New York State Medical Treatment Guidelines for Hip Fractures in workers compensation patients

Broken hips can happen in different ways, either from a sudden injury or over time due to repeated stress. When it comes to injuries at work, they often occur because of slips, trips, or car accidents. Stress fractures usually happen when a certain part of the body experiences force repeatedly in a short period, like within hours or days. The usual treatment involves avoiding whatever caused the problem and keeping an eye on it. Sometimes, physical therapy can be helpful in addressing issues with how muscles work and how we move, which might ease the strain on the injured area.

 

Related Terms

Fracture • Stress Fracture • Hip Fracture • Femoral Fracture •Intertrochanteric Fracture • Subtrochanteric Fracture • Acetabular Fracture

 

Initial Assessment

When checking out a person who might have broken their hip at work, the first assessment is usually pretty clear-cut. The story of what happened, how it happened, and the fact that they can’t use their hip well are strong clues for diagnosis. It’s also important to look into other systems like the knee, spine, belly, and the urinary and reproductive areas to get the full picture.

 

Diagnostic Studies

Bone Scan

Recommended – Use this approach selectively for patients experiencing sudden, ongoing, or lingering hip pain to aid in identifying potential fractures.

Indications: Individuals with hip fractures and suspected conditions like osteonecrosis, Paget’s disease, tumors, or heightened overall bone activity. Frequency/Dose/Duration: Typically, one scan suffices.

Occasionally, a second scan might be needed after at least three months, but only if there’s a significant shift in symptoms and signs leading to a substantial change in the diagnosis.

Rationale: Bone scanning proves valuable for diagnosing trauma, such as hidden fractures.

However, it’s generally not necessary for assessing hip osteoarthritis. If the diagnosis is certain and won’t affect treatment, there’s no need for a bone scan, as it doesn’t alter the course of action. Evidence supporting the use of Bone Scans.

 

Computerized Tomography (CT)

Recommended – This approach is suitable for assessing hip fracture patients, especially those with worries about osteonecrosis or those recovering from traumatic dislocations or recurrent dislocations associated with arthroplasty. CT is also a good choice for patients who require advanced imaging but can’t go through an MRI.

Indications: People with hip fractures experiencing pain due to osteonecrosis and suspicions of subchondral fractures, increased overall bone activity, or traumatic hip dislocations. This is especially crucial when seeking fragments of fractured acetabulum or femoral head; individuals with recurrent hip dislocations following arthroplasty to check the alignment of acetabular and femoral components; and those with contraindications for MRI.

Frequency/Dose/Duration: Typically, one evaluation is sufficient, and a second one is rarely necessary. Rationale: When it comes to imaging calcified structures in the hip, CT is generally considered better than MRI for most hip abnormalities.

 

Helical CT Scan

Recommended – This is a good option for specific patients dealing with hip fractures where there’s a suspicion of osteonecrosis or a need for advanced bone imaging. Especially useful for those with contraindications for MRI, like having implanted hardware.

Indications: Patients with hip fractures believed to involve osteonecrosis or requiring advanced bone imaging, but facing restrictions with MRI due to implanted hardware. Helical CT is particularly beneficial for vascular concerns, minimizing motion artifacts, and speeding up the scanning process.

Frequency/Dose/Duration: Typically, one evaluation does the job, and a second one is seldom necessary.

Rationale: While MRI has taken the spotlight, helical CT scanning still holds its ground, especially when it comes to assessing subchondral fractures. It’s a preferred choice for individuals with contraindications for MRI, such as those with implanted metal hardware, who need an assessment for avascular necrosis (AVN).

 

Magnetic Resonance Imaging (MRI)

Suggested – This is a good choice for specific hip fracture patients dealing with ongoing hip pain that’s been hanging around for a while. Especially useful when there’s a need to look into soft tissue problems or other diagnostic concerns.

Indications: Patients experiencing lingering hip pain for some time, where imaging of the soft tissues is necessary. This includes checking out structures around the joint or investigating masses. Not usually recommended for sudden hip pain, as regular X-rays usually do the trick.

