Dr Aruna Seneviratne: New York Orthopedic Surgeon NYCsportsmed-english

Hip Fractures

Written and edited by Aruna Seneviratne, M.D.

Hip fractures are common among elderly men and women who fall in their own home. A hip fracture is a break in top portion of your femur bone. It can occur in two locations – the femoral neck and the intertrochanteric area.

Symptoms:
The most common symptoms are pain in the hip. Your leg can turn outward and be shortened. It is nearly impossible for you to weight bear on that leg. You will need to be transported to an emergency room as soon as possible for evaluation and treatment.

Biology: Why does it occur?
Hip fractures in the elderly are usually a result of a simple fall. These are low energy injuries and are the result of weakened bones. This condition is called Osteoporosis. Patients with osteoporosis are at increased risk for fractures with minimal trauma. Some hip fractures are caused by high-energy mechanisms such as motor vehicle accidents. Yet another subset of hip fractures is seen in young patients who are runners – these are stress fractures of the hip. Rarely hip fractures can occur because of a cancerous lesion that has spread to the hip bone thereby weakening it.

Common Diagnostic Techniques:
History: Diagnosing the problem begins with a detailed history that your surgeon will obtain from you.
Physical Exam: A thorough physical examination is then conducted by your surgeon.
X-Rays: Plain radiographs (X-Rays) are the most important diagnostic study that is performed initially. Several views will be obtained to diagnose the condition.
MRI: Your surgeon may obtain additional studies such as an MRI especially if the x-rays do not show a fracture, but your surgeon is suspicious of an occult hip fracture.
Bone Scan: In certain situations a bone scan maybe useful in making the diagnosis.

Treatment:
Non –operative:
Unless the hip fracture is non-displaced and involves a certain area only, nearly all hip fractures require operative treatment. Stress fractures of the hip as seen in young runners maybe amenable to treatment with protected weight bearing with crutches for 6 to 8 weeks.

Operative:
There are four main surgical options for treating hip fractures. Each of them are explained below.

Hip pinning:
This type of surgery is utilized for fractures of the femoral neck that are minimally displaced. 3 large screws are usually placed through a small incision in the side of your thigh. Weight bearing maybe protected for 6 weeks with this type of surgery.

Open Reduction Internal Fixation (ORIF) with a Dynamic Hip Screw (DHS):
This type of surgery is used for the intertrochanteric type of hip fracture. It involves an incision about 8 to 10 inches depending on your anatomy, and placement of a metal plate with screws. Immediate weight bearing as tolerated is usually allowed after surgery.

Intramedullary Nailing with a Trochanteric Fixation Nail (TFN) or similar device:
This type of surgery in used for intertrochanteric fractures and subtrochanteric fractures. The surgery is performed through 2 or 3 small incisions about 2 inches in length. Immediate weight bearing as tolerated is usually allowed after surgery.

Hip Hemiarthroplasty:
This type of surgery is used for femoral neck fractures that are displaced and are not able to be restored to its normal anatomic position. It is similar to Total Hip Replacement surgery (THR) except the socket is not replaced. The ball is placed on a stem that is implanted into the femur and fixed either with cement or without cement to allow biological in-growth of the native bone onto the prosthesis. Immediate weight bearing as tolerated is usually allowed after surgery.



Hip Surgery – the hospital course – what to expect
Most likely you will be admitted to the hospital via the emergency room. Prior to the operation, your medical doctor (internist) and cardiologist (if you have heart problems) will work you up extensively to determine if you can undergo the procedure safely. It is very important to have the surgery within a 48hour period of the injury as complications can arise beyond that time period. Our surgeons work closely with the internists to ensure a timely work up and medical clearance for hip surgery.

Once you have been cleared for surgery, you will undergo the hip surgery that is most suitable for your hip fracture. Surgery usually lasts 1 to 2 hours. You are then transported to the recovery room where blood tests and x-rays of your hip will be performed. You will remain in the recovery room until certain criteria are met for you to be sent to your hospital room. In some cases, the patient is sent to the Intensive Care Unit (ICU) for close monitoring.

