Hip fracture in the elderly

Introduction

Hip fracture in the elderly constitutes a serious medical problem, with significant consequences on the health and quality of life of the individuals concerned. Often triggered by a fall, a common event among older adults due to the loss of stability and decreased bone density associated with aging, this fracture is of particular importance due to its impact on mobility.

The hip joint, essential for walking and balance, has its function impaired during a fracture, leading to a drastic reduction in independence. Affected older adults may experience severe pain, an inability to bear weight on the affected leg, and often, a loss of confidence in their ability to move safely.

Treatment of hip fracture in older adults generally requires a multidisciplinary approach. Although surgery is often essential to stabilize the fracture, fragile patients require special precautions. The postoperative recovery phase proves to be a prolonged and demanding process, involving attentive care, physical rehabilitation, and in many cases, psychological support to overcome the emotional challenges associated with the temporary loss of independence.

Fall prevention is a crucial aspect of the management of hip fractures in older adults. Measures such as improving home lighting, using non-slip mats, and participating in exercise programs aimed at strengthening stability and balance can help reduce the risk of falls and, in turn, consequently, hip fractures.

In conclusion, hip fracture constitutes a major challenge for the health of elderly people. Prevention, effective medical care, and multidisciplinary support are essential to minimize the impact of this delicate condition on the lives of affected individuals.

Factors that may compromise balance and thus predispose elderly patients to hip fracture

Factors that compromise balance in older adults may contribute to an increased risk of falls and, therefore, predispose these individuals to hip fractures. Some of these factors include:

1. Muscle weakness: Decreased muscle strength, particularly in the leg and core muscles, can lead to decreased stability and increase the risk of falls.
2. Decreased bone density (osteoporosis): Osteoporosis, characterized by a decrease in bone mineral density, makes bones more fragile and susceptible to fracture even in the event of a minor fall.
3. Vision problems: Degraded vision due to conditions such as cataracts, macular degeneration or other eye problems can impair perception of the environment, increasing the risk of falls.
4. Balance Disorders: Certain medical conditions, such as vestibular disorders, dizziness or other neurological problems, can compromise balance and coordination of movements.
5. Medication side effects: Certain medications, especially those that cause drowsiness, dizziness, or muscle weakness, may contribute to decreased balance.
6. Cognitive impairments: Cognitive impairments, such as dementia, can impair decision-making and perception of the environment, increasing the risk of falls.
7. Foot Problems and Improper Shoes: Foot problems such as peripheral neuropathy, deformities, or wearing improper shoes can affect balance.
8. Vitamin D deficiency: Vitamin D deficiency can contribute to decreased muscle strength and bone density, increasing the risk of falls and fractures.
9. Sedentary lifestyle: A sedentary lifestyle can lead to a loss of muscle mass and flexibility, affecting balance and stability.
10. Physical environment: Obstacles in the environment, such as slippery mats, cumbersome electrical cords, or dangerous steps, can increase the risk of falls.
11. History of falls: People who have had previous falls have an increased risk of future falls.

Epidemiology

In 1990, the annual incidence of hip fractures worldwide was 1.3 million, and it is predicted to reach 7 to 21 million by 2050[3]. The frequency of hip fractures generally doubles with each decade over the age of 50. In the United States, the annual incidence per 100,000 inhabitants is between 197 and 201 for men and between 511 and 553 for women[4]. The incidence increases with age, and the average age of patients with hip fracture is 80 years[2][4]. One in three adults aged 50 and over dies within 12 months of a hip fracture. Older adults have a five to eight times higher risk of dying in the first three months from a hip fracture. This increased risk of death persists for almost ten years. The fracture would then, for them, be a death sentence. About one in seven women will experience a hip fracture which may lead to hip replacement (a prosthesis is used to replace the broken hip bone).

Causes of hip fracture in the elderly

1. Osteoporosis: Osteoporosis is a condition characterized by loss of bone density, making bones more fragile and susceptible to fracture, even with relatively low impact.
2. Falls: Falls are the most common cause of hip fractures in older adults. Decreased muscle strength, balance problems, impaired vision and other age-related health problems increase the risk of falls.
3. Aging tissues: As we age, the connective tissues surrounding the hip joint can lose elasticity and become more fragile, increasing the risk of fracture.
4. Chronic illnesses: Certain medical conditions such as arthritis, Parkinson’s disease and other chronic illnesses can weaken bones and increase the risk of hip fracture.
5. Medications: Certain medications, especially those that can cause drowsiness, dizziness, or weaken muscles, increase the risk of falling and, therefore, hip fracture.
6. Genetic factors: Genetics may also play a role in predisposing to osteoporosis and other conditions that increase the risk of fractures.
7. Lack of physical activity: A sedentary lifestyle can lead to loss of muscle mass and balance, increasing the risk of falls and fractures.
8. Nutritional deficiency: Inadequate intake of calcium and vitamin D can weaken bones, increasing the risk of fractures.

