Review Article: Recommendations for the acute and long-term medical management of low-trauma hip fractures

Hip fractures are the most serious complication of osteoporosis and are associated with high morbidity and mortality. Generally, patients who sustain osteoporotic hip fractures are older adults who have a number of comorbid diseases which predispose them to perioperative complications, disability and death. Furthermore, patients who survive a hip fracture are at higher risk of a subsequent fracture. The morbidity and mortality of hip fractures can be substantially reduced by a structured multidisciplinary approach to preand postoperative management. This review will focus on the epidemiology of hip fractures, predictors of mortality and the acute and long-term management of hip fractures. Peer reviewed. (Submitted: 2012-12-21. Accepted: 2013-01-07.) © NOFSA and SAGS JEMDSA 2013;18(1):21-32 Review Article: Recommendations for the acute and long-term medical management of low-trauma hip fractures 22 2013 Volume 18 No 1 JEMDSA were identified in rural Gambia,14 and an age-related increase in hip fractures was not observed in Nigeria.15 However, in a more recent study from Cameroon, hip fractures were identified in 40 subjects (27 women and 13 men) aged 50 years and above.16 Compared to the USA, the substantially lower fracture rate was attributed to the significantly lower life expectancy. Similarly, the lower incidence of osteoporotic fractures in Morocco has also been ascribed to a lower life expectancy.17 However, these studies do show that osteoporotic fractures occur in Africa. In South Africa, studies have examined risk factors and the prevalence of osteoporosis in the different ethnic groups. Until recently, there has been only one study on the prevalence of hip fractures. This study18 reported an extremely low prevalence of hip fractures in black South Africans, which could not be explained by differences in bone mass. Bone mineral density (BMD) has been reported to be the same or higher in blacks than whites19, 20 and persons of mixed ancestry.21 However, a recent study reported hip fractures in all ethnic groups in South Africa and supports clinical experience that hip fractures are more common than previously thought.22 While the incidence of hip fractures appears to be stabilising in the more developed countries, it is projected that the burden of osteoporotic hip fractures will shift to Latin American, Asia and Africa, where the population are rapidly ageing. It is predicted that in the year 2050, 70% of over 6-million predicted fractures will occur in these populations. Within countries, ethnic differences have also been reported in the incidence of hip fractures. In the USA, the age-adjusted incidence rates of hip fractures were higher in whites than Asians, blacks and Hispanics.23 Higher bone mass and shorter hip-axis lengths in black and Hispanic populations may explain these differences.24 Similarly, differences in hip-axis length have also been suggested as a cause of the lower adjusted fracture rates in Indians than in Chinese and Malay subjects in Singapore.25 Other contributing factors for ethnic differences include variations in bone size, levels of physical activity, diet, neuromuscular functioning and frequency of falls.