Hip Fracture: Diagnosis, Treatment, and Secondary Prevention


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Am Fam Physician. 2014 Jun 15;89(12):945-951.

  Patient information: See related handout on hip fractures, written by the authors of this article.

Hip fractures cause significant morbidity and are associated with increased mortality. Women experience 80% of hip fractures, and the average age of persons who have a hip fracture is 80 years. Most hip fractures are associated with a fall, although other risk factors include decreased bone mineral density, reduced level of activity, and chronic medication use. Patients with hip fractures have pain in the groin and are unable to bear weight on the affected extremity. During the physical examination, displaced fractures present with external rotation and abduction, and the leg will appear shortened. Plain radiography with cross-table lateral view of the hip and anteroposterior view of the pelvis usually confirms the diagnosis. If an occult hip fracture is suspected and plain radiography is normal, magnetic resonance imaging should be ordered. Most fractures are treated surgically unless the patient has significant comorbidities or reduced life expectancy. The consulting orthopedic surgeon will choose the surgical procedure. Patients should receive prophylactic antibiotics, particularly against Staphylococcus aureus, before surgery. In addition, patients should receive thromboembolic prophylaxis, preferably with low-molecular-weight heparin. Rehabilitation is critical to long-term recovery. Unless contraindicated, bisphosphonate therapy should be used to reduce the risk of another hip fracture. Some patients may benefit from a fall-prevention assessment.

Older patients commonly experience hip fractures, which cause significant morbidity and are associated with increased mortality. The family physician's role involves multiple objectives: identify patients at increased risk of a hip fracture, promptly diagnose a hip fracture, facilitate long-term rehabilitation, reduce the risk of another hip fracture, and manage comorbid conditions.14

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Plain radiography should be the initial diagnostic test in patients with suspected hip fracture.

C

5

Hip fracture surgery should be performed 24 to 48 hours after a fracture unless a delay is needed to stabilize comorbidities.

C

34

Patients undergoing hip fracture surgery should receive thromboembolic and antibiotic prophylaxis.

A

4648, 50

Following a hip fracture, patients should usually be treated with a bisphosphonate, regardless of their bone mineral density, unless contraindicated.

C

53

Following a hip fracture, most patients should have a formal fall-prevention assessment.

C

55

Patients should receive post-fracture rehabilitation to help restore functional capability.

B

56


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Plain radiography should be the initial diagnostic test in patients with suspected hip fracture.

C

5

Hip fracture surgery should be performed 24 to 48 hours after a fracture unless a delay is needed to stabilize comorbidities.

C

34

Patients undergoing hip fracture surgery should receive thromboembolic and antibiotic prophylaxis.

A

4648, 50

Following a hip fracture, patients should usually be treated with a bisphosphonate, regardless of their bone mineral density, unless contraindicated.

C

53

Following a hip fracture, most patients should have a formal fall-prevention assessment.

C

55

Patients should receive post-fracture rehabilitation to help restore functional capability.

B

56


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Epidemiology

Women experience 80% of all hip fractures.5 The average age at the time of the fracture is 80 years, and almost all patients are older than 65 years.5 The lifetime prevalence of a hip fracture is 20% for women and 10% for men.1 The projection of annual new hip fractures by 2050 ranges from 500,000 to 1 million.6 The estimated annual cost in the United States is approximately $10.3 to $15.2 billion.7

Hip fractures are associated with increased mortality; 12% to 17% of patients with a hip fracture die within the first year, and the long-term increased risk of death is twofold.8,9 Of the patients who survive, only one-half walk independently again, and 20% must move to a long-term care facility.1 With regard to functional independence, 50% of patients recover prefracture capability of activities of daily living, and 25% recover full capability of their instrumental activities of daily living.10

Risk Factors

Sex and age are nonmodifiable risk factors that are highly associated with an increased risk of hip fracture (Table 11123). Women older than 85 years are 10 times more likely to sustain a hip fracture than those 60 to 69 years of age.11 A previous hip fracture, a family history of hip fracture, and low socioeconomic status are also associated with an increased risk.1215,24 Hip fracture clinical risk scores have been developed to identify high-risk patients in the primary care setting (see one example at http://www.aafp.org/afp/2007/0715/p273.html).3

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Table 1.

