![]() Recognizing the different fracture types is important as it influences the surgical management. This classification divides fractures into three groups based on the angle of the fracture from the horizontal plane :Ī3: reverse or transverse, unstable fracture Intracapsular hip fractures may be classified using the Pauwel classification. Fractures proximal to the capsular insertion are described as intracapsular, while fractures distal to this are extracapsular. The capsule is reinforced by three ligaments: the iliofemoral and pubofemoral ligaments anteriorly and the ischiofemoral ligament posteriorly. Distally the capsule inserts into the femur at the intertrochanteric line anteriorly and the intertrochanteric crest posteriorly. The joint capsule of the hip originates from the acetabulum and encompasses the entirety of the femoral neck. Generally speaking, hip fractures are described by comparing their location relative to the insertion of the joint capsule on to the femoral neck. It is important to recognize the fracture pattern on radiographic images as this will dictate the surgical management. If MRI is not available, then CT is a valid alternative however, it can miss fractures, particularly those that occur in the axial plane. MRI has demonstrated 100% sensitivity and 93% to 100% specificity at diagnosing occult hip fractures and is, therefore, the gold standard. Occult fractures are those that are not visible on x-ray and account for between 2% to 10% of hip fractures. An anteroposterior view of the pelvis should be obtained along with a lateral view of the affected hip. The majority of hip fractures can be diagnosed on plain film radiographs. Specific examinations to identify the cause of the fall should also be considered. It is always useful to assess the patient's cardiovascular and respiratory status prior to undergoing surgery. Further examination often reveals pain on any, or all, of the following: palpation in the groin or greater trochanter, axial loading of the hip, and 'pin-rolling' of the leg.Ī full primary trauma and secondary trauma assessment should be performed to assess the patient for other injuries. Recognizing this, deformity immediately makes one suspicious of a hip fracture. The classically described presentation is a shortened and externally rotated limb due to the unopposed pull of the iliopsoas muscle that attaches to the lesser trochanter. The degree of deformity seen is dependent on both the anatomical configuration of the fracture and the degree of displacement. The physical examination will demonstrate pain, immobility, and potentially a deformed limb. The aim of this is to recognize patients with underlying dementia or those who are developing an acute delirium, both of which are associated with a poorer prognosis. Ideally, this should be done both on admission and pos-operatively. It is recommended that a cognitive assessment be performed in all patients presenting with hip fractures. A thorough social history that provides baseline mobility and the patient's home circumstances is also of great value and is likely to guide postoperative rehabilitation and discharge planning. As these patients are often elderly with a complex medical background, a full medical history is vital and should include both a history of the presentation as well as a full assessment of the patient's medical background. Clinicians should explore potentially sinister causes of the fall, such as syncope, stroke, or myocardial infarction. Classically a fall leads to a painful hip with an associated inability to walk. Most hip fractures can be diagnosed, or at least suspected, from history alone. Arguably many more hip fractures could be described as pathological due to underlying osteoporosis, but this group is rarely labeled in this way. The two most frequent causes in relation to hip fractures are malignancy and bisphosphonate use. A pathological fracture is defined as a fracture caused by a disease process and not related to trauma. These patients are likely to have incurred multiple injuries and should be assessed and managed appropriately as per local trauma guidelines.Īround 5% of hip fractures have no history of trauma, and in these cases, an alternative cause should be suspected. Hip fractures that occur in younger adults are often the result of high-energy trauma. Many patients have multiple risk factors, and this, along with age-associated reduced bone quality, is the underpinning cause of most hip fractures. Risk factors for falls in the elderly population are numerous, but those with a strong independent association are a previous history of falls, gait abnormalities, the use of walking aids, vertigo, Parkinson disease, and antiepileptic medications. The majority of hip fractures are the result of a fall in the elderly population.
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