Introduction
A fracture of the hip in an elderly patient can be a life-threatening illness. Medical complications can arise when elderly patients are confined to bed due to hip fractures. The complications are what can turn a simple break into a life-threatening illness.
Causes
Many hip fractures occur from injures such as a fall. It is possible the fall may have happened as a result of fracturing the hip. The hip actually breaks first, causing the person to fall.
Osteoporosis is one condition that causes hip fractures. This disease can weaken the neck of the femur causing the bone to break suddenly. An uncertain step may result in a twist to the hip joint placing too much stress across the neck of the femur. The femoral neck breaks, and the patient falls to the ground. It happens so quickly it is unclear to the patient whether the fall or the break occurred first.
Symptoms
A hip fracture, like any broken bone, causes pain and makes it difficult to put weight on the leg. When a hip fracture occurs in an elderly person who lives alone, it may be hours before anyone finds the patient. The patient sometimes cannot get to the phone to alert anyone. This is the first life-threatening situation. This situation can result in dehydration, or if the fracture occurs outside, the patient may develop hypothermia. Both of these conditions can be deadly.
Diagnosis
History and Physical Examination
The diagnosis of a hip fracture usually occurs in the emergency room. The diagnosis begins with a history and physical examination. It is important that the doctor be advised of any other medical problems the patient has so treatment of the hip fracture can be planned. Most of the information from the history and physical examination will be used to try to evaluate the overall physical condition of the patient. Tests such as chest X-rays, blood work, and electrocardiograms may be ordered to assess the patient’s overall condition.
X-Rays
X-rays are typically used to determine if a hip fracture has occurred and if so, what type of fracture it is. The orthopedic surgeon will use the X-rays to determine if a surgical procedure will be necessary and to plan what type of procedure to suggest.
MRI Scan
In a few cases, X-rays may not show the fracture. If the hip continues to hurt and the doctor is suspicious that a hip fracture is present, an MRI (magnetic resonance imaging) scan may be suggested. The MRI scanner uses magnetic waves rather than radiation to take multiple pictures of the hipbones. The MRI machine is very sensitive and can show fractures that do not show up on regular X-rays.
This test is done to be certain there is no fracture before allowing the patient to put weight on the leg. Walking on a fractured hip may cause the two sides of the fracture to displace, or move apart, so that they no longer line up correctly. This is much harder to treat than a fracture that has not been displaced. A displaced fracture also increases the risk of damaging the blood supply to the femoral head.
Treatment
Hip fractures in the elderly are usually treated with some type of surgery to fix the fractured bones. If possible, the surgery is normally done within twenty-four hours of admission to the hospital. Rarely is a fracture considered stable, meaning it will not displace if the patient is allowed to sit in a chair. But if the fracture seems stable, the patient may be treated without surgery if the doctor feels the patient will be able to get out of bed within several days.
Most hip fractures would actually heal without surgery, but the problem is the patient would be in bed for eight to twelve weeks. Placing an elderly person in bed for this period of time has a far greater risk of creating serious complications than the surgery to fix a broken hip. This is the reason surgery is recommended to nearly all patients with fractured hips.
The goal of any hip fracture surgery is to hold the broken bones securely in position, allowing the patient to get out of bed as soon as possible. Many methods have been invented to treat the different types of fractures. Most hip fractures are treated in one of three ways: with metal pins, a metal plate and screws, or with artificial replacement of the broken femoral head.
Metal Pins
Fractures occurring through the neck of the femur may require only two or three metal pins to hold the two pieces of the fracture together. This procedure is fairly simple and allows patients to begin putting weight down right after surgery.
Metal Plate and Screws
Some hip fractures occur below the femoral neck in the area called the intertrochanteric region. These hip fractures are usually the result of a fall and often are the hardest type of fracture to treat. They often involve more than one break. As a result, several pieces of broken bone must be held together.
Surgeons usually fix this type of fracture using a metal plate and compression hip screw. This approach helps align the bones and relies on the force of the muscles to “compress” the fractured bones together so they will heal.
Artificial Replacement of the Femoral Head (Hemi
When the hip fracture occurs through the neck of the femur and the ball is completely displaced, there is a very high chance that the blood supply to the femoral head has been damaged. This makes it very likely that avascular necrosis (AVN) will occur as a complication of this type of hip fracture.
Avascular necrosis of the femoral head causes the bone of the femoral head to die. The bone of the femoral head begins to collapse weeks later causing more problems in the months to come. This may result in a second operation several months later to replace the hip due to the avascular necrosis. The likelihood of this is so great that most surgeons will recommend removing the femoral head immediately and replacing it with an artificial femoral head made of metal. This operation is called a hemiarthroplasty because only half of the joint is replaced. The socket of the hip joint is left intact.
Complications
The complications that can develop after a hip fracture are what make the injury a life-threatening problem. Some complications can result from surgery, but many can occur whether the fracture is treated with surgery or not.
Most of the complications that occur after a hip fracture result from having to put an elderly patient on bed rest. In general, this seems to make all the medical problems the patient has worse. Some of the more common problems that a hip fracture can increase the likelihood of include:
- Pneumonia
- Bed sores (pressure ulcers)
- Deep Vein Thrombosis (DVT) – blood clots in the large veins of the leg
- Mental confusion
Getting the patient out of bed and moving can reduce the risk of developing complications. An operation to stabilize the fracture and get the patient out of bed more quickly may reduce the overall risk of developing these complications. Complications may still occur after surgery. But, they are far easier to treat if the patient can be mobilized.
Rehabilitation
A physical therapist usually works with patients in the hospital soon after surgery. You’ll be assisted from your bed to a chair several times each day. You’ll begin walking with a walker or crutches, practice accessing the bathroom, and start doing exercises to tone the muscles around the hip and thigh and to prevent the formation of blood clots.
The amount of weight that can be placed on the operated leg depends on the type of surgery performed. Most patients are able to start weight bearing right away after surgery. Depending on the severity of the fracture, patients may only be able to place partial weight down right away.
Patients who require hemiarthroplasty follow a different treatment plan. This surgery is more involved and requires the doctor to open up the hip joint during surgery. This puts the hip at some risk for dislocation after surgery. To prevent hip dislocation after surgery, patients follow strict guidelines about which hip positions they must avoid, called “hip precautions.” Patients follow these precautions at all times for at least six weeks after surgery, until the soft tissues gain enough strength to keep the joint from dislocating. Patients may be instructed to use their walker or crutches to limit the amount of weight they place on the operated leg.
After you return home from the hospital, your doctor may have you work with a physical therapist for two to four in-home visits. This is to ensure you are safe in and about the home and getting in and out of a car. Your therapist will make recommendations about your safety, review your hip precautions, and make sure you are placing a safe amount of weight on your foot when standing or walking.
Additional visits to outpatient physical therapy may be needed for patients who have problems walking or who need to get back to physically heavy work or activities.
