Hip Fracture Treatment

What Is a Hip Fracture and Why Is It Serious?

A hip fracture is a break in the proximal (upper) portion of the femur. This region includes the femoral head (the ball), the femoral neck (the thin section just below the head), and the bony prominences called trochanters (where the muscles attach).

Hip fractures should be taken seriously for the following reasons:

• Severe Pain and Loss of Function: The patient usually cannot walk or move the leg.
• High Risk of Complications: Prolonged bed confinement, especially in elderly patients, leads to serious complications such as lung infection, urinary tract infection, deep vein thrombosis (blood clot in the leg), pulmonary embolism (a clot traveling to the lungs), bedsores (pressure ulcers), and muscle wasting.
• Increased Mortality Risk: In elderly patients who suffer a hip fracture, especially within the first year, the risk of death is unfortunately higher than in their peers. This is generally related not so much to the fracture itself as to complications arising from immobility and the patient’s other accompanying health problems.
• Loss of Independence: Many patients may not fully regain the level of independence they had before the fracture.

For these reasons, the fundamental treatment goal in hip fractures is to mobilize the patient as quickly and safely as possible. This is only possible with surgical treatment.

Types of Hip Fracture

Hip fractures are classified according to where on the femur the fracture is located. This classification directly affects the choice of treatment:

1. Femoral Neck Fractures:
   
   • Occurs in the “neck” section directly below the femoral head.
   • Because this region lies within the joint capsule, it is called an intracapsular fracture.
   • Important feature: Because the blood vessels supplying the femoral head pass through the femoral neck, the blood supply to the femoral head can be disrupted in this type of fracture (especially if the fragments are displaced). This increases the risk of the fracture failing to heal (nonunion) or, later on, of the femoral head deteriorating (Avascular Necrosis).
   • Classified according to the degree of fragment displacement (e.g., the Garden classification).
2. Intertrochanteric Fractures:
   
   • The fracture line passes between the large and small bony prominences (greater and lesser trochanters) below the femoral neck.
   • Because this region lies outside the joint capsule, it is called an extracapsular fracture.
   • Compared with femoral neck fractures, blood supply is generally better and healing potential is higher. The risk of avascular necrosis is very low.
   • However, because the fracture line affects a wider area and muscle pull can make the fragments more unstable, appropriate fixation methods are required.
3. Subtrochanteric Fractures:
   
   • The fracture line starts below the lesser trochanter and extends toward the upper shaft of the femur.
   • Usually results from higher-energy trauma (in younger people), or sometimes from long-term use of bone medications such as bisphosphonates (atypical femur fracture), or from a fall in elderly people with osteoporosis.
   • Because this region is under high mechanical stress, fixation and healing can be difficult, requiring special implants.

Causes and Risk Factors of Hip Fracture

• Falls: More than 90% of hip fractures are caused by falls. Especially in the elderly, even a simple sideways fall indoors or outdoors can cause a fracture.
• Osteoporosis (Bone Loss): This condition, which reduces bone density and strength, greatly increases the risk of hip fracture, especially in elderly women. It weakens the bone, causing fractures to occur even with simple falls.
• Other Risk Factors:
  
  • Advanced age (>65 years)
  • Female sex (especially after menopause)
  • Low body weight, weak muscle mass
  • Vision impairment, balance problems (neurological conditions, etc.)
  • Use of medications that cause dizziness or imbalance (sedatives, certain blood pressure medications, etc.)
  • Vitamin D and calcium deficiency
  • Previous history of hip fracture
  • Smoking and excessive alcohol consumption
  • Lack of physical activity

In younger people, hip fractures usually result from high-energy trauma (traffic accidents, falls from height).

What Are the Symptoms of a Hip Fracture?

• Severe Hip or Groin Pain: Usually begins suddenly.
• Inability to Walk or Stand: The patient cannot bear weight on the fractured leg.
• Malposition of the Leg: The fractured leg typically appears shorter and rotated outward compared to the healthy leg. This is a typical finding, particularly in displaced femoral neck and intertrochanteric fractures.
• Swelling and Bruising: Swelling and bruising may occur in the hip region.
• Pain That Worsens with Movement: Attempting to move the hip or leg causes severe pain.