The postoperative hospital course
You will be given medication to control the pain and prevent blood clots. Foot pumps will also be placed on your feet to pump blood back to your heart and prevent blood clots. You will be given an incentive spirometer – a breathing incentive device to help expand your lungs. Antibiotics will be administered to prevent infection. Physical therapists will work with you to begin your rehabilitation process immediately. Typically you will get up and take a few steps on the day after surgery. Patients are discharged from the hospital within 3 to 5 days of the operation. Depending on your condition and progress you may be discharged to home or to an inpatient rehabilitation facility. The decision where you will be discharged to will be made by the team comprised of your surgeon, physical therapist, nurse, and case manager/social worker

After Surgery
If you are discharged to home a home health aid, nurse, and a physical therapist will be made available to enable you to recover. The nurse will usually remove your skin staples about 7 to 10 days after surgery. If you are discharged to an inpatient rehabilitation facility your skin staples will be removed at the facility. Typically you will spend 1 to 2 weeks in such a facility after which you will be discharged home with the same services as above. For the first six weeks after surgery you will be given medication to prevent blood clots in your legs (DVT). Usually this is Aspirin, but Coumadin or other medications maybe utilized. You may require physical therapy to rehabilitate your joint for up to 6 months.

FAQ’s

Will I need a blood transfusion?
Depending on the type of hip fracture you may have bled a significant amount. This may necessitate a blood transfusion. In our experience about 40% of patients will require a blood transfusion.

Can I donate my own blood?
No. Autologous blood donation requires several days to process and thus is not suitable for urgent surgical procedures.

What are the risks of hip surgery?
Infection, bleeding, damage to nerves and blood vessels, blood clots that form in your legs (DVT), blood clots that can break off and travel to your lungs causing a pulmonary embolus (PE), and a remote chance of death either due to a PE or from cardiac complications. In addition, a syndrome called the Fat Embolism Syndrome (FES) may also manifest itself clinically in a small percentage of patients.

What are the risks after surgery?
DVT, PE, and infection remain a possibility for several months after surgery. In addition dislocation of a hemiarthroplasty may occur when the ball dislocates from the socket. The chance of dislocation is less than 0.5% in our patient population. You will be asked to follow hip precautions to prevent dislocating your hip.

What are hip precautions?
Hip precautions minimize the chance of dislocation and must be closely adhered to for 3 months post surgery. They are:
  1. Do not twist your body at the waist.
  2. Do not cross your legs at the knees.
  3. Do not turn operative foot inward.
  4. Do not flex your hip greater than 90°.
  5. Do not bend at the waist.
  6. Minimize lifting to less than 20 pounds in the first three months and 40 pounds thereafter.
  7. Sit only 30-45 minutes at a time.
  8. Place your abduction pillow (given to you after surgery) between legs when sleeping.
  9. May ride in a car, stopping every 30 minutes to get out and stretch for 5 - 10 minutes.
  10. May sleep on operative side two weeks after surgery with a pillow between your legs.

What equipment will I need at home after my surgery?
  1. Crutches or walker – possibly both.
  2. Cane.
  3. Raised commode (to put over your toilet because a regular toilet seat height is too low to sit on).
  4. Shower/tub chair (so that you can sit while you shower/bathe).
  5. Extended shoe horn (to assist in putting on your shoes).
  6. Long handled grabber (to help reach things on the floor or in high places).
  7. Hip chair (an elevated chair to help prevent you from bending greater than 90 degrees at the hip joint).
  8. Sock aide (to assist in putting on your socks).
  9. Elastic shoe laces (so that you do not have to bend down to tie your shoes).
  10. Long-handled sponge for bathing.


Do I need antibiotic prophylaxis for dental procedures and endoscopic procedures (colonoscopy and upper gastrointestinal endoscopy) after hip surgery?
If you had a hemiarthroplasty you will require antibiotic prophylaxis. Your surgeon can provide you with more details. The other procedures do not warrant antibiotic prophylaxis.

Will my hip implants set off metal detectors at airports?
Typically no, but newer more sensitive machines may pick up the metal. Your surgeon can provide you a card stating you have metallic implants.

How soon after hip surgery:

  1. Can I drive?
    Usually in 6 weeks.
  2. Can I return to work?
    About 6 to 12 weeks depending on your occupation.
  3. Can I shower?
    Soon after discharge from the hospital. Cover wound with plastic until the skin staples are removed.
  4. Can I resume sexual activity?
    Usually after 4 to 6 weeks after surgery. Please ask your surgeon for a hand out with specific guidelines.
  5. Can I fly in an airplane?
    In about 6 weeks – you must arrange for an aisle seat, have your bags handled by someone else, and you MUST do ankle pumps every 15minutes, as DVT is a major concern. You must also take Aspirin to prevent DVT.