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PATIENT STORY

A 60-year-old woman comes to the emergency room for hip pain. She felt a pop in her hip accompanied by the immediate onset of pain that prohibited her from walking. She had fallen 2 days prior. Figure 107-1 shows a transcervical left femoral neck fracture with varus angulation and superior offset of the distal fracture fragment. She was evaluated by an orthopedic surgeon and underwent surgery the next day in a hospital that provides co-management by a geriatrician (Figure 107-2). After many months of rehabilitation, she was able to walk again.

FIGURE 107-1

Transcervical left femoral neck fracture with varus angulation and superior offset of the distal fracture fragment. The femoral head is within the acetabular cup. Degenerative changes of the left hip are also present. (Reproduced with permission from John E. Delzell, Jr., MD.)

FIGURE 107-2

Postsurgical portable radiograph demonstrating good positioning of artificial hip. (Reproduced with permission from John E. Delzell, Jr., MD.)

EPIDEMIOLOGY

  • Approximately 300,000 hip fractures per year occur in the United States.1

  • More common in the United States (554 per 100,000 women, 197 per 100,000 men) and North Europe; intermediate prevalence in Asian countries; lowest prevalence in Latin America and Africa.2

  • 70% to 80% of hip fractures occur in women.1

  • Average age is 77 years in women; risk increases with age.3

  • Half of patients with a hip fracture have osteoporosis.4

ETIOLOGY AND PATHOPHYSIOLOGY

  • In postmenopausal women, 68% to 83% of hip fractures are caused by a fall.3

RISK FACTORS

  • Between the age of 60 and 80 years:

    • Women: lower body weight, prior osteoporotic fracture, hip fracture in first-degree relatives and lower plasma 25-hydroxyvitamin D (25OHD).5

    • Men: prior osteoporotic fracture and lower plasma 25OHD.5

  • Over age 80 years, in both women and men, falls are the most important risk factor.5

  • Short- and long-term use of a proton pump inhibitor is associated with an increased risk of fracture [RR = 1.26, 95% confidence intervals 1.16–1.36].6

DIAGNOSIS

CLINICAL FEATURES: HISTORY AND PHYSICAL

  • History

    • Risk factors including older age, female gender

    • Recent fall

    • Pain in the groin, which may be referred to the thigh or knee7

    • Inability to walk is common; rarely patients are ambulating with an assistive device and experience increased pain with walking7

  • Physical examination

    • Abducted and externally rotated hip; limp or refusal to walk7

    • Pain elicited with internal and external rotation while patient lies supine7

    • Groin pain elicited with an axial load7

TYPICAL DISTRIBUTION

  • Hip fractures are ...

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