The weather outside is frightful, but don’t think that snow and ice make winter the only time of year when hip fractures occur. As baby boomers age, the elderly population increases worldwide and so does the number of hip fractures.
I recently had the opportunity to speak with Dr. Scot Brown from the Rothman Orthopaedic Institute on “Your Radio Doctor,” a medical talk show that airs every Sunday morning at 10 a.m. on Talk Radio 1210 WPHT. We discussed the risks, management, and prevention of this common injury.
Q: Dr Brown, how common are hip fractures?
The major risk factors are osteoporosis and falls, both of which increase with age. With osteoporosis there is decrease in bone density and strength causing bones to become ‘brittle.’ This is more common in women, making their lifetime risk 17.5% vs. a 6% risk in men. It is thought that at least one in five older adults fall each year. In younger patients, hip fractures are more commonly a result of a motor vehicle accident or other traumatic injury. In my practice, I also treat patients who have fractures from cancer. These are called pathologic fractures.
Q: There is a common misconception that a fracture is not a broken bone. Can you explain?
A fracture is a broken bone. Some people think a fracture is a less severe injury or a ‘bruise.’ Fracture and broken bone are the same problem.
Q: What factors put a patient at risk?
- Elderly patients experience loss of balance and a decrease in activity and exercise leads to loss of muscle strength — making it easier to fall. Decrease in mentation also increases risk.
- Cancer that begins in a bone or spreads from other cancers to the bone.
- Medications prescribed to promote bone health can sometimes have the unintended side effect of causing bone loss, especially if taken too long. Talk to your doctor about the benefits and risks.
- Cardiovascular disease, diabetes, and an overactive thyroid
- Malnutrition
Q: How do you know you have a broken hip?
Symptoms can include severe pain in the groin or outside of the thigh, but the most important feature is the inability to walk. Also, the leg on the affected side may seem shorter than the opposite leg and it may be turned in an outward direction. In addition, if the Xray is negative but you have persistent pain, you should follow-up with an orthopaedic surgeon as soon as possible. You may need an MRI to find a subtle fracture. And before you leave the emergency department, request an assistive device (walker, cane).
Q: It is very important that you not go to urgent care center. Call an ambulance and go to an Emergency Department. Why?
Urgent care centers are important for patient access, however, if the pain is bad enough that you can’t walk, you should go to the hospital.
First, we have to determine what caused the fall. Was it a simple trip? Or did the patient ‘faint’ because of a stroke, heart attack, or abnormal heart rhythm? We also have to check for other injuries — head trauma; other fractures to the wrists, arms, ribs, and back.
If the patient does have a fracture, the goal is to operate within 24 hours. To avoid delay, the emergency staff can assess the patient for other medical problems such as diabetes, high blood pressure, heart or kidney disease (so they can maximize the safety of the surgery). Is the patient taking a blood thinner? We would need to give medication to help the blood clot normally during the surgery.
Q: How often does a hip fracture lead to surgery?
Most of the time, surgery is the preferred treatment. Some of the patients undergo a fixation or repair using screws and plates. About 1/3 are treated with a total hip replacement. The nature of the fracture and its likelihood of healing determine the appropriate surgery. Fractures that will heal reliably are usually fixed, whereas fractures less likely to heal are often replaced.
Some might ask if a patient is too old or frail for surgery. If a patient is bed-bound, we can still do a fixation (repair) to stabilize the hip. In this way, it decreases the patient’s pain, especially when turning them to be bathed or transferring them to a wheel chair or commode.
Q: Why is it important to operate within 48 hours?
- Delay in surgery allows for prolonged best rest prior to surgery. This can cause:
- A greater need for pain medications which can cause more confusion. Confusion can lead to aspiration with pneumonia and increase the risk for another fall.
- Increase in other complications — urinary tract infections, phlebitis (clots in veins), and skin ulcerations.
- Large studies show avoiding delay beyond 72 hours decreases the risk for complications and death.
Q: How is a patient’s pain controlled?
At Rothman, we work closely with the anesthesia doctors. We have developed a hip fracture “pathway” that often includes a nerve block prior to surgery.
We offer multi-modal pain control, which incorporates several different medications such as Tylenol, NSAID’s (non-steroidal anti-inflammatory drugs), opioids (if needed), and other techniques that reduce the need for opioids and decrease the possibility of subsequent opioid dependence.
It’s also important to note that elderly patients are more sensitive to opioid effects. They are more likely to develop confusion, which can also increase their stay in the hospital.
Q: What happens after surgery?
- Hip fracture is a sign of fragility. All patients are evaluated for osteoporosis.
- Blood thinner — due to the high risk of clots after the surgery.
- Follow blood count — patients can lose a good deal of blood from the fall and from the surgery.
Q: What are some good preventive measures?
- Secure any loose rugs in your home.
- Clear the path from your bedroom to the bathroom for those trips during the night when lights are dim.
- Put a grab bar in the shower and consider adding railings in the house.
- Always hold the railing when using the stairs.
- Wear proper shoes — not slippers or slippery leather soles.
- Be alert — the first step out the door down the driveway for the mail/newspaper, especially with black ice.
- A healthy diet, avoiding smoking, minimizing alcohol intake, and regular exercise.
- There is no stigma attached to using a cane or a walker. Using the appropriate walking aid to avoid a fall is much better than dealing with an injury and surgery!
Q: How has the pandemic affected care of hip fractures?
We have seen patients delay seeking care for hip fractures. We have also seen that delay in seeking care for severe joint pain and for treatment of bone and soft tissue tumors. This may lead to the condition worsening and the patient needing additional or more complicated treatment. Rothman Orthopaedic Institute is taking every measure to ensure safe treatment for our patients and providing telehealth visits when appropriate.
A special thank you to Dr. Scot A. Brown of the Rothman Orthopaedic Institute for sharing this valuable information. For more information, visit rothmanortho.com.
Some say “We come into the world through the pelvis and exit through the hip!” Follow these steps for prevention.
Tune in to “Your Radio Doctor” on Talk Radio 1210 WPHT every Sunday morning at 10 a.m. Each week, Dr. Ritchie interviews guests, including physicians from all specialties, researchers, and other leaders in the medical community. She takes on topics like heart disease, colon cancer, neonatal care and many others.