Hip Fractures, an Age-Old, Old Age Misery

In the U.S, there are 300,000 hip fractures a year in people 65 and older, and that number is going up.

Hip fractures are painful, debilitating, expensive and life-shortening, yet we barely give them their due as an epidemic we should address.

About 1 in 3 women and 1 in 12 men will sustain a hip fracture in their lifetime, most over age 65. In fact, 86% of all hip fractures occur in people in that age group. Hip fractures are also more common in women, probably because they live longer and are more likely to develop osteoporosis. Put another way, if I drove to each of the six emergency departments within five miles of my house, I’d find an older person, probably a woman, with a broken hip in at least one of them.

Hip fractures are a life-changing event for an older person, even if they were previously healthy, and they can be life-ending for those who are not. Healthy seniors who break their hip are at risk for all the things all hospitalized seniors can fall prey to: infection, blood clots, pneumonia, delirium and heart attack. Even after they’re out of the hospital, post-surgical hip fracture patients are at risk for more falls and fractures. This is why getting a hip fracture repaired promptly and rehabilitated well is a crucial later-life medical intervention.

In the first half of this article, I’ll explain the three most common kinds of hip fracture, their respective repair techniques and the best practices associated with a successful hip repair. i.e a return to mobility without pain. The second half of the article will look at what decisions can and should be made for people with advanced dementia and a hip fracture or those who cannot participate in rehabilitation for other health reasons. Finally, I’ll cover the prevention of hip fractures, another aspect of this condition that deserves more attention.

Hip Fractures Type 1, 2, and 3

The Three Common Hip Fractures

The most common type of hip fracture in the elderly is the first on the left, called a femoral neck fracture. This can sometimes result in a replacement of the ball socket of the joint, called a hemiarthroplasty. The second most common type of fracture is called an intertrochanteric fracture, or IT Fracture, for short. It is repaired using a pin and screws. A less common, but an important subtype of intertrochanteric fracture is a subtrochanteric fracture. While subtrochanteric fractures are more common in younger people who’ve been in accidents, these are also the type of fractures associated with bisphosphonate (osteoporosis medicine) use. All hip fractures require surgical repair for functional outcomes.

Best Practices

Getting a hip fracture repaired promptly and rehabilitated well is a crucial later life medical intervention.

There are a few key indicators of good quality care when getting a hip fracture repaired. Families should know what to expect and ask about.

Timeliness: The sooner the fracture is fixed surgically, the better the outcome, and the lesser the complications. The standard is within 24 hours. (See “Timing of Hip fracture repair,” by Daniel D. Dressler, MD, MSc, SFHM, FACP.)

Antibiotics: given before surgery to prevent infection of the wound.

Treatment for blood clots should begin as soon as possible with injections of heparin and compressive devices on the legs. Postoperative blood thinners are also going to be prescribed as an injection or pills and will be necessary until mobility is regained.

Pain management should start right away, and it should include regional anesthesia also known as nerve blocks. This will minimize the need for opiates, which cause constipation and delirium in higher amounts. After the repair, a short course of opiates will be prescribed, but gentle movement and physical therapy will also help with pain. Non-steroidal, like ibuprofen (Motrin) and Aleve, should be avoided as they delay healing. Tylenol in small doses is okay.

Up and at ’em early: Believe it or not, the standards for the timing and amount of weight bearing post hip fracture repair are not uniform, but the best evidence suggests, the more and earlier, the better. Gone are the days of lengthy rests in bed to allow bone callous to form. The latest thinking is that the earlier the joint bears weight, the better the healing. Many patients will go straight from the hospital to a rehabilitation facility for intensive physical therapy, but even those who go home will see a physical therapist regularly (at least three times a week) for three months.

Hip fracture treatment options for the frail, immobile, or demented person

Surgical repair of hip fractures has much better outcomes for those who wish to return to a good state of health or mobility, but surgery has other advantages too.

Even in patients who are not expected to walk again, surgical repair of a hip fracture allows caregivers to turn, bathe and toilet the person with much less pain than if the fracture is not surgically repaired.

Dr. Peter Looby, an Orthopedist in Sioux Falls, South Dakota says, “When we explain the risks and benefits of surgical compared to non-surgical treatment of hip fracture in a very old or demented patient, 90% of families opt for surgery. That’s because its too hard to look at their loved on in agony and not do something. Plus, surgeries are so much less involved now with new techniques. But about 10% of families with a very old or debilitated loved one will consider a hip fracture a terminal event, and will opt for aggressive pain control and hospice instead of surgery. It’s a very personal decision”

It’s a fact that people who sustain hip fractures tend to be older, more debilitated and have more medical problems to begin with. A study by Ken Covinsky et al. found that patients with hip fractures were significantly more debilitated with other medical illnesses before they broke their hip than their age-matched peers who did not. They conclude that geriatric palliative care should occur in older, less mobile or demented patients with or without hip fractures. But, as Dr. Convinsky told me,

“There needs to be recognition that hip fracture often signals the acceleration declining function with the need to address many palliative concerns ranging from symptom management, advance care planning, and addressing caregiver burden..”

