Hip Fracture

Treatment Overview

The goal of treatment for hip fractures is to allow you to do, without pain, most of the things you did before your fracture. The most common and almost always the best treatment for a hip fracture is surgery. Surgery helps make sure that the bones are lined up to heal correctly.

After your hip fracture is diagnosed, you may have a pillow placed under the knee of your injured leg. Or, you may be placed in gentle skin traction to help keep you more comfortable until surgery.⁵ Skin traction attaches a light weight to your leg using tape, straps, or a special boot, and this weight provides a constant pull on your leg.

Surgery is done as soon as possible after a diagnosis of hip fracture, often within 24 hours. Having surgery right away can help shorten your stay in the hospital and may decrease pain and complications.⁶ But in some cases, surgery may be delayed for 1 to 2 days for treatment of other medical problems, such as heart or lung conditions, so surgery will be less risky.

There are different types of surgery for hip fractures, depending on the location of the break, the position of the bone fragments, and your age. Surgery for a hip fracture may include one of the following:

• Internal fixation. Internal fixation involves stabilizing broken bones with surgical screws, rods, or plates. This type of surgery is usually used in people who have fractures in which the bones can be properly aligned.
• Hip replacement surgery (arthroplasty). Arthroplasty involves replacing part or all of the joint with artificial (usually metal) parts. A partial hip replacement may be done to replace the broken upper part of the thighbone (femur) with artificial parts. In some cases a total hip replacement can be done if the hip joint area was already damaged before the fracture by arthritis or an injury and the joint was not functioning correctly. Additionally, arthroplasty is often done for femoral neck fractures when the blood supply to the top of the thighbone is damaged and there is a chance that the bone might die (avascular necrosis), or when the fractured bones cannot be properly aligned.

Some surgeons are now performing minimally invasive hip replacement surgery. This means they use a smaller incision in order to minimize bleeding, healing time, and scar formation. But there may be a greater chance of complications such as infection, nerve damage, and poor positioning of the hip replacement components.⁷ The surgery looks promising, but it requires a very skilled and experienced surgeon, and there are few studies comparing it to standard procedures.^{8, 9} Until risks and long-term benefits are studied, there may be a risk in choosing a less experienced surgeon to do minimally invasive surgery and leave a smaller scar, instead of an experienced surgeon who will do a standard procedure.

Reduction (getting the bone lined up correctly) and internal fixation (stabilizing broken bones) often are done on younger, active people. Hip replacement surgery often is done on older, less active adults. In deciding what method to use for repairing a hip fracture, your surgeon will consider the type of fracture, your age and activity level, and also the possible trade-offs. Research on displaced hip fractures (where the bones are not aligned) shows that, in the long term, total hip replacements may need to be redone less often, but there is also more time in surgery, a greater chance of infection, and possibly a greater chance of death.¹⁰

Surgery usually is the most effective treatment for a hip fracture, although in most cases you will not regain all of the mobility that you had before the hip fracture. In general, if you were healthy and active before the fracture, then you will recover faster after surgery than a person who was not. If you have other health problems and have not stayed active, there is a greater chance of complications after surgery.

In rare cases surgery is not done—for example, in people who are at high risk for complications during or after surgery and who may not benefit significantly from surgery, such as those who were unable to walk before the hip fracture and who have minimal pain.¹¹ In these cases, your doctor will use medicine to manage your pain.

What to expect after surgery

Right after surgery for a hip fracture, you will have medicine to control pain and perhaps medicine to prevent blood clots (anticoagulants). You may have a urinary catheter so you don't have to get out of bed to urinate. You may also have a compression pump or compression stocking on your leg, which squeezes your leg to keep the blood circulating and to help prevent blood clots, and a cushion between your legs to keep your hip in the correct position. It is not unusual to have an upset stomach or feel constipated, so talk with your doctor or nurse if you don't feel well.

Your health professional may teach you to do simple breathing exercises to help prevent congestion in your lungs while your activity level is low. You may also learn to move your feet up and down to flex your muscles and keep your blood circulating, and begin to learn how to keep your hip in the right position while you move in bed and get out of bed.

It is very important to start moving around soon after surgery. This will speed recovery and reduce complications. On the first day after surgery, you will most likely be moved out of bed into a chair for a short time, and you will probably begin light exercises on the second day after surgery.

You will probably stay in the hospital for about 2 to 4 days after surgery. You may be transferred to an extended-care facility for additional rehabilitation before going home and so that help is available for daily activities, such as bathing on a bath stool. You will probably need a walking aid—a walker, cane, or crutches—for several months, and full recovery may take up to a year. For more information on using walking aids, see:

• Using a walker.
• Using crutches.
• Using a cane.