Note: In non-displaced femoral neck fractures, the pain may sometimes be milder, and the patient may be able to bear weight for a short distance. This can lead to delays in diagnosis. Persistent groin pain after a fall onto the hip region should always raise suspicion of a fracture.

How Is a Hip Fracture Diagnosed?

Diagnosis is usually straightforward:

• Patient History and Physical Examination: How the fall or injury occurred is determined. The position of the patient’s leg is observed, and the hip region is palpated for tenderness. Movement is severely limited due to pain. A vascular and neurological examination of the leg (circulation, sensation, movement) is always performed.
• X-ray: This is the primary and usually sufficient method for diagnosis. An anteroposterior (AP) view of the pelvis and a lateral view of the affected hip (usually a cross-table lateral) are taken. These images clearly show the location of the fracture (neck, intertrochanteric, subtrochanteric), its type, and the degree of fragment displacement, allowing classification.
• Other Imaging Methods (CT/MRI): In cases where X-ray cannot confirm the diagnosis but clinical suspicion remains high (occult fracture), or particularly for surgical planning of complex intertrochanteric/subtrochanteric fractures, CT or MRI may rarely be requested. MRI is the most sensitive method for detecting occult fractures.

Treatment: Why Is Surgery Almost Always Necessary and Urgent?

In the past, hip fractures were sometimes treated with casting or prolonged bed rest, but these methods were found to lead to very high complication and mortality rates, especially in elderly patients. The only way to prevent problems caused by immobility (lung infection, blood clots, bedsores, etc.) and to help the patient regain function is to get the patient back on their feet as soon as possible. This is only possible once the fracture has been surgically stabilized.

For this reason, treatment for hip fractures is almost always surgical, and the goal is to perform the operation generally within the first 24-48 hours, once the patient’s overall medical condition has been stabilized. Early surgery reduces the risk of complications, facilitates pain control, and allows rehabilitation to begin sooner.

Surgical Options (Based on Fracture Type and Patient):

The choice of surgery is based on the location of the fracture (neck, intertrochanteric, subtrochanteric), the degree of fragment displacement, the patient’s age, bone quality, pre-injury walking capacity, and overall health status.

1. Surgery for Femoral Neck Fractures:
   
   • Internal Fixation (ORIF – Fixing the Fracture): Preferred especially for non-displaced or minimally displaced fractures, in younger patients, or in physiologically young, active elderly patients. The fracture line is fixed with screws (multiple cannulated screws) or a specialized sliding hip nail/plate (SHS/DHS). The goal is to preserve the patient’s own femoral head. However, there is a risk of nonunion or the development of Avascular Necrosis.
   • Hemiarthroplasty (Partial Hip Replacement): Frequently preferred for displaced femoral neck fractures in elderly, frail, or demented patients. Only the fractured femoral head is removed and replaced with a metal prosthetic head. The acetabulum (socket) is not replaced. Compared with ORIF, the risk of revision surgery is lower, and it usually allows immediate full weight-bearing.
   • Total Hip Replacement (THR): Also used for displaced femoral neck fractures, but preferred in more active, healthier elderly patients with higher functional expectations, or in those who already have pre-existing osteoarthritis of the hip. Both the femoral head and the acetabulum (socket) are replaced with prosthetic components. Compared with hemiarthroplasty, it can potentially offer better long-term function and less groin pain.
2. Surgery for Intertrochanteric Fractures: Because blood supply to this region is good, the goal is to achieve stable fixation of the fracture to allow healing.
   
   • Sliding/Dynamic Hip Screw and Plate (SHS/DHS): A system consisting of a large screw that enters the femoral head and a plate positioned along the side of the femur. It promotes healing by allowing controlled compression and settling at the fracture line. This method has been used successfully for many years.
   • Intramedullary Hip Nail (Proximal Femoral Nail / Cephalomedullary Nail): Consists of a metal rod (nail) inserted into the femur (medullary canal) along with screws that pass from the nail into the femoral head/neck. It is increasingly preferred, especially for unstable fractures (reverse oblique, with subtrochanteric extension), or because some surgeons believe it provides more stable fixation and potentially allows earlier weight-bearing.
3. Surgery for Subtrochanteric Fractures: The high stress in this region requires strong fixation.
   
