Fractures of hip region

A hip fracture is another term for a broken hip. It is a common injury that mainly affects older women who often have underlying osteoporosis. Your hip can break in different places. A hip fracture can be 'intracapsular' (within the joint capsule) or 'extracapsular' (outside the joint capsule). Most people who have a hip fracture need an operation to fix the break in the bone. Whether your fracture is 'intracapsular' or 'extracapsular' will determine the exact treatment that the orthopaedic surgeon suggests. It is important that any underlying osteoporosis be treated after a hip fracture.

Some anatomy of your hip

Your hip joint is known as a 'ball and socket' joint. The ball (head) of your femur (your thigh bone) fits into the socket of your pelvic bone to make your hip joint. This socket is called the acetabulum. There is a strong but flexible joint capsule that surrounds the hip joint. It helps to give stability to the joint and also produces a fluid called synovial fluid to give lubrication and help joint movement.

What is a hip fracture?

A hip fracture is another term for a broken hip. Your hip can break in different places. A hip fracture can be 'intracapsular' (the bone within the joint capsule breaks) or 'extracapsular' (the bone outside the joint capsule breaks). The site of your hip fracture can determine the treatment that the orthopaedic surgeon suggests (see below).

Your hip fracture can also be 'displaced' or 'non-displaced'. A 'displaced' fracture is a fracture where the broken bones have moved out of their normal position. If the bone fragments have moved, they need to be put back (reduced) into their normal alignment. In a 'non-displaced' fracture, the bone fragments, even though they are broken, are still aligned in their normal position.

How common is a hip fracture?

A hip fracture is a very common injury that affects mainly older people. It is one of the most common reasons for being admitted to an orthopaedic (bone) ward in a hospital. Around 75,000 hip fractures are treated each year in the UK. However, given the UK's ageing population, this number is predicted to double by 2050.

About 8 in 10 people who fracture a hip are women. The average age of someone who fractures their hip is 80 years.

What causes a hip fracture?

For most older people, a hip fracture happens after a fall, usually just a fall from standing. If you have osteoporosis you are more likely to fracture your hip when you fall. Osteoporosis is the leading cause of hip fracture. Osteoporosis means that you have lost some bone material. Your bones become less dense and more 'honeycombed'. This makes them more prone to breaking. (See separate leaflet called 'Osteoporosis' for more detail.)

There are a number of reasons why an older person may fall. It may just be a simple trip over a loose rug or an item of furniture. However, sometimes there may be a medical reason for a fall. For example, low blood pressure, a heart rhythm abnormality, a faint, etc. If you fracture your hip, the doctors will usually try to look for any reason why you may have fallen. Any underlying problem may need to be treated as well.

A hip fracture can also occur in younger people. In these cases, it is more likely to be caused by accidents such as road traffic accidents or a fall from a significant height.

What are the symptoms of a hip fracture?

If you fracture your hip you will be in a lot of pain around the injured hip. You will be unable to move your hip, stand or walk. You may also notice that the affected leg looks shorter and is turned outwards compared to your other leg.

What should I do if I am concerned that I have a hip fracture?

If you think that you may have fractured your hip, you need to get to hospital as soon as possible. In most cases, this will mean calling a 999 ambulance. A friend, relative or neighbour may be able to help. Whilst waiting for the ambulance to arrive, do not try to move. You should also try to keep warm; covering up with a blanket may be helpful. Do not eat or drink anything while you are waiting for the ambulance to arrive. When the ambulance arrives, you may be given some pain relief for the journey. You will be carried on a stretcher to the ambulance and taken to hospital.

What happens when I arrive at hospital?

When you arrive at hospital, you will usually be seen in the Accident and Emergency department and assessed quickly. You may be given some further pain relief medication, if needed, and sent for an X-ray to look at your hip. If you are dehydrated, you may be given some intravenous fluids (fluids via a drip into one of your veins). You will then usually be seen by an orthopaedic surgeon who will decide the best way to treat your hip fracture (see below). Sometimes you may also be seen by another specialist if you have pre-existing health problems. This is to make sure that you are as fit as possible before you have any operation.

Occasionally, a hip fracture cannot be seen on a standard X-ray. If you have hip pain and have fallen, the doctors may want to be certain that you have not broken your hip. Sometimes, they may repeat your hip X-ray after 24 hours. Another possibility is that they suggest a radioisotope bone scan or an MRI scan of your hip.

What is the treatment for a hip fracture?

Most people who have a hip fracture need surgery to fix the break in the bone. The type of surgery that you have can depend on where you have broken your hip bone (whether you have an intracapsular or extracapsular fracture) and also any underlying health problems that you may have. You should discuss the options available with the surgeon who is performing your operation.

