eMedicine Specialties > Sports Medicine > Hip
Hip Fracture: Treatment & Medication
Updated: Jan 30, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Acute Phase
Rehabilitation Program
Physical Therapy
The treatment of femoral neck fractures, intertrochanteric hip fractures, and most tension femoral neck stress fractures requires surgical intervention. Stress fractures occur most often in the femoral neck and are classified according to the location (ie, inferior or compression, superior or tension). Tension fractures have a poor prognosis and tend to be unstable. Compression fractures may heal with conservative management.
Compression fractures are most commonly treated with several days of rest followed by protected, crutch-assisted weight bearing. Frequent serial x-ray films are recommended to monitor fracture healing and progress and to assess for any changes. The operative treatment of tension stress fractures and hip fractures is discussed in Surgical Intervention.
Medical Issues/Complications
The most commonly used classification system for femoral neck fractures is the Garden classification. The fractures are divided into 4 groups according to the degree of displacement and fracture fragments.1,2,3 This classification system gives guidance for treatment options and surgical implants. The following 4 groups comprise this classification system:
- Garden type I: Incomplete fracture with valgus impaction
- Garden type II: Complete fracture without displacement
- Garden type III: Complete fracture with partial displacement of the fracture fragments
- Garden type IV: Complete fracture with total displacement allowing the femoral head to rotate back to an anatomic position
This classification can be further simplified into nondisplaced, Garden I and II, or displaced Garden III and IV fractures.
Classification of intertrochanteric hip fractures is based on a system introduced by Evans in 1949. This system is based on the fracture pattern and the ability to obtain a stable reduction. Evans recognized the importance of restoring the posteromedial cortex as a contributing factor to fracture stability. Others classify intertrochanteric fractures by the number of fracture fragments present; however, for ease of description and simplicity, these fractures are best classified as follows:
- Stable: Fractures with an intact posteromedial cortex
- Unstable: Fractures with comminution of the posteromedial cortex, fractures with diaphyseal extension
The classification system used most commonly for pediatric hip fractures is that of Colonna. In this classification, the fracture prognosis is dependent on the location of the injury and its interference with the blood flow to the femoral head.
- Type I: Transepiphyseal fractures, account for 8% of pediatric hip fractures, AVN rate approaches 100%
- Type II: Transcervical fractures, account for 45% of pediatric hip fractures, 80% are displaced, AVN rate approaches 80%
- Type III: Cervicotrochanteric fractures, account for 30% of pediatric hip fractures, AVN rate of 20-30%
- Type IV: Intertrochanteric fractures, account for 10-15% of pediatric hip fractures, fewer complications than types I-III
A study by Shin and Gillingham classified stress fractures based primarily on MRI findings.4 The 3 basic categories were compression, tension, and displaced fatigue fractures. Compression side injuries were further subdivided on the basis of whether a fatigue line, which appears as a linear band of low-signal intensity lying perpendicular to the line of force across the femoral neck, was present.
The 2 subtypes are those that demonstrate a fatigue line less than 50% of the femoral neck width and those with a fatigue line greater than or equal to 50%. Tension side findings are subtle; their hallmark is increased signal intensity at the superior femoral neck on T2-weighted and short inversion time inversion recovery (STIR) images. Displaced fractures can be identified on plain radiographs.
Complications associated with poorly treated or misdiagnosed stress fractures are considerable. AVN, nonunion, varus deformity, osteonecrosis, and completely displaced femoral neck fractures may occur. These complications can lead to serious, life-altering changes in function and the patient's ability to ambulate efficiently and perform activities of daily living.
