Hip Fracture

Fractures happen when there’s more force applied to the bone than the bone can absorb. If your child has a fracture, it means that his bone has partially or completely broken. A hip fracture should be treated quickly and correctly — the hip is the body’s connection to the legs and is crucial for movement.

A hip fracture is a partial or complete break in any of the three bones of the pelvis that make up the hip: the illium (upper part), the ischium (lower part), or the central pubis that joins the ischium on either side. Fractures can also occur where the thigh bone (femur) angles into the hip socket (proximal femur fracture), or in the socket (acetabulum) where the thigh bone rotates. Hip fractures are common in the elderly and rare in children because a child's bones are designed to absorb more force.

Common signs and symptoms of a broken hip can include:

• Pain or swelling in the hip or groin
• An obvious deformity or uneven leg lengths
• Inability to stand or walk
• Limited range of motion in the hip area; outward turning of the leg
• Bruising (may indicate damage to blood vessels)

• A break in a bone usually occurs from trauma, a fall or a direct blow.
• In a closed fracture, the bone is broken but the skin is still intact.
• A complete fracture is a fracture involving the entire cross-section of the bone.
• In an open (compound) fracture, the bone exits and is visible through the skin; or a deep wound exposes the bone through the skin, increasing the risk of infection.

• Softer bones: Because children’s bones are softer than those of adults, they tend to absorb force more readily and therefore break less easily.
• Quicker healing: A child’s break heals much faster than an adult’s break. And the younger the child, the faster the healing. This is good news for recovery, but it also means that your child should get medical and/or surgical attention quickly to ensure that it heals in the correct position.
• Growth plates vulnerable: Children have open growth plates (physes) — areas of cartilage from which bone grows — at several sites in the pelvis as well as at the head of the thigh bone. In performing surgery on broken bones in children, surgeons must consider and account for these growth plates.
• Better bone remodeling capacity: Bone remodeling involves the absorption of bone tissue and the simultaneous depositing of new bone; a bone’s continuous self-renewal, self-healing and self-realignment, partially through reorientation of the growth plate. In kids’ fractures, the bone’s remodeling capability is usually very good, so poor alignment (mal-union) is rare.
• Less residual stiffness: Any stiffness from being in a cast readily dissipates in children, whose tissues are more resilient.

A risk for developing a fracture increases if he has:

• Trauma from a car crash, accident, sports injury, fall or physical abuse
• Low mineral content in his bones
• A genetic disorder that affects his bone metabolism and muscle mass
• Endocrine dysfunction
• Poor nutrition and/or is overweight
• A lack of calcium in his diet
• A previous history of fracture(s)

Hip fractures in teens are commonly due to sports injuries. When a hip is fractured, other structures housed by the pelvic bones can get injured, too. These can include:

• The lower portion of the intestines and rectum
• The urinary bladder and the reproductive organs

Note: Boston Children’s Skeletal Health Center provides comprehensive evaluations of children and adolescents who have, or are at risk for, low bone density.

If your child is diagnosed with a broken hip, you may feel a bit overwhelmed. It can be easy to lose track of the questions that occur to you. Lots of parents find it helpful to jot down questions as they arise — that way, when you talk to your child’s doctors, you can be sure that all your concerns are addressed. If your child is older, he may want to ask questions, too.

Some of the questions you may want to ask include:

• What bone or bones in the hip has my child broken?
• Are other tests needed to diagnose his fracture?
• Is there any damage to his nerves or blood vessels?
• What actions might you take after you confirm a diagnosis?
• Is this going to affect his growth plate, and his normal growth?
• How long will it take for him to heal?
• Will he need rehab or physical therapy?
• Will there be restrictions on my child’s activities? If so, for how long?
• Will there be long-term effects? Pain? Arthritis?
• What is the follow-up care plan?

If you’re teen with a broken hip, you have a lot to cope with. Besides the typical issues any teenager faces — from social acceptance to body changes and more — you’ll also have to deal with medical appointments and procedures, finding alternative ways to get around, keeping your cast or sling safe, clean and dry, and limiting your activities for a period of time.

If you’re usually active, to be experiencing pain or sitting on the sidelines for a while can be depressing and frustrating. If you feel down, angry or anxious through this important time in your life, speak to your doctor, parent or counselor to get help—they’re all on your team, and they want to help. And remember that Boston Children’s Orthopedics and Sports Medicine Department is always here for you, too.

It’s hard to prevent a child from breaking a bone — especially if your child is very active and plays sports. But the value of kids’ participation in sports and play greatly outweighs the risk of breaking a bone.

While you can’t prevent your child from breaking a bone, you can help him minimize his risk with simple, common-sense steps:

• Avoid risky behavior that can result in falls or accidents.
• See that your child wears proper sports and safety gear, including proper footwear if he is a runner.
• See that he wears his seat belt in the car.
• Make sure your baby or toddler is secured in his car seat.

A healthful diet: low in fat, high in protein, nutrients and fiber.

Make sure he has plenty of calcium in his diet (milk, yogurt, cheese, fish, and leafy green vegetables are high-calcium foods)

Monitor his portions to help him control his weight, since obesity puts him at greater risk for breaking a bone.

• Limit sodas and sugary snacks.
• Have regular sit-down mealtimes, and limit his between-meal snacking

Encourage him to get lots of weight-bearing physical exercise.

Discourage prolonged time watching TV, playing computer games or other sedentary activities.

