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What is the hip joint and what are hip fractures?

The hip joint is formed by two major bones namely the acetabulum or the pelvic bone and head of the femur i.e. the thigh bone. A break in the upper quarter of the femur constitutes a hip fracture.

 

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Why are hip fractures common in elderly?

The hip joint is shaped like a ball in a socket but has an inherent stability, due to the positioning of the ball within the socket and the strong ligaments that join the two bones. However, inspite of this stability, hip fractures are commonly seen in the elderly and are associated with a high rate of morbidity and mortality. Hip fractures are the most common fall-related injury among adults. They are seen as complications of osteoporosis.

What are the symptoms of hip fractures?

Some of the commonly reported signs and symptoms of a hip fracture include:

Bruising, stiffness and swelling of the hip region

  • Inability to bear weight on the side where the hip fracture is suspected
  • Inability to move immediately after a fall
  • Outward turning of the leg on the side where the hip fracture is suspected
  • Severe pain in the hip or groin region

What are the causes and risk factors of hip fractures?

A sudden and severe impact can result in hip fractures in people of all ages, for example in a car accident. However, in case of older adults, a hip fracture can occur even in low impact events like a fall from a small height stair or even by twisting of the leg in case of people with extremely weak bones.

The chances of hip fractures increase substantially with:

  • Age: The density of the bones becomes porous with age making them prone to easy fracture.
  • Gender: Women are more prone to hip fractures due to a decreased bone density in osteoporosis.
  • Chronic medical conditions: Disorders of the endocrine glands or conditions leading to poor vitamin D and calcium absorption can cause weakening of bones and hip fracture.
  • Prolonged use of medications like cortisonescan also have a weakening effect on the bones making them prone to fractures.
  • Dietary deficiencies: Diet deficient in calcium and vitamin D can cause decreased bone density and increase the risk of fracture later.
  • Sedentary lifestyle:Physical activities of weight-bearing nature help in strengthening of bones. Lack of exercise has an adverse long-term effect on the density of bones.
  • Substance abuse: Habit forming substances like alcohol and tobacco can interfere with the bone formation and maintenance, leading to loss of bone eventually.

 

What are the types of hip fractures?

Hip fractures can be classified into two types: intra-capsular and extra-capsular.

 

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Intra-capsular fractures:  Also known as a fracture of the neck of the femur, cervical or subcapital hip fractures, these are characterized by:

  • Common in patients above 50 years of age.
  • Commonly occur in females.
  • Trivial injury can lead to this kind of fracture. Pain and tenderness are mild and the patient may be able to walk.
  • There is usually no swelling.
  • There are slight deformation and shortening of the leg by less than 1 inch.

Extra-capsular fractures:Also known as an inter-trochanteric fracture or pertrochanteric fractures, these are characterized by:

  • Occurs in adults over 60 years of age.
  • It is common in males.
  • The significant injury is required for the occurrence of this kind of fracture.
  • There are severe pain and tenderness and inability to walk.
  • There is significant deformity and leg shortening of more than 1 inch is present.

How do doctors diagnose hip fracture?

The doctor can diagnose a hip fracture on the basis of a patient’s history, symptoms, physical examination, and diagnostic tests.

Some of the investigations that aid in the diagnosis of hip fractures include:

X-ray examination: Plain radiographs in most of the cases are useful in detecting the presence and exact location of the fracture in the bone.

Magnetic resonance imaging (MRI): Hip fractures which are not evident on plain x-raysor hairline fractures can be identified using an MRI.

Technetium-99m bone scanning: This is a sensitive technique for unrecognized hip fractures.

What is the treatment of hip fractures?

The aim of management of patients with hip fracture is to provide functional improvement as before the fracture. This is achieved by surgery followed by early mobilization. The type of surgery depends on the location of the fracture, bone quality, displacement and also the age of the patient.

 

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Fracture of neck of femur: Fracture of neck of femur is associated with an increased risk of complications because the blood supply is cut off and it is difficult to achieve and maintain the alignment of the fractured fragments in this kind of fracture. Therefore, fracture of neck of femur commonly requires surgical treatment. The aim of treatment is to achieve a union of the fractured fragments and maintain the alignment.

In the early postoperative period, the patient is allowed non-weight bearing movements using crutches. Usually, after 2-3 months, the fracture starts showing union and gradual weight bearing is advised.

In elderly, there is an increased risk of failure of this operative management. Therefore, in such cases, the head of the femur is excised and is replaced by a prosthesis.

In cases presenting late, or in cases of non-union of a femoral neck fracture, the fracture is reduced from the back side of the fracture. A muscle-bone graft with blood supply is used and the fracture is fixed with multiple screws.

  • Total hip replacement: The upper femur and the socket in the pelvic bone are replaced completely with an artificial joint or prostheses.
  • Partial hip replacement: In case of displacement or damage to the ends of the broken bone the head and neck of the femur may be partly removed and replaced with a prosthesis. This procedure is called partial hip replacement.