Surgical Intervention
Garden types I and II femoral neck fractures are surgically stabilized with closed reduction and internal fixation. Garden types III and IV are controversial in the type of implant used for treatment. In younger patients, closed or open reduction is recommended. In less active older patients, prosthetic replacement is recommended. Patients with intertrochanteric hip fractures require surgical stabilization.In acute (or chronic) displaced femoral neck tension stress fractures, most authors recommend aggressive treatment with internal fixation with percutaneously placed cannulated screws. Postoperative treatment is similar as above, with crutch-assisted touch-down weight-bearing ambulation for the first 6 weeks and partial weight bearing for the subsequent 6 weeks. Thereafter, a supervised physical therapy program is outlined for progressive activity, lower extremity strengthening, and full weight-bearing ambulation.
Treatment of pediatric hip fractures requires expedient evaluation and, usually, surgical reduction and stabilization for displaced fractures. Timing of treatment is important and may play a role in the final outcome.
Consultations
Femoral neck fractures and intertrochanteric hip fractures occur most often in elderly populations, who generally have other medical diagnoses. The fracture may have been due to a medically related problem such as a syncopal episode, dehydration, overmedication, or vertigo. The cause of a fall must be explored, and consultation with an internal medicine specialist is obtained to help rule out medical reasons leading to a fall and to obtain medical clearance for treatment and timing for surgical intervention. The reason for surgical treatment of hip fractures is to allow early patient mobilization and, hopefully, avoid associated medical complications from inactivity.
Consultation with a pediatric specialist is recommended for assistance in pediatric hip fractures. Complications of pediatric hip fractures include AVN, premature physeal closure, femoral shortening, coxa vara, short femoral neck, trochanteric arrest, and nonunion.
Recovery Phase
Rehabilitation Program
Physical Therapy
Compression side stress fractures are usually treated with conservative care, using MRI to identify the minority of patients who warrant internal fixation. If no fatigue line on MRI greater than 50% of the width of the neck is present, rest and crutch-assisted touch-down weight-bearing gait are initiated. Recommend interruption of all aggravating activities until the patient is free from pain. This is followed by gradual introduction of weight-bearing activities to the limit of pain, progressively increasing activity until the patient returns to his or her previous level of function. Weekly x-ray films are taken to monitor changes in fracture status, and any sign of fracture displacement requires surgical intervention.
Medical Issues/Complications
If a significant compression stress fracture is initially apparent on the x-ray film, a more aggressive treatment plan must be initiated because of the tendency for fracture displacement and its associated complications. Closed reduction and internal fixation is recommended. Postoperatively, these patients are allowed to return to athletic activity once fracture healing and remodeling are complete, which may require up to 12 months. The internal fixation devices may be removed 12-18 months after surgery. An additional period of 6 weeks of protected activity is recommended to allow restoration of bone strength, before engaging in excessive athletic conditioning and activity.
Those patients who have sustained a tension-type stress fracture of the femoral neck require surgical stabilization because of the high prevalence of displacement. Following fixation, a standard progressive rehabilitation protocol is recommended. Protected touch-down weight-bearing ambulation with crutches is initiated postoperatively for 6 weeks, under the supervision of a physical therapist. Hardware may be removed 12-18 months following surgery.
Maintenance Phase
Rehabilitation Program
Physical Therapy
Physical therapy in the maintenance phase focuses on more dynamic and functional training to ensure that the patient is able to safely return to his or her previous lifestyle. For athletes, sport-specific training must be incorporated, and the physical therapist must evaluate the overall condition of the hip and lower extremity in order to provide recommendations to the physician and patient. In elderly individuals, physical therapy continues until the patient has reached his or her maximum potential with range of motion and strength and until he or she is able to independently complete all required activities of daily living.
Medication
Nearly all patients with a femoral fracture are in significant pain, and parenteral analgesia should always be a consideration. Preoperative prophylactic antibiotics are recommended for the patient undergoing immediate internal fixation, with the usual dose being 1 g of a first-generation cephalosporin.
Prophylactic antibiotics are also indicated for open fractures. In a clean laceration smaller than 1 cm, an IV bolus of 1 g of a first-generation cephalosporin is adequate. An antibiotic that covers gram-negative organisms should be added for a laceration larger than 1 cm. With a laceration that has an extensive soft-tissue injury or appears moderately contaminated, 1.5 mg/kg of gentamicin or tobramycin should also be added. If the laceration appears grossly contaminated, penicillin should be added to cover clostridial infections.
