How to treat hip fractures?

At a Glance:

What is a hip fracture?

Fracture is defined as a break in the continuity of a bone. The break may either be severe as seen in accidents or maybe hairline which is difficult to diagnose. Hip fracture is the condition in which the bone of the hip joint gets fractured. The bone that is involved in the hip fracture is the thigh bone (femur) that is attached to the pelvic bone through a joint shaped like a ball and socket. The hip fracture occurs commonly in elderly patients due to multiple factors such as the risk of falling due to poor vision or loss of ability to balance or an underlying bone disorder such as osteoporosis. One of the common sites of hip fracture is the neck of the femur bone. This type of hip fracture is termed as femoral neck fracture. This is one of the most complicated hip fractures due to the reason that the blood supply in the upper part of the femur gets obliterated due to the fracture. Femoral neck fractures take considerable time to heal completely.

What are the types of hip fractures?

Hip fractures are classified according to their anatomical location, there are two most common types of hip fractures:

• Intracapsular Fractures: The break occurs below the ball or in the neck of the femur, within the capsule of the joint.
• Extracapsular Fractures: The break occurs outside the capsule of the joint. These are further classified into intertrochanteric, trochanteric, and subtrochanteric fractures depending on their location on the femur bone.

What are the signs & symptoms of a hip fracture?

The hip joint is one of the most important joints in the human body. Any abnormality of this joint such as hip fracture severely affects the quality of life. Some of the symptoms associated with hip fracture are: 

• Swelling and inflammation at the site of fracture.
• A person with a hip fracture is unable to stand, walk or run and any attempt to do these functions significantly increases the severity of pain.
• Hip fracture causes the destruction of healthy bone cells and the activation of pain receptors. A person with hip fracture experiences the pain of varying severity.
• Short leg appearance: The affected leg would appear shorter as compared to the normal leg.

Some common causes of hip pain in addition to fracture include:

• Arthritis
• Sprain
• Strain
• Infection
• Avascular necrosis

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What are the causes of hip fracture?

Some of the common causes of hip fracture are:

Slips and Falls: These are the most common reasons for hip fracture, especially in the elderly. The following factors during a fall increase the chances of hip fracture :

• The point of  impact is in close proximity with the hip joint
• The inability of the soft tissues to absorb the impact
• The energy of the fall is greater than the strength of the femur
• Failure of the protective responses of the body against the fall

Accident: Hip fracture may also be caused due to trauma during incidents like road traffic accidents.

Obesity: Femur or thigh bone bears the weight of the body. The pelvic bone along with the femur forms the hip joint. An increase in the stress on the femur due to increased weight increases its susceptibility to fracture even at a lower degree of impact.

Underlying medical conditions such as osteoporosis and bone cancer make the bone fragile and increase the risk for hip fracture in such persons.

Vigorous and repetitive physical activities: Vigorous and high-intensity activities, especially in those at high-risk may lead to the occurrence of stress fracture or a hairline fracture of the hip.

What are the risk factors of hip fracture?

Some of the factors that increase the risk for hip fracture are:

Age: The risk for hip fracture increases exponentially with advancing age. This is because as the age increases, muscle mass and bone density reduce significantly. Further, abnormal balance and poor vision also increase the risk for hip fracture at old age.

Genetics: People with a family history of osteoporosis and hip fractures are at higher risk. Further, those with a thin build are also at increased risk for hip fracture.

Underlying medical condition: Various diseases such as osteoporosis and cancers of the bone also increase the risk as these conditions make the bone weak and easily breakable.

Medications: Certain medications like anti-cancer drugs, steroids, etc increase the likelihood of fractures due to their bone weakening side-effects.

Unhealthy Lifestyle: Poor lifestyle such as smoking, excessive alcohol consumption, and physical inactivity also increases the risk for hip fracture.