Risk Factors for Hip Fracture

Nonmodifiable

Age > 65 years11

Family history of hip fracture12

Female sex13

Low socioeconomic status14,15

Prior hip fracture12

Modifiable

Chronic medications1619

Levothyroxine (decreases bone density)

Loop diuretics (impair calcium absorption in kidneys)

Proton pump inhibitors (reduce calcium absorption)

Selective serotonin reuptake inhibitors/sedatives (increase risk of falls caused by sedation, postural hypotension)

Decreased bone mineral density (osteoporosis)20

Falls21

Reduced level of activity 22

Vitamin D deficiency 23


Information from references 11 through 23.

Table 1.

Risk Factors for Hip Fracture

Nonmodifiable

Age > 65 years11

Family history of hip fracture12

Female sex13

Low socioeconomic status14,15

Prior hip fracture12

Modifiable

Chronic medications1619

Levothyroxine (decreases bone density)

Loop diuretics (impair calcium absorption in kidneys)

Proton pump inhibitors (reduce calcium absorption)

Selective serotonin reuptake inhibitors/sedatives (increase risk of falls caused by sedation, postural hypotension)

Decreased bone mineral density (osteoporosis)20

Falls21

Reduced level of activity 22

Vitamin D deficiency 23


Information from references 11 through 23.

The modifiable risk factors for hip fracture include falls, decreased bone mineral density, reduced level of activity, and chronic medication use. A fall is the most significant risk factor for hip fracture, with 90% of fractures associated with a fall.21 Falls usually occur from a standing position and are associated with reduced protective reactions, slower reaction times, and reduced overall strength.25 A fall may create a fear of future falls, which leads to decreased activity and mobility, and increased tension and tightening of the muscles.26,27 Many older persons become less active as they age, which increases their risk of a fracture.22

A bone mineral density T-score less than –2.5, as measured by dual energy x-ray absorptiometry, is associated with an increased risk of fractures.20 Low bone mineral density scores are associated with inadequate calcium intake, vitamin D deficiency, and a family history of osteoporosis. Vitamin D levels less than 20 ng per mL (50 nmol per L) are associated with an increased risk of falls.23

Several medications are associated with an increased risk of falls or fractures.16 Psychoactive medications, including selective serotonin reuptake inhibitors and benzodiazepines, are most consistently associated with an increased risk of falls.16,17 Long-term use of proton pump inhibitors18 and higher dosages of levothyroxine are associated with an increased risk of fractures.19

History

Patients with hip fracture have pain in the groin and are unable to bear weight on the affected extremity. Pain may be referred to the distal femur or upper knee. Rarely, a patient may be able to walk with a cane, crutches, or a walker. If the patient is able to walk, there is typically worsening pain in the buttock or groin with weight bearing and ambulation. When an older person presents with hip pain after a fall, he or she should be treated as if a hip fracture has occurred, until proven otherwise.

Physical Examination

A stress fracture or a nondisplaced fracture may have no obvious deformity. However, most patients have some fracture displacement. As a result, when the patient lies in the supine position, the leg is held in external rotation and abduction, and appears shortened. Pain is elicited with rotation, such as with the log roll maneuver, which involves gentle internal and external rotation of the lower leg and thigh in the supine position. In addition, a fracture may be suspected if groin pain is elicited when applying an axial load to the affected extremity. Because of the pain and instability, patients are unable to perform an active straight leg raise. Ecchymosis is rarely present initially. Distal pulses and sensation should be assessed and documented. Patients should be examined for any additional associated injuries.