Hip fracture is often a consequence of the complex interaction of several of these factors. It is important for older adults to take steps to maintain bone health, strengthen muscles, stay active, and take precautions to prevent falls

Symptoms of hip fracture in the elderly

1. Pain: Hip pain is often intense and localized. The person may feel severe pain in the hip or groin. Sometimes the pain may radiate to the thigh, knee, or groin area.
2. Inability to bear weight: The person may have difficulty bearing weight on the affected leg and may experience severe pain when trying to stand or walk.
3. Difficulty moving the leg: Due to pain and instability, the person may have difficulty moving the affected leg or performing movements of the hip joint.
4. Discomfort or swelling: The area around the hip may be swollen, and there may be tenderness or discomfort to the touch.
5. Abnormal leg rotation: The affected leg may appear to rotate outward abnormally, especially if the fracture is at the head of the femur.
6. Leg length discrepancies: The affected leg may appear shorter than the other due to deformity resulting from the fracture.
7. Immobilization: The person may have difficulty moving or turning the affected leg and may prefer to remain still due to the pain.

***Elderly patients with hip pain after a fall should be treated as if they had a hip fracture until proven otherwise.***

Classification (Delbet) of hip fracture

The classification of hip fracture according to Delbet, proposed at the beginning of the 20th century by the French surgeon Pierre Delbet, remains a historical reference in the medical field. This ancient classification categorizes hip fractures into four main types based on the specific location of the fracture.

The first type of fracture identified by Delbet concerns the cervical region, which is the part of the femur close to the head of the femur. This type of cervical fracture can have significant implications on the vascularization of the femoral head, potentially leading to severe complications.

The second type of fracture is located at the greater trochanter, a bony protuberance at the base of the femoral neck. Fractures of this type can influence the stability of the hip joint and often require surgical attention.

The third category of fractures, according to Delbet, concerns the intertrochanteric area, located between the greater trochanter and the cervical part of the femur. These fractures can present particular challenges due to their proximity to critical bony and vascular structures.

Finally, the fourth type of fracture according to this classification is located at the level of the subtrochanter, the region located under the major trochanter. These fractures can affect the mechanical stability of the hip and often require surgery to restore normal function.

Although Delbet’s classification played an important role in the understanding of hip fractures in its time, it is essential to note that more modern classifications are preferred in the medical field today. These more recent classifications take into account different factors, such as the specific nature of the fracture, the type of displacement of the bone fragments, and other important anatomical characteristics.

In conclusion, although the Delbet classification remains a historical reference, medical advances have led to the evolution of more precise classification methods adapted to current needs. Understanding these classifications, ancient and modern, is crucial for healthcare professionals in the diagnosis and management of hip fractures, ensuring appropriate interventions and optimal patient outcomes.

1. Type I – Cervical Fracture: This category concerns fractures located in the cervical region of the femur, near the head of the femur. Cervical fractures can have severe implications due to their proximity to the blood supply to the femoral head
2. Type II – Greater Trochanter Fracture: Fractures in this category occur at the greater trochanter, a bony protrusion at the base of the femoral neck. They can influence the stability of the hip joint.
3. Type III – Intertrochanteric fracture: This category concerns fractures located in the intertrochanteric area, between the greater trochanter and the cervical part of the femur. These fractures can present particular challenges due to their proximity to crucial bony and vascular structures.
4. Type IV – Subtrochanteric Fracture: Subtrochanteric fractures are located in the region below the greater trochanter. They can affect the mechanical stability of the hip, often requiring surgery to restore normal function.

Complication of intracapsular hip fracture

1. Avascular necrosis of the femoral head: A common complication of intracapsular fractures, particularly those of the femoral neck, is avascular necrosis of the femoral head. This occurs when the blood supply to the femoral head is compromised due to the fracture, which can lead to bone cell death.
2. Osteoarthritis: Intracapsular fractures can increase the risk of developing osteoarthritis of the hip, particularly if the fracture is not properly treated and heals poorly.
3. Nonunion or delayed union: Some fractures may have difficulty healing properly, which can result in nonunion (lack of healing) or delayed union (slower than normal healing).
4. Vascular and nervous complications: In the event of a severe fracture, there is a risk of associated vascular or nerve damage. Injury to surrounding blood vessels or nerves can have serious consequences.
5. Infection: Any open fracture (perforation of the skin) exposes the fracture site to the risk of infection. Infections can delay healing and cause other complications.
6. Mobility and function problems: Hip fractures can lead to mobility and function problems, especially in older adults. Recovery can be long, and some people may have difficulty returning to their previous level of activity.
7. Fat embolism syndrome: In some severe hip fractures, there may be a release of fat particles into the bloodstream, causing fat embolism syndrome. This can lead to pulmonary and neurological complications.