Poor nutrition: Healthy bone requires an optimum supply of nutrients such as calcium, potassium, and magnesium. Dietary deficiency of these minerals makes the bone weak and causes an increased risk for hip fracture.

Gender: Women are at higher risk of getting hip fracture as compared to men.

How to diagnose hip fracture?

The orthopaedic surgeon may diagnose hip fracture based on the person’s history, physical evaluation and imaging tests.

Physical evaluation: The doctor assesses the site of injury for the severity of pain, swelling, and restriction of movement. If a hip fracture is suspected, further imaging tests may be advised to the person.

Imaging tests: The X-ray of the pelvis is essential in diagnosing hip fracture in most cases. 

MRI: In case the X-ray is inconclusive and the hip fracture is still suspected, an MRI can be performed. It is more useful in cases of hairline fractures which may not be very evident in plain X-rays.

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How to treat hip fracture (broken hip treatment)?

Surgery is the most definitive option for broken hip treatment. It is done with the following goals:

• Decrease pain
• Prevent complications
• Stabilize the fracture to prevent further damage
• Increase mobility

The choice of surgery depends upon the underlying factors such as:

• Age of the person
• Underlying medical conditions such as osteoporosis, diabetes, arthritis and mental strength of the person for taking part in the rehabilitation program and physical activity level.

Types of surgery:

Repair or fixation of fracture :

• In all cases of extracapsular fracture, fixation of the fracture is done by keeping it in place with multiple screws or compression plate and screws (DHS). Proximal femoral nailing (PFN) is another well-accepted management of extracapsular fracture.
• Fixation is done for intracapsular fractures using cannulated screws or DHS in cases where:
  • The person is 60-65 years or below
  • The fracture is fresh or of recent occurrence

Hip Replacement:

Hip replacement surgery is usually recommended in the following cases:

• Older people with hip fracture i.e >65 years
• The fracture is old

Hip replacement may be of two types

• Partial hip replacement
• Total hip replacement

If a person is suffering from hip and groin pain due to fracture of the hip, pain-relieving medications are prescribed before and after the surgery.

What are the types of hip joint replacement or hip arthroplasty? What is total hip replacement?

Hip joint replacement can be done in different ways depending on the severity of the fracture and the underlying medical condition of the patient.

There are two main types of hip replacement operation, partial and complete hip replacement, but a number of different components and surgical techniques may be used.

• Hemiarthroplasty or partial hip replacement: In a partial hip replacement, only the damaged part of the femur is replaced with a prosthesis i.e the ball is replaced, and the cup is left intact. Partial hip replacement is suitable for patients who are older than 65 years but are not much active.
• Complete or total hip replacement: In the complete hip replacement surgery, both the part of the femur as well as the cavity of the pelvic bone gets replaced, i.e both the ball and the cup within the joint are replaced. Total hip replacement is suitable for patients who are older than 65 years but are living a highly active life.

The replacement parts can be metal, plastic or ceramic and can be used in different combinations:

• Metal-on-plastic prosthesis constitutes a metal ball with a plastic socket is one of the most frequently used combinations.
• Ceramic-on-plastic prosthesis constitutes a ceramic ball with a plastic socket or ceramic-on-ceramic i.e where both parts are ceramic is used often in younger, more active patients.
• Metal-on-metal prosthesis constituting a metal ball with a metal socket, instead of replacing the head of the femur with a prosthesis, a small metal cap is fitted on the head of the femur and the socket is also resurfaced to get it adapted to the metal cap. It is frequently used in younger, more active patients

What are the complications of hip fracture?

Complications of hip fracture can be serious, life-threatening and sometimes fatal, especially in the elderly. Some of the complications related to hip fracture are:

Blood clots: The patient suffering from hip fracture has a high risk of developing blood clot such as Deep Vein Thrombosis (DVT). The clot occurs in the vein of the legs and may travel to the other parts such as lungs resulting in a fatal condition.