• Encourage your young athlete — especially if he’s a runner — to do some cross-training to decrease the possibility of stress fractures

Immediately report any suspicion of physical abuse, or the danger of abuse.

At Boston Children’s Hospital, we know that the first step in treating your child’s broken hip is to form an accurate and complete diagnosis.

During a physical exam, the doctor obtains a complete medical history of your child and asks how your child got hurt. The physician will look for any injuries commonly associated with hip fractures. These can include injury to any of the structures housed by the pelvic bones, such as the lower portion of the intestines and rectum, the urinary bladder, and the reproductive organs. Other commonly associated injuries include head injuries and additional fractures.

The doctor will examine any lacerations to determine whether an open fracture (bone visible through the skin) has occurred, and will press on front and back of the pelvic area to help determine how stable the hip is. A rectal examination also may be performed to look for hemorrhage that may signify bone penetration into the rectum.

Diagnostic testing for a broken hip

• X-ray: Uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film — usually sufficient for the majority of fractures
• MRI (Magnetic Resonance Imaging): Uses a combination of large magnets, radio frequencies, and a computer to produce detailed images of organs and structures within the body; especially useful for assessing soft tissue around injured joints and bones
• Computed tomography scan (CT, CAT scan): Uses a combination of X-rays and computer technology to produce 3D cross-sectional images (slices), both horizontally and vertically, of the affected area — including bones, fat, and soft tissue
• Bone scan: Uses a radioactive dye to visualize the bones. It’s different from plain X-rays or CT in that it shows bone metabolism and cell activity in the bones. Bone scans are used to assess bone growth activity, bone remodeling activity, and/or blood flow in the affected area(s).

A hip fracture should be treated quickly and correctly — the hip is the body’s connection to the legs and is crucial for movement.

If you think your child has broken his hip, you should take him to the Emergency Room. If you’re waiting to see your child’s doctor, it may help to use self-care first aid remedies to reduce swelling and pain:

• Rest: Make sure he doesn’t exert his leg without support; he can use crutches or a cane, if it helps.
• Ice: Wrap a towel around ice cubes, an ice pack, or a frozen food package to ice the leg for 20 minutes at a time, at two-hour intervals.

Boston Children’s Hospital’s hip sub-specialists provide comprehensive treatment — including evaluation, diagnosis, consultation, and follow-up care — to their young patients. How we’ll treat your child’s hip fracture depends on the location, complexity, and severity of his break — as well as his age and overall health. Boston Children’s orthopedic experts in the Child and Young Adult Hip Preservation Program will provide comprehensive treatment — including evaluation, diagnosis, consultation, and follow-up care.

The overwhelming majority of children treated for a broken hip at Boston Children’s have corrections that enable their bones to grow normally — so they can walk, play, grow, and live active lives. Kids’ bones heal quickly, and usually without complications.

Our treatment goals are to:

• Control your child’s pain
• Promote healing
• Prevent complications
• Restore normal use of the fractured area

To restore your child’s use of his broken hip bone, his doctor may recommend some combination of these possible treatments:

• Rest and ice packs to reduce swelling, redness, and pain
• Medication
• Surgery: usually needed to put broken hip bone(s) back into place
  • in open reduction, the surgeon inserts metal screws and pins (internal fixation) to hold bone fragments in place to allow alignment and healing
• Pelvic cast or sling: immobilizes the injured area to promote bone alignment and healing, while also protecting the injured area from motion or impact; at Boston Children’s, our experts fit your child for his cast or sling
• Physical therapy: may be needed to strengthen your child’s muscles and help his hip return to full function

Other injuries

When a hip is fractured, other structures housed by the pelvic bones can get injured, too. These can include the lower portion of the intestines and rectum, the urinary bladder, and the reproductive organs. Other commonly associated injuries include head injuries and additional fractures.

Complications after treatment

Most non-surgical and surgical corrections of childhood fractures occur without complications. Although complications are relatively uncommon, they can occur and can include:

• Osteonecrosis (avascular necrosis): Bone death caused by lack of blood supply to the bone. A hip fracture can happen close to the network of blood vessels that go to the head of the femur.
• Growth disturbances: A fracture that extends into the bone’s growth plates in still-growing children can disturb or stop the normal growth of the bone (growth arrest). This can lead to limb length discrepancies or angular deformities. Surgery on broken bones in children must account for these growth plates.

Our research into bone problems means that we can provide your child with the most innovative care available. As a result, the overwhelming majority of children treated for hip fractures at Boston Children’s have corrections that enable their bones to grow normally — so they can walk, play, grow, and live active lives.

Tips if you or your young child is in a cast

• Keep your child’s cast clean and dry.
• Check for cracks or breaks in the cast.
• Put pads on rough edges to protect the skin from scratches.
• Don’t scratch the skin under the cast by inserting objects inside the cast.
• Use a hairdryer placed on a cool setting to blow air under the cast and cool down the hot, itchy skin. Never blow warm or hot air into the cast.
• Cover the cast while your child is eating to prevent food spills and crumbs from entering the cast.
• Prevent small toys or objects from being put inside the cast.
• Elevate the cast to decrease swelling.
• Encourage your child to move his toes to promote circulation.

Healing time after treatment

A hip fracture is a serious injury, and it usually means that your child will need surgery. There may be exceptions, but as a general guideline, the younger the child, the quicker he’ll heal.

• Children and teens typically need to be in a cast for four to six weeks after surgery.
• Infants, toddlers, and very young children who are treated non-surgically with a hip spica cast (a cast that includes the trunk of the body and one or more limbs) often need less time to heal.