Diagnostic Testing

Plain radiography is the initial diagnostic test for hip fracture5 (Figures 1 through 5). A cross-table lateral view of the hip and an anteroposterior view of the pelvis are appropriate. The frog-leg view should be avoided; positioning the limb for this view results in severe pain and can cause displacement of a nondisplaced fracture or worsen a displaced fracture.28 If radiography is negative and a hip fracture is still suspected, magnetic resonance imaging or a bone scan should be performed.29 The imaging study should be evaluated for other possibilities, such as pelvic, stress, or pathologic fractures. Computed tomography may be used, although it may not detect trabecular bone injuries in osteoporotic fractures or reveal bone marrow edema surrounding the fracture line.28

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Figure 1.

Left intertrochanteric fracture (minimally displaced; arrows).


Figure 1.

Left intertrochanteric fracture (minimally displaced; arrows).

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Figure 2.

Open reduction and internal fixation following left intertrochanteric fracture.


Figure 2.

Open reduction and internal fixation following left intertrochanteric fracture.

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Figure 3.

Left subtrochanteric femur fracture with intertrochanteric extension (arrows).


Figure 3.

Left subtrochanteric femur fracture with intertrochanteric extension (arrows).

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Figure 4.

Right femoral neck fracture.


Figure 4.

Right femoral neck fracture.

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Figure 5.

Hemiarthroplasty following femoral neck fracture.


Figure 5.

Hemiarthroplasty following femoral neck fracture.

Management

Hip fractures are classified by location for prognostic implications. The two categories are extracapsular (intertrochanteric and subtrochanteric) and intracapsular (femoral head and neck); these are summarized in Table 2.30 The intertrochanteric region contains a large amount of cancellous bone and an adequate blood supply.30 As a result, fractures in this region typically heal well with open reduction and internal fixation, which involves surgery to reduce the displaced bone, followed by internal fixation of the fracture with plates or screws. Subtrochanteric fractures, however, have an increased need for intramedullary rods or nails (impact devices) and have a higher rate of impact failure, mainly because of the high stresses on this part of the femur. The femoral neck region has a thin periosteum, little cancellous bone, and a relatively poor blood supply.30 Consequently, fractures in the intracapsular region have a higher incidence of avascular necrosis, nonunion or malunion, and degenerative changes.

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Table 2.

Hip Fracture Classification and Characteristics

CategoryCharacteristicSignificance

Extracapsular

Large amount of cancellous bone and good blood supply

Typically heals well, although subtrochanteric has higher rate of impact device failure

Intertrochanteric

Subtrochanteric

Intracapsular

Little cancellous bone and relatively poor blood supply

Higher incidence of avascular necrosis, nonunion, malunion, and degenerative changes

Femoral head

Femoral neck


Information from reference 30.

Table 2.

Hip Fracture Classification and Characteristics

CategoryCharacteristicSignificance

Extracapsular

Large amount of cancellous bone and good blood supply

Typically heals well, although subtrochanteric has higher rate of impact device failure

Intertrochanteric

Subtrochanteric

Intracapsular

Little cancellous bone and relatively poor blood supply

Higher incidence of avascular necrosis, nonunion, malunion, and degenerative changes

Femoral head

Femoral neck


Information from reference 30.

Initially, care should focus on adequate analgesia and consultation with an orthopedic surgeon. Surgery is the most viable option for most patients. Nonsurgical interventions are reserved for patients with severe debilitation, unstable patients with major uncorrectable diseases, nonambulatory patients, or patients at the end stages of a terminal illness.31 However, some patients with impacted stable fractures may be considered for nonsurgical management.32

At initial presentation, the physician should address comorbidities and search for other injuries. When planning for surgery, patients should be assessed for bleeding risk. The presence of two of the following indicates a higher risk of bleeding: peritrochanteric fracture, initial hemoglobin level less than 12 g per dL (120 g per L), and age older than 75 years.33

