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- Femoral neck, subcapital, or transcervical
- Intracapsular femoral neck fractures may disrupt blood supply, resulting in avascular necrosis (1).
- Intertrochanteric: fracture between the neck of the femur and the lesser trochanter
- Subtrochanteric: fracture below the lesser trochanter
- 90% caused by a low-impact fall or twist on planted foot (2)
- System(s) affected: musculoskeletal, neurologic, vascular
- Synonym(s): subcapital fracture; trochanteric fracture; femoral neck fracture
- Predominant age: 80% occur in patients ≥60 years.
- Average age: 80 years
- 80% of all hip fractures are in women.
- Hip fractures in men are associated with greater mortality (up to 38% in the 1st year).
- In the United States, 320,000 elderly patients sustain hip fractures annually—this is expected to increase as the population ages (3).
- In the United States, women >75 years; 1% annual incidence
- 4.5 million people worldwide are disabled from hip fractures each year with an estimated 21 million people in the next 40 years (4).
Lifetime prevalence: 20% for women; 10% for men (1)
Etiology and Pathophysiology
Increased bone resorption increases risk of osteoporosis and hip fracture.
- Direct blunt trauma
- Pathologic conditions (e.g., bone cancer)
- Stress fracture caused by overtraining
- Avascular necrosis
No known genetic factor
- Age >65 years
- Female sex
- Low socioeconomic status
- History of previous fracture (>50 years) or history of a low-impact fracture
- Family history of osteoporosis
- Gait, sensory, or visual impairment
- Low body mass or deconditioning
- Sedentary lifestyle (on feet <4 hours a day)
- Environmental hazards, such as throw rugs, loose cords, or inadequate lighting in the home
- Foot deformity
- Cigarette smoking
- ≥3 alcoholic beverages a day
- Osteoporosis: low bone mineral density (BMD)
- Osteoarthritis or rheumatoid arthritis
- Hyperthyroidism or diabetes mellitus
- Metastatic bone cancer
- Severe renal disease with secondary hyperparathyroidism
- Polypharmacy (use of ≥4 chronic medications)
- Glucocorticoid use
- Psychoactive medications (SSRIs, benzodiazepines, anticonvulsants)
- Long-term proton pump inhibitor therapy (high doses)
- High-dose levothyroxine
- Antihypertensives: The first 45 days after initiating treatment in the elderly have the highest risk of orthostatic syncope/fall.
Minimize risk factors:
- Address disordered eating or overtraining if concern for female athlete triad.
- Fall prevention
- Avoid long-acting sedatives and hypnotics in the elderly.
- Use ambulatory aids (canes or walkers) if patient has unsteady gait.
- Use sturdy rails in bathrooms, stairs, or ramps; avoid throw rugs and slippery surfaces; ensure adequate lighting. Home safety assessment can reduce falls by 39% (5)[A].
- Exercise with balance training or tai chi reduces the risk for falls (5)[A].
- Annual vision exams for elderly
- Minimize polypharmacy.
- Prophylactic treatment for osteoporosis (3)[C]:
- Ultrasound (US) and/or BMD measurements quantitatively assess bone health; at age 65 years (age 60 years if risk factors)
- Treatment of osteoporosis
- Treatment with bisphosphonates is successful only if combined with weight-bearing exercise and vitamin D supplementation.
- Bisphosphonates (adverse effect, esophagitis)
- Alendronate (Fosamax): 35 (prevention) to 70 mg (management) PO weekly
- Risedronate (Actonel): 150 mg PO monthly
- Ibandronate (Boniva): 150 mg PO monthly
- Zoledronic acid (Reclast): 5 mg IV yearly
- Estrogen replacement prevents decrease of BMD but has other risks (i.e., increased venous thromboembolism [VTE] and cancer risks).
- Selective estrogen-receptor modulators decrease risk of vertebral fractures but increases VTE risk.
- Parathyroid hormone (teriparatide [Forteo]) decreases the risk of vertebral fractures; treatment is limited by long-term safety concerns to 2 years.
- RANKL inhibitor: denosumab (Prolia) 60 mg SC every 6 months
Commonly Associated Conditions
- Metastatic malignancy
- Impaired cognition
- Gait instability
- Female athlete triad—low caloric intake, menstrual dysfunction, decreased BMD (stress fractures)