Hip Fractures, Part I
Hip Fractures, Part I
A 72-year-old woman fell as she was getting out of bed at a nursing home. She complained of right hip pain and was referred to the emergency room for further evaluation. As the orthopaedist on call, you are asked to examine her.
What are important questions to ask her or her caregivers?
View the correct answer.
<p>Given the patients' age and medical status, a careful history of her medical condition should be obtained. It is important to distinguish whether she had a syncopal episode or a mechanical fall, because the underlying cause for her fall -- potentially a mental status change or an underlying medical condition such as aortic stenosis or atrial fibrillation -- could require medical intervention before surgical intervention. Similarly, because the goal of treatment should be the restoration of preinjury function, the surgeon should know the patient's preinjury ambulatory status; eg, community ambulator without assistive devices, wheelchair-bound, or bedridden.</p><p>You determine that the patient had a mechanical fall and that she is ambulatory at the nursing home, with aid of a cane. You obtain an x-ray and diagnose her with an intertrochanteric hip fracture.</p>
What is the incidence of intertrochanteric hip fractures?
View the correct answer.
<p>Approximately 250,000 hip fractures occur each year in the United States.<sup type="ref">[1]</sup> By the year 2040, this figure is expected to double to 500,000.</p>
What is the importance of the primary and secondary cancellous bone patterns seen on an x-ray?
View the correct answer.
<p>There are 5 cancellous group patterns present in the hip:</p><p><ul><li>primary compressive;</li><li>secondary compressive;</li><li>primary tensile;</li><li>secondary tensile; and</li><li>greater trochanter groups.</li></ul></p><p><sup type="ref">[2]</sup></p><p><sup type="ref">[3]</sup></p>
If you were unable to detect an obvious fracture in the emergency room but were still suspicious of a fracture, which additional test would you order?
View the correct answer.
<p>Rizzo and colleagues<sup type="ref">[4]</sup> followed 62 consecutive patients in whom a hip fracture was clinically suspected but in whom x-ray findings were negative. MRIs, within 24 hours, and bone scans, within 72 hours, were performed on all patients. MRIs were as accurate as bone scans in the assessment of occult fractures of the hip. However, the MRI can be done within 24 hours, shortening the time to the operating room, while a bone scan is not accurate until 72 hours following the injury. To rule out an occult hip fracture, a bone scan should be performed at 72 hours.<sup type="ref">[5]</sup></p>
The patient and her family ask you about nonsurgical treatment options. What do you tell them about mortality rates and level of independence following such treatment methods?
View the correct answer.
<p>Evans' landmark study<sup type="ref">[6]</sup> comparing 101 patients treated nonoperatively with 110 fractures treated operatively showed that the mortality rate was 15% and 10.9%, respectively. In a study by Hornby,<sup type="ref">[7]</sup> patients were randomized into 1 of 2 treatment groups: a dynamic hip screw group and a skeletal traction group. Complications specific to the 2 treatments were low, and general complications, 6-month mortality and prevalence of pain, leg swelling, and unhealed sores, showed no difference between the 2 modes of treatment. However, operative treatment provided better anatomical results, a shorter hospital stay, and greater independence 6 months after injury.</p><p>You admit the patient to the hospital for surgical stabilization of the fracture. An internal medicine consultation is obtained, and the patient is medically cleared for surgery within 24 hours.</p>
What is the mortality rate for patients with intertrochanteric fractures, and how can this mortality be mitigated?
View the correct answer.
