Hip Fracture: Diagnosis, Treatment, and Secondary Prevention



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

This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz Questions.

  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

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

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

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

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

The Authors

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.

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