Treatment

What treatments should I consider?

Most hip fractures are treated by surgery. Intertrochanteric and subtrochanteric fractures are likely to heal with treatment by traction but the lengthy immobilization has been shown to be more dangerous than surgery. A fractured neck of femur is not likely to heal without being immobilized by surgical treatment. For most patients the surgery is done as soon as possible and under spinal anesthesia.

In older patients with fractures of the neck of the femur, the surgery most often chosen is replacement (arthroplasty). This may be a total hip replacement or the simpler operation of replacing the broken part with a metal head and neck. The major advantage of a replacement operation is that the broken bone does not need to heal and the patient can move, walk and put weight on the hip almost at once. The hip replacement operation also eliminates the possibility of certain complications such as nonunion or avascular necrosis.

Related Document: A Patient's Guide to Artificial Joint Replacement of the Hip

Where it is believed that the patient has a good chance of healing a femoral neck fracture or where it would be a great advantage to avoid an artificial hip, the treatment recommended will be pinning of the fracture. This can be done with minimally invasive technique. The fracture is straightened and screws are passed across it using X-ray control to make sure they are in the correct position. These screws hold the fracture in position until the bone heals. However, the fixation is not very strong and patients should avoid putting weight on the affected leg until there are signs of healing on x-ray.

Intertrochanteric fractures are usually treated by internal fixation. Although some intramedullary devices have been suggested, the most common method of internal fixation is a sliding nail plate. After the fracture has been straightened by manipulation and traction the outer side of the upper thigh bone is exposed. A large screw is passed across the fracture going up into the femoral head. This screw is then attached to a side-plate fixed to the thighbone with more screws. This fixation device is also sometimes used for neck of femur fractures. This plate is designed to allow the screw to slide back out if the fracture collapses and shortens. otherwise the screw would penetrate into the hip joint.

The plate and screw assembly will hold the parts of the fracture in position while the healing process takes place. If the fracture is unstable the surgery is planned to allow the fracture to collapse but into a position of greater stability guided by the screw and plate.

The role of joint replacement surgery in unstable intertrochanteric fractures is controversial. Studies show that patients who were walking normally before the fracture have some impairments afterward. It is thought that a successful hip replacement operation would offer these patients a better chance of normal function. Because the operation is more complex and stressful, the balance between risks and benefits has not been fully determined.

Subtrochanteric fractures may also be treated by a plate and screw; the plate is usually longer because the fracture extends further down. Other internal fixation devices used to fix these fractures include blade plates, condylar screw plates and intramedullary rods. The most common form of intramedullary rod fixation combines screws that fix into the femoral head and a rod that goes down inside the shaft of the thigh bone. In this way, the fracture is made stable above and below the fracture line. This is helpful when the fracture is very unstable or complex.

The internal fixation devices remain in place until the fracture heals. It is not common for them to cause symptoms after that but a few people experience discomfort or tenderness from the screws, plate or rod. In these cases the fixation hardware can be removed. If the patient has been treated by a hip replacement operation the prosthetic devices stay in place.