Acute Hip Fracture
Daniel J. Berry
The first decision to make when treating a patient with an acute femoral neck fracture is to consider internal fixation versus replacement. Optimal treatment aims to quickly restore function, minimize complications, and provide a durable result. Furthermore, the patient’s age, health, and functional context must also be considered. Although the decision is multifactorial, the following points may help guide treatment (Figure 12.1):
Location: Subcapital and mid cervical femoral neck fractures are at higher risk of nonunion because of their intracapsular location. Potential damage to the tenuous retinacular vessels that course along the neck also predisposes the femoral head to avascular necrosis. Conversely, basicervical, intertrochanteric, and subtrochanteric fractures are extracapsular and therefore have a better chance of healing with internal fixation.
Displacement: Femoral neck fractures with significant displacement (Garden 3-4) are less stable, more prone to failed internal fixation, and have a higher risk of osteonecrosis of the femoral head. On the other hand, nondisplaced and valgus impacted femoral neck fractures (Garden 1-2) are inherently more stable, have a higher likelihood of healing and a lower likelihood of osteonecrosis of the femoral head, and thus are amenable to internal fixation.
Fracture morphology: Fractures with comminution, and/or an elevated Pauwels angle (vertically oriented fracture resulting in high shear forces) are less stable and more prone to nonunion or malunion with internal fixation.
Patient’s age, health, and function: Elderly patients with poor preoperative baseline status and a displaced femoral neck fracture should favor hip replacement to allow for immediate weight bearing and pain relief and to minimize the possibility of additional surgery. On the other hand, younger patients (generally under the age of 65 years) with reasonable health often are better treated with preservation of their native hip by closed (or open if necessary) reduction and internal fixation.
Once hip replacement has been selected for treatment, the surgeon must consider what type of prosthesis is most appropriate.
Hemiarthroplasty: This has the advantage of being a fast and simple surgery while implanting a large diameter head that helps obviate postoperative dislocation. Unfortunately, the metal head that articulates with the patient’s native acetabulum may lead to articular cartilage wear and arthritis over time depending on the patient’s activity level. Hemiarthroplasty is therefore most appropriate for low-demand, elderly patients and those with predisposing risk factors for dislocation.
Total hip arthroplasty: Younger patients who are functionally independent and mobile should be considered for total hip replacement. The advantages of durable pain relief and function outweigh the risk of dislocation in this population. Similarly, patients with preexisting hip arthritis should be considered for total hip replacement over hemiarthroplasty.
A hip fracture in the geriatric patient should be considered a major, life-threatening injury. Treatment via a multidisciplinary team throughout the perioperative course can improve outcomes.
Timely preoperative medical optimization with the goal of surgery within 48 hours of the injury.
Minimization of opioid consumption via multimodal pain management and local and regional anesthesia.
Figure 12.1 ▪ Example of treatment decisions for displaced femoral neck fractures in 2 patients: radiographs of a 35-year-old woman with a valgus-impacted fracture after a fall from 10 feet (A) and 1 year following closed reduction and internal fixation with healed fracture and an intact femoral head (B); radiographs of an 83-year-old woman with a displaced unstable fracture after a fall from own height (C) and 1 year following bipolar hemiarthroplasty (D).
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