History
Patients with hip fractures may present in a variety of ways, ranging from an 80-year-old woman reporting hip pain after a trivial fall to a 30-year-old man in hemorrhagic shock after a high-speed motor vehicle accident.
Stress fractures usually manifest more insidiously, with an otherwise healthy person reporting pain related to activity and not healing with the conservative treatments suggested by their primary care doctor.
Although the classic presentation of a hip fracture is an elderly patient who is in extreme pain, a young, healthy athlete usually has the same presentation. The affected leg is externally rotated and may be shortened. The extremity shortening occurs because the muscles acting on the hip joint depend on the continuity of the femur to act, and when this continuity is disrupted, the result is a shorter-appearing leg. Assessing peripheral pulses and checking Doppler pressures to assure vascular patency is very important.
The patient with a stress fracture may present more subtly, reporting pain in the anterior groin or thigh. This pain increases with activity and can persist for hours afterward. The pain can progress to a point of consistency, even without activity. This pain generally expresses itself in the groin; however, it can also be referred to the knee. An antalgic gait pattern is often present. Signs and symptoms usually involve a diffuse or localized aching pain in the anterior groin or thigh region during weight-bearing activities that is relieved with rest. Night pain is also common.
A study by Brännström et al that included 408,000 older adults reported an association between antidepressant medications and hip fracture before and after the initiation of therapy. Further investigations are needed to study this association. [9]
Physical
Findings of the physical evaluation of the patient with a hip fracture may include the following:
-
Testing reveals a painful hip with limited range of motion, especially in internal rotation.
-
Pain is noted upon attempted passive hip motion. The heel percussion test also produces pain. Placing a tuning fork over the affected hip may also produce pain
-
Ecchymosis may or may not be present.
-
An antalgic gait pattern may be present.
-
Deep palpation in the inguinal area produces discomfort. Tenderness to palpation is noted over the femoral neck. This area may also be swollen.
-
Increased pain on the extremes of hip rotation, an abduction lurch, and an inability to stand on the involved leg may indicate a femoral neck stress fracture. If a femoral neck stress fracture is suggested, it must be excluded. Missing this diagnosis could lead to a completely displaced femoral neck fracture, AVN, nonunion of the bone, and eventual varus deformity.
Causes
Factors such as muscle fatigue, (which leads to abnormal gait patterns and altered stress distribution), training errors, improper footwear, and poor training surfaces can predispose an athlete to the development of stress fractures.
-
A subcapital femoral neck fracture. Slight compression of the femoral head onto the femoral neck can be seen. Note the cortical break medially. This fracture could be missed if not closely evaluated.
-
A view of the contralateral hip for comparison.
-
Intraoperative x-ray film (fluoroscopic view) of placement of the lag screw.
-
Addition of a superior derotational screw to maintain alignment and allow compression.
-
Internal fixation of the subcapital femoral neck fracture with a screw and short side plate with an additional derotational screw above. Final anteroposterior view.
-
Garden I femoral neck fracture. Note the valgus impaction with compression of the superior femoral head-neck junction.
-
Lateral view of a Garden I femoral neck fracture. Compression of the head-neck junction inferiorly.
-
Anteroposterior view of the pelvis with a displaced femoral neck fracture.
-
Lateral view of a displaced femoral neck fracture.
-
Displaced femoral neck fracture treated with a conventional, noncemented monopolar hemiarthroplasty.
-
Lateral view of a unipolar hemiarthroplasty.
-
An example of a calcar replacement hemiarthroplasty. A low femoral neck fracture extending into the calcar femoralis, not amenable to internal fixation or conventional hemiarthroplasty, requiring a calcar replacement prosthesis.
-
A lateral x-ray film of a calcar replacement hemiarthroplasty.
