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Nursing Diagnosis for Hip Fractures

Introduction

A fracture is a medical term used for a broken bone. It occurs when the physical force exerted on the bone is stronger than the bone itself. They commonly happen because of car accidents, falls, or sports injuries. Other causes are low bone density and osteoporosis, which cause the weakening of the bones.

To be more specific, a hip fracture is a break in the upper portion of the femur (thighbone). Most hip fractures occur in elderly patients whose bones have become weakened by osteoporosis. When a hip fracture occurs in a younger patient, it is typically the result of a high-energy event, such as a fall from a ladder or vehicle collision.

This blog post will outline a detailed description of various types of hip fractures, their respective symptoms, causes, nursing diagnoses, and the methods of prevention that nurses and physicians may use to care for patients with hip fractures. As you read, keep in mind that our professional nursing writers are ready to help with your assignment if you get stuck. All you need to do is place an order with us.

Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students for learning purposes only and should not be applied without an approved physician’s consent. Please consult a registered doctor if you’re looking for medical advice.

Types of Hip Fractures

There are three broad categories of hip fractures based on the fracture location: femoral neck fracturesintertrochanteric fractures, and subtrochanteric fractures.  

Femoral Neck Fractures/ Intracapsular Fractures

A femoral neck fracture occurs one to two inches from the hip joint. These fractures are common among older adults and can be related to osteoporosis. This type of fracture may cause a complication because the break usually cuts off the blood supply to the head of the femur, which forms the hip joint.

The femoral neck is the region of the femur bounded by the femoral head proximally and the greater and lesser trochanters distally. A femoral neck fracture is intracapsular, that is, within the hip joint and beneath the fibrous joint capsule.

Intracapsular fractures are further classified as nondisplaced or displaced based on radiographic findings:

Type 1: undisplaced and incomplete fracture
Type 2: undisplaced complete fracture
Type 3: complete fracture but incompletely displaced
Type 4: complete fracture and completely displaced

Intertrochanteric Fractures

An intertrochanteric hip fracture occurs three to four inches from the hip joint. They are breaks of the femur between the greater and the lesser trochanters. This type of fracture does not interrupt the blood supply to the bone and may be easier to repair. They are extracapsular fractures, that is, outside the hip joint’s fibrous capsule.

Subtrochanteric Fractures

This category of fractures is located between the lesser trochanter and the femoral isthmus. Subtrochanteric fractures are less stable than the other two types of hip fractures and, consequently, more difficult to fix.

Risk Factors For Hip Fractures

Risk factors for hip fracture include:

Gender: prevalent in women; postmenopausal twice as likely as premenopausal to have a hip fracture

Reduced bone density.

Falls and Accidents.

Medications: Some medications can cause a decrease in bone density, like cortisone.

Nutrition: It is well known that calcium and vitamin D increase bone mass, so a lack of it can cause several fractures, including hip fractures.

Age: the older you get, the higher the risk is for hip fractures. 90% of these fractures occur in persons over 70 years old.

Alcohol and tobacco: These products can reduce bone mass, causing a higher risk to have a hip fracture.

Medical problems: Endocrine disorders can cause the fragility of the bones.

Physical inactivityPhysical activity is very important for muscle mass and bone mass.

Stroke increases the risk factor for falls which can cause a hip fracture.

Parkinson’s disease increases the risk factor for falls which can cause a hip fracture.

Symptoms

Typically, a hip fracture is acutely painful. The pain is usually localized to the groin and the upper part of the thigh. With most hip fractures, you will not be able to stand, bear weight, or move the upper part of your leg or knee. You will be able to move your ankle and toes unless there is an injury to your lower leg in addition to your hip. Below are some of the most common signs and symptoms:

  •  Inability to get up from a fall or to walk
  • Severe pain in your hip or groin
  • Inability to put weight on your leg on the side of your injured hip
  • Bruising and swelling in and around your hip area
  • Shorter leg on the side of your injured hip
  • Outward turning of your leg on the side of your injured hip

Diagnosis

Patients typically present with pain and the inability to walk after a low-velocity fall. Depending on the type of fracture, some movement may be possible, but it will be painful. Pain is typically in the upper outer thigh or groin. If the fracture is displaced, the affected limb may appear shortened, abducted, and/or rotated.

Anterior-posterior pelvic and lateral hip X-rays are required when a hip fracture is suspected. Shenton’s line can be used to assess the position of the femoral head in relation to the acetabulum. Disruption to this line or to the cortical surface may indicate a fracture.

