What is hip fracture?
A hip fracture is a break in the top part of the femur (thigh bone) where it inserts into the pelvis to form the hip joint.
Symptoms and signs of hip fracture
Symptoms and signs of hip fracture usually follow a fall or other accident, and may include:
- Severe pain in the hip or lower groin region, sometimes radiating to the knee. Attempting to move the hip usually results in a significant increase in pain. In some cases, there may be only thigh or knee pain. Lower back pain may also occur.
- Stiffness, bruising, swelling, tenderness or deformity in and around the hip area.
- A shorter leg on the side of the injured hip.
- The leg on the side of the injured hip turns outward and is shortened.
- Difficulty walking. (Walking may still be possible with partial fractures)
- Inability to put weight on your leg.
What causes hip fracture?
In elderly people, the direct cause of a hip fracture is usually a fall or accident, which may sometimes be relatively minor. The underlying cause is likely to be osteoporosis (a condition in which bones become brittle and more prone to fracture as a result of mineral loss).
In younger people, however, hip fractures are usually caused by a more severe injury, such as a motor vehicle accident, sports injury or high-impact fall.
In some people with certain medical conditions, such as severe osteoporosis, cancer, paralysis or kidney disease, the bones can become so weak and brittle that a hip fracture can occur during regular daily activities, simply from bearing the body's weight.
Who gets hip fracture and who is at risk?
Those who suffer from osteoporosis are at risk and the risk factors are those for osteoporosis.
- Ageing. With age, the bones gradually lose calcium and other minerals and become less dense. Loss of density weakens bones and makes them more susceptible to fracture. Ninety percent of hip fractures occur in people over age 65.
- Female gender. Women lose bone density at a greater rate than men do, and as a result are two to three times more likely to experience a hip fracture: about one out of every seven women will have a hip fracture in her lifetime. Hip fractures are a particularly important concern for menopausal and post-menopausal women. During menopause, the ovaries stop making the hormone oestrogen, which helps protect against bone loss.
- Osteoporosis. The likelihood of hip fracture from a minor fall greatly increases if you have osteoporosis.
- Removal of the ovaries.
- Diet low in calcium or vitamin D.
- Sedentary lifestyle.
- Eating disorders such as anorexia and bulimia.
- Medications such as corticosteroids, and certain drugs prescribed for seizures and high blood pressure.
- Alcohol abuse.
- Certain diseases that weaken the bones or joints, such as hyperthyroidism, hyperparathyroidism, hypogonadism, rheumatoid arthritis and cancers affecting bone tissue.
- Low body weight or slight build.
Risk factors that increase the chance of a fall, which could lead to a hip fracture, include:
- Poor balance and co-ordination.
- Certain medications that may cause weakness or dizziness.
- Vision problems.
- Alcohol abuse.
- Disorientation or impaired reasoning (caused by conditions such as dementia).
- Physical abuse, including child abuse, elder abuse or spousal abuse.
- Living in an urban area.
How is hip fracture diagnosed?
The doctor will take a medical history and perform a physical examination. He or she will often be able to determine if you have a hip fracture from your symptoms, whether you have had a recent fall or accident, and by observing the abnormal position of your hip and leg. X-rays are used to confirm the diagnosis and pinpoint the location of the fracture.
Occasionally, a hip fracture cannot be seen on the initial X-ray, but may be suspected because of symptomatic pain or a recent fall. In these cases, an MRI (magnetic resonance imaging) scan or a bone scan, which provide clearer images of slight fractures, may be performed.
How is hip fracture treated?
The type of treatment you receive for hip fracture depends on the type of fracture you have and your overall medical condition. The goal of treatment is for you to regain your previous level of hip joint function and general activity.
Surgery is the most common and effective treatment for hip fractures, and may include one of the following procedures:
- Reduction and internal fixation. Reduction is the process of repositioning the broken bone. Internal fixation involves stabilizing broken bones with surgical screws, rods, pins or plates, which allow the broken edges to grow or "knit" together while healing.
- Partial hip replacement (hemiarthroplasty), involves replacing part of the joint (the broken upper part or head of the femur) with artificial parts. This may be a suitable option if the head of the femur(the ball part of the ball and socket joint) is completely broken off with interruption of it’s blood supply.
- Total hip joint replacement (arthroplasty) involves replacing the upper femur and the socket in the pelvic bone with a prosthesis. This may be deemed necessary if the hip joint area had already been damaged before the fracture by arthritis or previous injury, and the joint had not been functioning properly.
You will usually stay in hospital for about a week after surgery.
Post-operative rehabilitation is very important for a good outcome. Your doctor will prescribe a rehabilitation programme based on the location of your hip fracture and the type of surgery done.
Following a fracture and /or surgery, bones are being submitted to less stress than normal, and rebuild with lower mass. They need to be used again as soon as possible, through daily, gradually increasing exercise. Remaining inactive following surgery can also increase your risk for serious complications, such as blood clots. Therefore, you will meet with a physical therapist shortly after surgery (usually the following day) to begin gently exercising your hip joint, first by simply getting up out of bed, followed by light exercises and later (usually the second day after surgery) by supported walking. You will also learn to avoid movements that may strain your hip or any new prostheses.
You will need to continue your rehabilitation programme at home: exercising to regain mobility and strength, retraining in simple daily activities, and generally staying active.
You will probably need to use a walking aid (such as a walker, cane or crutches) for several months, and full recovery may take up to a year. Daily activities, such as bathing, may be difficult to do alone, and it may be necessary to organise someone to help with your care. Devices such as dressing aids, raised toilet seats and handrails may be helpful. Also, take note of the advice provided in the section Can hip fracture be prevented?
