The disability adjusted life-years (DALYs) lost as a result of hip fractures ranks in the top 10 of all-cause disability globally. The number of hip fractures is likely to exceed 500,000 annually in the United States and 88,000 in Canada over the next 40 years. All these fractures need operative treatment, some of them more than once, so they place a major economic burden on society. For the patient, impaired walking ability and leg shortening are common and may influence quality of life.
A Google search for “hip fractures” returns over 2,000,000 hits. The variable quality and lack of filtering mandates need for evidence-based guidelines for management.
Scary facts about hip fractures.
This data has been taken from various studies worldwide.
- Almost all of the hip fractures require surgical treatment.
- 30% of surgically treated hip fractures require revision surgery.
- 25% of patients after hip fracture surgery may need dedicated person in home for their care.
- 5-10 % chance that other hip may also fracture within 3 years of first hip fracture.
- Overall risk of having fracture is higher in women about 75% more than men.
- Men are at higher risk of dying than women after such fractures.
- The mortality (risk of death) is around 30% after one year of after hip fracture.
- The mortality rate after thirty days is 10%.
- The combined lifetime risk for hip, forearm and vertebral fractures is around 40%, which is same as the risk for cardiovascular disease.
- The cause of mortality and morbidity following a hip fracture is often due to clots in legs which can sometimes go to lungs, pneumonia, infection in chest, urine and bed sores.
- The majority of patients who sustain a hip fracture will require prolonged specialized care, such as a long-term nursing or rehabilitation facility.
For all of these reasons, one of the most important things that can be done is to take steps to prevent a hip fracture.
People reading this article may feel it’s too late, but that is not true! Whether you have sustained a broken hip, or your loved one fractured their hip, preventing future fractures is especially important
The management of hip fracture in elderly is challenging for health care professionals and the family. The standard of care is evidence based worldwide. We in India still don’t have any hip fracture care program me which guides clinicians about the best care for such patients. Lot of
money is spent on research, fall prevention and care of such patient worldwide. It is well accepted the importance of early surgery and coordinating care through a multidisciplinary hip fracture program me to help people recover faster and regain their mobility. In addition, we want to focus on management of osteoporosis and fall prevention.
Guidelines: The following guidance is based on the best available evidence
All patients presenting to hospital should have immediate pain relief and reassessed at 30 minutes after pain relief or every hourly until settled in the ward. Since these patients will be going for investigations, sufficient pain relief to allow movements necessary for investigations should be given. Safer to give paracetamol unless contraindicated.
We in our hospital in addition to above also offer nerve blocks by trained pain specialists. This makes our patient comfortable despite the fracture and allows them to be nursed better. It also decreases the need for pain medications and hence lesser complications like gastritis and pressure sores.
If patient has history of fall and x-rays are not showing any fracture but clinically suspicion is high, it is recommended that patients should be offered magnetic resonance imaging (MRI). If MRI is not available within 24 hours or is contraindicated, consider computed tomography (CT).
Up to 10 % patients can have occult fracture. Sometimes it is difficult to convince the family but further moralities like CT and MRI are extremely useful in such cases.
We in W Pratiksha hospital offer a formal assessment by geriatrician and have a hip fracture care programme where patients are rapidly optimized for fitness of surgery and set goals before the surgery for early mobilization and return to pre-injury level. The team consists of senior orthopedic surgeon, pain specialist, ortho-geriatricians, physiotherapist and occupational therapists. The multidisciplinary review continues till the discharge and lot of focus is targeted towards falls prevention and improved bone health. In addition, patients and those caring for them are also educated about after care.
If hip fracture complicates or precipitate terminal illness, the multidisciplinary team considers the role of surgery as palliative to minimize the pain and considers patient’s wishes about their end of life care.
Delay to surgery increases mortality and morbidity after hip fracture due to associated medical complications, i.e., thromboembolic events or cardiopulmonary complications. We recommend that operation is not delayed more than 48 hours from admission to hospital. Perform surgery on the day of, or the day after, admission. These patients take priority over the others surgeries listed. Identify and treat correctable comorbidities immediately so that surgery is not delayed by conditions which are correctable like low hemoglobin, electrolyte imbalance, dehydration, diabetes control, correctable heart conditions and acute chest problems must be corrected before surgery.
The risk of mortality (at 30 days and 1 year) is decreased in patients with hip fracture who undergo early (<48 hours) surgery compared to delayed.
Whatever surgical procedure is undertaken we aim to allow full weight bearing in the immediate post-operative period. Some people have half hip replacement of full hip replacement depending upon the age and activity level. This procedure is indicated for displaced fracture neck of femur.
People who were walking independently out of doors with no more than use of stick and are mentally alert and have no cognitive impairment are best suited for total hip replacement surgery. Those who have intertrochanteric fracture neck of femur should have sliding hip screw or nailing.
All patients should be ideally made to walk on the day of surgery unless medical or surgical reasons. They should have physiotherapy for regular chest and upper body also. We should aim to make them walk at least one a day.
Information for patient and care
All patients (their care and/or family) should be given verbal and printed information about treatment and care including their diagnosis, plan of management, anesthesia choice and surgical procedures. Patients and family should be well informed about the possible complications, rehabilitation, fall prevention and long-term outcomes of treatment.