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Hip Fracture in Emergency Medicine

  • Author: Moira Davenport, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
 
Updated: Feb 28, 2016
 

Practice Essentials

Hip fracture occurs in approximately 341,000 persons in the United States each year.[1] The rate of hip fracture increases with age, doubling every 5-6 years after age 60 years.[1] See the image below.

Femoral neck fractures. Top diagram is a nondispla Femoral neck fractures. Top diagram is a nondisplaced, or incomplete, femoral neck fracture. Bottom diagram is an impacted femoral neck fracture.

Guidelines for management of hip fracture in the elderly

The American Academy of Orthopaedic Surgeons released new guidelines on the management of hip fractures in patients over the age of 65. Recommendations supported by strong evidence include the following:[2, 3]

  • Regional analgesia can be used to improve preoperative pain control in patients with hip fracture.
  • In patients undergoing hip fracture surgery, similar outcomes can be achieved with general or spinal anesthesia.
  • Arthroplasty should be used for patients with unstable (displaced) femoral neck fractures.
  • Use of a cephalomedullary device is recommended for the treatment of patients with subtrochanteric or reverse obliquity fractures.
  • In asymptomatic postoperative hip fracture patients, a blood transfusion threshold of no higher than 8g/dl should be used.
  • Intensive post-discharge physical therapy improves functional outcomes.
  • Use of an interdisciplinary care program in hip fracture patients with mild to moderate dementia improves functional outcomes.
  • Multimodal pain management should be used after hip fracture surgery.

Signs and symptoms

In elderly patients, hip fracture most often results from a simple fall. The patient typically complains of pain and inability to move the hip.

With stress fractures in young athletes and nondisplaced fractures, the patient may complain of pain in hip or knee and may be ambulatory.

On physical examination, the anatomical position of the extremity provides useful clues to the type of injury, as follows:

  • Femoral head fracture: Posterior dislocation is most common (eg, a dashboard injury), in which case the extremity appears adducted and internally rotated; with anterior dislocation, the extremity is abducted and externally rotated
  • Femoral neck fracture: With partial or completely displaced fractures (types 3 and 4, respectively), the patient has severe pain and lies with the extremity slightly shortened, abducted, and externally rotated; with a stress fracture or severe impaction fractures (types 1 and 2, respectively), the only physical findings may be minor pain with little or no limitation in range of motion
  • Trochanteric fracture: With a greater trochanteric fracture, the patient presents with pain, especially with abduction and extension; no deformity may be apparent, but pressure through greater trochanters will result is pain; with a lesser trochanteric fracture, pain occurs during flexion and internal rotation
  • Intertrochanteric fracture: The extremity appears shortened and significantly externally rotated, in contrast to the minimal deformities associated with femoral neck fractures; pain, hip edema and ecchymosis, and pain with any movement may also be noted
  • Subtrochanteric fracture: The proximal femur usually is held in flexion and external rotation

See Clinical Presentation for more detail.

Diagnosis

On plain radiographs, anteroposterior (AP) and lateral views demonstrate most hip fractures.

For patients in whom femoral neck fracture is strongly suspected but standard x-ray findings are negative, an AP view with internal rotation provides a better view of the femoral neck.

If standard radiograph findings are negative and hip fracture still is strongly suspected, MRI and bone scan have high sensitivity in identifying occult injuries; MRI is 100% sensitive in patients with equivocal radiographic findings.

See Workup for more detail.

Management

Femoral head fractures

Treatment of type 1 femoral head fractures is as follows:

  • Obtain orthopedic consultation in the ED
  • Reduce dislocated femoral head and fracture fragment as soon as possible to avoid avascular necrosis
  • Small fracture fragments may need to be removed
  • If a single attempt at closed reduction fails, open reduction and internal fixation (ORIF) is the next treatment of choice

For type 2 femoral head fractures, early orthopedic consultation for admission and arthroplasty is recommended.

