06 Nov Hip Fractures
The hip is a ball and socket joint, which connects the lower limb to the pelvis. The socket side is actually part of the bony pelvis (called the acetabulum), so the vast majority of patients with a broken hip have a broken femur, near the top of the bone, through the part called the femoral neck.
A broken hip is a very common injury, and usually results from a fall. Most of these injuries typically occur in elderly patients, often from a simple fall at home. They occasionally happen in younger patients, when more force is required to cause the injury – this is typically something like a fall from a push bike, a motor vehicle accident.
A broken hip is extremely painful, and patients are usually unable to get up off the floor. Any movement of the leg causes severe pain, and generally patients are transported by ambulance to hospital, after pain-killing injections. The leg is often seen to be shortened, and rotated externally.
To diagnose a broken hip, your doctor will ask you questions about how you injured the area, and will examine your leg. Simple x-rays will almost always show this fracture, but at times a CT scan may help as well.
As these injuries typically occur in elderly patients, the medical management of the patient becomes as important as the fracture management – for this reason all of these patients are managed jointly between an orthopaedic surgeon and a medical physician. Investigations will be performed to look for reasons for the fall (eg vertigo, blood pressure problems, anaemia) as well as to assess bone quality. The importance of prevention of further fractures cannot be over-stated, and this process starts on the day of injury. Since almost all of these injuries require surgery, the physician will also make sure that the patient is medically as fit as they can be to undergo surgery, and monitor for post-operative complications such as chest or urinary infections, or DVT.
This is a very painful fracture, which results in the patient being bed-bound without surgery. Although some of the fractures would heal if left alone, it would mean several weeks in bed, which is neither safe nor practical for elderly patients. All of these fractures therefore require surgical management, unless it is impossible for medical reasons.
There is now good evidence from many centres around the world that early surgery leads to a better chance of both survival and return to walking for this patient group. Ideally surgery should be undertaken as soon as is safely possible, but certainly within 36 hours of injury. The biggest reason for delayed surgery is medical comorbidities that require time to make surgery safe. An example of this is a patient who is on blood thinners that cannot be reversed, and time is needed for the drug to be cleared from the blood.
The type of surgery depends on the type of fracture, and broadly speaking there are 2 typical places the bone can break.
If the Femur breaks inside the hip joint, then the joint needs to be replaced. This is most commonly done by replacing just the ball (a hemiarthroplasty procedure, or half a hip replacement), but for some patients who are fitter and normally more mobile, a total hip replacement may be a better option.
The left hip is broken, inside the hip joint (Arrow). Compare that area to the xray of the other hip.
A Hemiarthroplasty, or half a hip replacement has been done, to replace the broken part of the bone.
If the femur breaks outside of the hip joint, then the joint can be preserved and the fracture fixed with metal implants – most commonly with a rod that passes down the middle of the bone.
The left hip is broken, but away from the hip joint,
A rod has been placed inside the bone, to hold the fracture whilst it heals.
Rehabilitation / return to function
After any hip fracture operation, the aim is to have the patient out of bed the next day, and walking on that side. The injury is still painful at that stage, and so walking aids such as a frame or crutches may be needed, but early mobility is the best way to avoid complications and facilitate a speedy recovery. Physiotherapy will be heavily involved, and the physician will continue to monitor blood tests and the patients general medical state.
Most patients are in hospital for around 10 days after a broken hip, but after a few days discussions will start – involving the patient, the family and the hospital discharge team – to decide on the best place to discharge to. Sometimes this is back home, but often patients go somewhere else first, such as rehab or respite care.