   • Intramedullary Nail: Generally the preferred method. A long nail is inserted into the femur to provide stability.
   • Plate and Screws: Specially designed locking plates may also be used.

Prof. Dr. Murat Bozkurt carefully evaluates each patient’s fracture type and individual characteristics to determine the most appropriate surgical method (fixation or replacement) and applies it using modern techniques.

Risks, Benefits, and the Recovery Process

• Benefits (Surgery): Rapid reduction in pain, stabilization of the fracture, the ability to stand up and move early, prevention of complications related to immobility (infection, blood clots, bedsores), the ability to begin the rehabilitation process, and recovery of function and independence.
• Risks: Because hip fracture surgeries are performed particularly in elderly patients with additional health problems, they carry certain risks:
  
  • General anesthesia and surgical risks (bleeding, infection, wound healing problems).
  • Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE): Formation of a blood clot in the leg and its travel to the lungs (efforts are made to prevent this with blood-thinning medications).
  • Infection: There is a risk of infection both at the surgical site and of the prosthesis (PJI).
  • Fixation Hardware Problems: Loosening, breakage, or cut-out of the screws or nails used to fix the fracture.
  • Prosthesis Problems: Dislocation of the prosthesis, prosthetic infection, loosening, or wear.
  • Nonunion or Malunion: May be seen especially in fixation of femoral neck fractures or in challenging intertrochanteric/subtrochanteric fractures.
  • Avascular Necrosis: May develop following femoral neck fractures.
  • Leg Length Discrepancy.
  • Medical Complications: Additional medical problems such as postoperative heart issues, lung problems, or confusion (delirium) may develop.
  • Mortality: Especially within the first year, the risk of death is unfortunately increased due to accompanying conditions and complications.
• Recovery Process: Recovery after a hip fracture is a long and multidisciplinary process, requiring the cooperation of many specialties.
  
  • Early Mobilization: On the first day after surgery, the patient is encouraged to sit at the edge of the bed and, if possible, stand up and walk (with the help of a walker or physiotherapist). This is the most important step in preventing complications.
  • Weight-Bearing Status: Varies according to the surgery performed. Replacement surgeries generally allow earlier full weight-bearing, whereas fixation surgeries may require a period of protected (partial) weight-bearing (usually 6-8 weeks) afterward.
  • Physical Therapy and Rehabilitation: Begins in the hospital and continues for months after discharge. The goal is to restore joint range of motion, increase muscle strength (especially around the hip and knee), improve balance, regain safe walking and stair-climbing ability, and prevent falls.
  • Timeline: Full recovery generally takes 6 to 12 months. Many elderly patients may not fully return to their pre-fracture functional level, but the goal is for the patient to continue living as independently and pain-free as possible.

Hip Fracture Treatment in Ankara and Prof. Dr. Murat Bozkurt’s Approach

Hip fractures, also common in Ankara particularly among the elderly population, are conditions requiring urgent, specialized orthopedic care. Prof. Dr. Murat Bozkurt follows these principles in his approach to patients with hip fractures:

• Urgent and Accurate Assessment: Rapidly evaluates the type of fracture and the patient’s overall condition.
• Multidisciplinary Cooperation: Works together with other specialties such as anesthesiology, internal medicine, and cardiology to optimize the patient’s medical condition before surgery.
• Goal of Early Surgery: Aims to perform surgery within the first 24-48 hours, as the patient’s condition allows.
• Selection of the Appropriate Surgical Method: Chooses the most suitable surgical technique (fracture fixation – screw/plate/nail, or replacement – hemi/total) based on the type of fracture, the patient’s age, bone quality, and functional expectations. The goal is to achieve a stable outcome and get the patient back on their feet as soon as possible.
• Modern Techniques and Implants: Performs surgeries using up-to-date surgical techniques and modern, reliable implants.
• Initiating and Following Up on Rehabilitation: Emphasizes the importance of early postoperative mobilization and comprehensive rehabilitation, and guides the patient and family throughout this process.