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Key Features

Essentials of Diagnosis

  • Internal rotation of the hip is the best provocative diagnostic maneuver

  • Hip fractures should be surgically repaired as soon as possible (within 24 hours)

  • Delayed treatment of hip fractures in the elderly leads to increased complications and mortality

General Considerations

  • Approximately 4% of the 7.9 million fractures that occur each year in the United States are hip fractures

  • Risk factors

    • Osteoporosis

    • Female sex

    • Height > 5-foot 8-inches

    • Age over 50 years

  • Usually occur after a fall

  • High velocity trauma is needed in younger patients

  • Stress fractures can occur in athletes or individuals with poor bone mineral density following repetitive loading activities

Clinical Findings

Symptoms and Signs

  • Pain in the groin is typical, but pain may radiate to the lateral hip, buttock, or knee

  • If a displaced fracture is present, the patient will not be able to bear weight and the leg may be externally rotated

  • Patients with hip stress fractures have less pain on physical examination but typically have pain with weight bearing

Diagnosis

Imaging

  • Radiographic views include anteroposterior views of the pelvis and bilateral hips and frog-leg lateral views of the painful hip

  • CT scan or MRI may be necessary to identify the hip fracture pattern or to evaluate non-displaced fractures

Diagnostic Procedures

  • The Trendelenburg test can be performed to examine for weakness or instability of the hip abductors, primarily the gluteus medius muscle (eTable 41–3)

  • Another functional test is asking the patient to hop or jump during the examination

eTable 41–3.Hip examination.

Treatment

Surgery

  • Surgery is recommended for almost all patients within the first 24 hours

  • Femoral neck fractures

    • Hemiarthroplasty or total hip replacement performed most often

    • Arthroplasty becoming more common

  • Peritrochanteric hip fractures

    • Open reduction internal fixation (with plate and screw construct or intramedullary devices)

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