There are many issues to consider after hip surgery. Older adults often need extensive care, including physical therapy and help with cooking, taking medicine, and personal care. Anticoagulant medicines are prescribed to reduce the risk of blood clots and associated stroke, pulmonary embolism, or thrombophlebitis. You will probably keep taking this medicine until you are walking frequently and well, often at least 3 weeks.

After hip fracture surgery, your doctor will encourage you to participate in a rehabilitation program. Recent research shows that 6 months of outpatient rehabilitation that includes strength training can improve quality of life and decrease disability.¹² Following a rehabilitation program is very important, because it will speed up your recovery and allow you to return to daily activities sooner.

Prevention

There are steps you can take to help prevent a hip fracture.

Keep your bones strong:

Eating a nutritious diet with adequate calcium and vitamin D, which helps your body absorb calcium, can help strengthen your bones.

• The recommended daily calcium intake for adult men and women is between 1,000 and 1,200 mg per day.¹³ Women who do not get this amount of calcium from food each day may take calcium supplements. Calcium is found in dairy products such as milk, cheese, and yogurt; dark green, leafy vegetables such as broccoli; and other foods.
• The National Institutes of Health recommends 400 to 800 IU of Vitamin D per day. Do not take more than 800 IU per day unless your doctor prescribes it, because large doses of vitamin D may be harmful.¹³ You can get the amount of vitamin D you need each day by eating a variety of dairy products. You also will get the amount of vitamin D you need if you are outside in sunlight for at least 15 minutes each day.

Studies show that calcium and vitamin D supplements will not prevent fractures in people who already have risks of fracture such as low body weight or previous fractures.^{14, 15} But getting enough calcium and vitamin D over your lifetime will help you have stronger bones as you age.

Exercising and staying active help maintain bone strength. Weight-bearing exercises such as walking, jogging, and light weight training help to minimize bone loss. Talk to your doctor about an exercise program that is right for you. Begin slowly, especially if you have been inactive.

• A recent study revealed that moderate physical activity, such as walking, was associated with a substantially lowered number of hip fractures in postmenopausal women.²

Talk to your doctor about taking hormone replacement therapy or other medicines if you are at risk for osteoporosis. Some doctors recommend hormone therapy for osteoporosis, although its risks and benefits should be considered. Other medicines such as bisphosphonates, including alendronate (Fosamax) and zoledronic acid (Reclast); raloxifene (Evista); and calcitonin (Calcimar or Miacalcin) are also used to prevent or treat osteoporosis. Studies show that the bisphosphonates, in particular, significantly reduced the risk of hip fracture in older women with osteoporosis.¹⁶ For more information, see the topic Osteoporosis.

• Don't drink more than 1 alcoholic drink per day. People who drink more than this may be at higher risk for osteoporosis. Alcohol use also raises your risk of falling and breaking a bone.
• Don't smoke. Smoking puts you at a higher risk for developing osteoporosis and increases the rate of bone thinning after it starts.

For more information, see the topics Fitness and Healthy Eating.

Avoid falls:

Almost all hip fractures in older adults happen because of a fall. Things that increase your chance of falling include:

• Having poor balance and coordination.
• Having weakness in one or both legs.
• Using certain medicines that may cause sleepiness, weakness, or dizziness.
• Having vision problems.
• Drinking too much alcohol.
• Feeling confused or having impaired reasoning (caused by age or conditions such as dementia).

You can reduce your risk for falls by:

• Removing anything in your house that may cause you to fall. Household hazards that can cause falls include slippery floors, cords, poor lighting, cluttered walkways, furniture placement that does not allow a clear pathway for walking, and throw rugs.
• Using nonslip mats and grab bars in the bathtub and shower.
• Making sure stairways have handrails. Having rails on both sides of the stairs is best. Also be sure to turn on the lights when you use the stairs.
• Making sure you have enough light to see obstacles or pets as you move around your home.
• Exercising to help maintain strength and balance.
• Taking medicines only as directed and periodically reviewing your medicines with your primary care doctor, especially if you have more than one health professional. Some medicines, such as sleeping pills or pain relievers, can increase your risk of falling.
• Wearing low-heeled shoes that fit well.
• Using walking aids correctly.

For more information, see the topic Preventing Falls.

Hip protectors:

Hip protectors look like a girdle or underwear with pads on both hips to help reduce the force of a fall. A summary of several studies concluded that hip protectors do not prevent hip fractures in people who live at home, and they may not be helpful for people in nursing homes or other institutions.¹⁷ One problem with studying hip protectors is that people do not like wearing them even if they might help protect the hips. Hip protectors are bulky under clothing, hard to fit properly, and can irritate the skin.

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Author:	Shannon Erstad, MBA/MPH	Last Updated: July 9, 2007
Medical Review:	William M. Green, MD - Emergency Medicine Kenneth J. Koval, MD - Orthopedic Surgery, Orthopedic Trauma
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