Fractures of the Hip

Causes
Many hip fractures occur from injures such as a fall. It is possible the fall may have happened as a result of fracturing the hip. The hip actually breaks first, causing the person to fall.

Osteoporosis is one condition that causes hip fractures. This disease can weaken the neck of the femur causing the bone to break suddenly. An uncertain step may result in a twist to the hip joint placing too much stress across the neck of the femur. The femoral neck breaks, and the patient falls to the ground. It happens so quickly it is unclear to the patient whether the fall or the break occurred first.

Symptoms
A hip fracture, like any broken bone, causes pain and makes it difficult to put weight on the leg. When a hip fracture occurs in an elderly person who lives alone, it may be hours before anyone finds the patient. The patient sometimes cannot get to the phone to alert anyone. This is the first life-threatening situation. This situation can result in dehydration, or if the fracture occurs outside, the patient may develop hypothermia. Both of these conditions can be deadly.

Diagnosis

History and Physical Examination: The diagnosis of a hip fracture usually occurs in the emergency room. The diagnosis begins with a history and physical examination. It is important that the doctor be advised of any other medical problems the patient has so treatment of the hip fracture can be planned. Most of the information from the history and physical examination will be used to try to evaluate the overall physical condition of the patient. Tests such as chest X-rays, blood work, and electrocardiograms may be ordered to assess the patient's overall condition.  

X-rays: X-rays are typically used to determine if a hip fracture has occurred and if so, what type of fracture it is. The orthopedic surgeon will use the X-rays to determine if a surgical procedure will be necessary and to plan what type of procedure to suggest.

MRI Scan: In a few cases, X-rays may not show the fracture. If the hip continues to hurt and the doctor is suspicious that a hip fracture is present, an MRI (magnetic resonance imaging) scan may be suggested. The MRI scanner uses magnetic waves rather than radiation to take multiple pictures of the hip bones. The MRI machine is very sensitive and can show fractures that do not show up on regular X-rays.

This test is done to be certain there is no fracture before allowing the patient to put weight on the leg. Walking on a fractured hip may cause the two sides of the fracture to displace, or move apart, so that they no longer line up correctly. This is much harder to treat than a fracture that has not been displaced. A displaced fracture also increases the risk of damaging the blood supply to the femoral head.

Treatment
Hip fractures in the elderly usually require surgery.  If possible, the surgery is done within twenty-four hours of admission to the hospital. Rarely is a fracture considered stable, meaning it will not displace if the patient is allowed to sit in a chair. But if the fracture seems stable, the patient may be treated without surgery if the doctor feels the patient will be able to get out of bed within several days.

Most hip fractures would actually heal without surgery, but the problem is the patient would be in bed for eight to twelve weeks. Placing an elderly person in bed for this period of time has a far greater risk of creating serious complications than the surgery to fix a broken hip. This is the reason surgery is recommended to nearly all patients with fractured hips.

The goal of any hip fracture surgery is to facilitate early mobilisation, allowing the patient to get out of bed as soon as possible. The choice of operation depends on the exact diagnosis of the type of hip fracture, the age of the patient, their fitness for surgery and rehabilitation, and their walking potential. The method of treatment will usually be one of the following: fixation with metal screws or a metal plate and screws, or with replacement of the displaced femoral head with a joint prosthesis.(Hemiarthroplasty or Total Hip Arthroplasty)

Complications
The complications that can develop after a hip fracture are what make the injury a life-threatening problem. Some complications can result from surgery, but many can occur whether the fracture is treated with surgery or not. 

Most of the complications that occur after a hip fracture result from having to put an elderly patient on bed rest. In general, this seems to make all the medical problems the patient has worse. Some of the more common problems that a hip fracture can increase the likelihood of include:

Getting the patient out of bed and moving can reduce the risk of developing complications. An operation to stabilise the fracture and get the patient out of bed more quickly will  reduce the overall risk of developing these complications. Complications may still occur after surgery. But, they are far easier to treat if the patient can be mobilised.

Rehabilitation
A physical therapist usually works with patients in the hospital soon after surgery. You'll be assisted from your bed to a chair several times each day. You'll begin walking with a walker or crutches, practice accessing the bathroom, and start doing exercises to tone the muscles around the hip and thigh and to prevent the formation of blood clots.

The amount of weight that can be placed on the operated leg depends on the type of surgery performed. Most patients are able to start weight bearing right away after surgery. Depending on the severity of the fracture, patients may only be able to place partial weight down right away.

Patients who require hemiarthroplasty or Total arthroplasty  follow a different treatment plan. This surgery is more involved and requires the doctor to open up the hip joint during surgery. This puts the hip at some risk for dislocation after surgery. To prevent hip dislocation after surgery, patients follow strict guidelines about which hip positions they must avoid, called "hip precautions." Patients follow these precautions at all times for at least six weeks after surgery, until the soft tissues gain enough strength to keep the joint from dislocating. Patients may be instructed to use their walker or crutches to limit the amount of weight they place on the operated leg.

After you return home from the hospital, your doctor may have you work with a physical therapist for two to four in-home visits. This is to ensure you are safe in and about the home and getting in and out of a car. Your therapist will make recommendations about your safety, review your hip precautions, and make sure you are placing a safe amount of weight on your foot when standing or walking.

Additional visits to outpatient physical therapy may be needed for patients who have problems walking or who need to get back to physically heavy work or activities.

Dislocation
Dislocation of a joint occurs if a hemiarthroplasty or total hip arthroplasty has been done to replace the fractured femoral head, and the ball dislocates from the socket. The risk is greatest in the first six weeks after operation, until the ligaments and capsule of the joint have healed soundly, making the joint stable. Post-operative confusion can increase the dislocation risk. The hip must be reduced with an anaesthetic, and the recovery from the injury is considerably slowed.