Dr. Ken Covinsky, UCSF Geriatric Medicine

In other words, like a heart attack, stroke, or new cancer diagnosis, hip fractures are “red flag” events in older adults that may indicate the end of life is not far away.

Prevention

Three preventive steps people can take themselves to avoid breaking their hip is to have their vision checked frequently, quit smoking and limit alcohol consumption.

Hip fractures are still largely blamed on falls, but there have long been questions about which comes first, the fall or the fracture? One study from 1994 suggests that femoral neck fractures in osteopenic bones (a precursor to osteoporosis) can occur with normal weight bearing stress and are not the result of falls. However, most experts still agree that falls are the precipitating event in more than 95% of hip fractures in the elderly. Therefore, fall prevention is still the mainstay in preventing hip fractures.

Preventing falls requires that many risks be taken into consideration. Clearing physical obstacles, such as furniture and area rugs from the path of a frail elder is a start.

Three preventive steps people can take themselves to avoid breaking their hip is to have their vision checked frequently, quit smoking and limit alcohol consumption. Those three steps both lessen fall risk and help bones stay healthy.

Exercise, of a certain kind, helps prevent hip fractures.

A lot of weight (so to speak) is placed on strength and flexibility training in the prevention of hip fractures. Doctors used to view strength training as “bone strengthening,” but no evidence has been found to verify the claim that lifting weights at anything less than Herculean levels makes a difference for bone density. However, committing to muscle strengthening and balance exercises may make falls and fractures less likely for seniors. Pure aerobic exercise, on the other hand, may make fractures more likely in the older athlete.

To minimize the risk of falls, an older adult should also reduce their medications such as some blood pressure medicines, sleep aids or other psychoactive drugs that make falls more likely. That is is big focus of geriatrics as a specialty — they call it “deprescribing” — and it should be done under the guidance of a medical professional.

Preventing hip fractures is part and parcel of preventing osteoporosis, or severe bone weakening in the first place. So, what about vitamins and bone health? Ten years ago, nutrition and supplementation with Calcium and Vitamin D would be high on the list of strategies to prevent osteoporosis, not so much anymore as their efficacy at preventing fractures has been called into question. As stated by the US Preventative Task Force:

For postmenopausal women, there is not enough evidence to weigh the benefits and harms of taking >400 IU of vitamin D and >1000 mg of calcium daily, but there is some evidence that taking ≤400 IU of vitamin D and ≤1000 mg of calcium daily has no net benefit for preventing fractures.

United States Preventative Task Force (USPTF)

However, a diet rich in calcium-containing foods, and at least 400 IU of Vitamin D seem to be the most rational diet strategy to keep bones healthy and strong.

An important tool for some patients at risk of hip fractures are medicines called bisphosphonates. They are marketed under the brand names, Fosamax, Boniva, Actonel and Zometa (which is given intravenously). When looked at in total, bisphosphonates can reduce the likelihood of all fractures (both vertebral and hip) in people with osteoporosis diagnosed on DXA scans.

There are a few important side effects of the oral formulation of these medicines, esophagitis is the more common one, but the subtrochanteric femur fracture is a rarer complication. However, it’s important to realize that the incidence of bisphosphonate-associated fractures (the subtrochanteric variety) is 1/25th as common as the hip fractures they prevent (femoral neck fractures) .

Bisphosphonates can be taken orally, or intravenously as often as every day or as infrequently as once a month, or even once a year, depending on the formulation prescribed. Most guidelines suggest that therapy should only last for a total of five years, but they also stress that bisphosphonates can be restarted if Bone Mineral Density (BMD) drops again.

In particular, women who have very low bone density and have had other fractures (in the spine or hip) really stand to benefit from bisphosphonate therapy. Therefore, a person with very low bone density and a hip fracture may be prescribed bisphosphonates, even intravenously, to prevent the next fracture.

Diagnosing osteoporosis, or its precursor, osteopenia early is the only way to employ preventative strategies effectively. Women should get bone density scans at age 65 and sooner if they have certain risks define by the FRAX tool.

In addition, there are newer drugs coming to market every year for osteoporosis. Denosumab is one of them. It is prescribed for people with severe osteoporosis and a history of other fractures. In a dose of 60 mg given subcutaneously every six months for three years, it’s been shown to prevent both hip and vertebral fractures.

A broken hip has such a negative impact on an older person’s quality and quantity of life that in many cases, it can be considered a terminal illness. Quality surgical care, good physical rehabilitation and post-operative palliative care and hospice for some patients should be the standard for geriatric hip fractures. Perhaps even more importantly, we should employ good preventative strategies, such as exercise, nutrition and bisphosphonates for our at-risk seniors. More attention to preventing this common, painful, and burdensome condition would be a welcome advance in the care of seniors, especially women.