Bed Sores: During hip fracture treatment and recovery, the patient must stay on the bed for a considerable period and this may lead to pressure ulcers or bed sores. This is also because as the patient moves, he experiences a lot of pain.

Pneumonia: Pneumonia is a serious complication occurring in patients with hip repair surgery. This increases the recovery time and mortality in elderly patients.

Complications after hip fracture surgery: Sometimes after fixation, the fractures may not heal completely resulting in nonunion and at times the fractures do not heal as expected resulting in malunion. Apart from these complications, patient may experience cardiac complications in the intraoperative or postoperative period. However, the occurrence of these complications is very rare.

How to prevent hip injuries?

Injuries to the hip or hip fractures can be prevented by managing the controllable risk factors and certain lifestyle modifications that include:

• Being physically active and engaging in physical exercises.
• Avoid smoking and excessive alcohol drinking.
• Monitor level of calcium and Vitamin D and if found insufficient, take supplements as prescribed by the doctor.
• Get a regular check-up for bone mineral density and osteoporosis.
• Ensure adequate exposure to the sun: This will help in increasing the concentration of Vitamin D naturally.
• Have the vision check regularly. This will help in preventing sudden falls.
• Keep the bathroom clean and dry. Wet bathrooms are often a cause of falls resulting in fractures.
• Wear personal protective gear like a slip-resistant slipper.
• For imbalance in walking, use walking assistance like cane or walker to prevent falls.

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How long does it take to recover and rehabilitate from a hip injury?

The most common treatment for repairing a broken hip is surgery. The recovery from the hip surgery depends upon several factors such as the type of hip surgery i.e. whether it is an internal fixation, partial hip replacement or complete hip replacement, the age of the patient and an underlying medical condition such as arthritis or osteoporosis.

Hip replacement surgery: The day after surgery, the physiotherapist would make the person move with assistance. Two to three days after surgery, the movement is increased with the help of crutches or walker. If the person has moved well without any pain or slight pain, discharge from the hospital may be done after 5-6 days of surgery depending on the medical condition. Complete recovery usually takes around 4-6 months but most of the routine activities can be performed after 3-6 weeks of surgery.

Fixation: Patients treated with fixation by DHS or PFN will have to wait until the fracture heals before they can bear weight on the affected side.

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Hip fracture is one of the most serious fractures in the elderly. Hip fracture occurs when the femur or the thigh bone breaks due to a fall or accident. Hip fracture is diagnosed through physical evaluation and imaging techniques. Hip surgery is the common treatment for hip fractures and the complications increases with complexity in hip surgery. A person may be able to perform routine activities within 20-35 days of surgery and the complete recovery may take around 4-6 months. 

References:

• Minimally Invasive Total Hip Replacement. Available at: https://orthoinfo.aaos.org/en/treatment/minimally-invasive-total-hip-replacement/.Accessed on March 31, 2019
• Hip fracture. Available at: https://www.mayoclinic.org/diseases-conditions/hip-fracture/diagnosis-treatment/drc-20373472. Accessed on March 31, 2019
• 5 Hip Symptoms You Should Not Ignore. Available at: https://www.joionline.net/trending/content/5-hip-symptoms-you-should-not-ignore. Accessed on March 31, 2019
• Total Hip Replacement. Available at: https://orthoinfo.aaos.org/en/treatment/total-hip-replacement/. Accessed on March 31, 2019
• Hip Fractures. Available at: https://orthoinfo.aaos.org/en/diseases–conditions/hip-fractures. Accessed on March 31, 2019

About Author –

Dr. Shashi Kanth G, Sr. Consultant Orthopedic Surgeon, Yashoda Hospitals, Hyderabad
He is specialized in arthroscopy, sports medicine, and orthopedics. His expertise includes Lower Limb Joint Replacement Surgery, Lower Limb Arthroscopy, Sports Injuries, Foot and Ankle Surgery, & Management of Complex Trauma.