Frequency/Dose/Duration: Typically, one examination should do the job, and a second one is rarely necessary.

Rationale: MRI comes into play when evaluating patients with symptoms persisting for more than three months.

 

X-rays

Suggested – Get X-rays done to check for hip fractures. Indications: It’s a good call for all patients who might have a hip fracture. Also, consider it when there’s no obvious warning signs but the hip pain is quite intense, lasting for a few weeks, and there’s limited movement.

Frequency/Dose/Duration: Usually, getting X-rays once is enough. However, if someone is dealing with ongoing or worsening hip pain, it might make sense to go for a second round, especially if the symptoms are changing. Evidence supporting the use of X-rays for hip fracture evaluation

 

Ultrasound

Not Recommended – Skip the ultrasound when it comes to checking for hip fractures. Evidence against the use of ultrasound for evaluating hip fracture patients.

 

Medications

For many patients, the initial go-to medications are ibuprofen, naproxen, or other NSAIDs from the older generation. If NSAIDs aren’t suitable, acetaminophen (or its counterpart paracetamol) could be a reasonable alternative, although most studies indicate that acetaminophen is slightly less effective. Research indicates that NSAIDs can provide pain relief comparable to opioids (including tramadol) and are associated with fewer impairments.

 

Non-Steroidal Anti-inflammatory Drugs (NSAIDs)

Recommended – Use NSAIDs to tackle the pain that comes with a hip fracture. Indications: When dealing with hip fracture pain, it’s a good call to turn to NSAIDs, and trying out over-the-counter options first is worth a shot. Frequency/Duration: Many folks might find it reasonable to use these as needed. Knowing when to stop – once the pain is gone, if they’re not doing the trick, or if there are side effects that make you put a pause on them.

 

NSAIDs for Patients at High Risk of Gastrointestinal Bleeding

Recommended – If you’re at risk of gastrointestinal bleeding and need NSAIDs, consider taking protective meds alongside. Indications: Especially for those with a high-risk profile and needing NSAIDs, think about cytoprotective medications, especially if the treatment is going to be for the long haul. Those at risk include those with a history of gut bleeding, the elderly, diabetics, and smokers.

Frequency/Dose/Duration: Proton pump inhibitors, misoprostol, sucralfate, and H2 blockers are the go-tos, with dosages as per the instructions. No huge differences in effectiveness for preventing gut bleeding are generally believed. Knowing when to call it quits – if you can’t tolerate it, if there are side effects, or if you’re stopping the NSAID.

 

NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

If you’ve got a known heart condition or a bunch of risk factors for heart problems, it’s crucial to chat about the pros and cons of using NSAIDs for pain relief. Suggested – When it comes to being gentle on the heart, starting with acetaminophen or aspirin seems to be the safest bet. If NSAIDs are a must, the non-selective ones are preferable over the COX-2 specific drugs. For those on a low-dose aspirin regimen for heart health, it’s smart to time the NSAID at least 30 minutes after or 8 hours before the daily aspirin to avoid messing with its benefits.

 

Acetaminophen for Treatment of Hip Pain

Recommended – When it comes to dealing with hip fracture pain, especially for folks who can’t take NSAIDs, acetaminophen is a good go-to. Indications: It’s a suitable option for all types of hip pain – whether it’s just popped up, sticking around, chronic, or post-surgery. Dose/Frequency: Stick to what the manufacturer suggests, and use it when needed. But be mindful not to exceed four grams per day to avoid potential liver issues. Knowing when to stop – once the pain is gone, if there are side effects, or if you can’t tolerate it.

 

Bisphosphonates

Suggested – Consider using bisphosphonates for certain individuals dealing with hip fractures linked to osteopenia. Indications: It’s a good call for those with hip fractures believed to stem from osteoporosis or osteopenia, aiming to prevent further fractures. Perks: It helps boost bone mineral density and lowers the risk of additional fractures. Frequency/Dose/Duration: Stick to what the manufacturer recommends. Supporting evidence for the use of bisphosphonates.