<p>Kenzora and colleagues,<sup type="ref">[8]</sup> in a retrospective study of patients with proximal femoral fractures until death or for at least 1 year, found a mortality rate at 1 year of 15% for patients with intertrochanteric fractures, compared with an expected mortality rate in a population of similar age of about 9%. The number of preexisting medical conditions and whether surgery was performed within 24 hours of admission were highly predictive of mortality. Based on these findings, the authors recommended that serious medical conditions be maximally stabilized for at least 24 hours, and pulmonary and physical therapy instituted, before scheduling open surgical procedures.</p><p>Sexson<sup type="ref">[9]</sup> confirmed Kenzora's findings in a retrospective study analysis of 300 patients with proximal femoral fractures who had a mortality rate of 14.8%. Factors that predicted mortality were age, the number of preexisting medical conditions, the postoperative level of ambulation, and whether surgery was delayed more than 24 hours in relatively healthy patients. The authors recommended that, on the basis of this study, healthy patients should undergo surgery within 24 hours of admission. In less healthy patients, however, the benefits of medical stabilization outweigh the risks of delaying surgery necessary to attain stabilization.</p><p>Finally, Aharonoff and colleagues<sup type="ref">[10]</sup> showed that prevention of postoperative complications was the best way to reduce 1-year mortality. In a prospective, consecutive study of 612 elderly patients who sustained a nonpathologic hip fracture, 12.7% of the subjects died within a year of the fracture. The factors that predicted mortality were patient age greater than 85 years, preinjury dependency on caregivers or family members for the basic activities of daily living, a history of malignancy other than skin cancer, an American Society of Anesthesiologists (ASA) operative risk rating of 3 or 4, and the development of 1 or more in-hospital postoperative complications. Based on these and other studies, patients should be medically optimized and should undergo surgical stabilization within 72 hours of injury.</p>
When performing surgery, the stability of fracture-implant assembly depends on what factors?
View the correct answer.
<p>According to Kaufer,<sup type="ref">[11]</sup> there are 5 independent variables that determine fracture-implant assembly stability:</p><p><ul><li>bone quality;</li><li>fragment geometry;</li><li>adequate reduction;</li><li>choice of implant; and</li><li>placement of the implant.</li></ul></p><p>You choose a 135° dynamic hip screw to fix the fracture because it will provide excellent stability and allow impaction of the fracture fragments. After performing the surgery, AP and lateral radiographs are obtained.</p>
On the follow-up x-ray, what measurement is used to assess whether the implant has a high or low risk of cutout (failure)?
View the correct answer.
<p>Baumgaertner and colleagues<sup type="ref">[12]</sup> have developed a simple measurement, the Tip-Apex Distance (TAD), that can predict the rate of cutout. The TAD is the sum of 2 distances, after controlling for magnification:</p><p><ul><li>the distance from the tip of the lag screw to the apex of the femoral head on an anteroposterior x-ray of the hip;</li><li>this distance on a lateral x-ray of the hip, after controlling for magnification.</li></ul></p><p>In another study, Baumgaertner and colleagues<sup type="ref">[13]</sup> compared the results of 198 surgically treated trochanteric hip fractures with 118 such fractures treated after surgeons had been introduced to the TAD. The number of mechanical failures by cutout of the screw from the head decreased from 16 (8%) in the control group at a mean of 13 months to none in the study group at a mean of 8 months (P = .0015). There were significantly fewer poor reductions in the study group. The study confirmed the importance of good surgical technique in the treatment of trochanteric fractures, and supported the TAD as a clinically useful way of describing the position of the screw.</p>
What are the chances that this patient will regain her preambulatory level of functioning?
View the correct answer.
<p>Koval and colleagues<sup type="ref">[14]</sup> prospectively followed 336 community-dwelling, previously ambulatory, geriatric patients with hip fractures to determine ambulatory ability at a minimum follow-up of 1 year. Forty-one percent maintained their prefracture ambulatory ability, 40% remained ambulatory but became more dependent on assistive devices, 12% became household ambulators, and 8% became nonfunctional ambulators. Age, prefracture ambulatory ability, ASA rating of operative risk, and fracture type influenced recovery.</p>
Made possible through an unrestricted educational grant from Smith & Nephew.
A 72-year-old woman fell as she was getting out of bed at a nursing home. She complained of right hip pain and was referred to the emergency room for further evaluation. As the orthopaedist on call, you are asked to examine her.
What are important questions to ask her or her caregivers?
