Hip fractures in the geriatric population are a common injury encountered in the emergency department. The recommendations for preoperative medical workup and management of these patients have recently been evaluated. Although medical therapies have been designed in an attempt to decrease the rate of these fractures, attempts to medically manage osteoporosis has created a new “atypical” fracture pattern that must be recognized and managed appropriately. The current recommendations for preoperative medical evaluation and management of patients with hip fractures will be reviewed. In addition, the epidemic of new fractures created by long-term bisphosphonate use will be described, and the current recommendations for the management of these fractures detailed.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
Papers of particular interest, published recently, have been highlighted as: • Of importance
Johnell O, Kanis J. Epidemiology of osteoporotic fractures. Osteoporos Int. 2005;16 Suppl 2:S3–7.
van Staa TP, Leufkens HGM, Cooper C. Does a fracture at one site predict later fractures at other sites? A British cohort study. Osteoporos Int. 2002;13:624–9.
Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res. 2007;22:465–75.
Cooper C, Campion G, Melton LJ. Hip fractures in the elderly: a world-wide projection. Osteoporos Int. 1992;2:285–9.
Bhandari M, Devereaux PJ, Swiontkowski MF, Tornetta P, Obremskey W, Koval KJ, et al. Internal fixation compared with arthroplasty for displaced fractures of the femoral neck. A meta-analysis. J Bone Joint Surg Am. 2003;85A:1673–1681.
Murphy DK, Randell T, Brennan KL, Probe RA, Brennan ML. Treatment and displacement affect the reoperation rate for femoral neck fracture. Clin Orthop Relat Res. 2013;471:2691–702. Compares the use of hemiarthroplasty and internal fixation for femoral neck fractures in elderly patients in terms of risk for reoperation.
Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev. 2010;(9):CD000093.
Palm H, Lysén C, Krasheninnikoff M, Holck K, Jacobsen S, Gebuhr P. Intramedullary nailing appears to be superior in pertrochanteric hip fractures with a detached greater trochanter: 311 consecutive patients followed for 1 year. Acta Orthop. 2011;82:166–70.
Baumgaertner MR, Solberg BD. Awareness of tip-apex distance reduces failure of fixation of trochanteric fractures of the hip. J Bone Joint Surg Br. 1997;79(6):969–971.
Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. The Journal of bone and joint surgery. American volume. Am Orthop Assoc. 1995;77:1058–64.
Rubio-Avila J, Madden K, Simunovic N, Bhandari M. Tip to apex distance in femoral intertrochanteric fractures: a systematic review. J Orthop Sci. 2013;18:592–8. Examines the importance of lag screw tip to apex distance in the treatment of hip fractures with regards to fixation failure.
Ban I, Palm H, Birkelund L, Eschen J, Kring S, Brix M, et al. Implementing, adapting, and validating an evidence-based algorithm for hip fracture surgery. J Orthop Trauma. 2014;28:e21–6. Presents an evidence-based algorithm for treatment of hip fractures at single institution and the differences in patient outcomes resulting from algorithm implementation.
Weller I, Wai EK, Jaglal S, Kreder HJ. The effect of hospital type and surgical delay on mortality after surgery for hip fracture. J Bone Joint Surg Br Vol. 2005;87:361–6.
Bottle A, Aylin P. Mortality associated with delay in operation after hip fracture: observational study. BMJ. 2006;332:947–51.
Mundi S, Pindiprolu B, Simunovic N, Bhandari M. Similar mortality rates in hip fracture patients over the past 31 years. Acta Orthop. 2014;85:54–9. Review of multiple electronic databases singling out patients who underwent surgical management of hip fractures and reporting their postoperative mortality.
McGuire KJ, Bernstein J, Polsky D, Silber JH. The 2004 Marshall Urist award: delays until surgery after hip fracture increases mortality. Clin Orthop Relat Res. 2004;428:294–301.
Siegmeth AW, Gurusamy K, Parker MJ. Delay to surgery prolongs hospital stay in patients with fractures of the proximal femur. J Bone Joint Surg Br Vol. 2005;87:1123–6.
Mutlu H, Bilgili F, Mutlu S, Karaman O, Cakal B, Ozkaya U. The effects of preoperative non-invasive cardiac tests on delay to surgery and subsequent mortality in elderly patients with hip fracture. J Back Musculoskelet Rehabil. 2015. Retrospective study looking at the effects of preoperative cardiac testing on the surgical treatment plan, cardiac treatment plan, patient mortality, and complications.
Moja L, Piatti A, Pecoraro V, Ricci C, Virgili G, Salanti G, et al. Timing matters in hip fracture surgery: patients operated within 48 hours have better outcomes. A meta-analysis and meta-regression of over 190,000 patients. PLoS ONE. 2012;7:e46175. Meta-analysis of examining the time to hip fracture surgery and the effects on mortality and postoperative complications.
Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation. 2002;2007:e418–99.
Stitgen A, Poludnianyk K, Dulaney-Cripe E, Markert R, Prayson M. Adherence to preoperative cardiac clearance guidelines in hip fracture patients. J Orthop Trauma. 2015;29:500–3. This study examines the use of preoperative cardiac consultations in accordance with ACC/AHA guidelines and the resulting cardiac care, time to surgical treatment, complications, and mortality in geriatric patients presenting with a hip fracture.
Bernstein J, Roberts FO, Wiesel BB, Ahn J. Pre-Operative Testing for Hip Fracture Patients Delays Surgery, Prolongs Hospital Stays and Rarely Dictates Care. J Orthoped Traumatol. 2015. An investigation into the prevalence of additional preoperative cardiac testing in geriatric patients prior to hip fracture surgery and the effects on patient time to the operating room and overall length of hospital admission.