Possible complications of surgery
There may occasionally be complications associated with surgery for hip fracture, particularly if you have other health problems and lead a sedentary lifestyle. Complications may include problems associated with anaesthesia, including respiratory or cardiac malfunction. The procedure itself may be complicated by infection. You may develop a deep vein thrombosis and this may lead to a pulmonary embolus.
An artificial hip joint lasts on average for 15 to 20 years. Rarely, a prosthesis will break, wear out or loosen, making revision surgery necessary.
Non-surgical treatments for hip fracture are used only occasionally, for example if you have other health problems that would make surgery too risky, or perhaps if you are already confined to a bed or a wheelchair. One type of treatment, traction, involves using weights and pulleys to keep the bones correctly aligned while they heal. This is sometimes difficult to achieve successfully with the femur. Also, because traction requires that you stay immobile for long periods, other complications can develop, such as bedsores, blood clots, pneumonia and urinary tract infections.
What is the outcome of hip fracture?
Hip fractures can be serious because they occur most often in older adults and usually require surgery. Fortunately, in most cases surgery to repair hip fractures is effective and recovery is good, although this often takes time and you will usually not regain all of the mobility that you had before the injury. Generally, the better your health and mobility before the injury, the better your chances for complete recovery.
About two-thirds of older people are expected to return to their previous level of joint function and activity after treatment for a hip fracture. At least half of those who have had hip fractures will require an assistive device, such as a walker, to allow them to move around after recovery.
An estimated 20% of people treated for hip fracture will require nursing home care after their injury (mostly those who were already frail and infirm prior to the fall).
Can hip fracture be prevented?
The most important way to prevent hip fractures is to keep your bones strong. The higher your peak bone mass, the less likely you'll be to have fractures later in life. Maximum peak bone mass depends on your inherited ability to make bone, the amount of calcium you consume and your exercise level. The process of building bone mass peaks at about age 30. After this age, you start to gradually lose bone mass. Following a healthy lifestyle during your peak bone-mass-building years and afterward may contribute to a higher peak bone mass and reduce your risk for osteoporosis.
The following measures can help you prevent a hip fracture:
- Get sufficient calcium and vitamin D. Both of these nutrients are important for building bone mass, and calcium can also protect against bone loss.
The recommended daily calcium intake for adult men and women is between 1000 and 1200 mg per day. Women over 65 years of age, and women over 51 years of age who are not on hormone replacement therapy, need 1500 mg of calcium per day. Good sources of dietary calcium include dairy products, egg yolk, beans, cauliflower, broccoli, rhubarb and citrus fruits.
The recommended daily intake of vitamin D, which helps the body absorb calcium, is between 400 and 800 IU per day. Vitamin D is found in foods such as milk, fish liver oils and fatty fish (salmon, tuna, herring, sardines), egg yolk, liver, oysters, butter and yeast. Your skin also manufactures vitamin D using the sun's energy. You can receive sufficient vitamin D by drinking at least one glass of milk or spending at least 15 minutes in the sunlight each day.
Ask your doctor whether calcium or vitamin D supplements would be appropriate in your case. The amount of supplementary calcium you may need depends on factors such as your age, diet, whether you're taking medications such as corticosteroids and how much sunlight you get.
- Exercise. Thirty minutes (in one session or broken up into smaller segments) of moderate weight-bearing exercise, such as walking, jogging, low-impact aerobics, swimming or light weight training, encourages your body to increase bone density to handle the additional stress placed on the muscles and bones. Exercise also increases your overall strength, balance and co-ordination, making falls less likely. Discuss an exercise programme that is suitable for you with your doctor. Begin gradually and carefully, especially if you have been inactive.
- Stop smoking. Smoking contributes to loss of bone density, possibly by decreasing the amount of oestrogen your body produces and reducing calcium absorption in your intestine. Also, women smokers tend to enter menopause earlier than nonsmokers.
- Consider hormone replacement therapy (HRT) if you are menopausal or post-menopausal and at risk for osteoporosis. HRT can help slow the loss of calcium from your bones after menopause, when oestrogen levels decline. Ask your doctor about having a baseline bone density test done at menopause to find out if you need to take action to increase your bone density.
- Limit yourself to one alcoholic beverage per day. People who drink more than this may be at higher risk for osteoporosis. Being under the influence of alcohol also increases your risk of falling.
- "Fall-proof" your home:
- Keep your home well lit.
- Get rid of unfixed floor rugs, carpets with upturned edges, slippery floor surfaces and exposed electrical cords.
- Place furniture where you're unlikely to bump into it.
- Consider installing handrails in the bathtub, shower and along stairways, and non-slip carpeting and stair treads. Using a shower chair can also help avoid falls.
- Keep floors and passages uncluttered.
- Wear sensible shoes. Choose shoes with low heels and non-slip soles that fit well.
- Avoid strenuous and dangerous activities that may result in falls. Avoid lifting heavy objects, climbing, engaging in unusually vigorous activities, and stretching to reach objects placed up high.
- Use a cane or walker if you are unsteady.
- Have your eyes checked regularly.
When to call the doctor
If you suspect that you or someone you know has had a hip fracture, call your doctor or an emergency medical service immediately. Limit movement of the leg as much as possible and do not try to straighten the limb, even if it is very uncomfortable. Applying an ice pack to the painful area may help to reduce swelling.
Reviewed by Dr Sirk Loots, orthopaedic surgeon.