Given the patients' age and medical status, a careful history of her medical condition should be obtained. It is important to distinguish whether she had a syncopal episode or a mechanical fall, because the underlying cause for her fall -- potentially a mental status change or an underlying medical condition such as aortic stenosis or atrial fibrillation -- could require medical intervention before surgical intervention. Similarly, because the goal of treatment should be the restoration of preinjury function, the surgeon should know the patient's preinjury ambulatory status; eg, community ambulator without assistive devices, wheelchair-bound, or bedridden.You determine that the patient had a mechanical fall and that she is ambulatory at the nursing home, with aid of a cane. You obtain an x-ray and diagnose her with an intertrochanteric hip fracture.
View the correct answer.
<p>Given the patients' age and medical status, a careful history of her medical condition should be obtained. It is important to distinguish whether she had a syncopal episode or a mechanical fall, because the underlying cause for her fall -- potentially a mental status change or an underlying medical condition such as aortic stenosis or atrial fibrillation -- could require medical intervention before surgical intervention. Similarly, because the goal of treatment should be the restoration of preinjury function, the surgeon should know the patient's preinjury ambulatory status; eg, community ambulator without assistive devices, wheelchair-bound, or bedridden.</p><p>You determine that the patient had a mechanical fall and that she is ambulatory at the nursing home, with aid of a cane. You obtain an x-ray and diagnose her with an intertrochanteric hip fracture.</p>
What is the incidence of intertrochanteric hip fractures?
Approximately 250,000 hip fractures occur each year in the United States. By the year 2040, this figure is expected to double to 500,000.
View the correct answer.
<p>Approximately 250,000 hip fractures occur each year in the United States.<sup type="ref">[1]</sup> By the year 2040, this figure is expected to double to 500,000.</p>
What is the importance of the primary and secondary cancellous bone patterns seen on an x-ray?
There are 5 cancellous group patterns present in the hip:
primary compressive;
secondary compressive;
primary tensile;
secondary tensile; and
greater trochanter groups.
View the correct answer.
<p>There are 5 cancellous group patterns present in the hip:</p><p><ul><li>primary compressive;</li><li>secondary compressive;</li><li>primary tensile;</li><li>secondary tensile; and</li><li>greater trochanter groups.</li></ul></p><p><sup type="ref">[2]</sup></p><p><sup type="ref">[3]</sup></p>
If you were unable to detect an obvious fracture in the emergency room but were still suspicious of a fracture, which additional test would you order?
Rizzo and colleagues followed 62 consecutive patients in whom a hip fracture was clinically suspected but in whom x-ray findings were negative. MRIs, within 24 hours, and bone scans, within 72 hours, were performed on all patients. MRIs were as accurate as bone scans in the assessment of occult fractures of the hip. However, the MRI can be done within 24 hours, shortening the time to the operating room, while a bone scan is not accurate until 72 hours following the injury. To rule out an occult hip fracture, a bone scan should be performed at 72 hours.
View the correct answer.
<p>Rizzo and colleagues<sup type="ref">[4]</sup> followed 62 consecutive patients in whom a hip fracture was clinically suspected but in whom x-ray findings were negative. MRIs, within 24 hours, and bone scans, within 72 hours, were performed on all patients. MRIs were as accurate as bone scans in the assessment of occult fractures of the hip. However, the MRI can be done within 24 hours, shortening the time to the operating room, while a bone scan is not accurate until 72 hours following the injury. To rule out an occult hip fracture, a bone scan should be performed at 72 hours.<sup type="ref">[5]</sup></p>
The patient and her family ask you about nonsurgical treatment options. What do you tell them about mortality rates and level of independence following such treatment methods?
Evans' landmark study comparing 101 patients treated nonoperatively with 110 fractures treated operatively showed that the mortality rate was 15% and 10.9%, respectively. In a study by Hornby, patients were randomized into 1 of 2 treatment groups: a dynamic hip screw group and a skeletal traction group. Complications specific to the 2 treatments were low, and general complications, 6-month mortality and prevalence of pain, leg swelling, and unhealed sores, showed no difference between the 2 modes of treatment. However, operative treatment provided better anatomical results, a shorter hospital stay, and greater independence 6 months after injury.You admit the patient to the hospital for surgical stabilization of the fracture. An internal medicine consultation is obtained, and the patient is medically cleared for surgery within 24 hours.