Differential diagnosis of intracapsular hip fracture

1. Muscle sprain or tear: Muscle sprains or tears around the hip can cause pain similar to that of a fracture, but they do not necessarily involve an interruption in bone continuity.
2. Hip dislocation: A hip dislocation can cause severe pain and inability to use the leg, but it does not necessarily result from a fracture. However, a hip dislocation can sometimes be associated with a fracture or ligament damage.
3. Hip bursitis: Inflammation of the synovial bursae around the hip, called bursitis, can cause pain in the hip area, but it does not cause a fracture.
4. Osteoarthritis of the hip: Osteoarthritis of the hip can cause pain similar to that of a fracture, especially in older people. However, osteoarthritis is a degenerative condition of the joints and does not result from an acute fracture.
5. Tendonitis: Inflammation of the tendons surrounding the hip can cause local pain, but it does not represent a fracture.
6. Deep vein thrombosis (DVT): DVT can cause pain and swelling in the leg, sometimes confused with fracture symptoms. However, DVT does not involve disruption of the bone.
7. Fracture of other parts of the femur: It is important to distinguish intracapsular fractures from fractures of other parts of the femur, such as subtrochanteric or diaphyseal fractures.

Diagnosis and treatment of intracapsular hip fracture

Intracapsular hip fracture is a serious injury that occurs within the joint capsule of the hip joint. This capsule surrounds the joint and contains synovial fluid, which lubricates and nourishes the joint. Intracapsular fractures are generally classified into two main types: femoral neck fractures and femoral head fractures.

Diagnostic :

1. Imaging tests: X-rays are often used to diagnose intracapsular hip fractures. They make it possible to assess the location and severity of the fracture.
2. CT scan: In some cases, a CT scan may be performed to obtain more detailed images of the fracture and its surrounding structures.
3. Magnetic resonance imaging (MRI): MRI can be used to assess damage to the soft tissues around the hip, providing a more complete perspective of the injury.

Treatment :

1. Closed reduction: If the bone fragments retain some stability, closed reduction can be attempted. This involves realigning the fragments without resorting to surgery.
2. Internal fixation: Most intracapsular fractures require surgery to stabilize the bone fragments. Internal fixation, such as the placement of screws or pins, is often performed to hold the bones in the correct position.
3. Hip replacement: In severe cases, especially in older people, hip replacement (arthroplasty) may be recommended. This involves replacing the femoral head and sometimes the femoral neck with artificial implants.
4. Rehabilitation: After surgery, rehabilitation is crucial to restore muscle strength, mobility and balance. Exercises are prescribed to promote recovery and minimize the risk of complications.
5. Pain Management: Analgesic and anti-inflammatory medications may be prescribed to control postoperative pain and inflammation.

Prompt diagnosis and appropriate treatment of intracapsular hip fracture are essential to minimize complications and promote successful recovery. The choice of treatment depends on various factors, including the severity of the fracture, the patient’s age, and their general health.

Factors that contribute to the high risk of death after femoral neck fracture

Femoral neck fractures in older adults may be associated with an increased risk of serious complications, including mortality. Several factors contribute to this high risk of death after a femoral neck fracture, including:

1. Advanced age: Older people, especially those over 65, have an increased risk of serious complications after a femoral neck fracture. Advanced age is often associated with increased frailty, pre-existing health conditions and reduced capacity for recovery.
2. Underlying health conditions: Older adults who have pre-existing health conditions such as cardiovascular disease, diabetes, kidney failure, lung disease or other medical conditions have a higher risk of complications and death after a femoral neck fracture .
3. Delay in surgery: A significant delay between the occurrence of the fracture and repair surgery can increase the risk of complications, including infections and respiratory problems, which can contribute to increased mortality.
4. Thromboembolic complications: People who have suffered a femoral neck fracture are at risk of developing blood clots, which can lead to thromboembolic complications such as pulmonary embolism, a potentially life-threatening condition.
5. Infections: Infections, especially respiratory and urinary tract infections, can occur after a femoral neck fracture, increasing the risk of serious complications.
6. Postoperative shock syndrome: Some patients may develop postoperative shock syndrome, a serious reaction of the body to surgery, which may be associated with an increased risk of death.
7. Loss of independence: Fracture of the femoral neck can lead to significant loss of autonomy, making people more vulnerable to medical complications and infections.
8. Bone fragility: Fracture of the femoral neck in the elderly is often linked to bone fragility, generally due to osteoporosis. This fragility can negatively influence recovery.

