Hip Fractures: The Complete Management Guide

Hip fractures (Neck of Femur / NOF fractures) are the most common reason for admission to an orthopaedic trauma ward. They are a fragility fracture, signaling the end of independent living for many elderly patients.

For the exam, this is a Mandatory Pass topic. You must know the literature, the classification, and the management cold.

1. Anatomy and Blood Supply

The decision to Fix vs. Replace hinges on the blood supply to the femoral head.

• Medial Circumflex Femoral Artery: The primary supply. Passes posterior to the neck.
• Lateral Circumflex Femoral Artery: Lesser supply.
• Ligamentum Teres: Negligible in adults.

Intracapsular fractures (Subcapital, Transcervical) endanger the blood supply -> High risk of AVN. Extracapsular fractures (Intertrochanteric, Subtrochanteric) preserve the blood supply -> High healing potential.

2. Intracapsular Fractures

Classification: Garden

Based on AP radiograph displacement.

• Type I: Incomplete / Valgus impacted. (Stable).
• Type II: Complete, Non-displaced. (Stable-ish).
• Type III: Complete, Partially displaced. (Trabeculae usually varus).
• Type IV: Complete, Fully displaced. (Femoral head dissociates from acetabulum).

Simpler System: Non-Displaced (I/II) vs Displaced (III/IV).

Management Algorithm

A. Undisplaced (Garden I/II):

• Treatment: Fixation in situ (Cannulated Screws or DHS).
• Reason: Preserve the native head. Low risk of AVN/Non-union compared to displaced.
• Controversy: Some argue for Hemiarthroplasty in the very elderly/frail to avoid re-operation if fixation fails.

B. Displaced (Garden III/IV):

• Young (<60): URGENT FIXATION. Reduce and Fix (DHS + De-rotation screw or Cannulated Screws). Every hour counts to save the head.
• Elderly (>65): REPLACE. The risk of AVN/Non-union is too high (~30-40%).
  • Hemiarthroplasty: For low demand, cognitive impairment, or limited life expectancy.
  • Total Hip Arthroplasty (THA): For the "Active Elderly."
    • NICE Guidelines Criteria for THA: Walk independently, cognitively intact, medically fit for anesthesia.
    • Evidence (HEALTH Trial): THA has lower re-operation rate and better function than Hemi, but higher dislocation risk.

3. Extracapsular Fractures (Intertrochanteric)

Classification: Evans (Simplified)

• Stable: Posteromedial cortex intact. Resists collapse.
• Unstable: Posteromedial comminution, Reverse Obliquity, or Subtrochanteric extension.

Management Algorithm

A. Stable Intertrochanteric:

• Gold Standard: Sliding Hip Screw (DHS).
• Why? Controlled collapse impaction. Less expensive than nail.

B. Unstable / Reverse Oblique / Subtrochanteric:

• Gold Standard: Cephalomedullary Nail (PFN / Gamma Nail).
• Why? A nail is a load-sharing device. It is closer to the mechanical axis (shorter lever arm) and prevents medialization of the shaft.

Visual Element: Diagram comparing the load mechanics of a DHS (lateral plate) vs a Nail (intramedullary) showing the lever arm distance.

4. Surgical Technical Pearls

Tip-Apex Distance (TAD)

Baumgaertner defined the TAD as the sum of the distance from the screw tip to the apex of the femoral head on AP + Lateral views.

• The Rule: TAD must be < 25mm.
• Consequence: TAD > 25mm is the strongest predictor of "Cut-out" (Fixation failure).

Reduction Maneuvers

Never accept a varus reduction. Varus = Failure.

• Acceptable: Slight Valgus is protective.
• Maneuver: Traction, Abduction, Internal Rotation.

5. Medical Management (Orthogeriatrics)

Fixing the bone is only half the job.

• Time to Surgery: Ideally < 36-48 hours. Delay increases mortality. (HIP ATTACK trial).
• Anticoagulation: Do not delay > 48 hours for INR correction unless extreme.
• Nerve Blocks: Fascia Iliaca Block provides excellent opioid-sparing analgesia. Reduces delirium.
• Delirium: Avoid urinary catheters, treat pain, orient patient.

6. Complications

• Mortality: ~30% at 1 year. (Tell the family this is a life-threatening event).
• Infection: 1-2%.
• Dislocation: (After Arthroplasty). Higher in posterior approach. Many use Lateral approach for fractures.
• Cut-out: (After Fixation). Due to poor TAD or osteoporosis.

Conclusion

Hip fracture management is protocol-driven.

1. Classify (Intra vs Extra, Displaced vs Undisplaced).
2. Assess Patient (Age, Function).
3. Select Implant (Screw, DHS, Nail, Hemi, THA).
4. Optimize Logistics (Surgery < 48hrs).

Clinical Pearl: In the exam, always mention the "Multidisciplinary Team" (Ortho, Geriatrics, Physio, Social Work). Hip fracture care is a team sport.

References

1. Bhandari, M., et al. (2019). "Total Hip Arthroplasty or Hemiarthroplasty for Hip Fracture (HEALTH)." NEJM.
2. Baumgaertner, M. R., et al. (1995). "The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip." JBJS.
3. NICE Guidelines [NG124]. (2011/2023). "Hip fracture: management."