The timing of surgery may affect the eventual outcome. Early surgery (within 24 to 48 hours) is prudent. This allows earlier mobilization and rehabilitation, which speeds functional recovery and decreases the risk of pneumonia, skin breakdown, deep venous thrombosis, and urinary tract infections.34 Earlier surgery is associated with reduced pain and shorter length of stay in the hospital.34 Patients with comorbidities have an increased risk of mortality; therefore, surgery may need to be delayed until 48 to 72 hours after the fracture to stabilize these conditions.35,36

Some physicians consider the use of traction, either skin or skeletal, before surgery. However, no data suggest a benefit.37 General anesthesia is most common for surgery, although spinal anesthesia may be chosen for some patients. Regional anesthesia may reduce postoperative confusion, yet no evidence suggests a clinically important difference between the two types of anesthesia.38

The consulting orthopedic surgeon determines the most appropriate surgical procedure. For femoral neck fractures, there is debate as to whether open reduction and internal fixation or arthroplasty is the better treatment. Arthroplasty replaces the acetabulum and the head of the femur, whereas hemiarthroplasty replaces only the femoral head. Internal fixation results in lower morbidity, including decreased blood loss and deep wound infection. However, lower reoperation rates have been noted with arthroplasty. Additionally, arthroplasty has a reduced risk of avascular necrosis and nonunion, and allows for earlier recovery.39,40 Intertrochanteric fractures may be treated with open reduction and internal fixation or with arthroplasty. There is insufficient evidence to determine which method is best.40,41

Trochanteric fractures (greater or lesser) are usually isolated avulsion fractures that typically occur in younger, active patients.42 These often heal with conservative, nonoperative management, unless significant displacement (greater than 1 cm) is noted, in which case an orthopedic surgeon should be consulted.43 Patients with nondisplaced fractures should not bear weight for three to four weeks, and are usually able to return to full activity within three to four months.

There is concern about the safety of metal-on-metal implants because of a higher failure rate compared with other bearings. Implants typically last the remainder of patients' lives; however, they have a failure rate of 12% (twice the industry average), resulting in corrective procedures (revision surgery) within five years.44 Recent data suggest that metal-on-metal bearing surfaces were not associated with an increased risk of cancer diagnoses in patients who were followed for seven years postoperatively, but the biologic effects of these metals is not fully known.44,45

Prophylaxis

Patients should receive prophylactic antibiotics within one to two hours before surgery, particularly against Staphylococcus aureus, the major pathogen of concern. Cefazolin, 1 to 2 g intravenously every eight hours, is typically used and recommended within one hour of surgery.46,47 If the patient is allergic, then 1 g of intravenous vancomycin should be administered every 12 hours and started within two hours of surgery. Antibiotics should be provided for 24 hours.48

Patients should receive thromboembolic prophylaxis, preferably with low-molecular-weight heparin, although studies comparing it with unfractionated heparin found no difference in bleeding rates.49 A guideline from the American College of Chest Physicians recommends starting low-molecular-weight heparin 12 hours or more preoperatively or postoperatively, rather than within four hours of surgery, to reduce the risk of bleeding.50 The guideline also recommends extending prophylaxis up to 35 days, rather than 10 to 14 days, to prevent nine additional venous thromboembolic events per 1,000 persons. Aspirin may be used, but is suboptimal and not preferred for protection against thromboembolic events.50

The use of intermittent pneumatic compression devices is suggested with anticoagulation until the patient is ambulatory on a regular basis.51 Routine use of graduated compression stockings is not recommended in patients who are able to tolerate anticoagulation.52

Long-Term Care

Because a previous hip fracture is a risk factor for another hip fracture and because bisphosphonates reduce that risk,22 patients should receive bisphosphonate therapy, regardless of bone mineral density results, unless contraindicated.53 Calcium (1,000 mg per day) and vitamin D (at least 800 IU per day) supplements are usually combined with bisphosphonate therapy. Risks associated with bisphosphonate therapy may increase after five years of use.54 Most patients benefit from a fall-prevention assessment, which includes removing home environmental hazards, reviewing medications, and assessing muscle strength, balance, and gait.55