Intracapsular hip fractures

• • Non-displaced fractures - usually, if you have a non-displaced intracapsular hip fracture, you will have an operation to join together and hold in place the broken bone fragments. This is known as 'internal fixation'. Various devices can be used to provide the fixation, including screws, nails, plates and rods. Internal fixation like this enables quicker healing of the broken hip bone and usually allows you to get up and mobile more quickly.

  • Sometimes, a non-displaced intracapsular fracture is treated conservatively. This means that no operation is done and your hip bone is left to heal naturally. However, if this is the case, your stay in hospital tends to be longer. There is also the risk that the bone fragments can move so that the hip fracture becomes 'displaced'. This treatment is usually reserved for people who have severe underlying health problems or who are very frail and would not be able to go through an operation.

  • Displaced fractures - if you have a displaced intracapsular hip fracture, the bone fragments need to be re-aligned. They can then be fixed in place during an operation using internal fixation as described above. Sometimes, a hip replacement is used to treat a hip fracture. Hip replacement is also known as hip arthroplasty. During a hip replacement, the surgeon removes parts of the bones that make up your hip and replaces them with artificial hip parts, also called 'prostheses'. A total hip arthroplasty is where both sides of the hip joint are replaced (the ball, or head, of the femur and the acetabulum socket). A hemiarthroplasty is where only the head of the femur is replaced by an artificial part.

  • If you already have some hip joint disease - for example, osteoarthritis - and you are reasonably active and otherwise well, a total hip replacement may be a good option to treat a displaced intracapsular hip fracture.

Extracapsular hip fractures

An operation is also needed to treat extracapsular hip fractures. A special screw called a 'sliding hip screw' is usually fitted to hold the bone fragments in place. Sometimes a nail (called an intramedullary nail) is used instead.

Types of anaesthetic used in hip fracture surgery

Spinal or epidural anaesthesia is often used during hip fracture surgery. A spinal anaesthetic is when a local anaesthetic drug is injected through a needle into the small of your back to numb the nerves from your waist downwards for two to three hours. An epidural anaesthetic is where a small plastic tube (an epidural catheter) is passed through a needle into the small of your back. Through this tube, you are given local anaesthetic and pain relieving drugs. Again, it produces numbness in your lower body but it can be topped up and so the effects last longer than with a spinal anaesthetic.

Sometimes, you may be given a general anaesthetic when you have surgery after a hip fracture. This is an anaesthetic where you are put to sleep.

What happens after surgery for a hip fracture?

After surgery you will usually be taken from the operating theatre to an orthopaedic ward. You should be given pain relief as needed. Oxygen therapy (via a facemask or nasal cannulae) is usually needed. A drip to give you intravenous fluids will also be required by most people.

When you have recovered from the surgery, rehabilitation is then needed to get you back on your feet. The aim these days is to get you up and moving as quickly as possible after your operation. For some people, this can be as soon as the following day. A team of healthcare professionals are usually available to help you in your recovery. As well as doctors and nurses, this may include a physiotherapist to help with walking and exercises. You may also be seen by an occupational therapist to help you reach your maximum level of function and independence after your hip fracture. They can help with any adaptations that may be needed around your home to allow you to return home safely.

Some hospitals have specialised geriatric-orthopaedic rehabilitation wards that are set up to help elderly people who have sustained injuries including hip fractures.

Treatment of any underlying osteoporosis

If you are an elderly person who has broken your hip, it is common for there to be underlying osteoporosis. Depending on your age, you may be referred for a special DEXA bone scan to look for any evidence of bone thinning and osteoporosis. However, women over the age of 80 almost all have a degree of osteoporosis, and so this bone scan is usually only suggested for people under the age of 75.

Treatment of osteoporosis is commonly with a group of drugs called bisphosphonates. These are often prescribed with dietary supplements of calcium and vitamin D. The separate leaflet called 'Osteoporosis' gives more details about its treatment.

Are there any complications after a hip fracture?

You may not experience any complications after a hip fracture. However, rarely, complications can occur in some people. These may include:

• • Infection - you may be given some antibiotics to try to prevent infection (such as wound infection) after surgery to treat a hip fracture. Pneumonia is another infection that can occur after a hip fracture.

  • Deep vein thrombosis - a deep vein thrombosis (DVT) is a blood clot in a vein, usually a leg vein. It can be caused by immobility. As you will be more immobile after a hip fracture, you are at increased risk of developing a DVT. For this reason, you will also usually be given some medication to help prevent DVT after you have a hip fracture. See separate leaflet called 'Deep Vein Thrombosis' for further details.

  • Blood loss - this can occur after a fractured hip. Because of possible blood loss, you may need fluid replacement via a drip. Sometimes a blood transfusion is needed.

