A 60-year-old woman comes to the emergency room for hip pain. She felt a pop in her hip accompanied by the immediate onset of pain that prohibited her from walking. She had fallen 2 days prior. Figure 105-1 shows a transcervical left femoral neck fracture with varus angulation and superior offset of the distal fracture fragment. She was evaluated by an orthopedic surgeon and underwent surgery the next day (Figure 105-2). After many months of rehabilitation, she was able to walk again.

• Approximately 300,000 hip fractures per year occur in the United States.1
  
• Seventy percent to 80% of hip fractures occur in women.1
  
• Average age is 70 to 80 years; risk increases with age.1
  
• Half of the patients with a hip fracture have osteoporosis.2

• Approximately 95% of hip fractures are caused by a fall.

• Low body mass index (BMI) and low physical activity in postmenopausal women.3
  
• Low physical activity.3

Long-term use of proton pump inhibitor (PPI) is associated with increased risk of any fracture, including hip fracture.4

Clinical Features: History and Physical

• In a population study, major risk factors for hip fracture include:
  
  
  
  • Low bone mineral density (3.6-fold [95% confidence interval (CI), 2.6 to 4.5] in women and 3.4-fold [95% CI, 2.5 to 4.6] in men for each standard deviation [SD] [0.12 g/cm2] reduction in bone mineral density).5
    
  • Postural instability and/or quadriceps weakness.
    
  • A history of falls.
    
  • Prior hip fracture.5
    
  • Other factors associated with increased risk include: dementia, tobacco use, physical inactivity, impaired vision, and alcohol use.

Physical examination—Abducted and externally rotated hip; limp or refusal to walk.

• Hip fractures are classified according to anatomic location.6
  
  
  
  • Intracapsular (femoral neck fracture; Figures 105-1 and 105-3).
    
  • Extracapsular (intertrochanteric or subtrochanteric fracture; Figure 105-4).

Imaging