View the correct answer.
<p>Evans' landmark study<sup type="ref">[6]</sup> comparing 101 patients treated nonoperatively with 110 fractures treated operatively showed that the mortality rate was 15% and 10.9%, respectively. In a study by Hornby,<sup type="ref">[7]</sup> patients were randomized into 1 of 2 treatment groups: a dynamic hip screw group and a skeletal traction group. Complications specific to the 2 treatments were low, and general complications, 6-month mortality and prevalence of pain, leg swelling, and unhealed sores, showed no difference between the 2 modes of treatment. However, operative treatment provided better anatomical results, a shorter hospital stay, and greater independence 6 months after injury.</p><p>You admit the patient to the hospital for surgical stabilization of the fracture. An internal medicine consultation is obtained, and the patient is medically cleared for surgery within 24 hours.</p>
What is the mortality rate for patients with intertrochanteric fractures, and how can this mortality be mitigated?
Kenzora and colleagues, in a retrospective study of patients with proximal femoral fractures until death or for at least 1 year, found a mortality rate at 1 year of 15% for patients with intertrochanteric fractures, compared with an expected mortality rate in a population of similar age of about 9%. The number of preexisting medical conditions and whether surgery was performed within 24 hours of admission were highly predictive of mortality. Based on these findings, the authors recommended that serious medical conditions be maximally stabilized for at least 24 hours, and pulmonary and physical therapy instituted, before scheduling open surgical procedures.Sexson confirmed Kenzora's findings in a retrospective study analysis of 300 patients with proximal femoral fractures who had a mortality rate of 14.8%. Factors that predicted mortality were age, the number of preexisting medical conditions, the postoperative level of ambulation, and whether surgery was delayed more than 24 hours in relatively healthy patients. The authors recommended that, on the basis of this study, healthy patients should undergo surgery within 24 hours of admission. In less healthy patients, however, the benefits of medical stabilization outweigh the risks of delaying surgery necessary to attain stabilization.Finally, Aharonoff and colleagues showed that prevention of postoperative complications was the best way to reduce 1-year mortality. In a prospective, consecutive study of 612 elderly patients who sustained a nonpathologic hip fracture, 12.7% of the subjects died within a year of the fracture. The factors that predicted mortality were patient age greater than 85 years, preinjury dependency on caregivers or family members for the basic activities of daily living, a history of malignancy other than skin cancer, an American Society of Anesthesiologists (ASA) operative risk rating of 3 or 4, and the development of 1 or more in-hospital postoperative complications. Based on these and other studies, patients should be medically optimized and should undergo surgical stabilization within 72 hours of injury.
View the correct answer.
<p>Kenzora and colleagues,<sup type="ref">[8]</sup> in a retrospective study of patients with proximal femoral fractures until death or for at least 1 year, found a mortality rate at 1 year of 15% for patients with intertrochanteric fractures, compared with an expected mortality rate in a population of similar age of about 9%. The number of preexisting medical conditions and whether surgery was performed within 24 hours of admission were highly predictive of mortality. Based on these findings, the authors recommended that serious medical conditions be maximally stabilized for at least 24 hours, and pulmonary and physical therapy instituted, before scheduling open surgical procedures.</p><p>Sexson<sup type="ref">[9]</sup> confirmed Kenzora's findings in a retrospective study analysis of 300 patients with proximal femoral fractures who had a mortality rate of 14.8%. Factors that predicted mortality were age, the number of preexisting medical conditions, the postoperative level of ambulation, and whether surgery was delayed more than 24 hours in relatively healthy patients. The authors recommended that, on the basis of this study, healthy patients should undergo surgery within 24 hours of admission. In less healthy patients, however, the benefits of medical stabilization outweigh the risks of delaying surgery necessary to attain stabilization.</p><p>Finally, Aharonoff and colleagues<sup type="ref">[10]</sup> showed that prevention of postoperative complications was the best way to reduce 1-year mortality. In a prospective, consecutive study of 612 elderly patients who sustained a nonpathologic hip fracture, 12.7% of the subjects died within a year of the fracture. The factors that predicted mortality were patient age greater than 85 years, preinjury dependency on caregivers or family members for the basic activities of daily living, a history of malignancy other than skin cancer, an American Society of Anesthesiologists (ASA) operative risk rating of 3 or 4, and the development of 1 or more in-hospital postoperative complications. Based on these and other studies, patients should be medically optimized and should undergo surgical stabilization within 72 hours of injury.</p>
When performing surgery, the stability of fracture-implant assembly depends on what factors?