 

Calcitonin

Not Recommended – Skip the calcitonin if you’re dealing with a hip fracture. Evidence against the use of calcitonin.

 

Opioids

Suggested – Opt for a short course of opioids for certain patients recovering from hip surgery. Indications: It’s a good move for post-operative hip fractures, with a brief opioid stint lasting a few days to no more than a week. Opioids might also come in handy for brief nighttime use after surgery. However, for other hip fracture cases, it’s better to steer clear of opioids. Most patients should give NSAIDs or acetaminophen a shot before turning to opioids for pain control. Knowing when to quit – once the hip fracture pain is gone, if other meds are doing the trick, if opioids aren’t effective, or if there are side effects that make you hit the brakes.

 

 

Treatments

 

Hot and Cold Therapies

Cryotherapy for Acute, Subacute, Chronic, or Post-operative Hip Pain

Suggested – Try out cryotherapy for acute, ongoing, long-term, or post-surgery hip pain. Indications: It’s a good fit for anyone dealing with hip pain. Frequency/Duration: Go for about three to five self-applications each day as necessary. Knowing when to stop – once the pain is gone, if there are side effects, or if you’re not keeping up with it.

 

Heat Therapy for Acute, Subacute, Chronic, or Post-operative Hip Pain

Suggested – Give heat therapy a shot for acute, lingering, chronic, or post-surgery hip pain. Indications: It’s suitable for all hip pain cases. Frequency/Duration: Apply it on yourself about three to five times a day as needed.

 

Surgery

Surgical Intervention for Hip Fracture

Suggested – Opt for surgery as soon as the patient’s health is in the clear. Indications: This is the way to go for hip fractures. Reasoning: There’s a variety of surgical methods and tools for fixing the issue. The decision on the specific surgical approach (like pins, screws, or nails) or whether to go for non-operative management is left to the treating surgeon. Supporting evidence for the use of surgical treatment for hip fractures.

 

Arthroplasty for Hip Fractures

Suggested – Consider arthroplasty, especially if dealing with displaced femoral neck and subcapital fractures. Evidence supporting the use of total hip arthroplasty.

 

Hemiarthroplasty

Suggested – Go for hemiarthroplasty, particularly for patients with displaced femoral neck and subcapital fractures. Indications: This is a good move for hip fractures, especially the displaced femoral neck and subcapital ones. Evidence supporting the use of hemiarthroplasty.

 

Systemic Antibiotics

Suggested – Consider using antibiotics for patients undergoing hip surgery, typically for just a day. Evidence supporting the use of antibiotics for hip surgery.

Suggested – Opt for antibiotics, especially with a prosthesis, for patients undergoing hip surgery. Indications: It’s a standard practice for systemic prophylactic antibiotics, offering the benefit of reducing the risk of joint or prosthetic infection. Evidence supporting the use of antibiotics.

 

Wound Infection Management (Post-operative Complications)

Suggested – Think about antibiotics for managing wound infections after surgery. Indications: Useful for handling post-operative complications and dealing with recurring infections.

 

Treatment of Infected Prosthesis

Suggested – Addressing an infected prosthesis is a serious matter that often requires surgical intervention, drainage, and the right antibiotics. Treatment might involve an extended course of intravenous antibiotics and, in some cases, removal of implanted hardware.

 

Treatment of Dislocations

Suggested – If there’s a dislocation issue, it’s best to refer the patient back to the treating surgeon for proper reduction and to minimize the chance of it happening again.

 

Other

Acupuncture

Suggested – Consider acupuncture, particularly after hip arthroplasty procedures. Indications: This could be beneficial for those who’ve undergone hip arthroplasty. Frequency/Dose/Duration: Give it a go for up to three days after the operation. Reasoning: Two well-conducted trials have shown that acupuncture is effective for hip arthroplasty patients, even helping in reducing the need for opioids.