Hip Fracture in the ED Treatment & Management

Updated: Aug 12, 2021
  • Author: Moira Davenport, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Treatment

Prehospital Care

Prehospital treatment of a patient who complains of hip pain should include immobilization on a stretcher.

If the patient is a victim of multiple traumas, address the ABCs and immobilize the cervical spine as appropriate.

If fracture or deformity of the femur is obvious, apply a traction splint and place an IV line for hydration.

If the patient is hypotensive or tachycardic, initiate crystalloid fluid bolus and place patient on supplemental oxygen.

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Emergency Department Care

If the patient is a victim of trauma, attend to the ABCs first and conduct a thorough search for other possible injuries. In cases of obvious femur fracture, immobilize the patient, place 2 large-bore IV lines for hydration and possible transfusion, restrict the patient's oral intake to nothing by mouth (NPO), and obtain specimens for preoperative labs if necessary. Orthopedic treatment decisions vary significantly among different practitioners; thus, early consultation for all hip fractures is recommended. Initiate appropriate parenteral analgesia as soon as possible.

Ultrasound-guided femoral nerve blocks may also be used to achieve adequate analgesia. [34, 35]  Ultrasound-guided femoral nerve block was found to be equally effective in intracapsular and extracapsular hip fractures in patients 60 years or older presenting to EDs with hip fracture. Mean pain scores in patients with intracapsular hip fractures decreased from 6.23 to 3.81 (P< 0.0001) at 2 hours and from 6.23 to 3.87 (P< 0.0001) at 3 hours. In the extracapsular group, mean pain scores decreased from 6.62 to 3.89 (P< 0.0001) at 2 hours and from 6.62 to 3.46 (P< 0.0001) at 3 hours. [36]

In a Netherlands ED study in hip fracture patients who received fascia iliaca compartment block (FICB), a clinically meaningful decrease in pain was achieved after 30 minutes in 62% of patients (54% with the use of opioids, 8% without opioids); after 4 hours in 82% of patients (18% with opioids, 64% without opioids); and after 8 hours in 88% of patients (16% with opioids, 72% without opioids). [37]

Femoral head fractures

For type 1 femoral head fractures, orthopedic consultation in the ED should be obtained. Treatment is to reduce dislocated femoral head and fracture fragments as soon as possible to avoid avascular necrosis. Small fracture fragments may need to be removed. If a single attempt at closed reduction fails, then open reduction and internal fixation (ORIF) is the next treatment of choice. For type 2, early orthopedic consultation for admission and arthroplasty is recommended.

Femoral neck fractures

For type 1 femoral neck fractures, some practitioners handle these fractures nonoperatively with initial immobilization in selected patients, while others prefer operative treatment in all patients. For 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

For type 1 trochanteric fractures, management is most often conservative, and orthopedic consultation is recommended. Type 2 fractures usually are treated with reduction and internal fixation, except in older or debilitated patients in whom conservative treatment is appropriate.

Intertrochanteric fractures

Apply traction or a traction splint for intertrochanteric fractures. 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 with subtrochanteric fractures, 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, and consult an orthopedic surgeon for admission and ORIF for most patients.

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Consultations

Most patients should be admitted to the hospital under the care of an orthopedic surgeon. If operative repair is planned, the patient should be cleared medically by his or her primary care physician or internist.

Patients with multiple medical problems can be admitted to the primary care service with orthopedic consultation.

Patients who have sustained multiple traumas should be admitted to the trauma service or general/trauma surgeon.

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Prevention

The best prevention is deterrence—specifically, avoiding the risk factors and undertaking fall prevention in older persons. An older patient who presents after a fall should undergo a risk assessment to prevent further falls. 

A study of 134 emergency department elderly patients (>55 years old) with a hip fracture reported that nearly half (45.5%) had an ED visit or inpatient admission in the year before the fracture visit. In 27.5% of the visits, a fall that did not result in a fracture was the presenting complaint.  However, only 8% of the patients with a previous visit due to a fall received falls prevention education. [38]   

Calcium supplementation, bisphosphonates, parathyroid hormone, and estrogen replacement therapy may decrease the risk of hip fractures in individuals with osteoporosis.

A meta-analysis was performed to evaluate the efficacy of oral supplemental vitamin D in preventing nonvertebral and hip fractures among older individuals (65 y or older). The meta-analysis included 12 double-blind, randomized, controlled trials (RCTs) for nonvertebral fractures (n = 42,279) and 8 RCTs for hip fractures (n = 40,886) and compared oral vitamin D (with or without calcium) with either calcium alone or placebo. The results showed that nonvertebral fracture prevention with vitamin D is dose dependent, and a higher dose reduced fractures by at least 20% for individuals aged 65 years or older. [39]

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