Femoral neck fractures

  • Type 1: Some practitioners handle these fractures nonoperatively with initial immobilization in selected patients, while others prefer operative treatment in all patients
  • Types 2, 3, and 4: Management usually includes ORIF or arthroplasty; however, some impacted fractures can be treated conservatively; early orthopedic consultation is recommended

Trochanteric fractures

  • Type 1: Management is most often conservative, and orthopedic consultation is recommended
  • Type 2: These fractures usually are treated with ORIF, except in older or debilitated patients in whom conservative treatment is appropriate

Intertrochanteric fractures

  • Apply traction or a traction splint
  • Note the potential for significant blood loss; IV fluid resuscitation is generally recommended
  • Stable and unstable fractures usually are treated with ORIF unless the patient is not an operative candidate for other reasons
  • Early orthopedic consultation is recommended

Subtrochanteric fractures

  • Significant hemorrhage is common, and IV fluid resuscitation is frequently necessary
  • ED application of traction or traction splint is necessary
  • Properly evaluate the entire patient to rule out associated severe injuries
  • Consult orthopedic surgeon for admission and ORIF for most patients

See Treatment and Medication for more detail.

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Background

Fractures of the hip are relatively common in adults and often lead to devastating consequences. Disability frequently results from persistent pain and limited physical mobility. Hip fractures are associated with substantial morbidity and mortality; approximately 15-20% of patients die within 1 year of fracture. Interestingly, morbidity and mortality in those older than 90 years sustaining a hip fracture were not found to be statistically higher than others in the same age group without such an injury.

Most hip fractures occur in elderly individuals as a result of minimal trauma, such as a fall from standing height. In young, healthy patients, these fractures usually result from high-velocity injuries, such as motor vehicle collisions or falls from significant heights. Despite comparable fracture locations, the differences in low- and high-velocity injuries in older versus younger patients outweigh their similarities. High-velocity injuries are more difficult to treat and are associated with more complications than minor trauma injuries.

Egan et al identified several risk factors associated with the risk of a hip fracture patient sustaining a second fall.[4] Increasing age, cognitive impairment, decreasing bone mass, decreasing depth perception, decreased mobility, dizziness, and a poor/fair self-perceived state of health were all linked to increasing likelihood of sustaining a second fall and thus a possible second hip fracture.

Several recent studies have identified additional risk factors for hip fracture. Sennerby et al identified generalized cardiovascular disease as a significant risk factor for hip fracture,[5] while Carbone et al determined that heart failure is a specific risk for hip fracture[6] . Specific characteristics in men were evaluated to determine the relationship to hip fracture; smoking, tall stature, stroke, and dementia were found to increase the risk of hip fracture, while non–work-related physical activity and high BMI were found to be protective.[7] Kettunen at al studied previously elite male athletes and found that these individuals sustained hip fractures at significantly older ages than their less active counterparts.[8]

Two medication classes have also been implicated in hip fractures. Nursing home patients on antipsychotic medications and HIV-positive patients on protease inhibitor therapy were more likely to sustain fractures than those on other agents.[9, 10]

For more information, see Medscape's Fracture Resource Center.

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Skeletal Anatomy

The hip joint is a large multiaxial ball-and-socket synovial joint, enclosed by a thick articular capsule. The hip joint is designed for stability and a wide range of movement. Next to the shoulder, it is the most moveable of all joints. During standing, the entire weight of the upper body is transmitted to the heads and necks of the femurs. The round head of the femur articulates with the cuplike acetabulum. The depth of the acetabulum is increased by the reinforcing fibrocartilaginous labrum, which "grasps" the femoral head, covering more than half of it. Articular cartilage covers the entire head of the femur, except for the pit (fovea) for the ligament of the femoral head.

The strong, loose fibrous capsule permits free movement of the hip joint, attaching proximally to the acetabulum and transverse acetabular ligament. The fibrous capsule attaches distally to the neck of the femur only anteriorly at the intertrochanteric line and root of the greater trochanter. Posteriorly, the fibrous capsule crosses to the neck proximal to the intertrochanteric crest without attaching to it. The fibrous capsule thickens to form 3 ligaments of the hip joint: the Y-shaped iliofemoral ligament (of Bigelow), the pubofemoral ligament, and the ischiofemoral ligament.

