By Dr Anil Menedal, MS (Orthopaedics)
A hip fracture is a break in the upper quarter of the femur (thigh) bone. The type of surgery used to treat a hip fracture is primarily based on the bones and soft tissues affected or on the level of the fracture.
Hip fractures most commonly occur from a fall or from a direct blow to the side of the hip. Some medical conditions such as osteoporosis, cancer, or stress injuries can weaken the bone and make the hip more susceptible to breaking. In severe cases, it is possible for the hip to break with the patient merely standing on the leg and twisting.
The patient with a hip fracture will have pain over the outer upper thigh or in the groin. There will be significant discomfort with any attempt to flex or rotate the hip.
If the bone is completely broken, the leg may appear to be shorter than the non-injured leg. The patient will often hold the injured leg in a still position with the foot and knee turned outward (external rotation).
The diagnosis of a hip fracture is generally made by an X-ray of the hip and femur.
Hip fractures occur at the upper end of the thigh bone (femur).
In some cases, if the patient falls and complains of hip pain, an incomplete fracture may not be seen on a regular X-ray. In that case, magnetic resonance imaging (MRI) may be recommended. The MRI scan will usually show a hidden fracture.
An MRI may identify a hip fracture, therefore, otherwise missed on a plain X-ray.
If the patient is unable to have an MRI scan because of an associated medical condition, computer tomography (CT) may be obtained instead.
Intracapsular fracture. This fracture occurs at the level of the ‘neck’ of the bone and may have a loss of blood supply to the bone.
Intertrochanteric fracture. This occurs further down the bone and tends to have a better blood supply to the fracture pieces.
Once the diagnosis of the hip fracture has been made, the patient’s overall health and medical condition will be evaluated. In very rare cases, the patient may be so ill that surgery would not be recommended. In these cases, the patient’s overall comfort and level of pain must be weighed against the risks of anaesthesia and surgery.
Most surgeons agree that patients do better if they are operated on fairly quickly. It is, however, important to insure patients’ safety and maximize their overall medical health before surgery. This may mean taking time to do cardiac and other diagnostic studies.
Stable impacted fracture
Certain fractures that have not moved (‘displaced’) may not require surgery. Because there is a risk that they may move later on, they are often fixed.
Patients who might be considered for non-surgical treatment include those who are too ill to undergo any form of anaesthesia and people who were unable to walk before their injury and may have been confined to a bed or a wheelchair.
If patients are confined to bed as part of the management for these fractures, they will need to be closely monitored for complications that can occur from prolonged bed rest. These include infections, bed sores, lung infections, the formation of blood clots, and nutritional wasting.
Anaesthesia for surgery
This could be either general anaesthesia or regional anaesthesia, where the patient is wide awake during surgery.
Appropriate blood tests, chest X-rays, electrocardiograms, and urine samples will be obtained before surgery. Many elderly patients may have undiagnosed infections that could lead to an infection of the hip after surgery.
Complicated cases
In some cases of fracture of the hip, although the fracture is repaired, the blood supply to the ‘ball’ of the femur is impaired.
In the older patient, the chance that the blood supply to the head of the femur is impaired is higher. It is generally felt that for these fractures, patients will do better if some of the components of the hip are replaced. In some cases, this can mean a replacement of the ball, or head of the femur (hemiarthroplasty). In other cases, this can mean the replacement of both the ball and socket, or head of the femur and acetabulum (total hip replacement).
Most intertrochanteric fractures are managed with either a compression hip screw or an intramedullary nail, which also allows for impaction at the fracture site.
The compression hip screw is fixed to the outer side of the bone with bone screws and has a large secondary screw (lag screw) that is placed through the plate into the neck and head of the hip
There are no definitive studies to show that one device is superior to another. The decision as to which to use is based on the surgeon’s preference and experience.
After surgery
Patients may be discharged from the hospital to their home or find that a stay in a rehabilitation facility is necessary to assist them in regaining their ability to walk.
Patients may be encouraged to get out of bed as early as on the day following surgery. The amount of weight that is allowed to be placed on the injured leg will be determined by the surgeon and is generally a function of the type of fracture and type of surgery that has been done.
The physical therapist will work with the patient to help regain strength and the ability to walk. This process may take up to three months.
Occasionally, a blood transfusion may be required after surgery, but long-term antibiotics are generally not necessary.
Most patients will be placed on medicines to thin their blood to reduce the chances of developing blood clots for up to 6 weeks. These medicines may be in the form of pills or injections. Elastic compression stockings or inflatable compression boots may also be used.
During the appointments that take place after surgery, the surgeon may need to check the wound, remove sutures, follow the healing process using X-rays, and prescribe additional physical therapy, if necessary.
The good news is that following hip fracture surgery, most patients will regain much, if not all, of the mobility and independence they had before the injury.
