Hip fractures in the elderly are critical ailments, with
possible life-endangering complications. Surgeries to fix breaks
are common and consistently effective, while healing can take an
entire year. And once a senior suffers from a broken hip, his or
her health can take a downward spiral as the break can trigger
other problems and affect the elderly immune system.
Here is a scenario:
When Teresa Lang remembered a last-minute item she needed for
her trip to Europe, she jumped up from her couch. She tumbled over
a small suitcase on the floor, right into a wall. "The instant I
did this, before I hit the wall, I knew what had happened," says
the 88-year-old Lang. She had broken her left hip.
Hip fractures in the elderly are common. In fact, for every 10
hip fractures, about nine occur in people over the age of 60. "Hip
fractures double with every five-year increase in age [after age
50]," says Sandy B. Ganz, PT, DSc, GCS, the director of
rehabilitation at Amsterdam Nursing Home in New York City. By 90
years of age, one in four women and one in eight men will have
fractured a hip, according to a study done by the Center for
Disease Control and Prevention.
Causes and Risk Factors
Elderly people are at a high risk for
falling, the usual traumatic event that leads to hip fractures.
"They fall because they lose their coordination. They have
difficulty with their eye sight and they have difficulty with their
balance, and they become weak," says Dr. Charles A. Peterson, an
orthopedic surgeon at Seattle Orthopaedic and Fracture Clinic.
"When they fall, they tend to have a higher frequency of fractures
due to osteoporosis and weaker bones."
The risk factors for suffering a broken hip are numerous,
- Osteoporosis: This disease causes bones to become weaker,
making them more susceptible to fracture. In the U.S., an estimated
10 million individuals already have
osteoporosis, and 80% of those affected are women. In this
population, hip fractures can occur during simple weight-bearing
- Sex: Women lose bone density more quickly than men due to a
decrease in estrogen levels after menopause begins.
- Heredity: Small-boned, slender-framed people; Caucasians; and
Asians have an increased risk of suffering from osteoporosis.
- Nutrition: Poor nutrition in childhood increases hip-fracture
risk. Eating disorders such as anorexia nervosa and bulimia damage
- Tobacco and alcohol use: Smoking and drinking too much can lead
to bone loss.
- Medications: Taking four or more medications at a time or
taking any psychoactive medications are risk factors for
- Home environment: Throw rugs and electrical wires are tripping
hazards, as are a lack of stair railings and grab bars, unstable
furniture, and poor lighting.
- Medical conditions: The following conditions can increase the
risk of hip fractures, either through bone loss or by increasing
the risk of falling: endocrine disorders, such as type 1 diabetes;
gastrointestinal disorders; rheumatoid disorders; prolonged bed
rest or immobility; nervous system disorders such as
Parkinson's disease or
Signs and Symptoms
Most often, an individual knows right away that she has broken
her hip. For example, Lang was unable to stand up and was
discovered by her son who happened to stop by that day. Usually
severe pain is felt in the hip or groin areas and the person cannot
walk. Other symptoms include stiffness, contusions, or inflammation
in the hip area; the leg on the broken hip side is shorter or turns
outward. If the head of the hip bone is impacted onto the neck of
the hip bone, the person might not know he has a broken hip, as
this break can be less painful, according to Peterson.
Because hip fractures in the elderly are life-threatening, make
sure your loved one heads to a hospital immediately. Surgery to fix
the fracture is usually done within 24 hours. The examining doctor
can diagnose a broken hip simply from symptoms, but an x-ray or MRI
will verify the break and display the fracture type.
Treatment: Surgery for Hip Fractures in the Elderly
There are two main types of hip fractures, and older people
almost always undergo surgery to repair these breaks:
- Femoral neck fracture: The femoral neck is right below the ball
(or head) of the ball-and-socket hip joint. Because this type of
fracture diminishes and can sometimes stop the flow of blood to the
broken part of the bone, surgery is almost always done to correct
it. Partial hip replacement, called hemiarthroplasty, replaces the
ball and femoral neck with a metal prosthesis, usually made from
stainless steel or chrome cobalt alloy. While the patient is under
general or spinal anesthesia, the surgeon makes an incision. The
broken head is removed, and the surgeon clears out cartilage and
damaged bone from the hip socket. The new socket, which includes a
ball and stem, is cemented in place. Muscles and tendons are
positioned around the prosthesis and the incision is closed.If the
patient has arthritis or a previous injury that has damaged the
joint and they are physiologically sound, a total hip replacement
may be done for a femoral neck fracture.
- Intertrochanteric region fracture: Just below the femoral neck,
this is where the thigh bone juts out. The fracture runs between
two bumps called trochanters. While the patient is under general or
spinal anesthesia, the surgeon makes an incision on the side of the
thigh. The patient's bones are manipulated to correct their
position. A large screw called a hip nail is placed along the break
and up into the femoral head. This screw is held to a metal plate
that is attached to the outside of the thigh using several smaller
screws. This plate and screw helps the bones heal, compressing them
so they grow together.