The hip joint is further supported by the femur and the muscles that cross the joint; this bone and these muscles are the largest and most powerful in the human body. The anatomy of the femur is shown below.

Shenton line and angular anatomy of the femur. Shenton line and angular anatomy of the femur.

The length, angle, and narrow circumference of the femoral neck permit substantial range of motion at the hip but also subject the femoral neck to incredible shearing forces. A fracture results when these forces exceed the strength of the bone. The intertrochanteric line is an oblique line that connects the greater and lesser trochanters, dividing the femoral neck from the shaft. Hip fractures involve fracture of any aspect of the proximal femur, from the head to the first 4-5 cm of the subtrochanteric area.

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Vascular Supply

The vascular supply to the proximal femur is tenuous and provided largely by two sources.

Branches of the medial and lateral circumflex femoral arteries, usually branches of the deep femoral artery, ascend on the posterior aspect of the femoral neck in the retinacula (reflections of the capsule along the neck of the femur toward the head). The branches of the medial and lateral circumflex arteries perforate the bone just distal to the head of the femur where they anastomose with branches from the foveal artery and with medullary branches located within the shaft of the femur.

The ligament of the head of the femur usually contains the artery of the ligament of the head of the femur (foveal artery), a branch of the obturator artery. The foveal artery enters the head of the femur only when the center of the ossification has extended to the pit (fovea) for the ligament of the head, around age 11-13 years. This anastomosis persists even in advanced age but is never established in 20% of the population.

Femoral neck fractures often disrupt the blood supply to the head of the femur. The medial circumflex artery supplies most of the blood to the head and neck of the femur and is often torn in femoral neck fractures. In some cases, the blood supplied by the foveal artery may be the only blood received by the proximal fragment of the femoral head. If the blood vessels are ruptured, the fragment of bone may receive no blood and undergo avascular necrosis (AVN).

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Classifying Fractures

Hip fractures can be classified based on their relation to the hip capsule (intracapsular and extracapsular), geographic location (head, neck, trochanteric, intertrochanteric, and subtrochanteric), and degree of displacement. Higher-grade displacement implies worse prognosis. Fractures of the femoral head and neck are intracapsular, whereas those of the trochanteric, intertrochanteric, and subtrochanteric regions are extracapsular. The treatment as well as the prognosis for successful union and restoration of normal function varies considerably with fracture type.

Intracapsular hip fractures, like all other intracapsular fractures, frequently have complicated healing. The thick capsule that surrounds these fractures separates them from adjacent soft tissue and capillaries, leading to impaired callous formation. Thus, nonunion and AVN are added complications of these fractures.

Femoral head fractures

Isolated femoral head fractures are rare and are usually associated with hip dislocations. Superior femoral head fractures normally are associated with anterior dislocations, while inferior femoral head fractures are associated with posterior dislocations. They are usually best appreciated on postreduction radiographs for hip dislocations. Fractures of the femoral head are more common in younger patients as a result of major trauma, which is more likely to cause femoral neck fractures in older patients.

  • Type 1 - Single fragment fractures (see image below)
  • Type 2 - Comminuted fractures (see image below)
    Femoral head fractures. Top diagram is a single-fr Femoral head fractures. Top diagram is a single-fragment femoral head fracture. Bottom diagram is a comminuted femoral head fracture.

Femoral neck fractures

These are rare among younger patients but are commonly seen in older adults, most often secondary to osteoporosis or osteomalacia. These fractures usually result from minor trauma with falls accounting for 90%, or torsion. From proximal to distal, femoral neck fractures can be further delineated as subcapital, transcervical, and basicervical, all of which are intracapsular and associated with potential disruption of the vascular supply. The incidence of avascular necrosis (AVN) is up to 15% in nondisplaced fractures and increases to nearly 90% with untreated, completely displaced fractures.