All patients require rehabilitation therapy after hospital discharge, but the best strategies to improve mobility are not fully known.4,56 The location of the therapy (home, outpatient, or skilled nursing facility) depends on the patient's capabilities and motivation. Outpatient therapy may lead to improved functional status.57 The optimal duration of therapy is unclear. Early ambulation improves patient outcomes and may commence with unrestricted weight bearing. Any nutritional concerns should be addressed. In malnourished patients, protein supplements reduced medical complications.58

Displaced fractures have an increased risk of avascular necrosis.59 Therefore, periodic radiography should be performed following surgery. Depending on the health of the patient, the frequency of imaging should be individualized and discussed with the orthopedic surgeon. If avascular necrosis is suspected, magnetic resonance imaging may be necessary because plain radiography may not show changes for six months after avascular necrosis develops. Long-term care is essential to return the patient to the most functional state as soon as possible, ideally to prefracture level of activity.60

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BEST PRACTICES IN PREVENTIVE MEDICINE: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Do not use DEXA to screen for osteoporosis in women younger than 65 years or men younger than 70 years with no risk factors.

American Academy of Family Physicians

Do not routinely repeat DEXA scans more often than once every two years.

American College of Rheumatology


DEXA = dual energy x-ray absorptiometry.

Source: For supporting citations, see http://www.aafp.org/afp/cw-table.pdf. For more information on the Choosing Wisely Campaign, see http://www.aafp.org/afp/choosingwisely. To search Choosing Wisely recommendations relevant to primary care, see http://www.aafp.org/afp/recommendations/search.htm.

BEST PRACTICES IN PREVENTIVE MEDICINE: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Do not use DEXA to screen for osteoporosis in women younger than 65 years or men younger than 70 years with no risk factors.

American Academy of Family Physicians

Do not routinely repeat DEXA scans more often than once every two years.

American College of Rheumatology


DEXA = dual energy x-ray absorptiometry.

Source: For supporting citations, see http://www.aafp.org/afp/cw-table.pdf. For more information on the Choosing Wisely Campaign, see http://www.aafp.org/afp/choosingwisely. To search Choosing Wisely recommendations relevant to primary care, see http://www.aafp.org/afp/recommendations/search.htm.

Data Sources: A search of Essential Evidence Plus and the U.S. Preventive Services Task Force was completed for the following keywords: femoral diaphysis fracture, femoral neck fractures, and hip fractures. A literature search of PubMed was completed using the keyword hip fractures (classification, drug therapy, epidemiology, history, mortality, prevention and control, radiography). The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Search dates: February 19 and 20, 2012, and March 6, 2014.

The Authors

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KIM EDWARD LeBLANC, MD, PhD, FAAFP, FACSM, CAQSM, is the executive director of the Clinical Skills Evaluation Collaboration in Philadelphia, Pa. At the time the article was written, Dr. LeBlanc was the Bernard and Marie Lahasky Professor and head of the Department of Family Medicine at Louisiana State University School of Medicine, New Orleans....

HERBERT L. MUNCIE JR., MD, is a professor in the Department of Family Medicine at Louisiana State University School of Medicine.

LEANNE L. LeBLANC, MD, FAAFP, is in clinical practice affiliated with Temple University in Philadelphia.

Author disclosure: No relevant financial affiliations.

Address correspondence to Kim Edward LeBlanc, MD, 3750 Market St., Philadelphia, PA 19104. Reprints are not available from the authors.

The authors thank Christine L. Manalla for her editorial assistance in the writing and preparation of the manuscript.

Figures 1 through 5 courtesy of Drs. Michael L. Maristany, William Shaffer, and Michael Hanemann, Louisiana State University School of Medicine, New Orleans.

