Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.
Initial Diagnosis
- First visit: with Primary Care Physician MO/DO or to emergency care
- Determine cause: initial evaluation:
- Determine the type of trauma (fall, motor vehicle accident, etc.).
- Determine patient history and whether the problem is acute, subacute, chronic, or of insidious onset.
- Determine the severity and specific anatomic location of the pain.
- Assess the ability of the patient to walk and assess range of motion.
- Search for evidence of an open or penetrating wound.
- Determine any present medication, co-morbidities or pre-existing conditions (including pregnancy, anemia, etc.) that may affect medication or surgery.
- Initial diagnosis:
- Traumatic (see "Fractures" or "Dislocations" below)
- Fractures or Dislocations (see the original guideline document for International Classification of Diseases, Ninth Revision [ICD-9] codes for this and other diagnoses)
- Avascular necrosis (the death of bone tissue due to a lack of blood supply, most often affects the head of femur, causing hip pain)
- Other (see "Conservative Treatment" below)
- Sprain or contusion
- Laceration
- Coccygodynia
- Sacroiliitis
- Hip overuse syndrome
Management in Accident & Emergency
Early assessment, in accident & emergency or on the ward, should include a formal recording of:
- Pressure sore risk
- Hydration and nutrition
- Fluid balance
- Pain
- Core body temperature using a low reading thermometer
- Continence
- Co-existing medical problems
- Mental state
- Previous mobility
- Previous functional ability
- Social circumstances
Fractures and Dislocations
Fractures
Possible Causes
- Trauma (most common)
- Lytic lesions (Cancerous metastasis, Paget disease, bone cysts)
- Osteoporosis
Patients admitted to accident & emergency with a suspected hip fracture should be managed as follows:
- Use soft surfaces to protect the heel and sacrum from pressure damage.
- Keep the patient warm.
- Administer pain relief to allow for regular, comfortable change of patient position.
- Instigate early radiology.
- Measure and correct any fluid and electrolyte abnormalities.
Patients should be transferred to the ward within two hours of their arrival in accident & emergency.
See "Imaging Studies" below.
Hip Fracture Classifications
Determine the anatomic locations (head, neck, intertrochanteric, trochanteric, and subtrochanteric) and note whether it is intracapsular or extracapsular. Femoral head and neck fractures are considered intracapsular, while trochanteric, intertrochanteric, and subtrochanteric fractures are considered extracapsular. Intracapsular hip fractures frequently have complicated healing.
Preoperative Care
Patients should be operated on as soon as possible (within 24 hours).
All patients undergoing hip fracture surgery should receive antibiotic prophylaxis.
Patients should have clinical and laboratory assessment of possible hypovolaemia and electrolyte balance, and deficiencies appropriately and promptly corrected.
Oxygen saturation should be checked on admission. Supplementary oxygen should be administered to all patients with hypoxemia.
Anaesthetic Management
Regional anesthesia is recommended for patients undergoing hip fracture repair, providing there are no specific indications for general anesthesia or contraindications to regional anesthesia.
Surgical Management
Most undisplaced intracapsular hip fractures that are treated surgically should have internal fixation, except in the very elderly, when hemiarthroplasty may be considered.
Extracapsular hip fractures should all be treated surgically unless there are medical contraindications.
Femoral Head Fractures
Type 1 (single fragment fractures): Reduce dislocated femoral head and fracture fragment as soon as possible to avoid avascular necrosis of fracture fragment. Early orthopedic consultation is a must. Small fracture fragments may need to be removed.
Type 2 (comminuted fractures): Early orthopedic consultation for admission and arthroplasty is recommended.
Femoral Neck Fractures
Type 1 (stress fractures or incomplete fractures): Some practitioners handle these fractures nonoperatively with initial immobilization in selected patients, while others prefer operative treatment in all patients.
Types 2, 3, and 4 (impacted fractures, partially displaced fractures, completely displaced or comminuted fractures): Management usually includes internal fixation or arthroplasty; however selected cases of impacted fracture can be treated conservatively. Early orthopedic consultation is recommended.
Intertrochanteric Fractures
Note potential for significant blood loss. Intravenous (IV) fluid resuscitation may be necessary.