A third type of break, called asubtrochanteric fracture, occurs
in the thigh bone or femur, and is quite rare. The surgical repair
is similar to the plate and screw system used in intertrochanteric
fractures, although the recovery period is much longer.
In rare instances, people who have hip fractures do not have
surgery. If someone is too sick for surgery to occur, traction or
other methods are used to repair the break.
Recovery and Therapy
Although surgeries to repair fractures are straightforward and
relatively simple fixes, complications after surgery can be
dangerous. Mortality rates in the year following a hip fracture are
about 25 percent. Complications include blood clots, infection, and
pneumonia. With a partial hip replacement, the patient can also
dislocate the prosthesis before it stabilizes. If an individual has
fragile bones, the hip nail or screw may pull out of the bone.
Post-surgery complications more often lead to death if a patient
already suffers from another serious medical condition.
Recovery after hip surgery is a lengthy process. The typical
hospital stay lasts four days to a week, but a longer stay isn't
unusual. Lang remained in the hospital for about a week, and then
moved to a sub-acute rehabilitation center for a month. Now she is
at home, receiving assisted care from her family, and two
therapists work with her twice a week. After a hospital stay,
patients can follow many different routes, depending on insurance,
age, and complications. According to Ganz:
- Some live in acute rehabilitation centers, which offer a
minimum of three hours of physical and occupational therapy each
- Some patients live in a skilled nursing facility for sub-acute
rehabilitation, which offers a minimum of 30 minutes per day of
- Others go straight home and receive
in-home assisted care and therapy;
- Others go home with no home care, but receive therapy as an
out-patient in a private practice or hospital.
Up to 25 percent of community-dwelling seniors who sustain hip
fractures remain in an institutional assisted care setting such as
a nursing home
for at least a year.
Physical and occupational therapists begin to work with
recovering patients right at the hospital, helping them begin
walking with assistance usually the day after surgery. "Physical
therapy intervention for a hip fracture usually consists of muscle
re-education, strengthening exercises, balance retraining, bed
mobility, and transfer and gait training," says Ganz. "Occupational
therapy focuses on the activities of daily living: dressing,
grooming, bathing, as well as balance retraining and strengthening
The amount of therapy a patient receives depends on insurance.
"Unfortunately, right about the time therapy typically ends, about
four to six months post operatively, is when the patient is first
physically and physiologically able to receive more intensive
therapy," says Ganz.
While a patient may recover from surgery quickly, there is a
difference between healing and recovery. "After recovery, they can
continue doing everything on their own to get stronger," says Jill
Heitzman, PT, DPT, GCS, FCCWS, a physical therapist at Mary Greely
Rehab and Wellness in Ames, Iowa. "When they are actually healed,
they are back to doing everything they want to do." Healing, she
says, typically takes nine months to a year.
About 25 percent of hip fracture sufferers will experience a
full recovery and return to a semblance of their post-fall life.
Fifty percent will need to use a cane or walker, and about 20
percent of individuals who break their hip will permanently live in
a nursing home. Caregivers can help ensure the best outcome by
helping their loved ones adhere to their therapy regimens and
taking some preventive measures such as fall-proofing their
Ideally, one can prevent hip fractures in the elderly in the
first place. People who have broken a hip also have a good chance
of falling again. You can help by making sure your loved one's home
environment is safe, as well as seeing that she stays as healthy as
Homes, rehabilitation centers, and nursing homes all need to be
fall-proofed. Ganz includes the following recommendations in a
- Lighting should not be too dim or too direct, and light
switches should be accessible.
- Carpets and rugs should be tacked down.
- Bathrooms should have a chair for bathing or skid-resistant
mats, grab bars should be placed where needed and the toilet seat
needs to be tall enough for easy transferring.
- Chairs need to be stable (without wheels) and have arm
- Kitchen items that are frequently used should be at waist level
or on low shelves, a rubber mat should be placed in front of the
sink and non-slip wax should be used on the floor.
- Stairways need handrails and steps should not be slippery.
There are several other simple suggestions that can help prevent
falls and hip fractures. People need to have regular eye-checkups;
wear sensible, hard-soled flat shoes; and be mindful of
medication's side effects. Individuals can also wear hip padding to
minimize the impact of a fall. A doctor can talk with your loved
one about how to increase her bone density through taking
supplements, including bisphosphonates for osteoporosis sufferers,
calcium, vitamin D, or starting estrogen or hormone replacement
therapy, says Ganz.
Exercise is imperative for preventing falls. Heitzman recommends
that a regimen includes:
- an aerobic workout that elevates heart rate and increases
- a strength-training program that involves lifting against
- exercising on different surfaces-such as carpets, stairs, and
gravel-to challenge one's balance.
Healing from a hip fracture takes time and patience. Seven weeks
after her fall, Lang uses a walker to move around her apartment and
the world outside. Before her accident, she occasionally used a
cane for outings, saying she found it elegant. Now she looks
forward to just using her cane. "They say you'll never be exactly
how you were, but you will be a pretty good facsimile of that!"