REFERENCES

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1. Landefeld CS. Goals of care for hip fracture: promoting independence and reducing mortality. Arch Intern Med. 2011;171(20):1837–1838....

2. Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB. Incidence and mortality of hip fractures in the United States. JAMA. 2009;302 (14):1573–1579.

3. Ebell MH. Predicting hip fracture risk in older women. Am Fam Physician. 2007;76(2):273–275.

4. Carriero FP, Christmas C. In the clinic. Hip fracture. Ann Intern Med. 2011;155(11):ITC6-1–ITC6-15.

5. Parker M, Johansen A. Hip fracture. BMJ. 2006;333(7557):27–30.

6. Brown CA, Starr AZ, Nunley JA. Analysis of past secular trends of hip fractures and predicted number in the future 2010–2050. J Orthop Trauma. 2012;26(2):117–122.

7. Dy CJ, McCollister KE, Lubarsky DA, Lane JM. An economic evaluation of a systems-based strategy to expedite surgical treatment of hip fractures [published correction appears in J Bone Joint Surg Am. 2011;93(14):1334]. J Bone Joint Surg Am. 2011;93(14):1326–1334.

8. LeBlanc ES, Hillier TA, Pedula KL, et al. Hip fracture and increased short-term but not long-term mortality in healthy older women. Arch Intern Med. 2011;171(20):1831–1837.

9. Haentjens P, Magaziner J, Colón-Emeric CS, et al. Meta-analysis: excess mortality after hip fracture among older women and men. Ann Intern Med. 2010;152(6):380–390.

10. Magaziner J, Simonsick EM, Kashner TM, Hebel JR, Kenzora JE. Predictors of functional recovery one year following hospital discharge for hip fracture: a prospective study. J Gerontol. 1990;45(3):M101–M107.

11. Samelson EJ, Zhang Y, Kiel DP, Hannan MT, Felson DT. Effect of birth cohort on risk of hip fracture: age-specific incidence rates in the Framingham Study. Am J Public Health. 2002;92(5):858–862.

12. Kanis JA, Johnell O, De Laet C, et al. A meta-analysis of previous fracture and subsequent fracture risk. Bone. 2004;35(2):375–382.

13. von Friesendorff M, Besjakov J, Akesson K. Long-term survival and fracture risk after hip fracture: a 22-year follow-up in women. J Bone Miner Res. 2008;23(11):1832–1841.

14. Quah C, Boulton C, Moran C. The influence of socioeconomic status on the incidence, outcome and mortality of fractures of the hip. J Bone Joint Surg Br. 2011;93(6):801–805.

15. Guilley E, Herrmann F, Rapin CH, Hoffmeyer P, Rizzoli R, Chevalley T. Socioeconomic and living conditions are determinants of hip fracture incidence and age occurrence among community-dwelling elderly. Osteoporos Int. 2011;22(2):647–653.

16. Huang AR, Mallet L, Rochefort CM, Eguale T, Buckeridge DL, Tamblyn R. Medication-related falls in the elderly: causative factors and preventive strategies. Drugs Aging. 2012;29(5):359–376.

17. Liu B, Anderson G, Mittmann N, To T, Axcell T, Shear N. Use of selective serotonin-reuptake inhibitors or tricyclic antidepressants and risk of hip fractures in elderly people. Lancet. 1998;351(9112):1303–1307.

18. Khalili H, Huang ES, Jacobson BC, Camargo CA Jr, Feskanich D, Chan AT. Use of proton pump inhibitors and risk of hip fracture in relation to dietary and lifestyle factors: a prospective cohort study. BMJ. 2012;344:e372.

19. Turner MR, Camacho X, Fischer HD, et al. Levothyroxine dose and risk of fractures in older adults: nested case-control study. BMJ. 2011; 342:d2238.

20. Lyles KW, Colón-Emeric CS, Magaziner JS, et al. HORIZON Recurrent Fracture Trial. Zoledronic acid and clinical fractures and mortality after hip fracture. N Engl J Med. 2007;357(18):1799–1809.