  • Type 1 - Stress fractures or incomplete fractures (see image below)
  • Type 2 - Impacted fractures (see image below)
    Femoral neck fractures. Top diagram is a nondispla Femoral neck fractures. Top diagram is a nondisplaced, or incomplete, femoral neck fracture. Bottom diagram is an impacted femoral neck fracture.
  • Type 3 - Partially displaced fractures (see image below)
    Partially displaced femoral neck fracture. Partially displaced femoral neck fracture.
  • Type 4 - Completely displaced or comminuted fractures (see image below)
    Completely displaced femoral neck fracture. Completely displaced femoral neck fracture.

Trochanteric fractures

Greater trochanteric fractures usually result from avulsion injuries at the insertion of the gluteus medius. Lesser trochanteric fractures may be caused by avulsion injuries of the iliopsoas secondary to forceful contraction. These are most common in children and young athletes (eg, dancers, gymnasts).

  • Type 1 - Nondisplaced fractures (see image below)
  • Type 2 - Displaced fractures; >1 mm displacement for fractures of the greater trochanter and >2 mm displacement for fractures of the lesser trochanter (see image below)
    Trochanteric fractures. Top diagram is a nondispla Trochanteric fractures. Top diagram is a nondisplaced trochanteric fracture. Bottom diagram is a displaced trochanteric fracture.

Intertrochanteric fractures

These extracapsular fractures occur in a line between the greater and lesser trochanters, generally in elderly patients and women secondary to osteoporosis.

  • Type 1 - Single fracture line without displacement; stable (see image below)
  • Type 2 - Multiple fracture lines (comminution) with displacement; unstable (see image below)
    Intertrochanteric fractures. Top diagram is a sing Intertrochanteric fractures. Top diagram is a single fracture line intertrochanteric fracture. Bottom diagram is a displaced, or multiple fracture line, intertrochanteric fracture.

Subtrochanteric fractures

These fractures have a bimodal age distribution and are seen most often in those aged 20-40 years in association with high-energy trauma and in patients older than 60 years secondary to falls on osteoporotic bones.

  • Stable: Bony contact of medial and posterior femoral cortices
  • Unstable
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Frequency

United States

In the United States, hip fracture occurs in approximately 341,000 persons each year.[1] The rate of hip fracture increases with age, doubling every 5-6 years after age 60 years.[1] The fracture rate does decrease slightly after age 85 years.[1] Nearly half of all hip fractures occur in adults older than 80 years. Hip fracture at a young age is rare and is usually the result of a high-velocity injury or, rarely, secondary to bone pathology.

International

The US frequency of hip fracture, when age and sex are adjusted, ranks the highest in the world. Western Europe and New Zealand also have reported high rates, with the lowest rates occurring in the South African Bantu people and in East Asian countries, where the incidence of osteoporosis is low.

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Mortality/Morbidity

Reported overall mortality rate of hip fractures is 15-20%, yet in older persons this can increase to 36% over the year following hip fracture. Rate of mortality is greatest in the first few months following injury but remains high for up to 1 year. It then returns to the same rate for age- and sex-matched people without hip fracture. Surgical delay independently affects mortality. Patients for whom surgery is delayed for 2 days or more, have a 17% higher mortality rate at 1 month. A subsequent study showed increased mortality but decreased readmission rate in those repaired more than 4 days from the time of injury.[11] Also, general anesthesia was associated with higher morbidity than was spinal/epidural anesthesia.[11]

Morbidity associated with hip fracture is staggering, especially in older persons. Morbidity from immobilization includes development of deep vein thrombosis, pulmonary embolism, pneumonia, and muscular deconditioning. Morbidity from surgical procedures includes complications of anesthesia, postoperative infection, loss of fixation, malunion or nonunion, as well as the complications associated with immobilization as outlined above. As many as 20% of patients return to the emergency department in the year following a hip fracture with concerns relating to the morbidity of the initial fracture.[12]

Surgical delay of greater than 48 hours has also been shown to increase morbidity and mortality.[13]

Hip fracture resulting from major trauma often is associated with other bone and soft-tissue injuries, intra-abdominal and intrapelvic injuries, major blood loss, head and neck injuries, and other extremity injuries. Morbidity associated with an inability to return to a prefracture level of mobility results in a loss of independence, reduction in quality of life, and depression, particularly in older persons.

