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Femoral Neck Fractures

The majority of hip fractures occur after a simple fall at home, usually in older patients who lack the reflexes to "break the fall" and in whom the bones are brittle. These injuries may result from straightforward accidents or as part of a gradual deterioration associated with other medical problems such as high blood pressure, poor balance and poor vision. Patients who fall regularly at home are at very high risk of hip fracture and this underlying in-coordination limits recovery afterwards.

These fractures can also occur when young adults have high energy injuries; skiing, mountain biking or road traffic accidents.

Surgery is usually recommended to patients with hip fractures as the natural process of bone healing is very unpredictable and requires prolonged bed rest, which is best avoided. These are not minor operations, sometimes the fracture is bolted together or alternatively the head is replaced with an artificial joint (hemiarthroplasty) or a total hip replacement is performed.

There is growing evidence [National Institute for Clinical Effectiveness: http://www.nice.org.uk/CG124] that fit active elderly patients with displaced hip fractures just below the femoral head (intra-capsular) are best treated with a total hip replacement, performed by an experienced hip surgeon.

All displaced intra-capsular femoral neck fractures in patients with rheumatoid arthritis should be treated with a total hip replacement, there is no place for hemiarthroplasty.

In the days after the operation it is usually possible to walk with a frame or crutches, most patients need to use a stick for 6-8 weeks. Recovery after the operation depends greatly upon each patient's level of preoperative mobility and independence. Every elderly patient presenting with a hip fracture should be assessed for osteoporosis and treatment discussed with their GP.

Healing of hip fractures can be unpredictable especially in patients with osteoporosis and other medical conditions. When the initial treatment has not been successful the fracture can become very painful and the hip deteriorates very rapidly. The diagnosis of failed fixation of a hip fracture can be made with simple X-rays. In cases where initial attempts at fixation have been unsuccessful a conversion of the original operation to a total hip replacement may be advised.

It is important to exclude infection before implanting any new metalwork, this may require a biopsy. Where the fracture is limited to the head/neck of the femur a standard total hip replacement can be performed. If the bone below the head is damaged a more extensive operation may be required.

Acetabular Fractures

Fractures of the pelvic bone that involve the hip joint are called acetabular fractures. These fractures are usually caused by significant high energy injuries, road crashes, fall from a ladder or horse riding.
Posterior wall acetabular fracture. Anterior column acetabular fracture. Transverse acetabular fracture.

Thankfully the majority of these injuries are undisplaced and simply require a period of time of crutches for the bone to heal. When the joint surface is disrupted there is a risk of rapid joint wear, secondary osteoarthritis.

In young patients there is some healing potential and fixation of the fracture is recommended, as close to the normal position as possible. For elderly patients it may be better to plan a total hip replacement after the bone has solidified.

Avulsion Fractures

In these cases a small amount of bone is pulled off at the point were a muscle attaches (imagine a chain pulling a chunk of plaster from a wall). A great deal of force is required to cause these injuries and they are most commonly seen as sports injuries or after substantial trauma. There are several sites around the hip were these fractures can occur:

Avulsion fractures around the hip and pelvis

For more details see the Teaching Zone on this topic.

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