Panaji: Fractures of the hip in the elderly are fairly common. Generally, they are called fragility fractures, which occur due to low energy trauma. A minor fall or a jerk leads to a break in an already weak bone. Weak bones are associated with old age, especially in women who are post-menopausal for a number of years. If they are not under treatment for osteoporosis, they are more susceptible to such fractures.
We now have a very high population of elderly persons compared to the past. This is due to an improved lifestyle, better medical facilities and a better understanding of the problems of geriatrics. Proportionately, there is a rise in the number of hip fractures.
In the past, these fractures were thought of as the beginning of the end. A famous saying of the yesteryears was, ”We enter the world through the brim of the pelvis and exit the world through the neck of the femur.“ However, with the advances in the medical sciences, safer anaesthesia and better implants, today, almost all the patients who have had these fractures go back to their original lifestyle. It is no longer thought to be the beginning of the end.
Old people generally have associated comorbidities, like diabetes Mellitus, Hypertension, Ischemic heart disease, renal pathologies, bronchial asthma, and stroke with paralysis, Alzheimer’s disease etc., and these complicate the management. The fractures of the hip can be of two types: Intracapsular, which are close to the head of the femur.
Extracapsular, which are at the junction of the neck and the shaft of the femur. Both fractures, though, are just about an inch apart. They have dissimilar characteristics due to the anatomy of the neck of the femur. The extracapsular fracture has a good blood supply and heals faster, and the intracapsular ones do not heal well due to the nature of the blood vessel distribution.
The head of the femur is supplied blood through the neck of the femur, and hence in cases of fracture, the blood supply is compromised. This leads to non-union of the fracture, and the head of the femur becomes avascular and can die. Due to the fracture in the hip, the person is unable to bear weight on the leg. Any old person is in the best of health while he is up and about, and once the person becomes bedridden, various complications of recumbency are likely to crop up.
The problems of recumbency are:
1: Circulatory problems: The thromboembolic phenomenon. Due to the stasis of the blood flow, there is likely hood of thrombus formation in the veins of the calf muscle. This thrombus can form emboli and lodge in the pulmonary veins causing sudden death. The same can lodge in the brain vessels and can cause paralysis. These dangerous problems can be solved by early mobilisation of the patient.
2: Respiratory complications: Due to constant lying down, there is a compromise of the chest expansion. This can lead to consolidation in the lung. Seldom old people aspirate the liquids that they drink, and this can cause complications like aspiration pneumonia. This, too, is a dangerous complication.
3: Bedsores or pressure ulcers are common in bedridden persons. They occur in the areas of the body which are in contact with the bed, especially over a bony prominence. Due to constant pressure over the skin, the blood supply is compromised, and the skin and the underlying tissues die, leading to the formation of an ulcer. The only treatment for bedsores is to relieve the pressure by early mobilisation. Prevention is the best treatment of bedsores.
4: Complications of the kidneys: To avoid the problem of passing urine in bed, most of the elderly avoid drinking adequate water. This causes a rise in blood urea and electrolyte imbalance. The indwelling catheter, too, has its own problems like infection. In the elderly, due to lack of immunity, there is a chance of septicemia, more so in patients suffering from diabetes mellitus.
5: Psychological problems: Depression is common in the old due to recumbency. It is more common in patients who do not have adequate family support or financial backing. Due to the depression, their participation in the rehabilitation program becomes difficult.
All the above problems are of medical nature. However, due to changing demographic patterns, there are many social problems associated with the fractured elderly. In nuclear families, often the old person lives alone or does not have any responsible relative who could be responsible. Often we come across the elderly with hip fractures who have their children settled or working abroad. There are no close relations who could offer support.
The aim of the treatment of hip fractures is to make the patient pain free and ambulatory. This goal can be achieved only by surgical methods. There is no role of non-operative treatment in the management.
In case of the fracture of the neck of the femur, there are high chances of non-union and avascular necrosis of the head of the femur; it is best treated by prosthetic replacement. This is a simple operation and allows very early mobilisation and ambulation.
Similarly, fractures around the trochanters also can be effectively fixed using special devices. The fixation of such a fracture allows early and pain-free ambulation.
The surgeries are associated with a fair amount of risk. The risk varies depending upon the associated comorbidities. Before the patients can be subjected to surgery, it is imperative that all medical problems are addressed. There should be a good control of blood sugar in diabetics, correction of low haemoglobin, correction of renal parameters and electrolytes. In cases under treatment with blood-thinning agents, surgery needs to be delayed for at least a week after stopping the medication.
Avoiding surgery is also an associated risk because of the various problems of recumbency, as mentioned earlier. The outcome of the conservatively treated Fracture of the Trochanter is always uncertain, and more often than not, the person succumbs to one or more of the complications of the recumbency.
On weighing the two options, the balance tilts heavily towards the operative treatment. For a good outcome for the elderly hip fractures, a combined effort by a team of physicians, orthopaedic surgeons, anesthesiologists, and a good physiotherapist is imperative. Each one has a definite role in the management, and each one needs to support the other for a successful outcome.
Preventions of the fracture of the hip in the elderly is the best treatment. If certain guidelines are followed, it is possible to avoid this mishap.
Avoid clutter in the house: Often the falls are due to some things like toys, loose carpets, and dog chains etc., which are left on the floor.
Proper lighting in the house: Most elderly have diminished vision, and dim lighting is not desirable. A torch or a light switch should be nearby the bed.
Hearing Aids: Often the falls or accidents are caused due to lack of hearing. Wherever possible, the use of hearing aids can help in avoiding such mishaps.
Dentures: Whenever there is a problem with chewing, one tends to avoid protein-rich foods. This causes osteoporosis, which could cause hip fractures.
Everyday essentials: Proper clothing and footwear and a walking aid like a walking stick when taking a stroll or walking outdoors also help to avoid falls, especially in wet weather.
A fracture of the hip is a mishap in the life of the elderly person and his family. Fortunately, modern treatment has been giving consistently good results. The treating doctor and the patient’s family should weigh the risk-benefit ratio and take a decision. There should be no hesitation in making the decision in favour of surgical treatment if so advised.
(The writer is a Consultant Orthopedic Surgeon)