Race

The incidence of hip fracture is 2-3 times greater in whites than in nonwhites, primarily because of the increased rate of osteoporosis in whites. This difference is not unique to females; African American and Asian men have been found to have significantly higher bone densities than their Caucasian and Latino counterparts.[14]

Sex

Rate of hip fracture is 2-3 times greater in women than in men. At least 75% of all hip fractures occur in women. The lifetime risk of hip fracture in white women and men is 15% and 5%, respectively. Femoral neck fractures are more common in women than in men by about 4:1, while intertrochanteric fractures are more common in women than in men by about 5:1. See the Fracture Index WITH known Bone Mineral Density (BMD) calculator.

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Epidemiology

The incidence of hip fracture is 2-3 times greater in whites than in nonwhites, primarily because of the increased rate of osteoporosis in whites. This difference is not unique to females; African American and Asian men have been found to have significantly higher bone densities than their Caucasian and Latino counterparts.[14]

Rate of hip fracture is 2-3 times greater in women than in men. At least 75% of all hip fractures occur in women. The lifetime risk of hip fracture in white women and men is 15% and 5%, respectively. Femoral neck fractures are more common in women than in men by about 4:1, while intertrochanteric fractures are more common in women than in men by about 5:1.

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Contributor Information and Disclosures
Author

Moira Davenport, MD Attending Physician, Departments of Emergency Medicine and Orthopedic Surgery, Allegheny General Hospital

Moira Davenport, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eric L Legome, MD Chief, Department of Emergency Medicine, Kings County Hospital Center; Professor Clinical, Department of Emergency Medicine, State University of New York Downstate College of Medicine

Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, Council of Emergency Medicine Residency Directors, American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Francis Counselman, MD, FACEP Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School

Francis Counselman, MD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Norfolk Academy of Medicine, Association of Academic Chairs of Emergency Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Gigi R Madore, MD, and Geoff Winkley, MD, to the development and writing of this article.

References
  1. Kim SH, Meehan JP, Blumenfeld T, Szabo RM. Hip fractures in the United States: Nationwide emergency department sample, 2008. Arthritis Care Res. Dec 2011.

  2. Barclay, L. New Guidelines Address Hip Fractures in Older Adults. Medscape Medical News. Available at http://www.medscape.com/viewarticle/831690. Accessed: September 15, 2014.

  3. [Guideline] American Academy of Orthopaedic Surgeons. Management of Hip Fractures in the Elderly: Evidence- Based Clinical Practice Guideline. Available at http://www.aaos.org/research/guidelines/HipFxGuideline.pdf. Accessed: September 14, 2014.

  4. Egan M, Jaglal S, Byrne K, Wells J, Stolee P. Factors associated with a second hip fracture: a systematic review. Clin Rehabil. 2008 Mar. 22(3):272-82. [Medline].

  5. Sennerby U, Melhus H, Gedeborg R, Byberg L, Garmo H, Ahlbom A, et al. Cardiovascular diseases and risk of hip fracture. JAMA. 2009 Oct 21. 302(15):1666-73. [Medline].

  6. Carbone L, Buzkova P, Fink HA, Lee JS, Chen Z, Ahmed A, et al. Hip fractures and heart failure: findings from the Cardiovascular Health Study. Eur Heart J. 2010 Jan. 31(1):77-84. [Medline]. [Full Text].

  7. Trimpou P, Landin-Wilhelmsen K, Oden A, Rosengren A, Wilhelmsen L. Male risk factors for hip fracture-a 30-year follow-up study in 7,495 men. Osteoporos Int. 2010 Mar. 21(3):409-16. [Medline].