  • Fracture non-union - this is where the bone fragments of the fracture do not heal and join back together in the normal way.

  • Avascular necrosis - this is more likely if you have an intracapsular hip fracture. The blood supply to the head of the femur (the thigh bone) is damaged by the fracture. Without blood, the bone tissue can die. This can lead to problems including chronic pain around the hip.

  • Pressure ulcers - a pressure ulcer is an ulcerated area of skin caused by irritation and continuous pressure on part of your body. If you are not very mobile and are spending long periods in bed or in a chair (as you are after a hip fracture), you are at increased risk of developing a pressure ulcer. See separate leaflet called Pressure Ulcers' for more details.

What is the prognosis (outlook) after a hip fracture?

This can depend to some extent on how fit you were before you broke your hip. However, even for the fittest of people, a hip fracture can mean that you do not regain your full mobility afterwards. Some people may also have persistent pain in their hip area after a fracture. If you were less fit when you broke your hip, you may find that after a hip fracture, it becomes difficult for you to live independently.

Some people need extra care when they move back home after a hip fracture. Others may need to move into a residential or nursing home so that they can get the extra care with mobility that they need. For these reasons, fracturing a hip is something that many people fear as they get older.

Can a hip fracture be prevented?

A fall in someone who has osteoporosis is a frequent cause of a hip fracture. Therefore, prevention of a hip fracture should be aimed at trying to prevent osteoporosis, at treating any osteoporosis that is already present, and at trying to prevent falls.

The separate leaflet on osteoporosis discusses its prevention in detail. But briefly, osteoporosis prevention includes:

• • Regular weight-bearing exercise such as brisk walking, aerobics, dancing, running, etc.

  • Ensuring adequate calcium and vitamin D intake in your diet (and possible supplements for those who may be deficient).

  • Stopping smoking and reducing your alcohol intake. Chemicals from tobacco in your bloodstream can affect your bones and make bone loss worse. If you smoke, you should make every effort to stop. Also, cut down on alcohol if you drink heavily.

There are a number of different ways to reduce the chances of you having a fall. They can include:

• • Looking at any particular hazards that you may have in your home, such as loose rugs or furniture.

  • Having a regular check of your eyesight.

  • Seeing your doctor regularly for a review of your medication, your blood pressure and your general health.

If you are concerned that you are at risk of falling, you should discuss this with your doctor or social worker.

A note about hip protectors

Another thing that has been suggested in the past to try to reduce the chance of breaking your hip is to wear special padding around your hip (known as a hip protector) to protect your hip if you fall. On the basis of early reports of some trials, hip protectors were suggested as a good idea. However, there is increasing evidence that hip protectors are not effective in preventing a broken hip if you live at home. Their effectiveness for someone living in, for example, a nursing home, is uncertain.

References

• • Management of Hip Fracture in Older People, SIGN (June 2009)

  • Parker M, Johansen A; Hip fracture. BMJ. 2006 Jul 1;333(7557):27-30.

  • British Orthopaedic Association Standards for Trauma (BOAST); BOAST 1: Hip fracture in the older person. September 2008.

  • Bilezikian JP; Efficacy of bisphosphonates in reducing fracture risk in postmenopausal osteoporosis. Am J Med. 2009 Feb;122(2 Suppl):S14-21. [abstract]

  • Bischoff-Ferrari HA, Dawson-Hughes B, Baron JA, et al; Calcium intake and hip fracture risk in men and women: a meta-analysis of prospective cohort studies and randomized controlled trials. Am J Clin Nutr. 2007 Dec;86(6):1780-90. [abstract]

  • Mayor S; UK hip fracture audit is launched to improve care and reduce costs. BMJ. 2007 Sep 29;335(7621):634-5.

  • Parker MJ, Gillespie WJ, Gillespie LD; Effectiveness of hip protectors for preventing hip fractures in elderly people: systematic review. BMJ. 2006 Mar 11;332(7541):571-4. Epub 2006 Mar 2. [abstract]

  • Bischoff-Ferrari HA, Willett WC, Wong JB, et al; Prevention of nonvertebral fractures with oral vitamin D and dose dependency: a meta-analysis of randomized controlled trials. Arch Intern Med. 2009 Mar 23;169(6):551-61. [abstract]

  • Davenport M; Fracture, Hip. eMedicine. Updated: Apr 23, 2009.

  • The assessment and prevention of falls in older people, NICE (2004)

  • Osteoporosis - primary prevention, NICE Technology Appraisal Guideline (October 2008); Alendronate, etidronate, risedronate, raloxifene and strontium ranelate for the primary prevention of osteoporotic fragility fractures in postmenopausal women

  • Osteoporosis - secondary prevention including strontium ranelate, NICE Technology Appraisal Guideline (October 2008); Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women