Geriatric Hip Fracture

The "hip" is a ball-and-socket joint. It allows the leg to bend and rotate at the pelvis. Hip fracture in general refers to fracture upper end of the thigh bone, or femur. Fracture of the socket, or acetabulum, is not considered as a "hip fracture." Management of fractures of the socket is different.

Hip fractures become more common as people age because falls are more likely and bones become less dense i.e. osteoporosis. People with osteoporosis can get a fracture from simple, everyday activities, not just a dramatic fall or injury. In younger patients with stronger bones, more common causes of a broken hip include high-energy injuries such as car accidents. Hip fractures can also be caused by bone weakened from tumor or other bone disease, a problem called a pathologic fracture.

A hip fracture can change the quality of your life significantly. In addition, while recovering from a hip fracture, several possible complications can be life-threatening. These include pneumonia, pressure sore and a blood clot in the leg, which can dislodge and travel to cause a clot in the lungs. These are related to immobility following a hip fracture. A patient who previously sustained a hip fracture is at higher risk of breaking their other hip again.

Elderly patients with osteoporosis are at much higher risk of developing a hip fracture than someone without osteoporosis.

Hip fractures most commonly occur from a fall or form a direct blow to the side of the hip.
Other possible causes to elderly falls include: acute stroke, high blood pressure, poor eyesight, side effects of drugs and the living environment factors.

The patient will have pain over the upper thigh or in the groin. If the bone has been weakened by disease (such as a stress injury or cancer), the patient may notice aching in the groin or thigh area for a period of time before the break. If the bone is completely broken, the leg may appear to be shorter than the other leg. It will be painful to move the leg.

The diagnosis of a hip fracture is generally made by an X-ray. Occasionally an incomplete fracture may not be seen on a regular X-ray. In that case, some more imaging studies may be necessary.

No hip fracture is identical. Hip fractures are separated into several types depending on which part of the upper femur is involved.

Femoral Neck Fractures
A femoral neck fracture occurs when the femoral head fractured off the femur. Treatment of a femoral neck fracture depends on the age of the patient and the amount of displacement of the fracture. This fracture may have loss of blood supply to the bone.(Fig 1)

Intertrochanteric Hip Fractures
An intertrochanteric hip fracture occurs just below the femoral neck. These fractures are amenable to fixation more often than femoral neck fractures. The usual surgical treatment involves placement of screw, plate or nail to stabilize the fracture.(Fig 2)

Subtrochanteric Fracture
This fracture is much less common than femoral neck fracture and intertrochanteric fracture. It occurs below the lesser trochanter.(Fig 3)

In more complicated cases, the amount of breakage of the bone can involve more than one of these zones. This is taken into consideration when surgical repair is considered.

 Once the diagnosis of the hip fracture has been made, the patient's overall health condition will be evaluated. In some cases, the patient may be so ill that anesthesia and surgery would not be recommended. In these cases, the patient's overall comfort and level of pain must be weighted against the risks of anesthesia and surgery.

Most surgeons agree that patients do better if they are operated on fairly quickly. It is, however, important to ensure patients' safety and maximize their overall medical health before surgery. This may mean taking time to do cardiac and other diagnostic studies.

Nonsurgical Treatment
This can be considered for those who are too ill to undergo any form of anesthesia and those who were unable to walk before their injury.

Surgical Treatment

Before Surgery

Appropriate blood test, chest X-ray and electrocardiograms will be obtained before surgery.

All patients will receive prophylactic antibiotics. Anesthesia for surgery can be general anesthesia, spinal anesthesia, epidural anesthesia or combined.

Surgery

The type of surgery depends on the type of fracture and the degree of fracture displacement.

There are two types of operations: joint replacement (Hemiarthroplasty) or internal fixation.

The important issue with femoral neck fractures is that the blood supply to the fractured portion of bone will be disrupted if the displacement is significant. Because blood flow is diminished, these fractures are at high risk of not healing & osteonecrosis. Therefore, most will be treated by a partial hip replacement. Hip hemiarthroplasty is a half of a hip replacement. In this procedure, the ball of the ball-and-socket joint is removed, and a metal prosthesis is implanted into the joint.