21. Grisso JA, Kelsey JL, Strom BL, et al. Risk factors for hip fracture in black women. The Northeast Hip Fracture Study Group. N Engl J Med. 1994;330(22):1555–1559.

22. Sato Y, Inose M, Higuchi I, Higuchi F, Kondo I. Changes in the supporting muscles of the fractured hip in elderly women. Bone. 2002;30(1):325–330.

23. Bischoff-Ferrari HA, Dawson-Hughes B, Staehelin HB, et al. Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trials. BMJ. 2009;339:b3692.

24. von Friesendorff M, McGuigan FE, Besjakov J, Akesson K. Hip fracture in men-survival and subsequent fractures: a cohort study with 22-year follow-up. J Am Geriatr Soc. 2011;59(5):806–813.

25. Sabick MB, Hay JG, Goel VK, Banks SA. Active responses decrease impact forces at the hip and shoulder in falls to the side. J Biomech. 1999;32(9):993–998.

26. Visschedijk J, Achterberg W, Van Balen R, Hertogh C. Fear of falling after hip fracture: a systematic review of measurement instruments, prevalence, interventions, and related factors. J Am Geriatr Soc. 2010;58(9):1739–1748.

27. Marks R, Allegrante JP, Ronald MacKenzie C, Lane JM. Hip fractures among the elderly: causes, consequences and control. Ageing Res Rev. 2003;2(1):57–93.

28. Sarwark JF, ed. Essentials of Musculoskeletal Care. 4th ed. Rosemont, Ill.: American Academy of Orthopaedic Surgeons; 2010:563–567.

29. Kirby MW, Spritzer C. Radiographic detection of hip and pelvic fractures in the emergency department. AJR Am J Roentgenol. 2010;194(4):1054–1060.

30. LaValle DG. Fractures and dislocations of the hip. In: Campbell WC, Canale ST, Beaty JH, eds. Campbell's Operative Orthopaedics. 11th ed. Phildelphia, Pa.: Mosby/Elsevier; 2008:3237–3283.

31. Raaymakers EL, Marti RK. Non-operative treatment of impacted femoral neck fractures. A prospective study of 170 cases. J Bone Joint Surg Br. 1991;73(6):950–954.

32. Handoll HH, Parker MJ. Conservative versus operative treatment for hip fractures in adults. Cochrane Database Syst Rev. 2008;(3):CD000337.

33. Dillon MF, Collins D, Rice J, Murphy PG, Nicholson P, Mac Elwaine J. Preoperative characteristics identify patients with hip fractures at risk of transfusion. Clin Orthop Relat Res. 2005;439:201–206.

34. Orosz GM, Magaziner J, Hannan EL, et al. Association of timing of surgery for hip fracture and patient outcomes. JAMA. 2004;291(14):1738–1743.

35. Vidán MT, Sánchez E, Gracia Y, Marañón E, Vaquero J, Serra JA. Causes and effects of surgical delay in patients with hip fracture: a cohort study. Ann Intern Med. 2011;155(4):226–233.

36. Brown CA, Boling J, Manson M, Owens T, Zura R. Relation between prefracture characteristics and perioperative complications in the elderly adult patient with hip fracture. South Med J. 2012;105(6):306–310.

37. Handoll HH, Queally JM, Parker MJ. Pre-operative traction for hip fractures in adults. Cochrane Database Syst Rev. 2011;(12):CD000168.

38. Parker MJ, Handoll HH, Griffiths R. Anaesthesia for hip fracture surgery in adults. Cochrane Database Syst Rev. 2004;(4):CD000521.

39. Parker MJ, Gurusamy K. Internal fixation versus arthroplasty for intracapsular proximal femoral fractures in adults. Cochrane Database Syst Rev. 2006;(4):CD001708.

