Hip fractures: Prevention, treatment, and rehabilitation

One of the biggest fears of many older adults is sustaining a hip fracture. And this is with a fair amount of justification. After all, probably tens of thousands of Filipinos (more than 300,000 in the US) fracture a hipbone every year. It’s estimated that up to 20 percent of older adults who sustain a hip fracture die within a year of the injury. Others may experience a loss of mobility and independence.

However, the prognosis actually isn’t all that bad. This is especially true the better your health and the more mobile you are at the time of the injury. The surgical procedures used to fix most hip fractures are usually very effective. Early rehabilitation is important and, for most people, the goal is to be on their feet  with help, within a day or two of the surgery. Substantial recovery is common. And during the recovery process, it’s important to take steps to prevent another hip fracture in the future.

The hip joint

The hip is the largest ball-and-socket joint in the body and has great strength and stability. The “socket” of the joint is part of the pelvis, and the “ball” of the joint is the top end of the thigh bone or femur. The two most common types of hip fractures are the femoral neck fracture and the intertrochanteric fracture (See Fig. 1 for illustration of hip fractures).

Older adults are at risk of hip fractures for two main reasons:

• With age, bone can gradually become weaker due to the bone-thinning process of osteoporosis. Women are especially susceptible to accelerated bone thinning after menopause, which is the main reason why about 60 to 75 percent of hip fractures occur in women.

• Balance, agility, and strength often decline with age. Medical issues such as arthritis, pain, vision problems, and dizziness can also be factors in falls.

In older adults, hip fracture is typically the result of mild trauma, such as a fall from a simple, standing position. In more extreme cases when the bone is very weak, fractures can occur with more ordinary stress on the bone such as a misstep off a stair or a twisting motion while standing or even by walking.

Most older adults who fracture a hip experience severe pain in the hip or groin area and may not be able to move their leg, let alone put weight on the leg. Stiffness, swelling, and bruising around the hip area may develop. The injured leg may also be shorter than the uninjured leg and turned outward due to the unbalanced pull of muscles.

Rarely, a hip fracture  particularly a non-traumatic stress-type fracture  causes only vague pain in such areas such as the buttocks, knees, thighs, groin area or back, and you’re still able to walk.

Surgery

Emergency care is required for a hip fracture. It’s usually best to call for emergency medical care, when available, and wait for the emergency personnel to move you safely. An initial evaluation in the emergency room usually involves physical exam, x-ray imaging, and efforts to control pain.

Surgery is almost always the best hip-fracture treatment, and it’s typically better if the surgery is done within 24-48 hours of your fall. Still, your surgeon needs to take time to evaluate your overall health to determine what steps need to be taken to maximize health and safety during surgery. Blood tests, heart tests, and other medical tests may be part of this process. Internal bleeding or other factors may require preparation for blood transfusions before or during surgery.

Figure 2 shows the three most common surgical procedures done for hip fractures, depending on the different characteristics of the fracture, such as location, alignment, stability, presence of significant osteoporosis or osteoarthritis, and others. Not shown are two other types of surgery for hip fractures, which are not commonly done as the three shown in Figure 2. One is a full hip replacement. If the socket of the hip joint is damaged by osteoarthritis or a previous injury, a total hip replacement, where both the socket and the top portion of the femur are replaced, may be the better option. The other procedure is by the use of a supportive, intrabone rod. This is used for fractures that occur or extend below the intertrochanteric area, a supportive rod (intramedullary nail) may be inserted into the narrow canal of the femur and fixed into place with screws. By and large, however, the three methods of treatments for hip fractures illustrated in Figure 2 are the most commonly used.

Rehabilitation

A primary goal of surgical hip fracture repair is to get you back on your feet  with the help of the physiatrist (a medical specialist in Physical Medicine and Rehabilitation) and physical therapist, and supportive equipment. Early movement helps reduce the length of your hospital stay and reduces complications such as blood clots in the legs, pneumonia, and bedsores.

Hospital stay after hip surgery usually lasts about a week. Depending on your condition and the situation at your home  such as how much help your family can provide  you may be able to go straight home. Continued rehabilitation would most likely be needed, initially at home or as an out-patient at the hospital for several weeks.

With rehabilitation, you may get close to your pre-fracture functional level of mobility and independence within three to six months.

Fracture prevention

The following tips can help you prevent a hip fracture:   • Medication for bone thinning. Several prescription drugs can help prevent bone loss or even increase bone density over time, lowering the risk of a second fracture. These include sodium ranelate (Protos), alendronate (Fosavance), risedronate (Actonel), ibandronate (Bonviva), and zolendronic acid (Aclasta and Zometa),  among others.   

• Adequate calcium and vitamin D. The US Institute of Medicine recommends 1,000 milligrams (mg) of calcium for men 51 to 70, and 1,200mg for women 51 and older, and men 71 and older. The Institute recommends that adults up to age 70 get 600 international units (IU) of vitamin D daily and that adults, age 71 and older, get 800IU a day.        • Exercise. Weight-bearing exercises, such as walking, and strength-training exercises, help build bone density. Also balance-training exercises make falls less likely. Tai-chi exercises, for example, have been shown to lessen the chances of falls in older people.

• Trip-proof your home. Remove throw rugs and place electrical cords along walls. Add grab bars where needed and make sure stair railings are sturdy. Try to improve lighting in dim areas.

• Address other factors. An annual eye exam can help keep your vision acute so that you can avoid tripping hazards. Ask your doctor to review your medications to reduce side effects that cause dizziness or drowsiness. Don’t smoke and avoid excessive alcohol consumption, as both are bad for bone health.