CLINICAL ARTICLE

 

Management of intracapsular fractures of the hip in elderly patients

 

 

ND Naidoo

MBChB, Dip PEC(SA), H Dip Orth(SA). Registrar, Department of Orthopaedic Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal

Reprint requests

 

 

---

ABSTRACT

Intracapsular fractures of the neck of femur in the elderly patient population results in an enormous economic and social burden. The aim of this paper is to present a review of the literature providing guidelines for the management of this common fracture with emphasis on patient selection, optimisation and preventative strategies.

---

 

 

“Full text available only in PDF format”

 

References

1. Cummings SR, Kelsey JL, Nevitt MC, O'Dowd KJ: Epidemiology of osteoporosis and osteoporotic fractures. Epidemiol Rev 1985;7:178-208.         [ Links ]

2. Gallagher JO, Melton LJ, Riggs BL, Bergstrath E: Epidemiology of fractures of the proximal femur in Rochester, Minnesota. Clin Orthop 1980;150:163-171.         [ Links ]

3. Koval KJ, Zuckerman JD: Functional recovery after hip fractures. J Bone Joint Surg 1994;77A:751-758.         [ Links ]

4. Parrot S: The economic cost of hip fractures in the UK. www.dti.gov.uk        [ Links ]

5. Crock HV: An atlas of the arterial supply of the head and neck of the femur in Man. Clin Orthop 1980;152:17-27.         [ Links ]

6. Trueta J, Harrison MHM: The normal vascular anatomy of the femoral head in adult man. J Bone Joint Surg 1953;35B:442-461.         [ Links ]

7. Gautier E, Ganz K, Krugel N, Gill I, Ganz R: Anatomy of the medial femoral circumflex artery and its surgical implications. J Bone Joint Surg 2000;82B:679-683.         [ Links ]

8. Catto M: A histological study of avascular necrosis of the femoral head after transcervical fracture. J Bone Joint Surg 1965;47B:749-776.         [ Links ]

9. Sevitt S: Avascular necrosis and revascularization of the femoral head after intracapsular fractures: A combined arteriography; and histological necropsy study. J Bone Joint Surg 1964;46B:270-296.         [ Links ]

10. Sevitt S, Thompson RG: The distribution and anastomoses of arteries supplying the head and neck of the femur. J Bone Joint Surg 1965;47B:560-573.         [ Links ]

11. Swiontkowski, MF: Intracapsular hip fractures. In Browner BD, Jupiter JB, Levine AM, Trafton PG (eds). Skeletal Trauma. Philadelphia, WB Saunders 1369-1442, 1992.         [ Links ]

12. Stromqvist B, Nilsson LT, Egund N, Thorngren KG, Wingstrand H.: Intracapsular pressures in undisplaced fractures of the femoral neck. J Bone J Surg 1980;70B:192-194.         [ Links ]

13. La Velle D. Fractures of the hip. In: Canale ST(ed).Campbell's Operative Orthopaedics. 10^th Ed. Mosby inc. Vol 3. 2873-2920.         [ Links ]

14. Kyle RF, Cabanela ME, Russell TA, et al: Fractures of the proximal part of the femur. Instr Course Lect 1995;44:227-253.         [ Links ]

15. Aitken JM: Relevance of osteoporosis on women with fracture of the femoral neck. Br Med J 1984;288:597-60l.         [ Links ]

16. Wong SY, Kariks J, Evans RA, Dunstan CR, Hills-E: The effect of age on bone composition and vitality in the femoral head. J Bone Joint Surg Am 1985;67(2):274-83.         [ Links ]

17. Garden RS: The structure and function of the proximal end of the femur. J Bone Joint Surg 1961;43B:576-589.         [ Links ]

18. Frandsen PA, Anderson PE, Madsen F, Sjokdt T: Garden classification of femoral neck fractures. J Bone Joint Surg 1988;70B: 588-590.         [ Links ]

19. Caviglia H, Osorio P, Comando D: Classification and diagnosis of intracapsular fractures of the proximal femur. Clin Orthop 2002;399:17-27.         [ Links ]

20. Hieu T Truong: Femoral neck fractures. www.emedicine.com 2004.         [ Links ]

21. Stromqvist B, Hansson LI, Ljung P: Preoperative and postoperative scintimetry after femoral neck fracture. J Bone Joint Surg 1984;66(1):49-54.         [ Links ]

22. Heim M, Adunski A, Chechnik A: Non-operative treatment of Intracapsular fractures of the proximal femur. Clin Orthop 2002;399:35-41.         [ Links ]

