Fractures of the hip: does the type of fall really affect the site of fracture?

doi:10.1016/S0020-1383(98)00133-8

Injury

Volume 29, Issue 8, October 1998, Pages 585-587

https://doi.org/10.1016/S0020-1383(98)00133-8 Get rights and content

Abstract

The purpose of this study was to test accepted theories relating the characteristics of a fall to the anatomical site of hip fracture in the elderly. Twisting injuries are said to result in intracapsular fractures and falls directly onto the side are said to result in extracapsular fractures. 618 consecutive patients with a hip fracture were studied prospectively by being questioned with regard to the nature of their fall. After exclusions, 552 patients were left in the study. Of these, 324 patients sustained intracapsular fractures and 228 extracapsular fractures. More intracapsular fractures were associated with a fall onto the affected side than extracapsular fractures and rotation at the hip during the fall had a significant association with extracapsular fractures. In this study 84 per cent of all fractures occurred by falling directly onto the affected side. The clinical significance of this finding is that protective padding on the hip might be beneficial.

Introduction

Hip fractures (proximal femoral fractures) can be subdivided anatomically into intracapsular and extracapsular types [1]. Intracapsular fractures are those in which the fracture line is proximal to the capsular insertion at the base of the femoral neck; the fracture line of extracapsular fractures is distal to the capsular insertion.

It is traditionally taught that the anatomical site at which the hip fractures in elderly patients is influenced by the characteristics of any preceding fall. There are conflicting statements, however, as to which type of fall predisposes to which type of fracture. Some say, for example, that intracapsular fractures of the proximal femur result from a twisting injury and that extracapsular fractures result from a fall directly onto the greater trochanter 2, 3. The twisting injury has been postulated to comprise external rotation of the hip such that continued external rotation, after the femoral neck has impinged on the posterior acetabular rim, fractures the neck of the femur at this point. In contrast, a fall directly onto the greater trochanter is postulated to cause a fracture in the region of the greater trochanter (extracapsular) owing to the direct blow to this part of bone. Others suggest that intracapsular fractures result from a trivial injury whilst extracapsular fractures result from a sharp twisting injury [4]. Evidence supporting any of these theories, however, is lacking. To test these theories and to gain further insight into how the characteristics of a fall might really influence the hip fracture sustained, a prospective study of the characteristics of the fall was undertaken in those patients in whom a fall had caused a hip fracture.

Section snippets

Patients and methods

618 patients with a hip fracture admitted consecutively to a District General Hospital between June 1995 and July 1997 were questioned with regard to the cause of their fracture. The questioning of the patients with regard to the nature of their fall was part of an ongoing propective study of hip fractures. Questioning was normally conducted the morning after the patient's admission and the interview included an assessment of mental state and mobility. The mental state assessment comprised a

Results

Of the 552 patients included in the study, 231 fell into the group who were both unable to describe their fall and had no witness to the fall. Because this group of patients was to be excluded from the main part of the study, certain characteristics of this group of patients (Group A) were compared with those of the 321 patients for whom there was a description of the fall (Group B) to see how these differed. The comparison is detailed in Table 1.

For the 321 patients in Group B, with a

Discussion

Comparing the characteristics listed in Table 1, those patients in Group A tended to be older, had a lower mental test and mobility score, and were more likely to live in a residential or nursing home than those in Group B. This is as would be expected considering that each one of these patients in Group A was unable to describe their injury, unlike those patients in Group B, of whom the majority were able to describe their fall themselves. A greater percentage of patients in Group B had their

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Prompt treatment of medical conditions44 and minimising delay to surgery22,38 also reduces long-term (1 year) mortality. We found there were more patients sustaining an intracapsular than extracapsular hip fracture, similar to another study of 552 patients of which 58.7% had an intracapsular hip fracture.56 Patients with extracapsular hip fractures are known to have greater morbidity and mortality than those with intracapsular fractures.13,57
Hip fractures are common injuries in the elderly, with significant associated morbidity and mortality rates. The National Hip Fracture Database (NHFD) was implemented to audit care according to national standards thus improving its clinical and cost-effectiveness.
We retrospectively examined the care pathway for all hip fractures after its introduction at our centre over 1 year, with an audit of care according to the BOA-BGS ‘Blue Book’ guidelines. Data between the first (period 1: initial audit) and second (period 2: re-audit) six months of the study period were compared.
There were 372 patients (28% male, 72% female) in total with 190 in period 1 and 182 in period 2. For all patients, the median age was 85 years (range 33–101) and the median time to surgery was 24.5 h (1–519.3), with 251 (67.5%) within 36 h. Surgical delay was mainly due to lack of theatre space (37.6%) and medical reasons (54.7%). The median length of stay was 11 days (2–92) and the inpatient mortality rate was 6.2% (23). When comparing the two study periods, there were significantly more patients undergoing falls (p < 0.01) and bone protection (p < 0.01) assessments in period 2. Lack of theatre space was a significantly less common (p < 0.01), with a significantly shorter median time to surgery (p = 0.01) and length of stay (p < 0.01) in period 2. More patients were discharged to rehabilitation units and the mortality rate was non-significantly lower in period 2 (7.4% vs. 5%). The best practice tariff was met in 45.3% and 70.3% (p < 0.001) of patients in periods 1 and 2 respectively providing a total income of £95230.00 (GBP).
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Citation Excerpt :
In addition, we did not collect data on pre-fracture fall dynamics, another potential determinant of fracture type [19,40]. The fact that we did not assess fall dynamics is another limitation of our study, although it should be noted that a number of studies [2,16,41] did not report an association between fall characteristics and the type of hip fracture and that any retrospective data assessment of pre-fracture characteristics is subject to significant recall bias [10,19,30]. Finally, our study did not assess the potential impact of specific operative or rehabilitative procedures on differences in short-term functional outcome between fracture types.
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¹: J. A. Hopkinson-Woolley is now a Specialist Registrar in Orthopaedics at Addenbrooke's Hospital NHS Trust.

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