Stable and unstable fractures usually are treated with open reduction and internal fixation unless patient is not an operative candidate for other reasons.
Early orthopedic consultation is recommended.
Trochanteric Fractures
Type 1 (nondisplaced fractures): Management is most often conservative, and orthopedic consultation is recommended.
Type 2 (displaced fracture): These usually are treated with reduction and internal fixation, except in older or debilitated patients in whom conservative treatment is appropriate.
Subtrochanteric Fractures
Significant hemorrhage is common, and IV fluid resuscitation is frequently necessary.
Emergency department (ED) application of traction or traction splint is necessary.
Consult orthopedic surgeon for admission and open reduction with internal fixation for most patients.
Dislocations
Possible Causes
- Trauma (most common)
- Congenital disorder
A hip dislocation requires immediate pain management, full medical screening examination, and reduction of the dislocation within 6 to 12 hours. The incidence of subsequent avascular necrosis (AVN) of the femoral head is a time-dependent phenomenon, one most likely to occur if relocation is delayed beyond 6 hours.
See "Imaging Studies" below.
Determine type of dislocation:
Anterior Hip Dislocation
Anterior dislocation of the hip occurs from a direct blow to the posterior aspect of the hip or, more commonly, from a force applied to an abducted leg that levers the hip anteriorly out of the acetabulum. Because of the mechanism of force causing this dislocation, the patient should also be evaluated for femur fractures, ligamentous stability, and pelvic fractures.
Central Hip Dislocation
Central dislocations occur when a direct impact to the lateral aspect of the hip forces the hip centrally through the acetabulum into the pelvis. This is a fracture-dislocation.
Posterior Hip Dislocation (90% of all hip dislocations)
Posterior dislocations occur when the knee and hip are flexed and a posterior force is applied at the knee. Conduct a full medical screening, including examination of the knee, foot and ankle joints.
Closed reduction is recommended for hip dislocation if possible.
Indications for open reduction include:
- Irreducible dislocation (approximately 10% of all dislocations)
- Persistent instability of the joint following reduction (e.g., fracture-dislocation of the posterior acetabulum)
- Fracture of the femoral head or shaft
- Neurovascular deficits that occur after closed reduction
Imaging Studies for Fractures and Dislocations
Plain Radiography
- Plain radiographs of the pelvis should routinely be obtained in patients with a severe mechanism of injury, such as a motor vehicle accident (MVA) or fall from a substantial height. Pelvic fractures may occur in as many as 10% of patients.
Computed Tomography (CT)
- CT scan of the hip is accurate in delineating the extent and nature of acetabular and hip fractures and dislocations.
- If the patient's condition is sufficiently stable and if surgical repair is contemplated, CT scans provide essential information for the orthopedist.
- The severity of acetabular fractures tends to be underestimated on plain radiographs, which are therefore less useful than CT scans in this situation.
Magnetic Resonance Imaging (MRI)
- MRI of the hip is usually impractical in the initial evaluation of a trauma patient. It is, however, the best imaging modality in detecting and assessing AVN of the hip and in detecting nondisplaced stress fractures of the femoral neck.
- MRI is also useful in the diagnosis of bone tumors, osteomyelitis, osteoarthritis, and congenital abnormalities of the hip joint.
Conservative Treatment
Conservative treatment applies to most cases of osteoarthritis, inflammatory arthritis, strains and sprains, tendonitis and non-displaced trochanteric fractures.*
Minor Injuries
Following MRI or ultrasonography, rest, ice, compression, and physical therapy are recommended.
Arthritic Conditions
Oral analgesics and exercise are recommended. Joint arthroplasty may be needed for end stage osteoarthritis. Following progression of inflammatory arthritis, anti-rheumatic drugs may be prescribed.
*Most non-displaced greater trochanteric fractures can be treated conservatively with protected weight bearing on the affected leg until the symptoms resolve. However, a nondisplaced greater trochanteric fracture that results from a fall needs to be evaluated to confirm that the fracture does not extend into the intertrochanteric region, which could result in displacement of the fracture. To evaluate the fracture, limited MRI or a bone scan may be useful. If the trochanteric fracture involves a large, completely displaced, and mechanically significant fragment of bone, it may require reduction and fixation.
