Hip fracture: Getting back on your feet

A hip fracture is one of the most dreaded injuries, and for good reason. Quality of life declines significantly, with decreased mobility and independence for up to — or longer than — a year. As many as 25 percent of hip fracture patients require continued home care following hospitalization, and as many as 20 percent die within a year of their hip surgery.

Why are hip fractures so dangerous? According to Colleen Christmas, MD, director of the Hip Fracture and Geriatric Consultation Service at Johns Hopkins, “We don’t really know all the answers to this question yet. We do know that the heartier and more active people were before they broke a hip, the more likely they are to recover.”

A hip fracture often results in a significant decline in mobility, and unfortunately, not everyone is able to regain a full range of function even with rehabilitation. This decline in mobility makes the now-disabled person dependent on others and more prone to complications such as pneumonia.

Another bad news is that the number of hip fractures is expected to increase significantly. Hip fracture risk increases after age 65 in both sexes, with women sustaining about three-fourths of all hip fractures. “The major reason for the projected increase is that people are living longer and have more comorbidities (other medical conditions) that may contribute to fracture risk,” says Elton Strauss, MD, chief of orthopedic trauma and adult reconstructive surgery at Mount Sinai Hospital in New York City. “In the future, we expect to see more traumatic fractures in the baby boomer generation from activities such as golf, tennis, and other sports, that increase their risk of falls and fractures.

The good news is, you can lower your chance of hip fracture with exercise, nutrition, and simple in-home modifications. And if you do fracture a hip, surgical advances allow for less invasive procedures with shorter recovery times.

Why It Happens

The hip joint has great strength and stability. As the largest ball-and-socket joint in your body, it’s designed to bear weight and allow for a wide range of motion. The hip joint includes the femoral head — that’s the ball-like head of the upper leg’s bone (femur). The femoral head fits into the hip socket called the acetabulum.

With age though, bone is gradually lost, becoming less strong. Women are especially prone to accelerated bone loss after menopause and are more likely to develop the bone-thinning condition known as osteoporosis, which increases the risk of a fracture. The femur, which is where hip fractures occur, is an area where bone loss tends to be greatest.

In older adults, hip fracture is typically the result of trauma, such as a fall. Signs and symptoms may include:

• Severe pain in the hip or groin area

• An inability to put weight on the leg

• Stiffness, bruising and swelling in and around the hip area

• A shortened leg on the injured side, which may be outwardly rotated

Rarely, some people with hip fracture experience only vague pain, which may occur in the buttocks, knees, thighs, groin area or back, and they may still be able to walk.

Surgical Options

Hip fractures can vary in location and severity but usually occur in one or two locations on the femur:

•The femoral neck, which is the area of the upper portion of the leg bone just below the ball-like head of the femur.

•The intertrochanteric region, which is the upper portion of the femur that juts outward between the femoral neck and shaft.

Surgical treatment is almost always the best method to repair a hip fracture (see illustration). The type of procedure done depends upon where the fracture occurred. If the break is on the femoral neck, one of the following approaches is typically chosen.

• Placement of metal screws. If the bone is properly aligned after the break, metal screws may be inserted into the bone to hold it together as it heals. This is called internal fixation.

• Replacement of a portion of the femur. If the break in the bone isn’t aligned or if the bone is damaged, the top portion of the femur may be removed and replaced with a metal prosthesis. This is called a hemiarthoplasty.

• Total hip replacement (arthroplasty). This procedure involves replacing the upper portion of the femur and the socket in your pelvic bone with an artificial joint (prosthesis). This is generally a good option if the hip joint has been damaged by osteoarthritis or a previous injury.

If the hip fracture occurs in the intertrochanteric region, a compression hip screw may be used to repair the break. The screw is inserted across the femur and then attached to a plate that runs down alongside the femur. This keeps the bone stable as it heals, allowing the bone to gradually compress together as weight bearing on the joint is increased over time.

Road To Recovery

“Really, only the patient can do the hard work of recovery,” states Dr. Christmas. And rehabilitation is the key. “Patients need to work as hard as possible with their rehab doctor and physical therapist,” she says.

Rehabilitation starts as soon as possible after surgery. Physical therapists help with small tasks such as sitting, standing or walking to the bathroom, while still in the hospital. Therapy progresses to muscle strengthening exercises and learning how to use assistive devices like canes and walkers.

The majority of people treated for hip fracture require a few weeks of recovery care. You may need to keep weight off the repaired hip for as long as six to 12 weeks. Some types of hip fractures may allow weight-bearing activity earlier on, depending on bone health. Different people recover at different rates, but most people will stay in the hospital for about one to two weeks, followed by several months of physical therapy. In-patient hospitalization is especially likely if you have other medical conditions, such as arthritis or cardiopulmonary disease.

Reduce Your Risk

There are steps you can take to help reduce the risk of hip fracture:

• Feed your bones.  Make a point to get adequate calcium and vitamin D in your diet or through supplements. Healthy men and women age 50 and older should consume at least 1,200 mg of calcium and a minimum of 400 IU of vitamin D everyday. A glass of milk contains about 300 mg of calcium. Postmenopausal women and men over 70 should aim for at least 600 IU of vitamin D daily. Vitamin D improves bone health by helping calcium absorption.

• Diagnose and treat bone thinning. If your bone density is low (osteopenia) or osteoporosis is present, work with your doctor to determine what treatment might be best for you. Several prescription drugs can help prevent bone loss, and some may even increase bone density over time. The most commonly used are bisphosphonates such as ibandronate (Bonviva), alendronate (Fosamax), and risedronate (Actonel). Those can reduce fracture risk by about 50 percent.

•Get regular weight-bearing activity. Whether by regular walking program or workouts at the gym, challenge your muscles daily with physical activity. Physical activity also improves overall balance and strength, reducing risks of falls.

•You can also support bone health by avoiding excessive alcohol or caffeine use and not smoking. Some medications such as proton pump inhibitors (PPIs), selective serotonin reuptake inhibitors (SSRIs), oral corticosteroids, benzodiazepines, and other sedatives  may raise your risk of a hip fracture. If you’re taking one of these medications, talk with your doctor.

•Lastly, a positive attitude is an important factor in the recovery process. The more motivated the patient, the faster she will be back on her feet.