According to Kaufer, there are 5 independent variables that determine fracture-implant assembly stability:
bone quality;
fragment geometry;
adequate reduction;
choice of implant; and
placement of the implant.
View the correct answer.
<p>According to Kaufer,<sup type="ref">[11]</sup> there are 5 independent variables that determine fracture-implant assembly stability:</p><p><ul><li>bone quality;</li><li>fragment geometry;</li><li>adequate reduction;</li><li>choice of implant; and</li><li>placement of the implant.</li></ul></p><p>You choose a 135° dynamic hip screw to fix the fracture because it will provide excellent stability and allow impaction of the fracture fragments. After performing the surgery, AP and lateral radiographs are obtained.</p>
On the follow-up x-ray, what measurement is used to assess whether the implant has a high or low risk of cutout (failure)?
Baumgaertner and colleagues have developed a simple measurement, the Tip-Apex Distance (TAD), that can predict the rate of cutout. The TAD is the sum of 2 distances, after controlling for magnification:
the distance from the tip of the lag screw to the apex of the femoral head on an anteroposterior x-ray of the hip;
this distance on a lateral x-ray of the hip, after controlling for magnification.
View the correct answer.
<p>Baumgaertner and colleagues<sup type="ref">[12]</sup> have developed a simple measurement, the Tip-Apex Distance (TAD), that can predict the rate of cutout. The TAD is the sum of 2 distances, after controlling for magnification:</p><p><ul><li>the distance from the tip of the lag screw to the apex of the femoral head on an anteroposterior x-ray of the hip;</li><li>this distance on a lateral x-ray of the hip, after controlling for magnification.</li></ul></p><p>In another study, Baumgaertner and colleagues<sup type="ref">[13]</sup> compared the results of 198 surgically treated trochanteric hip fractures with 118 such fractures treated after surgeons had been introduced to the TAD. The number of mechanical failures by cutout of the screw from the head decreased from 16 (8%) in the control group at a mean of 13 months to none in the study group at a mean of 8 months (P = .0015). There were significantly fewer poor reductions in the study group. The study confirmed the importance of good surgical technique in the treatment of trochanteric fractures, and supported the TAD as a clinically useful way of describing the position of the screw.</p>
What are the chances that this patient will regain her preambulatory level of functioning?
Koval and colleagues prospectively followed 336 community-dwelling, previously ambulatory, geriatric patients with hip fractures to determine ambulatory ability at a minimum follow-up of 1 year. Forty-one percent maintained their prefracture ambulatory ability, 40% remained ambulatory but became more dependent on assistive devices, 12% became household ambulators, and 8% became nonfunctional ambulators. Age, prefracture ambulatory ability, ASA rating of operative risk, and fracture type influenced recovery.
View the correct answer.
<p>Koval and colleagues<sup type="ref">[14]</sup> prospectively followed 336 community-dwelling, previously ambulatory, geriatric patients with hip fractures to determine ambulatory ability at a minimum follow-up of 1 year. Forty-one percent maintained their prefracture ambulatory ability, 40% remained ambulatory but became more dependent on assistive devices, 12% became household ambulators, and 8% became nonfunctional ambulators. Age, prefracture ambulatory ability, ASA rating of operative risk, and fracture type influenced recovery.</p>
Made possible through an unrestricted educational grant from Smith & Nephew.
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