  8. Kettunen JA, Impivaara O, Kujala UM, Linna M, Maki J, Raty H, et al. Hip fractures and femoral bone mineral density in male former elite athletes. Bone. 2010 Feb. 46(2):330-5. [Medline].

  9. Jalbert JJ, Eaton CB, Miller SC, Lapane KL. Antipsychotic use and the risk of hip fracture among older adults afflicted with dementia. J Am Med Dir Assoc. 2010 Feb. 11(2):120-7. [Medline].

  10. Calmy A, Fux CA, Norris R, Vallier N, Delhumeau C, Samaras K, et al. Low bone mineral density, renal dysfunction, and fracture risk in HIV infection: a cross-sectional study. J Infect Dis. 2009 Dec 1. 200(11):1746-54. [Medline].

  11. Radcliff TA, Henderson WG, Stoner TJ, Khuri SF, Dohm M, Hutt E. Patient risk factors, operative care, and outcomes among older community-dwelling male veterans with hip fracture. J Bone Joint Surg Am. 2008 Jan. 90(1):34-42. [Medline].

  12. Bryson DJ, Knapp S, Middleton RG, Faizi M, Bhansali H, Uzoigwe CE. Representation to the accident and emergency department within 1-year of a fractured neck of femur. J Orthop Surg Res. Dec 2011. 6:63.

  13. Maggi S, Siviero P, Wetle T, Besdine RW, Saugo M, Crepaldi G. A multicenter survey on profile of care for hip fracture: predictors of mortality and disability. Osteoporos Int. 2010 Feb. 21(2):223-31. [Medline].

  14. Marshall LM, Zmuda JM, Chan BK, Barrett-Connor E, Cauley JA, Ensrud KE, et al. Race and ethnic variation in proximal femur structure and BMD among older men. J Bone Miner Res. 2008 Jan. 23(1):121-30. [Medline].

  15. Wilczek ML, Kälvesten J, Algulin J, Beiki O, Brismar TB. Digital X-ray radiogrammetry of hand or wrist radiographs can predict hip fracture risk-a study in 5,420 women and 2,837 men. Eur Radiol. 2013 May. 23(5):1383-91. [Medline]. [Full Text].

  16. Kirby MW, Spritzer C. Radiographic detection of hip and pelvic fractures in the emergency department. AJR Am J Roentgenol. 2010 Apr. 194(4):1054-60. [Medline].

  17. O'Malley NT, Blauth M, Suhm N, Kates SL. Hip fracture management, before and beyond surgery and medication: a synthesis of the evidence. Arch Orthop Trauma Surg. Nov 2011. 131:1519-27.

  18. Ritcey B, Pageau P, Woo MY, Perry JJ. Regional Nerve Blocks For Hip and Femoral Neck Fractures in the Emergency Department: A Systematic Review. CJEM. 2016 Jan. 18 (1):37-47. [Medline].

  19. Dickman E, Pushkar I, Likourezos A, Todd K, Hwang U, Akhter S, et al. Ultrasound-guided nerve blocks for intracapsular and extracapsular hip fractures. Am J Emerg Med. 2015 Dec 14. [Medline].

  20. Groot L, Dijksman LM, Simons MP, Zwartsenburg MM, Rebel JR. Single Fascia Iliaca Compartment Block is Safe and Effective for Emergency Pain Relief in Hip-fracture Patients. West J Emerg Med. 2015 Dec. 16 (7):1188-93. [Medline].

  21. Bischoff-Ferrari HA, Willett WC, Wong JB, Stuck AE, Staehelin HB, Orav EJ, et al. Prevention of nonvertebral fractures with oral vitamin D and dose dependency: a meta-analysis of randomized controlled trials. Arch Intern Med. 2009 Mar 23. 169(6):551-61. [Medline].

  22. Barclay L. Geriatrics Society Guidelines: Vitamin D May Prevent Falls. Medscape Medical News. Available at http://www.medscape.com/viewarticle/819047. Accessed: January 19, 2014.