If a hip fracture is suspected but not visible on X-ray, magnetic resonance imaging may be used to confirm the diagnosis.

Treatment

Treatment for a hip fracture usually involves a combination of surgery, rehabilitation, and medication.

Surgery

The type of surgery to have generally depends on where and how severe the fracture is. Broken bones displacement, age, and underlying health conditions also play a key role in determining the type of surgery. The options include:

  • Internal repair using screws – Metal screws are inserted into the bone to hold it together while the fracture heals. Sometimes screws are attached to a metal plate that runs down the femur.
  • Total hip replacement – The upper femur and the socket in the pelvic bone are replaced with artificial parts.
  • Partial hip replacement. If the ends of the broken bone are displaced or damaged, a surgeon might remove the head and neck of the femur and install a metal replacement. Partial hip replacement might be recommended for adults who have other health conditions or cognitive impairment or who no longer live independently.

Treatment Based on Type of Hip Fracture

Femoral Neck Fractures

Treatment of Stable Fractures

Stable fractures are nondisplaced, exhibiting no deformity, or impacted in a valgus position. These fractures may not be detectable on plain radiographs, and MRI scanning may be required.

Stable femoral neck fractures are generally best treated with surgical stabilization and immediate mobilization. Treatment is by operative pinning with three parallel cannulated screws placed adjacent to the femoral neck cortex. 

Treatment of Unstable Fractures

Unstable femoral neck fractures are displaced and can be seen on plain radiographs.

On physical examination, the leg of the affected side is externally rotated and shortened. The degree of rotation and shortening varies with the degree of displacement.

Displaced fractures in young patients are usually treated with pinning. Pining is chosen because the risks of arthroplasty, including prosthetic wear and loosening, are high for young patients. Younger patients may opt for screw fixation and hip salvage. In hemiarthroplasty, the acetabular cartilage is left intact, and the implant articulates with the acetabulum.

Hemiarthroplasty requires less surgery than a total joint replacement because the acetabulum is not resurfaced. There is a smaller risk of dislocation with hemiarthroplasty because it uses a much bigger head size than total hip arthroplasty. In more active patients, hemiarthroplasty also has a risk of acetabular cartilage wear and revision to total hip arthroplasty. Femoral implants can be cemented or cementless, and there are many designs of each type. Implant fixation can be achieved by the injection of bone cement around the prosthesis or by bony ingrowth into the prosthesis. A bipolar implant has two heads so that motion can occur between one head and the acetabular cartilage and between the two heads.

In theory, this arrangement helps to reduce acetabular wear and provides increased motion. A unipolar implant has only one large head that articulates with the acetabular cartilage.

Total joint replacement typically is performed on an active patient or one with preexisting arthritis. During a total joint replacement, the acetabulum is resurfaced, and a metal cup with a polyethylene liner is fixed inside. Articulation at the hip takes place between the implant’s head and the polyethylene liner.

The decision to treat femoral neck fractures with pinning or with arthroplasty is controversial. The advantages of pinning include less invasive surgery, less blood loss, and less postoperative morbidity. However, treatment by pinning carries a higher risk of more surgery in the future. As implied, arthroplasty results in more acute postoperative morbidity, but it offers fewer reoperations for nonunion, hardware failure, and osteonecrosis.

Treatment Failures

The failures of screw treatment are nonunion and late avascular necrosis—nonunion results primarily from a failure to achieve adequate mechanical stabilization of the fracture. If the bone does not heal, the screws will slide and back out as the fracture collapses.

Nonunion typically presents with worsening groin or buttock pain. Late avascular necrosis results from an insult to the blood vessels that supply the femoral neck and head. Radiographic monitoring up to 3 years should detect most cases of avascular necrosis. The treatment for avascular necrosis or nonunion is hip replacement.

Failure of hemiarthroplasty results in pain and acetabular erosion. Other complications include dislocation, fracture, and infection. The treatment for a failed hemiarthroplasty is conversion to a total hip replacement.

The failures of a total hip replacement are similar to those of a hemiarthroplasty: loosening, implant wear, infection, fracture, and dislocation. Treatment for a failed total hip replacement is a revision arthroplasty.

 Intertrochanteric Fractures

Treatment of Stable Fractures

If the fracture is stable, treatment is with a sliding hip screw coupled to a side plate that is screwed onto the femoral shaft. The screw provides proximal fragment fixation. It is set inside a telescoping barrel that allows impaction of the bone, which promotes fracture union. The lateral buttress must be intact so that the screw will not stop sliding.