23. Harper WM, Greg PJ: The treatment of intracapsular proximal femoral fractures: A randomized prospective trial. J Bone Joint Surg 1992;74B(Suppl iii):282.         [ Links ]

24. Hornby R, Evans JG, Vardon V: Operative or conservative treatment for trochanteric fractures of the femur: A randomized epidemiological trial in elderly patients. J Bone Joint Surg 1989;71B:619-623.         [ Links ]

25. Brown AG, Visram AR, Jones RD, et al: Pre-operative and post-operative oxygen saturation in the elderly following spinal or general anaesthesia - an audit of current practice. Anaesth Intensive Care 1994;22:150-154.         [ Links ]

26. Fugere F, Owen H, Ilsley A, et al: Changes in oxygen saturation in the 72 hours after hip surgery: the effect of oxygen therapy. Anaesth Intensive Care 1994;22:724-728.         [ Links ]

27. Jerre R, Doshe A, Karlsson J: Preoperative skin traction in patients with hip fractures is not useful. Clin Orthop 2000;378:169-173        [ Links ]

28. Parker MJ, Handoll HH: Pre-operative traction for fractures of the proximal femur. Cochrane Database Syst Rev 2002;(2).         [ Links ]

29. Finsen V, Borset M, Buvik GE, Hauke I: Preoperative traction in patients with hip fractures. Injury 1992;23:242-244.         [ Links ]

30. Cullum N, Deeks J, Sheldon TA, et al: Beds, mattresses and cushions for pressure sore prevention and treatment. Cochrane Database Syst Rev 2002;(2).         [ Links ]

31. Hartgrink HH, Wille J, Konig P, et al: Pressure sores and tube feeding in patients with a fracture of the hip: a randomized clinical trial. Clin Nutr 1998;17:287-292.         [ Links ]

32. Handoll HH, Farrar MJ, McBirnie J, et al: Heparin, low molecular weight heparin and physical methods for preventing deep vein thrombosis and pulmonary embolism following surgery for hip fractures. Cochrane Database Syst Rev 2002(2).         [ Links ]

33. Eskander MB, Limb D, Stone MH, et al: Sequential mechanical and pharmacological thromboprophylaxis in the surgery of hip fractures. A pilot study. Int Orthop 1997;21:259-261.         [ Links ]

34. Warwick D: New concepts in Orthopaedic Thromboprophylaxis: J Bone Joint Surg 2004;86B:788-792.         [ Links ]

35. Fisher CG, Blachut PA, Salvian AJ, et al: Effectiveness of pneumatic leg compression devices for the prevention of thromboembolic disease in orthopaedic trauma patients: a prospective, randomized study of compression alone versus no prophylaxis. J Orthop Trauma 1995;9:1-7.         [ Links ]

36. Anglen JO, Goss K, Edwards J, Huckfeldt RE: Foot pump prophylaxis for deep venous thrombosis: the rate of effective usage in trauma patients. Am J Orthop 1998;27:580-582.         [ Links ]

37. Agu O, Hamilton G, Baker D: Graduated compression stockings in the prevention of venous thromboembolism. Br J Surg 1999;86:992-1004.         [ Links ]

38. Critchley LA, Conway F: Hypotension during subarachnoid anaesthesia: haemodynamic effects of colloid and metaraminol. Br J Anaesth 1996;76:734-736.         [ Links ]

39. Yap JC, Critchley LA, Yu SC, et al: A comparison of three fluid-vasopressor regimens used to prevent hypotension during subarachnoid anaesthesia in the elderly. Anaesth Intensive Care 1998;26:497-502.         [ Links ]

40. Parker MJ, Handoll HH, Griffiths R: Anaesthesia for hip fracture surgery in adults. Cochrane Database Syst Rev 2004;(4):CD000521.         [ Links ]

41. Pitout JDD, Mennen MA: Principles of surgical patient care. Mieny & Mennen. 2^nd Ed. 2003 New Africa Books p 66.         [ Links ]

42. Tidermark J: Quality of life and femoral neck fractures. Acta Orthopaedica Scandinavica. Supplementum 2003;74(309):1-42.         [ Links ]

43. Leighton RK. Fractures of the Neck of Femur. In: Bucholz RW, Heckman JD, Court-Brown CM (eds). Rockwood & Green's Fractures in Adults. 6th Ed. Vol 2. Lippincott Williams & Wilkins. 1753-1791.         [ Links ]

