Hip fractures in the non-elderly—Who, why and whither?

Abstract

Nonelderly hip fracture patients have gathered little scientific attention, and our understanding of the group may be biased by patient case-mix and lack of follow-up. Preconceptions may thwart adequate investigation of bone health and other comorbidities. This literature review focusses on who these patients between 20 and 60 years are, how to treat them and how to evaluate the outcome. 2-11% of the hip fractures occur in non-elderly, equally common in men and women. Every second to forth patient smoke, have chronic diseases, and abuse alcohol. Poor self-rated health, sleep disturbances, low cognitive function and education are associated with increased hip fracture risk in young adults. Bone health is poorly investigated, but literature suggest young patients to have lower bone mineral density regardless of trauma mechanism. Studies contradict on whether surgery within 8-12 h reduce the risk of avascular necrosis in femoral neck fractures (FNF). Based on rationality, surgery ought to be performed promptly, in order to reduce pain and permit rehabilitation. There is no convincing support from the existing literature to use open reduction. Good reduction is mandatory, preferably using a closed reduction technique. The failure rate following internal fixation of displaced FNF in younger patients can be as high as 59%. In some cases a displaced FNF is better treated with a primary arthroplasty; in case of rheumatoid arthritis or osteoarthritis for example. Complications after extracapsular fractures vary from 6 to 23%. The relatively few studies looking at functional outcome in non-elderly use a multitude of outcome measures, precluding comparisons. Many non-elderly patients seem not to fully recover. While some non-elderly hip fracture patients are healthy individuals sustaining high energy trauma, others have low-energy fractures and comorbidities including reduced bone strength (either as a primary or secondary condition). i.e. non-delaying medical optimization, proper surgical technique, bone health investigation and secondary fracture prevention is necessary. Younger hip fracture patients are at risk of permanent loss of function, and negative socioeconomic and psychological consequences. High-energy trauma does not exclude the presence of osteopenia. A hip fracture in adulthood and middle-age is very seldom caused by bad luck only!

Preliminary effect and feasibility of physiotherapy with strength training and protein-rich nutritional supplement in combination with anabolic steroids in cross-continuum rehabilitation of patients with hip fracture: protocol for a blinded randomized controlled pilot trial (HIP-SAP1 trial)

“…The following protocol amendments were approved by the ethics committee (28 September 2018) and the Danish Medicines Agency (26 October 2018): The inclusion criterion age was changed from ≥ 65 years to ≥ 60 years. The cut ≥ 60 years is often used internationally when referring to elderly compared with nonelderly patients with hip fracture [59]. Further, patients from 60 to 64 years old would have the same potential benefit from the intervention.The exclusion criterion concerning PSA values was changed, so assessment of PSA is moved to the 3-week control, because a falsely elevated PSA value could be seen during admission due to urine catheterization.The exclusion criterion terminal illness was changed to active cancer or suspected pathological fracture .The time frame for baseline testing was changed from 6–10 days to 3–10 days due to short hospitalization for some patients.The intramuscular injection of trial medication was described to be administered in the gluteal muscle of the nonfractured leg.…”

“…The inclusion criterion age was changed from ≥ 65 years to ≥ 60 years. The cut ≥ 60 years is often used internationally when referring to elderly compared with nonelderly patients with hip fracture [59]. Further, patients from 60 to 64 years old would have the same potential benefit from the intervention.…”

High conversion rate to total hip arthroplasty after hemiarthroplasty in young patients with a minimum 10 years follow‐up

“…In the early 1980 s, some centers expanded the indications to include the primary treatment of degenerative arthritis of the hip [4]. Although internal fixation would be the first alternative for femoral neck fracture in young patients, high reoperation rate after internal fixation and better patient-reported outcome after both THA and BHA with medium follow-up have been reported [5,6]. In proximal femur fractures such as femoral neck fractures with an intact acetabular cartilage, BHA remains an option that can be expected to be successful [7].…”

Low bone density and high morbidity in patients between 55 and 70 years with displaced femoral neck fractures: a case-control study of 50 patients vs 150 normal controls

“…The literature on elderly patients older than 70 years with displaced FNFs is extensive and arthroplasty is clearly recommended as the treatment of choice [8–14]. The middle-aged patient group aged 55-70 years is less well described and the treatment for displaced FNFs is still controversial [11–13]. These patients are probably still working and demand a high level of activity.…”