Types of Fractures
In general, there are three different types of hip fractures based on their location around the upper thigh bone (femur). These fractures usually occur due to falls in the elderly with soft osteoporotic bones, known as osteoporotic hip fractures, or pediatric fractures, in the young who are involved in high-velocity accidents such as motor vehicle crashes or falls from a substantial height.
1. Femoral Neck Fractures
These fractures occur at the level of the neck 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.
2. Intertrochanteric Fracture
This fracture occurs between the neck of the femur and a lower bony prominence called the lesser trochanter.
This occurs further down the bone and tends to have better blood supply to the fracture pieces.
3. Subtrochanteric Fracture
This fracture occurs even further down the bone from the femoral neck and may be broken into several pieces.
Most surgeons agree that patients do better if they are operated on fairly quickly. This is to enable them to be mobilised quickly to prevent problems of prolonged recumbency (lying too long in a hospital bed) such as bed sores, chest and urinary tract infections and deep vein thrombosis (blood clots in the legs). It is, however, important to ensure that patients are medically fit to undergo surgery and this may mean taking time to do cardiac and other diagnostic studies.
Stable Impacted Fracture
Certain fractures that have not moved (“displaced”) may not require surgery. However, there is a risk that these fractures may displace later on, especially if the patient starts putting weight on the injured limb too early.
Patients who might be considered for nonsurgical treatment include those who are too ill to undergo any form of anesthesia and those who with poor walking ability even before the fall, such as those who are bed or wheelchair bound.
If the choice is for non-surgical management of the fracture, we will need to follow up the patient 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.
There are usually two types of anesthesia for surgeries- general and regional anesthesia. In rare circumstances where patients are very ill, we can perform the surgery under local anesthesia with sedation. Patients will be assessed for their fitness for surgery by the anesthetist and in some cases, other specialists such as cardiologist might be called in to perform pre-surgery checks.
Femoral Neck Fractures
In undisplaced femoral fractures, several screws are placed across the fracture site to stabilise the fracture. In some cases, a large single screw (dynamic hip screw) is used instead of several small screws.
Displaced fractures in young patients are treated differently from older patients (60 and above). In the young, these fractures are realigned into their normal anatomical positions and then held in place by screws as described above. However, in about 20-30% of cases, a complication called osteonecrosis or avascular necrosis can occur. This term refers to “bone death” of the femoral head and eventually, the round head can collapse and flatten and in the long-term, the patient will develop arthritis.
Displaced fractures in the elderly are treated by removing the femoral head and replacing it with a metal prosthetic head. This is known as a hemiarthroplasty procedure. In some patients with pre-existing arthritis of the hip, a total hip replacement is performed.
An intertrochanteric fracture can be stabilised with an intramedullary nail or a dynamic hip screw (mentioned above).
These fractures are stabilised using an elongated intramedullary nail. These are very unstable fractures that usually result from high-velocity type injuries and there are potenti