44. Bosch, Ulrich MD; Schreiber, Thomas MD; Krettek, Christian MD: Reduction and fixation of displaced intracapsular fractures of the proximal femur: Clin Orth 2002;399:59-71.         [ Links ]

45. Raaymakers EL, Marti RK: Non-operative treatment of impacted femoral-neck fractures. J Bone Joint Surg 1991;73B:950-954.         [ Links ]

46. Bosch U, Schreiber T, Skutek M, et al: Minimal invasive screw fixation of the femoral neck fracture in elderly patients. Chirurg 2001;72:1292-1297.         [ Links ]

47. Manninger J, Kazár C, Fekete C, et al: Avoidance of avascular necrosis of the femoral head, following fractures of the femoral neck, by early reduction and internal fixation. Injury 1985;16:437-448.         [ Links ]

48. Swiontkowski MF, Winquist RA, Hansen ST: Fractures of the femoral neck in patients between the ages of twelve and forty-nine years. J Bone Joint Surg 1984;66A:837-846.         [ Links ]

49. Partanen J, Jalovaara P: Functional comparison between uncemented Austin-Moore hemiarthroplasty and osteosynthesis with three screws in displaced femoral neck fractures-a matched-pair study of 168 patients. International Orthopaedics 2004;28(1):28-31.         [ Links ]

50. Heikkinen T, Wingstrand H, Partanen J, Thorngren KG, Jalovaara P: Hemiarthroplasty or osteosynthesis in cervical hip fractures: matched-pair analysis in 892 patients. Archives of Orthopaedic & Trauma Surgery 2002;122(3):143-7.         [ Links ]

51. Parker MJ, Khan RJ, Crawford J, Pryor GA: Hemiarthroplasty versus internal fixation for displaced intracapsular hip fractures in the elderly. A randomised trial of 455 patients. Journal Bone Joint Surg 2002;84(8):1150-5.         [ Links ]

52. Iorio R, Healy WL, Lemos DW, Appleby D, Lucchesi CA, Saleh KJ: Displaced femoral neck fractures in the elderly: outcomes and cost effectiveness. Clin Ortho 2001;383:229-42.         [ Links ]

53. Blomfeldt R, Tornkvist H, Ponzer S, Soderqvist A, Tidermark J: Internal fixation versus hemiarthroplasty for displaced fractures of the femoral neck in elderly patients with severe cognitive impairment. Journal Bone Joint Surg 2005;87B (4):523-529.         [ Links ]

54. Kenzora JE, Magaziner J, Hudson J, Hebel JR, Young Y, Hawkes W, Felsenthal G: Outcome after hemiarthroplasty for femoral neck fractures in the elderly. Clinical Orth 1998;348:51-8.         [ Links ]

55. Raia FJ, Chapman CB, Herrera MF, Schweppe MW, Michelsen CB, Rosenwasser MP: Unipolar or bipolar hemi-arthroplasty for femoral neck fractures in the elderly? Clinical Orth 2003;414:259-65.         [ Links ]

56. Ong BC, Maurer SG, Aharonoff GB, Zuckerman JD, Koval KJ: Unipolar versus bipolar hemiarthroplasty: functional outcome after femoral neck fracture at a minimum of thirty-six months of follow-up. Journal of Orthopaedic Trauma 2002;16(5):317-22.         [ Links ]

5. Manninger J, Kazár C, Fekete C, et al: Significance of urgent (within 6h) internal fixation in the management of fractures of the neck of the femur. Injury 1989;20:101-105.         [ Links ]

58. Leadbetter GW: A treatment for fracture of the neck of the femur. J Bone Joint Surg 1933;15:931-941.         [ Links ]

59. Garden RS: Low-angle fixation in fractures of the femoral neck. J Bone Joint Surg 1961;48B:647-663.         [ Links ]

60. Weintrobe M, Stankewich CJ, Mueller B, Tencer AF: Predicting the mechanical outcome of femoral neck fractures fixed with cancellous screws: An in vivo study. J Orthop Trauma 1998;12:27-36.         [ Links ]

61. Rodríguez-Merchán, E. Carlos MD: In situ fixation of non displaced femoral neck fractures. Clin Orth 2002;399:42-51.         [ Links ]

62. Rogmark C, Carlsson A, Johnell O, Sernbo I: A prospective randomised trial of internal fixation versus arthroplasty for displaced fractures of the neck of the femur. Functional outcome for 450 patients at two years. Journal Bone Joint Surg 2002;84(2):183-8.         [ Links ]