Hemiarthroplasty is a type of hip replacement in which only the "ball" of the hip is replaced. (Fig 4)

For undisplaced or minimally displaced fracture, the surgeon  may decide to fix the fracture instead of replacement.

Repair of an intertrochanteric fracture with an intramedullary nail. The nail is in the hollow cavity of the femur (thighbone) rather than on the side of it (as with a plate).

Most intertrochanteric fractures are managed with a compression hip screw with a metal plate (Fig 5) or an intramedullary nail (Fig 6). This allows impaction at the fracture site. 

Fig 5

Fig 6

Subtrochanteric Fracture
At the subtrochanteric level, fractures are managed with an intramedullary nail or a long plate.

Complications are very common in patients who sustain a hip fracture. One of the most important reasons for performing surgery on patients who have a hip fracture is to help prevent these complications. By getting patient up and out of bed as soon as possible, the risk of these complications is diminished.

Common complications:

• Pressure sores caused by bed bound
• Venous thrombosis, pulmonary embolism
• Infection
• Wound bleeding or hematoma
• Improper wound healing
• Exacerbation of illnesses experienced before surgery, such as high blood pressure, stroke or diabetes

Complications due to surgery:

• Anesthetic risk
• Fracture, nerve damage, blood vessels damage leading to paralysis or loss of limb(rare)
• Wound infection
• Leg length discrepancy
• Deep vein thrombosis
• Deterioration of pre-existing disease leading to worsening of symptoms
• Persistent limping and the use of walking aids

Complications related to hip screw / dynamic hip screw / proximal femoral nail surgery Fixation:

• Implant loosening
• Osteonecrosis of femoral head
• Fracture healing problem
• Sciatic nerve injury

Complications related to hip replacement:

• Dislocation, subsidence
• Loosening
• Sciatic nerve injury
• Heterotopic ossification

Patients may be encouraged to get out of bed on the day following surgery with assistance. The amount of weight that is allowed to be placed on the injured leg is generally a function of the type of fracture and repair (replacement or fixation).

The physiotherapist will work with the patient to help regain strength and the ability to walk, This process may take up to few months.

Hip replacement surgery

When patients feel less pain, they can try sitting up. Patients who have undergone hip replacement may require a special hip chair to prevent hip dislocation at the early rehabilitation phase. Rehabilitation is initiated immediately and patients can usually walk with their full weight on the implant. Home environment assessments by occupational therapist sometimes are necessary.

After hip replacement surgery, doctor may use an abduction pillow for temporary immobilization of lower limbs. It can be replaced by a sling later on, and patients can then move their limbs more freely.

Fixation surgery

Patients are usually allowed to begin walking immediately following surgery. In some cases, if there were small fracture fragments or difficulty with alignment of the fracture, weight may be restricted. Most commonly, patients will get up with the physiotherapist few days following surgery. Time for complete healing is usually about few months, but most patients are walking well before that time.

Medical Care

Occasionally, a blood transfusion may be required after surgery. Long term antibiotics are generally not necessary.

Patients may be discharged to their home or find that a stay in a rehabilitation facility is necessary.

Follow Up Care

During the appointments that take place after surgery, the surgeon will want to check the wound, follow the healing process using X-rays, and prescribe additional physiotherapy, if necessary.

• Prevent and treat osteoporosis
• Keep eye sight and hearing normal
• For patient with high blood pressure, maintaining stable blood pressure to avoid dizziness.
• Use suitable walking support to treat leg injuries, knee pains or to keep balance: umbrellas and furniture are not reliable
• Practice limb movements regularly or undergo balance training.
• Alert and minimize household dangers, such as water, objects or small floor rugs, the passage to toilet should be clear of obstacles and well lit, especially at nighttime.
• People at a higher risk can consider wearing a hip protect