Hip fracture

doi:10.1136/bmj.322.7292.968

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William John Gillespie (bill.gillespie@stonebow.otago.ac.nz), professor

Dunedin School of Medicine, University of Otago, Dunedin, New Zealand

Background

Definition Hip fracture is a fracture of the femur above a point 5 cm below the distal part of the lesser trochanter.1 Intracapsular fractures occur proximal to the point at which the hip joint capsule attaches to the femur. Undisplaced fractures include impacted or adduction fractures. Displaced intracapsular fractures may be associated with disruption of the blood supply to the head of the femur. Numerous subdivisions and classification methods exist for these fractures. In the most distal part of the proximal femoral segment (below the lesser trochanter), the term subtrochanteric is used. Extracapsular fractures occur distal to the hip joint capsule.

Intervention

Beneficial:

Sliding hip screw device for internal fixation of extracapsular fracture

Antibiotic prophylaxis before surgery

Mattress on operating tables to prevent pressure sores

Likely to be beneficial:

Regional anaesthesia for surgery

Arthroplasty for displaced intracapsular fracture

Postoperative prophylaxis with heparin to reduce venous thromboembolism

Postoperative prophylaxis with antiplatelet agents to reduce venous thromboembolism

Postoperative prophylactic cyclical compression of the foot or calf to reduce venous thromboembolism

Nutritional supplementation after fracture

Geriatric hip fracture programmes in acute orthopaedic units

Trade off between benefits and harms:

Early supported discharge programmes

Unknown effectiveness:

Arthroplasty for extracapsular hip fracture

Nerve blocks for pain control

Use of graduated elastic compression to prevent venous thromboembolism

Specialised orthopaedic rehabilitation units for elderly people

Systematic home based rehabilitation

Unlikely to be beneficial:

Conservation (non-surgical) treatment of extracapsular fractures

Preoperative bed traction to the injured limb

Likely to be ineffective or harmful:

Intramedullary fixation with cephalocondylic nail for extracapsular fracture (less effective or more harmful than sliding hip screw)

Intramedullary fixation with condylocephalic nail for extracapsular fracture

Incidence/prevalence Hip fractures may occur at any age but are most common in elderly people. In industrialised societies, the lifetime risk of hip fracture is about 18% in women and …