Radiographic signs of femoral neck fracture

Radiographic signs of a femoral neck fracture can be seen on medical x-rays. Here are some of the things radiologists look for when evaluating x-rays for a femoral neck fracture:

1. Fracture line: The femoral neck fracture may be visible as a broken or abnormal line on the x-ray. The location of this line can vary, and different classifications can be used to describe the fracture, such as Garden’s.
2. Displacement: The x-ray helps determine if the bone fragments are displaced or if they remain aligned. The degree of displacement often influences the recommended treatment.
3. Angular displacement: The angle formed by the bone fragments can be assessed to determine if there is rotation or angular displacement of the fracture.
4. Fracture Type: Femoral neck fractures can be classified based on their location and direction of the fracture line. For example, a fracture can be transcervical, basocervical, intertrochanteric, etc.
5. Indirect signs: In addition to direct signs of fracture, x-rays may show indirect signs such as bleeding into the hip joint, signs of avascular necrosis, or other associated complications.
6. Analysis of surrounding structures: X-rays also help evaluate the condition of surrounding structures, such as the hip joint, blood vessels, and soft tissues.

Reference

1. Deandrea S, Lucenteforte E, Bravi F, Foschi R, La Vecchia C, Negri E. Risk factors for falls in community-dwelling older people: a systematic review and meta-analysis. Epidemiology. 2010 Sep;21(5):658-68. [PubMed]
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13. Credit in part:Benjamin R. Emmerson; Matthew Varacallo; Dominic Inman.

Questionnaire 1

1. What is the main cause of hip fracture in older people?
   • A) Arthrose
   • B) Chutes
   • C) Osteoporosis
   • D) Hip dislocation
   • E) Vitamin D deficiency
2. What is the impact of hip fracture on the mobility of older people?
   • A) Improved mobility
   • B) No impact
   • C) Drastic reduction of independence
   • D) Increased muscle strength
   • E) Stabilization of balance
3. What factor contributes to bone fragility and increases the risk of fractures?
   • A) Regular exercise
   • B) Muscle weakness
   • C) Balanced diet
   • D) Youth
   • E) Adequate hydration
4. What complication is associated with intracapsular fractures, particularly those of the femoral neck?
   • A) Infection
   • B) Arthrose
   • C) Avascular necrosis of the femoral head
   • D) Deep vein thrombosis
   • E) Cognitive impairment
5. What is the classification of hip fracture according to Delbet?
   • A) Type A – Fracture cervicale
   • B) Type B – Fracture trochantérienne
   • C) Type C – Subtrochanteric fracture
   • D) Type D – Diaphyseal fracture
   • E) Type E – Epiphyseal fracture
6. What is one of the symptoms of hip fracture in older adults?
   • A) Hip burn
   • B) Numbness of the feet
   • C) Increased flexibility
   • D) Normal leg rotation
   • E) Inability to bear weight on the affected leg
7. What is one factor that contributes to the high risk of death after a femoral neck fracture?
   • A) Youth
   • B) Delay in surgery
   • C) Muscle weakness
   • D) Early treatment
   • E) Weight loss
8. What is the complication that can result from a release of fat particles into the bloodstream after a severe hip fracture?
   • A) Pulmonary embolism
   • B) High blood pressure
   • C) Diabetes
   • D) Renal failure
   • E) Visual impairment
9. What is the main radiographic feature looked for to diagnose a femoral neck fracture?
   • A) Bloodshed
   • B) Angular displacement
   • C) Interrupted fracture line
   • D) Signs of osteoarthritis
   • E) Cognitive impairment
10. What factor is not mentioned as contributing to hip fracture risk?
    • A) Sedentary lifestyle
    • B) Cognitive impairment
    • C) Non-slip mats
    • D) High muscle strength
    • E) Degraded vision

Answers to multiple choice questions:

1. What is the main cause of hip fracture in older people?
   • Answer: C) Osteoporosis
2. What is the impact of hip fracture on the mobility of older people?
   • Answer: C) Drastic reduction in independence
3. What factor contributes to bone fragility and increases the risk of fractures?
   • Answer: B) Muscle weakness
4. What complication is associated with intracapsular fractures, particularly those of the femoral neck?
   • Answer: C) Avascular necrosis of the femoral head
5. What is the classification of hip fracture according to Delbet?
   • Answer: A) Type A – Cervical fracture
6. What is one of the symptoms of hip fracture in older adults?
   • Answer: E) Inability to bear weight on the affected leg
7. What is one factor that contributes to the high risk of death after a femoral neck fracture?
   • Answer: B) Delay in surgery
8. What is the complication that can result from a release of fat particles into the bloodstream after a severe hip fracture?
   • Answer: A) Pulmonary embolism
9. What is the main radiographic feature looked for to diagnose a femoral neck fracture?
   • Answer: C) Interrupted fracture line
10. What factor is not mentioned as contributing to hip fracture risk?
    • Answer: D) High muscular strength