 

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Fracture of the inter-trochanteric region: As compared to fractures of the neck of femur, inter-trochanteric fractures unite easily. Conservative measures such as traction or surgical methods such as internal fixation aim to maintain a normal femoral neck-shaft angle during the union of the fracture. Fracture reduction and internal fixation can be done using a dynamic hip screw, nails. External fixation is indicated in patients who are unfit for surgery.

In the elderly patients, prolonged bed rest can further lead to complications such as bed sores or pneumonia. Hence, Internal fixation is performed in the elderly patients to prevent prolonged bed rest in traction, the duration of which can be as long as 3-4 months.

What are the rehabilitation process required after a hip fracture surgery?

The objective of a rehabilitation program after a surgery is to enhance the recovery duration and strengthened muscle strength and to reduce the problems of bed sores. The ultimate goal is to enable the ability to walk well, as they were able to before they suffered a hip fracture. Common rehabilitation process include;

Pain management- several ways to minimize pain include;

  • Correct movement
  • Correct posture
  • Electrical devices
  • Ice pack application

Exercises- it is an essential step for fast recovery from the surgery. There are three levels of exercise-initial exercise program (normally 4 to 6 weeks after surgery), intermediate exercise program and advanced exercise program. Common exercises include;

  • Hip and abdomen strengthening program
  • Leg raises
  • Press ups
  • Regular walk
  • Sciatic nerve glide
  • Wall squats

Education and training- A physiotherapist will provide sessions on physical therapy, the right way to executing the exercises and postures to maintain after surgery

What are the complications associated with hip fractures?

Hip fractures, especially in case of elderly people have many associated complications which can affect future independence and sometimes even life span. Some of the common complications include

  • Fracture of neck of femur: Fracture of neck of femur is associated with increased risk of complications due to the poor blood supply. The following complications can occur with a fracture of neck of femur:

  • Nonunion: 30-40% of fractures of the neck of femur lead to non-union despite immobilization. There may be implant failure because the implant which was holding the fractured fragments together gives way. The patient complains of pain and inability to bear weight on the affected side and shortening and distortion of the limb. This complication is treated in younger patients by neck reconstruction or a procedure called osteotomy. In elderly patients a procedure called replacement arthroplasty maybe

  • Avascular necrosis: Fracture of neck of femur is commonly associated with cut off of blood supply to the head of the femur. This result is a condition known as avascular necrosis. This may, in turn, lead to non-union also. The head of the femur may become deformed and may collapse due to lack of blood supply. A long-term complication of osteoarthritis can also occur in such patients. This complication is treated in young patients with bipolar arthroplasty or rarely total hip replacement. In the elderly patients, a hemi-replacement arthroplasty is performed, or total hip replacement is performed if there is associated damage to the hip.

  • Osteoarthritis: Fracture of neck of femur is associated with a long-term complication of osteoarthritis which is commonly seen due to avascular deformation of the head of femur and union in faulty alignment. The patient complains of pain and stiffness. The pain gradually increases and becomes persistent. In younger patients, this complication is treated by a procedure called inter-trochanteric osteotomy or arthrodesis of the hip and in the elderly patient total hip replacement is performed.

  • Fracture of the inter-trochanteric region: intertrochanteric fractures are associated with the following complications:

  • Malunion: In certain cases, the fractured fragments of the bones may not be properly aligned despite treatment, leading to malunion which results in shortening of leg and deformity. In elderly, this complication can be compensated by a shoe raise, however, in young patients correction of the deformity by internal fixation may be required.

  • Osteoarthritis: After a few years of hip fracture, osteoarthritis may develop in the hip which can be treated by physiotherapy, trochanteric osteotomy or total hip replacement (in the elderly).

Further, if a long-term immobility caused due to hip fracture can lead to:

  • Bedsores
  • Blood clots in the legs or lungs
  • Loss of muscle mass, further increasing an individual’s risk of falls
  • Pneumonia
  • Urinary tract infection

Can hip fractures be prevented?

The prevention of hip fractures involves addressing the risk factors associated with them. These factors are mainly about having healthy bones and avoidance of falls and accidents. Some of the preventive measures include:

  • Having a diet rich in calcium and vitamin D. It is good to have 1,200 milligrams of calcium per day, and 600 international units of vitamin D per day for men and women when they are 50 years or older.
  • Exercise regularly, especially weight-bearing exercises like walking helps in strengthening of bones and promotes the ability to balance.
  • Cessation of habits like smoking or excessive drinking: As tobacco and alcohol use can have a bone density reducing the effect on bones and alcohol also impairs balance thus increasing the likelihood of falls.
  • Undertake a safety assessment of the house to eliminate probable hazards like excess furniture, rugs, loose electrical cords etc that may cause tripping.
  • Get your vision checked routinely.
  • Look for side effects of any medications that you may be taking like feeling weak and dizzy, etc and take necessary precautions by consulting your doctor.

 

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Disclaimer: The shared article is only for awareness and education purpose. Readers are advised to consult their doctor for proper evaluation of the condition and more information. Do not self-medicate.

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