A proximal femoral fracture is a break in the upper part of the thigh bone (femur) near the hip joint. Commonly called a “hip fracture,” this injury is most frequent in older adults due to falls but can happen at any age from significant trauma. Prompt medical attention is required, as the location and nature of the break guide the course of treatment and recovery.
Anatomy and Fracture Classifications
The proximal femur includes the femoral head (the “ball” of the hip’s ball-and-socket joint), the femoral neck which connects the head to the shaft, and the trochanteric region where major leg muscles attach. Fractures are categorized based on their location relative to the hip joint capsule, a strong ligamentous sac that encloses the joint. This leads to two primary classifications.
Intracapsular fractures occur within the joint capsule, affecting the femoral head or neck. A concern with these fractures is the potential disruption of blood supply to the femoral head, as the arteries that supply it travel up the femoral neck, which can complicate healing.
Extracapsular fractures happen outside the joint capsule and involve the trochanteric region. These are further divided into intertrochanteric fractures, which occur between the trochanters, and subtrochanteric fractures, located just below them. Because this region has a robust blood supply, these fractures have a lower risk of blood supply disruption compared to intracapsular types.
Diagnosis and Immediate Care
The signs of a proximal femoral fracture are distinct. An individual will experience intense pain in the hip or groin, be unable to stand or put weight on the affected leg, and the leg may appear shorter and rotated outwards. Upon arrival at a hospital, diagnosis begins with a physical examination and is confirmed with imaging tests.
An X-ray is the standard tool used to visualize the fracture, its location, and severity. If a fracture is suspected but not clearly visible on an X-ray, a computed tomography (CT) scan or magnetic resonance imaging (MRI) may be ordered for a more detailed view. Immediate care focuses on stabilizing the patient and managing pain. Analgesic medications are administered, and the injured limb is positioned in a splint or traction to minimize movement. Intravenous fluids are often started to ensure the patient is well-hydrated for surgery.
Surgical Treatment Options
Surgery is the standard treatment for nearly all proximal femoral fractures, with the goal of stabilizing the broken bone to allow for healing and enable early mobilization. The choice of surgical procedure is linked to the fracture’s classification, the patient’s health, and age. Non-surgical management is rare and reserved for patients too medically frail for an operation or for certain non-displaced fractures.
For intracapsular fractures in the femoral neck, treatment depends on bone displacement and patient age. In younger individuals with non-displaced fractures, a procedure called internal fixation, or “hip pinning,” uses several screws to hold the femoral head in place. For older adults or when the fracture is displaced, arthroplasty (hip replacement) is often the preferred treatment. A hemiarthroplasty replaces only the femoral head, while a total hip replacement replaces both the femoral head and the hip socket.
Extracapsular fractures are treated with different fixation devices. A common method is the use of a sliding hip screw, which consists of a large screw inserted into the femoral head and a plate secured to the side of the femur. This device allows the fracture fragments to compress together, which promotes healing.
Another widely used option for unstable fractures is an intramedullary nail. This involves inserting a metal rod down the center of the femur through the fracture site. Screws are then placed through the nail and into the femoral head and lower femur to lock the bone in position, providing strong fixation that allows for earlier weight-bearing.
Recovery and Rehabilitation
The recovery journey begins almost immediately after surgery. A patient’s hospital stay lasts for several days, focusing on pain management, wound care, and initiating rehabilitation. Physical therapy often starts as early as the day following the operation, as early mobilization helps prevent post-operative complications and restores independence.
The initial phase of rehabilitation involves simple exercises in bed, such as ankle pumps and gentle knee bending, to maintain circulation. As the patient gains strength, a physical therapist guides them through sitting, standing, and eventually walking, using assistive devices like a walker or crutches for support.
Adhering to the weight-bearing restrictions prescribed by the surgeon is a necessary part of recovery. The amount of weight a patient can put on the leg depends on the fracture and the surgery, and these instructions protect the healing bone.
Over time, the therapist will introduce more advanced exercises to improve range of motion, strength, and balance, with the goal of returning to daily activities. The timeline for a full recovery can vary, often taking many months to a year.
Potential Complications and Risk Management
While surgery is generally successful, potential complications can arise. A risk associated with intracapsular femoral neck fractures is avascular necrosis (AVN). This condition occurs when the blood supply to the femoral head is permanently damaged, leading to the death of bone tissue and potential collapse of the femoral head.
Reduced mobility after surgery increases the risk of developing blood clots in the legs, a condition known as deep vein thrombosis (DVT). If a piece of the clot travels to the lungs, it can cause a life-threatening pulmonary embolism (PE). To mitigate this risk, patients are prescribed blood-thinning medications and encouraged to mobilize as soon as possible.
Other potential issues include infection at the incision site, nonunion (where the bone fails to heal), or malunion (where the bone heals in an incorrect position). These complications may require additional surgery to correct.
Managing underlying health conditions is also part of long-term risk management. For many patients, the fracture is related to osteoporosis, so treatment may include medications and lifestyle changes to improve bone density and reduce the risk of future fractures.