Hip Trauma Surgery
Type of Fracture
The type of hip fracture determines what kind of operation is required. This is fully dependent on the fracture configuration, the quality of bone and the presumed damage to blood supply to the femoral head. This determination can usually be made by viewing good quality X-rays. Occasionally a CT Scan is required if the fracture is in determinant. The treatment of hip fractures requires a specialised assessment of a patient, taking into account the patient comorbidities and their general health and function. In rare circumstances, hip fractures are treated non operatively. This is usually reserved for people who do not walk, or are medically unfit for surgery.
Blood supply as a factor
The blood supply to the hip comes mostly from the vessels within the hip capsule. The hip capsule is a ligamentous structure that envelopes the hip joint and provides stability to the hip, as well as creates a closed environment for synovial fluid to move around within the hip. This blood supply changes as a person gets older, with younger people having a more robust blood supply. If the fracture is in a region within the capsule, it is called “intracapsular” which usually means that the blood supply is disrupted. In most patients, this means that a replacement of some kind will be used, as fixing with plates/screws/nail will usually fail. In some cases, when the fracture is minimally displaced (i.e. the fracture fragments have not moved very much), fixing is a good option as it is presumed that the blood supply is not disrupted. If the fracture is treated with a replacement, a hemi (half) arthroplasty or a total hip arthroplasty is used. Total hip replacements are generally reserved for those who have pre-existing hip pain from arthritis, or those who are younger. Studies show that patients who have total hip replacements do better than those with hemi arthroplasties. There is risk in performing a total hip replacement in the setting of fracture, as the rate of complication after surgery is higher – such as in dislocation. This is because the soft tissue around the hip is usually damaged in a different way, and also due to patient factors.
When an intracapsular fracture is treated with a plate/screws/nail, it is thought that the blood supply was not damaged. If the fracture does not heal, it is usually because the blood supply has been damaged (something that does not show up on Xray). A surgeon will look closely at the X-rays over a 2 year period to ensure that the fracture heals. In younger patients, there are more attempts to treat the fracture with fixation rather than replacement as usually the hip joint is in good condition, and there are better outcomes if the patient can keep their own joint.
Extracapsular fractures are those that occur outside the capsule, and therefore have a low risk of damaging the blood supply. They are almost always treated with screws/plate/nail as they usually heal very well. Typically Dr Chien-Wen Liew will perform most of this type of surgery using a nail as it is more biomechanically stronger and is a minimally invasive approach, using small skin cuts and causing less muscle damage.
Mobility after a hip fracture
Young people with a healed fracture generally do very well. If the patient is older, or has many medical problems, then this may cause a drop in mobility. This means that a previously independent person may require a walking stick or frame after the surgery. Each case is different, and is treated on a case by case basis. Sometimes, a hip fracture is a major event in determining if a patient becomes dependent on help from others to perform their normal daily activities.
Hip fractures in young athletes
Stress fractures of the hip can occur in young athletes. This is found in those who have overuse situations or in people who increase their training rapidly without giving the body enough time to adapt. It is most commonly seen in endurance athletes who ignore the pain in their body and over train. Stress fractures are more common in females than males. Often the fracture will not show up on Xray, and would only be visible on an MRI scan or Bone Scan. An MRI is preferred as it does not require any dye (contrast agent) to be injected into the body, and does not use any ionising radiation. The treatment for stress fractures is dependent on several factors, however is usually operative. A long period of rest is required, and usually means that the athlete is not able to play sports or train for a minimum of 6 months. Stress fractures can generally be prevented by listening to your body and decreasing training if pain starts.
For more information on the treatment of hip fractures, please arrange an appointment with Dr Chien-Wen Liew on (08) 7099 0188.