63. Bhandari M, Tornetta P 3rd, Ellis T, Audige L, Sprague S, Kuo JC, Swiontkowski MF: Hierarchy of evidence: differences in results between non-randomized studies and randomized trials in patients with femoral neck fractures. Archives of Orthopaedic & Trauma Surgery 2004;124(1):10-6.         [ Links ]

64. Khan RJ, MacDowell A, Crossman P, Keene GS: Cemented or uncemented hemiarthroplasty for displaced intracapsular fractures of the hip - a systematic review. Injury 2002;33(1):13-7.         [ Links ]

65. Faraj AA, Branfoot T: Cemented versus uncemented Thompson's prostheses: a functional outcome study. Injury 1999;30(10):671-5.         [ Links ]

66. Cornell CN, Levine D, O'Doherty J, Lyden J: Unipolar versus bipolar hemiarthroplasty for the treatment of femoral neck fractures in the elderly. Clinical Orth 1998;348:67-71.         [ Links ]

67. Johansson T, Jacobsson SA, Ivarsson I, Knutsson A, Wahlstrom O: Internal fixation versus total hip arthroplasty in the treatment of displaced femoral neck fractures: a prospective randomized study of 100 hips. Acta Orthopaedica Scandinavica 2000;71(6):597-602.         [ Links ]

68. Ravikumar KJ, Marsh G: Internal fixation versus hemi-arthroplasty versus total hip arthroplasty for displaced sub-capital fractures of femur - 13 year results of a prospective randomised study. Injury 2000;31(10):793-7.         [ Links ]

69. Burns RB, Moskowitz MA, Ash A, Kane RL, Finch M, McCarthy EP: Do hip replacements improve outcomes for hip fracture patients? Medical Care 1999; 37(3):285-94.         [ Links ]

70. Carson JL, Terrin ML, Barton FB, et al: A pilot randomized trial comparing symptomatic vs. hemoglobin-level-driven red blood cell transfusions following hip fracture. Transfusion 1998;38:522-529.         [ Links ]

71. Skelly JM, Guyatt GH, Kalbfleisch R, et al: Management of urinary retention after surgical repair of hip fracture. CMAJ 1992;146:1185-1189.         [ Links ]

72. Hartgrink HH, Wille J, Konig P, et al: Pressure sores and tube feeding in patients with a fracture of the hip: a randomized clinical trial. Clin Nutr 1998;17:287-292.         [ Links ]

73. Parker MJ, Lewis SJ, Mountain J, Christie J, Currie CT: Hip fracture rehabilitation - a comparison of two centres. Injury 2002;33(1):7-11.         [ Links ]

74. Parker MJ, Gurusamy K: Arthroplasties (with and without bone cement) for proximal femoral fractures in adults.The Cochrane Library 2006;(3).         [ Links ]

75. Keene GS, Parker MJ, Pryor GA: Mortality and morbidity after hip fractures. Br Med Journal 1993; 307:1248-1250.         [ Links ]

76. Holmberg S, Conradi R, Kalen R, Thorngren KG: Mortality after cervical hip fractures. Acta Orth Scand 1986;57:8-11.         [ Links ]

77. Ramanathan TS, Moppet IK, Wenn R, Moran CG: POSSUM scoring for patients with neck of femur fracture. Br J Anaesthesia 2005;94(4):430-33.         [ Links ]

78. McClure R et al: Population based interventions for the prevention of fall related injuries in older people. The Cochrane Library 2006 (3).         [ Links ]

79. Szulc P et al: Structural determinants of hip fracture in elderly women: re-analysis of data from the EPIDOS study. Osteoporosis Int 2006;17:231-236.         [ Links ]

80. Gillespie LD et al: Interventions for preventing falls in elderly people. The Cochrane Library 2006 (3).         [ Links ]

81. Lukhele M, Vlok GJ, Mody GM: Practical guidelines for orthopaedic surgeons on the management of osteoporosis and fragility fractures. SAOJ 2007;6(1):8-16.         [ Links ]

 

 

Reprint requests:
Dr ND Naidoo
Department of Orthopaedic Surgery, University of KwaZulu-Natal. Nelson R Mandela School of Medicine
Private Bag X7 Congella, 4013
Tel: (031) 260-4297; Fax: (031) 260-4518
Email: naven33@webmail.co.za

 

 

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. This research was not submitted to an ethical committee. This article is free of plagiarism.