A few years ago, during my first year as a pain management nurse practitioner, I took care of a patient who constantly complained of chronic lower back pain. On one of her follow-up visits, she complained of a new left lower back pain that increased while standing and walking. She reported that the pain was unbearable at times, and she was having difficulties performing normal daily activities. Since her pain was new, I sent her for new X-rays of her lower back and her left hip. Her images were negative. However, on her next visit when she crossed her legs during a physical assessment, she screamed with a loud yelp. She was immediately sent for an MRI of her lower back and hips. The MRI results of her left hip indicated a non-displaced hip fracture. She was referred to an orthopedic surgeon for consultation and treatment. Fortunately, since the patient was in good health, no surgery was required.

What is a hip fracture?

● A hip fracture is a break in the upper portion of the femur (thigh bone).
● A non-displaced hip fracture (bone has cracked but is not separated) of the femoral neck may not be painful at first, and the patient may still be able to move the affected leg and bear weight even if painful.
● A minimally displaced fracture means that the bone has shifted along the break.
● A displaced fracture means that the bone has become completely detached.
● In some instances, patients may not have symptoms at all.
● Most hip fractures occur in elderly people whose bones have become weakened by osteoporosis.
● When hip fractures occur in younger people, it is usually from a traumatic event such as a fall or motor vehicle accident (MVA).
● Hip fractures can occur in four separate areas of the femur and are identified according to how far the bone has moved from the original position.
o These areas are the femur neck, the intertrochanteric area, the subtrochanteric area, and the femoral head.
o Intertrochanter and femoral neck fractures are the most common types of hip fractures.
o Femoral head fractures are extremely rare and are the result of a high impact traumatic event that may result in a fracture dislocation of the hip.
o Stress fractures are from repeated impacts that occur in the femoral neck and are often experienced by long distance runners.

Signs and Symptoms

Signs and symptoms of a fracture may include the following:

▪ acute pain located in the groin and upper part of the thigh
▪ swelling
▪ bruising
▪ the hip appears deformed
▪ inability to stand
▪ inability to bear weight on the affected leg
▪ inability to move the upper part of a leg or knee
▪ the affected leg may be drawn up appearing to be shorter than the opposite leg and may be twisted either internally or externally

Other Effects

▪ Walking and standing may cause the fracture to spread, which will increase the pain significantly.
▪ The pain from a hip fracture can be so debilitating that patients may hurt too much to move and may become bed bound.

If you suspect either yourself or someone else of having a broken hip, call 911 and go directly to the ER by ambulance. Treatment and workup will begin immediately by an ER physician and orthopedic surgeon.

Diagnosis

● Images performed will include an X-ray to assess the bone structure.
● A magnetic resonance imaging (MRI) will assess tissue damage and undetected fractures not seen on the X-rays.
● A computer topography (CT) scan may be included to observe a detailed cross section image of the hip.

Treatment

● Most surgeries will take place within 1 to 2 days of the injury.
● If the fracture is nondisplaced, then the injury may be treated without surgery in a healthy patient.
● Recovery depends on the type of hip fracture and treatment.
● When pins and screws are required to secure the bone, the patient should try to resume walking with a walker as soon as he or she is permitted by the orthopedic surgeon.
o Treating the fracture and getting the patient out of the bed as soon as possible helps prevent medical complications such as bed sores, blood clots, and pneumonia.
o Prolonged bed rest makes rehab and recovery exceedingly difficult.
o Therefore, rehab begins after surgery.
o Some patients go home a few days after surgery and will receive home physical therapy until they are strong enough to go to therapy at an outside facility.
o Others, usually the elderly or patients who do not have a caregiver at home, will go to short-term care facilities for rehab and stay until they can walk independently and manage their daily activities.

hip-fracture
Figure 1: Types of hip fracture

References

American Academy of Orthopedic Surgeons. (2020). Hip Fractures. https://orthoinfo.aaos.org/en/diseases–conditions/hip-fractures/.

Double Brain. (2020). [Illustration]. Types of hip fracture. Non-displaced intracapsular, extracapsular trochanteric and subtrochanteric fractures. https://www.shutterstock.com/image-vector/types-hip-fracture-nondisplaced-intracapsular-extracapsular-789080593.

Harvard Health Publishing. (2020). Hip Fracture. https://www.health.harvard.edu/a_to_z/hip-fracture-a-to-z.

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