  23. Delee JC. Fractures in Adults. Lippincott-Raven Publishers; 1996. 1659-63.

  24. Geiderman J. Hip injuries. Harwood-Nuss A, Linden CH, eds. The Clinical Practice of Emergency Medicine. Lippincott-Raven Publishers; 1991. 407-409.

  25. Gurr DE, Gibbs MS. Femur and hip. Rosen's Emergency Medicine: Concepts and Clinical Practice. 5th ed. Mosby Inc; 2002. 643-674.

  26. Holder LE, Schwarz C, Wernicke PG, Michael RH. Radionuclide bone imaging in the early detection of fractures of the proximal femur (hip): multifactorial analysis. Radiology. 1990 Feb. 174(2):509-15. [Medline].

  27. LaVelle DG. Fractures of hip. Campbell's Operative Orthopaedics. 10th ed. Mosby Inc; 2003. 2873-2938.

  28. Lin JT, Lane JM. Osteoporosis: a review. Clin Orthop Relat Res. 2004 Aug. 126-34. [Medline].

  29. Lu-Yao GL, Baron JA, Barrett JA, Fisher ES. Treatment and survival among elderly Americans with hip fractures: a population-based study. Am J Public Health. 1994 Aug. 84(8):1287-91. [Medline].

  30. McGuire KJ, Bernstein J, Polsky D, Silber JH. The 2004 Marshall Urist award: delays until surgery after hip fracture increases mortality. Clin Orthop Relat Res. 2004 Nov. 294-301. [Medline].

  31. Norton R, Campbell AJ, Lee-Joe T. Circumstances of falls resulting in hip fractures among older people. J Am Geriatr Soc. 1997 Sep. 45(9):1108-12. [Medline].

  32. Quinn SF, McCarthy JL. Prospective evaluation of patients with suspected hip fracture and indeterminate radiographs: use of T1-weighted MR images. Radiology. 1993 May. 187(2):469-71. [Medline].

  33. [Guideline] Recommendations Abstracted from the American Geriatrics Society Consensus Statement on Vitamin D for Prevention of Falls and Their Consequences. J Am Geriatr Soc. 2013 Dec 18. [Medline].

  34. Simon RR, Koenigsknecht SJ. Emergency Orthopedics: The Extremities. 3rd ed. McGraw-Hill Professional Publishing; 1995. 251-262.

  35. Steele MT, Ellison SR. Trauma to the pelvis, hip and femur. Tintinalli JE, et al, eds. Emergency Medicine: A Comprehensive Study Guide. The McGraw-Hill Companies Inc; 2004. 1717-1726.

  36. Van Balen R, Steyerberg EW, Polder JJ, et al. Hip fracture in elderly patients: outcomes for function, quality of life, and type of residence. Clin Orthop Relat Res. 2001 Sep. 232-43. [Medline].

  37. van de Kerkhove MP, Antheunis PS, Luitse JS, Goslings JC. Hip fractures in nonagenarians: perioperative mortality and survival. Injury. 2008 Feb. 39(2):244-8. [Medline].

  38. Zuckerman JD. Hip fracture. N Engl J Med. 1996 Jun 6. 334(23):1519-25. [Medline].

 
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Shenton line and angular anatomy of the femur.
Femoral head fractures. Top diagram is a single-fragment femoral head fracture. Bottom diagram is a comminuted femoral head fracture.
Femoral neck fractures. Top diagram is a nondisplaced, or incomplete, femoral neck fracture. Bottom diagram is an impacted femoral neck fracture.
Partially displaced femoral neck fracture.
Completely displaced femoral neck fracture.
Trochanteric fractures. Top diagram is a nondisplaced trochanteric fracture. Bottom diagram is a displaced trochanteric fracture.
Intertrochanteric fractures. Top diagram is a single fracture line intertrochanteric fracture. Bottom diagram is a displaced, or multiple fracture line, intertrochanteric fracture.
 
 
 
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