40. Butler M, Forte ML, Joglekar SB, Swiontkowski MF, Kane RL. Evidence summary: systematic review of surgical treatments for geriatric hip fractures [published correction appears in J Bone Joint Surg Am. 2011;93(21):2032]. J Bone Joint Surg Am. 2011;93(12):1104–1115.

41. Parker MJ, Handoll HH. Replacement arthroplasty versus internal fixation for extracapsular hip fractures in adults. Cochrane Database Syst Rev. 2006;(2):CD000086.

42. Waters PM, Millis MB. Hip and pelvic injuries in the young athlete. Clin Sports Med. 1988;7(3):513–526.

43. Schipper IB, Steyerberg EW, Castelein RM, et al. Treatment of unstable trochanteric fractures. Randomised comparison of the gamma nail and the proximal femoral nail. J Bone Joint Surg Br. 2004;86(1):86–94.

44. Cohen D. How safe are metal-on-metal hip implants? BMJ. 2012; 344:e1410.

45. Smith AJ, Dieppe P, Porter M, Blom AW. Risk of cancer in first seven years after metal-on-metal hip replacement compared with other bearings and general population: linkage study between the National Joint Registry of England and Wales and hospital episode statistics. BMJ. 2012;344:e2383.

46. Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med. 1992;326(5):281–286.

47. Bratzler DW, Dellinger EP, Olsen KM, et al. American Society of Health-System Pharmacists; Infectious Diseases Society of America; Surgical Infection Society; Society for Healthcare Epidemiology of America. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195–283.

48. Gillespie WJ, Walenkamp GH. Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures. Cochrane Database Syst Rev. 2010;(3):CD000244.

49. Handoll HH, Farrar MJ, McBirnie J, Tytherleigh-Strong G, Milne AA, Gillespie WJ. Heparin, low molecular weight heparin and physical methods for preventing deep vein thrombosis and pulmonary embolism following surgery for hip fractures. Cochrane Database Syst Rev. 2002;(4):CD000305.

50. Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 suppl):e278S–e325S.

51. Westrich GH, Rana AJ, Terry MA, Taveras NA, Kapoor K, Helfet DL. Thromboembolic disease prophylaxis in patients with hip fracture: a multimodal approach. J Orthop Trauma. 2005;19(4):234–240.

52. Cohen AT, Skinner JA, Warwick D, Brenkel I. The use of graduated compression stockings in association with fondaparinux in surgery of the hip. A multicentre, multinational, randomised, open-label, parallel-group comparative study. J Bone Joint Surg Br. 2007;89(7):887–892.

53. National Osteoporosis Foundation. NOF's Clinician's Guide to Prevention and Treatment of Osteoporosis. http://nof.org/hcp/clinicians-guide. Accessed March 13, 2014.

54. Black DM, Bauer DC, Schwartz AV, Cummings SR, Rosen CJ. Continuing bisphosphonate treatment for osteoporosis—for whom and for how long? N Engl J Med. 2012;366(22):2051–2053.

55. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012;(9):CD007146.

56. Handoll HH, Sherrington C, Mak JC. Interventions for improving mobility after hip fracture surgery in adults. Cochrane Database Syst Rev. 2011;(3):CD001704.

57. Carmeli E, Sheklow SL, Coleman R. A comparative study of organized class-based exercise programs versus individual home-based exercise programs for elderly patients following hip surgery. Disabil Rehabil. 2006;28(16):997–1005.

58. Avenell A, Handoll HH. Nutritional supplementation for hip fracture aftercare in older people. Cochrane Database Syst Rev. 2010;(1): CD001880.

59. Bachiller FG, Caballer AP, Portal LF. Avascular necrosis of the femoral head after femoral neck fracture. Clin Orthop Relat Res. 2002;(399): 87–109.

60. Hung WW, Egol KA, Zuckerman JD, Siu AL. Hip fracture management: tailoring care for the older patient. JAMA. 2012;307(20):2185–2194.



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