髋部骨折：诊断与管理

Hip Fractures: Diagnosis and Management

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AMERICAN FAMILY PHYSICIAN

影响因子:3.5

分区:医学3区 / 医学：内科3区初级卫生保健3区

发表日期:2022 Dec

作者: Jeremy D Schroeder, Sean P Turner, Emily Buck

摘要

髋部骨折是常见的致残原因，1年内死亡率可达30%。不可修改的危险因素包括较低的社会经济地位、老龄、女性、既往骨折、代谢性骨疾病及骨肿瘤。可修改的危险因素主要包括低体质量指数（BMI）、骨质疏松、跌倒风险增加、使用增加跌倒或降低骨密度的药物以及药物滥用。髋部骨折的典型表现为前腹股沟疼痛、不能负重或肢体短缩、外展、外旋。常规胸片通常足以诊断，但如怀疑未被发现的骨折，仍应行核磁共振成像（MRI）。在骨折发生后24至48小时内进行手术治疗可优化预后。骨折多通过手术处理，手术方式根据骨折类型和位置选择，麻醉方式可为脊髓或全身麻醉。对于不适合手术的患者，也可考虑非手术治疗。术前和术后给予抗葡萄球菌抗生素以预防感染，建议使用抗凝药物预防深静脉血栓形成。医生应密切关注术后常见的谵妄。早期术后活动和康复有助于改善预后。后续治疗侧重于预防，包括增强体力活动、家庭安全评估和减少多药使用。少见的髋部骨折还包括股骨颈应力性骨折和功能不全性骨折。股骨颈应力性骨折多见于20至30岁的舞蹈者、耐力运动员和军人，常由训练过度引起。功能不全性骨折是在绝经后妇女中因骨质脆弱而无外伤发生的，应及早诊断和治疗，否则可能演变为完全骨折、移位，发生不愈合和缺血性坏死的风险极高。

Abstract

Hip fractures are common causes of disability, with mortality rates reaching 30% at one year. Nonmodifiable risk factors include lower socioeconomic status, older age, female sex, prior fracture, metabolic bone disease, and bony malignancy. Modifiable risk factors include low body mass index, having osteoporosis, increased fall risk, medications that increase fall risk or decrease bone mineral density, and substance use. Hip fractures present with anterior groin pain, inability to bear weight, or a shortened, abducted, externally rotated limb. Plain radiography is usually sufficient for diagnosis, but magnetic resonance imaging should be obtained if suspicion of fracture persists despite normal radiography. Operative management within 24 to 48 hours of the fracture optimizes outcomes. Fractures are usually managed by surgery, with the approach based on fracture type and location; spinal or general anesthesia can be used. Nonsurgical management can be considered for patients who are not good surgical candidates. Pre- and postoperative antistaphylococcal antibiotics are given to prevent joint infection. Medications for venous thromboembolism prophylaxis are also recommended. Physicians should be alert for the presence of delirium, which is a common postoperative complication. Early postoperative mobilization, followed by rehabilitation, improves outcomes. Subsequent care focuses on prevention, with increased physical activity, home safety assessments, and minimizing polypharmacy. Two less common hip fractures can also occur: femoral neck stress fractures and insufficiency fractures. Femoral neck stress fractures typically occur in dancers 20 to 30 years of age, endurance athletes, and military service members, often because of training overload. Insufficiency fractures due to compromised bone strength occur without trauma in postmenopausal women. If not recognized and treated, these fractures can progress to complete and displaced fractures with high rates of nonunion and avascular necrosis.