Ricci WM, Brandt A, McAndrew C, Gardner MJ. Factors affecting delay to surgery and length of stay for patients with hip fracture. J Orthop Trauma. 2015;29:e109–14. Retrospective study at a single institution analyzing relationships between patient demographics and medical comorbidities, day of the week of admission, preoperative cardiac testing, time to the operating room, and length of stay in patients who underwent operative intervention for a hip fracture.
Ricci WM, Rocca Della GJ, Combs C, Borrelli J. The medical and economic impact of preoperative cardiac testing in elderly patients with hip fractures. Injury. 2007;38 Suppl 3:S49–52.
Cluett J, Caplan J, Yu W. Preoperative cardiac evaluation of patients with acute hip fracture. Am J Orthop. 2008;37:32–6.
O'hEireamhoin S, Beyer T, Ahmed M, Mulhall KJ. The role of preoperative cardiac investigation in emergency hip surgery. J Trauma. 2011;71:1345–7.
Bone HG, Hosking D, Devogelaer J-P, Tucci JR, Emkey RD, Tonino RP, et al. Ten years’ experience with alendronate for osteoporosis in postmenopausal women. N Engl J Med. 2004;350:1189–99.
Liberman UA, Weiss SR, Bröll J, Minne HW, Quan H, Bell NH, et al. Effect of oral alendronate on bone mineral density and the incidence of fractures in postmenopausal osteoporosis. The Alendronate Phase III Osteoporosis Treatment Study Group. N Engl J Med. 1995;333:1437–43.
Black DM, Cummings SR, Karpf DB, Cauley JA, Thompson DE, Nevitt MC, et al. Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Lancet. 1996;348:1535–41.
Park-Wyllie LY, Mamdani MM, Juurlink DN, Hawker GA, Gunraj N, Austin PC, et al. Bisphosphonate use and the risk of subtrochanteric or femoral shaft fractures in older women. JAMA. 2011;305:783–9.
Canalis E, Giustina A, Bilezikian JP. Mechanisms of anabolic therapies for osteoporosis. N Engl J Med. 2007;357:905–16.
Feldstein AC, Black D, Perrin N, Rosales AG, Friess D, Boardman D, et al. Incidence and demography of femur fractures with and without atypical features. J Bone Miner Res. 2012;27:977–86. Retrospective review describing the incidence of atypical femur fractures with major and/or minor features.
Shane E, Burr D, Ebeling PR, Abrahamsen B, Adler RA, Brown TD, et al. Atypical subtrochanteric and diaphyseal femoral fractures: Report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2010;25:2267–94.
Shane E, Burr D, Abrahamsen B, Adler RA, Brown TD, Cheung AM, et al. Atypical subtrochanteric and diaphyseal femoral fractures: second report of a task force of The American Society for Bone and Mineral Research. J Bone Miner Res. 2013;29:1–23. A report modifying the definition of atypical femur fractures, as well as a review of the epidemiology, pathogenesis, and medical treatment of atypical femur fractures.
Unnanuntana A, Saleh A, Mensah KA, Kleimeyer JP, Lane JM. Atypical femoral fractures: what do we know about them? J Bone Joint Surg Am Vol. 2013;95:e81–13. Pathogenesis and treatment of atypical femur fractures.
Einhorn TA, Bogdan Y, Tornetta P. Bisphosphonate-associated fractures of the femur: pathophysiology and treatment. J Orthop Trauma. 2014;28:433–8. Description of pathophysiology and treatment for atypical femur fractures, operative and nonoperative indications.
Priemel M, von Domarus C, Klatte TO, Kessler S, Schlie J, Meier S, et al. Bone mineralization defects and vitamin D deficiency: histomorphometric analysis of iliac crest bone biopsies and circulating 25-hydroxyvitamin D in 675 patients. J Bone Miner Res. 2009;25:305–12.
Heaney RP, Holick MF. Why the IOM recommendations for vitamin D are deficient. J Bone Miner Res. 2011;26:455–7
Whiting SJ, Calvo MS. Correcting poor vitamin D status: do older adults need higher repletion doses of vitamin D3 than younger adults? Mol Nutr Food Res. 2010;54:1077–1084.
Chiang CY, Zebaze RMD, Ghasem-Zadeh A, Iuliano-Burns S, Hardidge A, Seeman E. Teriparatide improves bone quality and healing of atypical femoral fractures associated with bisphosphonate therapy. Bone. 2013;52:360–5. Improvement in fracture healing was found in atypical femur fractures treated with teriparatide.
Fukuda F, Kurinomaru N, Hijioka A. Weekly teriparatide for delayed unions of atypical subtrochanteric femur fractures. Biol Ther. 2014;4:73–9. A case report describing successful treatment of delayed union of an atypical femur fracture with teriparatide.
Koh JSB, Goh SK, Png MA, Kwek EBK, Howe TS. Femoral cortical stress lesions in long-term bisphosphonate therapy: a herald of impending fracture? J Orthop Trauma. 2010;24:75–81.
Conflict of Interest
Patrick Strotman declares that he has no conflict of interest.
William Lack declares that he has no conflict of interest.
Mitchell Bernstein has received compensation from Smith & Nephew, Synthes, and Ellipse for service as a consultant.
Michael Stover declares that he has no conflict of interest.
Hobie Summers declares that he has no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
This article is part of the Topical Collection on Emergency Medicine
About this article
Cite this article
Strotman, P., Lack, W., Bernstein, M. et al. Evaluation of Common Fractures of the Hip in the Elderly. Curr Geri Rep 5, 38–43 (2016). https://doi.org/10.1007/s13670-016-0161-1
- Atypical femur fracture
- Bisphosphonate fracture
- Hip fracture
- Intertrochanteric femur fracture
- Fragility fracture
- Cardiac clearance
- Preoperative evaluation