Antibiotics
Antibiotic therapy must be comprehensive and cover all likely pathogens in the context of the clinical setting.
Cefazolin (Ancef, Kefzol, Zolicef)
First-generation semisynthetic cephalosporin that arrests bacterial cell wall synthesis, inhibiting bacterial growth. Primarily active against skin flora, including Staphylococcus aureus. Typically used alone for skin and skin-structure coverage. IV and IM dosing regimens are similar.
Adult
250 mg to 2 g IV/IM q6-12h depending on severity of infection; not to exceed 12 g/d
Pediatric
25-100 mg/kg/d IV/IM divided q6-8h depending on severity of infection; not to exceed 6 g/d
Probenecid prolongs effect; coadministration with aminoglycosides may increase renal toxicity; may yield false-positive urine-dip test result for glucose
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in patients with renal impairment; superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy.
Tobramycin (Nebcin)
Used in skin, bone, and skin-structure infections caused by S aureus, Pseudomonas aeruginosa, Proteus species, Escherichia coli, Klebsiella species, and Enterobacter species. Indicated in the treatment of staphylococcal infections when penicillin or potentially less toxic drugs are contraindicated and when bacterial susceptibility and clinical judgment justifies its use.
Adult
Serious infection: 3 mg/kg/d IV/IM divided tid
Life-threatening infections: 5 mg/kg/d IV/IM divided tid/qid, and reduce to 3 mg/kg/d as soon as clinically indicated; to prevent increased toxicity caused by excessive blood levels, do not exceed 5 mg/kg/d unless serum levels are monitored
Pediatric
6-7.5 mg/kg/d IV divided tid/qid (2-2.5 mg/kg q8h or 1.5-1.9 mg/kg q6h)
Increases effects of neuromuscular blockers and potentiates effect of extended-spectrum penicillins; concurrent administration with amphotericin B, cephalosporins, and loop diuretics increases risk of nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Avoid use in patients with renal impairment, preexisting auditory or vestibular impairment, and in patients with neuromuscular disorders; aminoglycosides are associated with nephrotoxicity and ototoxicity.
Ampicillin and sulbactam (Unasyn)
Drug combination of beta-lactamase inhibitor with ampicillin. Covers skin, enteric flora, and anaerobes. Not ideal for nosocomial pathogens.
Adult
1.5 (1 g ampicillin + 0.5 g sulbactam) to 3 g (2 g ampicillin + 1 g sulbactam) IV/IM q 6-8h; not to exceed 4 g/d sulbactam or 8 g/d ampicillin
Pediatric
3 months to 12 years: 100-200 mg ampicillin/kg/d (150-300 mg Unasyn) IV divided q6h
>12-years: Administer as in adults; not to exceed 4 g/d sulbactam or 8 g/d ampicillin
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in patients with renal failure; evaluate rash and differentiate from hypersensitivity reaction.
Gentamicin (Gentacidin, Garamycin)
Aminoglycoside antibiotic for gram-negative coverage. Used in combination with both an agent against gram-positive organisms and one that covers anaerobes.
Adult
1.5 mg/kg IV with 1-2 g ampicillin 30 min before procedure; not to exceed 80 mg
Pediatric
2 mg/kg IV with ampicillin (50 mg/kg) 30 min before procedure
Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, thus prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly).
Documented hypersensitivity; non–dialysis-dependent renal insufficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Narrow therapeutic index (not intended for long-term therapy); caution in patients with renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in the presence of renal impairment
Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or who have sustained injuries.
Morphine sulfate (Duramorph, Astramorph, MS Contin, MSIR, Oramorph)
DOC for analgesia because of reliable and predictable effects, safety profile, and ease of reversibility with naloxone.
