone density before a person breaks a bone
• Predict a person’s chances of breaking a bone in the future
• Confirm a diagnosis of osteoporosis when a person has already broken a bone
• Determine whether a person’s bone density is increasing, decreasing or remaining stable (the same)
• Monitor a person’s response to treatment

Who Should Have a BMD Test?
There are some reasons (called risk factors) that increase your likelihood of developing osteoporosis. The more risk factors you have, the more likely you are to get osteoporosis and broken bones. Some examples are being small and thin, older age, being female, a diet low in calcium, lack of enough vitamin D, smoking and drinking too much alcohol.
Your healthcare provider may recommend a BMD test if you are:
• A postmenopausal woman under age 65 with one or more risk factors for osteoporosis
• A man age 50-70 with one or more risk factors for osteoporosis
• A woman age 65 or older, even without any risk factors
• A man age 70 or older, even without any risk factors
• A woman or man after age 50 who has broken a bone
• A woman going through menopause with certain risk factors
• A postmenopausal woman who has stopped taking estrogen therapy (ET) or hormone therapy (HT)
Some other reasons your healthcare provider may recommend a BMD test:
• Long-term use of certain medications including steroids (for example, prednisone and cortisone), some anti-seizure medications
and aromatase inhibitors
• A man receiving certain treatments for prostate cancer
• A woman receiving certain treatments for breast cancer
• Overactive thyroid gland (hyperthyroidism) or taking high doses of thyroid hormone medication
• Overactive parathyroid gland (hyperparathyroidism)
• X-ray of the spine showing a fracture or bone loss
• Back pain with a possible fracture
• Significant loss of height
• Loss of sex hormones at an early age, including early menopause
• Having a disease or condition that can cause bone loss (such as rheumatoid arthritis or anorexia nervosa

What your T-score means:

A T-score between +1 and -1 is normal bone density. Examples are 0.8, 0.2 and -0.5.
A T-score between -1 and -2.5 indicates low bone density or osteopenia. Examples are T-scores of -1.2, -1.6 and -2.1.
A T-score of -2.5 or lower is a diagnosis of osteoporosis. Examples are T-scores of -2.8, -3.3 and -3.9.
The lower a person’s T-score, the lower the bone density. A T-score of -1.0 is lower than a T-score of 0.5; a T-score of -2.0 is lower than a T-score of -1.5; and a T-score of -3.5 is lower than a T-score of -3.0.

Considerations
Regular BMD testing can be important in combating osteoporosis in certain people. The overall cost-benefit value of screening everyone, including those who are not at high risk, is still a matter of debate. Many insurance companies today will pay for bone density testing under certain circumstances.

Most experts agree postmenopausal women over age 65 years are at highest risk and should have bone density tests.

Woman under 65 may also be screened if they have additional risk factors, such as:

Chronic rheumatoid arthritis
Fracture (if they are over 50)
Early menopause (either from natural causes or surgery)
Smoking
Strong family history of osteoporosis
Taking corticosteroid medications (prednisone, methylprednisolone) every day for more than 3 months
Three or more drinks of alcohol per day on most days
Simple bone density scans using portable machines may be available as part of health fairs or screenings. These portable scanners may check the density of your wrist or heel. However, keep in mind that hip and spine scans are more reliable.

Alternative Names
BMD test; Bone density test; Bone densitometry

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