A four-part fracture has several fracture lines.

The fractured bone pieces include:

1) the femoral head

2) the lesser trochanter

3) the greater trochanter

4) the remaining femur.

Fractures with multiple pieces and fracture lines are termed ”comminuted .”The more pieces, the less stable is the fracture pattern. Comminution may make fixation with a sliding hip screw and side plate more likely to fail.

Treatment of Unstable Fractures

Approximately 5 percent of fractures are extremely unstable, and the direction of the fracture is parallel to the femoral neck. This fracture type is called the reverse oblique pattern. A high rate of failure occurs if the fracture is treated with a sliding hip screw and a side plate. Because of the angle of the fracture, there is no bone laterally to stop the screw from sliding.

For unstable intertrochanteric fractures, an intramedullary hip screw is indicated. This device combines a sliding hip screw with an intramedullary nail. There are many proprietary varieties, including the Gamma Nail (Stryker, Mahwah, NJ), the Trigen Trochanteric Entry Nail, and the Proximal Femoral Nail. Intramedullary hip screws can be placed through small incisions, and blood loss may be less than with a hip screw and side plate. The nail acts as a metal buttress to prevent sliding and provides better fixation in unstable fracture patterns. No differences have been found between the two devices in stable fractures. With a short intramedullary hip screw, the nail does not extend down the full shaft of the femur. Cross-locking of the nail is through a jig, which prevents rotation of the nail within the femur. Short intramedullary hip screws can create a stress riser in the bone at the distal screw.

With a long intramedullary hip screw, cross locking cannot be done with a jig and must be done freehand under fluoroscopy. Therefore, cross-locking is more difficult. The nail extends throughout the shaft, protecting the rest of the bone from future fracture.

The hip screw should be placed centrally within the femoral head in the strong subcortical bone. Evaluation of hip screw placement is made by determining the tip-apex distance under fluoroscopy. The tip-apex distance is the sum of the distances from the tip of the hip screw to the apex of the femoral head as measured on AP and lateral radiographs.

Baumgaertner et al. showed that no fracture had a loss of fixation secondary to screw cut-out when the tip-apex distance was less than 24 mm. When the tip-apex distance was greater than 45 mm, the screw cut-out rate increased to 60%.

Failure mechanisms of a hip screw include nonunion, screw cut-out, nail breakage, malunion, and limp. Although sliding of the hip screw allows for bone compression and hopeful healing, it makes the limb shorten and causes abduction weakness. Most complications are treated with total hip arthroplasty.

Subtrochanteric Fractures

Treatment

A subtrochanteric fracture is treated with an intramedullary hip screw.

No lateral buttress exists in a subtrochanteric fracture and, therefore, sliding hip screws with side plates provide poor fixation. After surgery for a hip fracture, weight-bearing should be allowed as tolerated. It has been shown that patients with less stable fracture patterns protect themselves by self-restricting weight-bearing and movement.

Rehabilitation

Care team should get a patient out of bed and moving on the first day after surgery. Physical therapy will initially focus on range-of-motion and strengthening exercises.
In extended care and at home, a patient might work with an occupational therapist to learn techniques for independence in daily life, such as using the toilet, bathing, dressing, and cooking. An occupational therapist will determine if a walker or wheelchair might help you regain mobility and independence.

Rehabilitation program components

  • Hip extension (theraband and manual exercise)
  • Heel raises onto toes (theraband and manual exercise)
  • Resisted rowing (double arm lifting) (theraband and manual exercise)
  • Standing diagonal reach (theraband and manual exercise)
  • Modified get up and go (theraband and manual exercise)
  • Overhead arm extensions (theraband and manual exercise)
  • Repeated chair stands (vest and manual exercise)
  • Lunges – forward and back (vest and manual exercise)
  • Stepping up and down a step (vest, manual exercise, and plyometric step)
  • Calf raises – both legs and one leg (manual exercise)

Summary

A hip fracture is a break in the upper portion of the femur (thighbone). There are three broad categories of hip fractures based on the location of the fracture: femoral neck fracturesintertrochanteric fractures, and subtrochanteric fractures.

The symptoms of hip fracture include the inability to get up from a fall or to walk, severe pain in your hip or groin, inability to put weight on your leg on the side of your injured hip and bruising, and swelling in and around your hip area.

X-ray imaging and magnetic resonance imaging are used for diagnosis.

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