Various IV doses are used; commonly titrated until desired effect obtained.
Adult
Starting dose: 0.1 mg/kg IV/IM/SC
Maintenance dose: 5-20 mg/70 kg IV/IM/SC q4h
Relatively hypovolemic patients: Start with 2 mg IV/IM/SC; reassess hemodynamic effects of dose
Pediatric
Infants and children: 0.1-0.2 mg/kg dose IV/IM/SC q2-4h prn; not to exceed 15 mg/dose; may initiate at 0.05 mg/kg/dose
Phenothiazines may antagonize analgesic effects of opiate agonists; TCAs, MAOIs, and other CNS depressants may potentiate adverse effects of morphine.
Documented hypersensitivity; hypotension; potentially compromised airway where establishing rapid airway control would be difficult
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with hypotension, respiratory depression, nausea, emesis, constipation, and urinary retention; caution in the presence of atrial flutter and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate
Ketorolac (Toradol)
Inhibits prostaglandin synthesis by decreasing the activity cyclooxygenase, which results in decreased formation of prostaglandin precursors.
Adult
30-60 mg IM initially, followed by 15-30 mg q6h prn; not to exceed 5 d of treatment
Pediatric
Not established; recommended dose is 0.4-1 mg/kg IM once
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding; do not administer into CNS
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low WBC counts (rare) usually return to normal during ongoing therapy; discontinue therapy if persistent leukopenia, granulocytopenia, or thrombocytopenia occur
More on Hip Fracture |
| Overview: Hip Fracture |
| Differential Diagnoses & Workup: Hip Fracture |
 Treatment & Medication: Hip Fracture |
| Follow-up: Hip Fracture |
| Multimedia: Hip Fracture |
| References |
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References
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DeLee JC, Drez D, eds. Orthopaedic Sports Medicine: Principles and Practice. Vol 2. Philadelphia, Pa: WB Saunders; 1994:1076-80.
Anderson MK, Hall SJ, Martin M, eds. Sports Injury Management. Baltimore, Md: Lippincott Williams & Wilkins; 2000:412-3.
Shin AY, Gillingham BL. Fatigue fractures of the femoral neck in athletes. J Am Acad Orthop Surg. Nov 1997;5(6):293-302. [Medline].
Canavan PK, ed. Rehabilitation in Sports Medicine: A Comprehensive Guide. Stamford, Conn: Appleton & Lange; 1998:265-6.
Davison BL, Weinstein SL. Hip fractures in children: a long-term follow-up study. J Pediatr Orthop. May-Jun 1992;12(3):355-8. [Medline].
Egol KA, Koval KJ, Kummer F, Frankel VH. Stress fractures of the femoral neck. Clin Orthop Relat Res. Mar 1998;348:72-8. [Medline].
Kyle RF, Gustilo RB, Premer RF. Analysis of six hundred and twenty-two intertrochanteric hip fractures. J Bone Joint Surg Am. Mar 1979;61(2):216-21. [Medline]. [Full Text].
Leboff MS, Narweker R, Lacroix A, et al. Homocysteine levels and risk of hip fracture in postmenopausal women. J Clin Endocrinol Metab. Jan 27 2009;epub ahead of print. [Medline].
Shabat S, Nyska M, Eintacht S, et al. Serum leptin level in geriatric patients with hip fractures: possible correlation to biochemical parameters of bone remodeling. Arch Gerontol Geriatr. Mar-Apr 2009;48(2):250-3. [Medline].
Zarin JS, Zurakowski D, Burke DW. Claw plate fixation of the greater trochanter in revision total hip arthroplasty. J Arthroplasty. Feb 2009;24(2):272-80. [Medline].
Further Reading
Keywords
hip fracture, femoral neck fracture, intracapsular hip fracture, hip stress fracture, femoral neck stress fracture, femoral stress fracture, Garden classification, Colonna classification, Evan classification, broken hip, fractured hip, cracked hip
