Hip fracture in the elderly

Bone fractures and soft tissue injuries often occur after age 50. This is due not only to the fact that a person becomes less active and more clumsy. This age is often characterized by beriberi, osteoporosis, lack of minerals. Yes, and banal age-related changes make themselves felt. Of particular danger is a fracture of the femoral neck in the elderly. This is an injury that all patients over the age of 45-50 should be informed about.

Epidemiology

A hip fracture is one of the most devastating injuries for the elderly. Moreover, people receive such damage not only on the street, but also at home, so even a sedentary elderly person can be injured.

According to statistics, more than half of the cases of femoral neck fractures are recorded in the warm season: about 10% in May, and about the same number in the period from September to October. More than 75% of fractures occur indoors.

Older people are most often injured when trying to overcome any obstacles or obstacles on the way, which can be thresholds, rugs, etc. (about 40% while at home, and more than 55% while outside). Falls from chairs, beds, stairs, etc. Are less common.

Causes of the hip fracture in the elderly

The thigh bone is a fairly large skeletal element that has to face a huge load every day, since it is located in the upper segment of the lower limb. According to anatomical data, this bone is divided into three parts: the body, neck and head, localized in the cavity of the joint. It turns out that the neck of the femur is a kind of “weak link” in this area, so the corresponding fractures happen quite often. [1]

Osteoporosis makes a special negative “contribution” to the development of a fracture. This is a pathology inherent mainly in older people (mainly women), and is associated with demineralization and increased bone fragility. In addition to osteoporosis, there are other negative factors - for example, in older people, the blood supply to the femoral neck is disturbed, which not only affects the quality of bone tissue, but also impairs its recovery if there is already damage.

In most patients, a femoral neck fracture occurs after a side fall, because in this case there is a powerful targeted blow directly to the hip joint area. But with advanced osteoporosis, even one wrong turn of the body or an awkward tilt is enough to get injured.

Increase the likelihood of a fracture and some risk factors.

Risk factors

Predisposing traumatic factors are often:

• menopause, hormonal problems, increased calcium leaching from bone tissue;
• obesity, hypodynamia;
• prostate hyperplasia;
• alcohol abuse, poor nutrition, impaired absorption of vitamin and mineral substances.

Many chronic pathologies lead to weakening of the bones - in particular, the femoral neck. Thus, the risk of injury increases significantly in older people suffering from arthrosis, osteochondrosis, spondylolisthesis or spondylarthrosis, intervertebral hernia. Bone fragility increases against the background of diabetes mellitus, kidney and liver diseases, and thyroid diseases.

Pathogenesis

The neck and head of the femur are supplied with blood mainly through intraosseous vascular arterial branches. Less involved is the vascular network of the ligament of the femoral head, which is often obliterated in older people.

With an intra-articular fracture of the femoral neck, the basic intraosseous network of arteries is disturbed, which leads to a deterioration in trophic processes in the proximal femoral neck and head. At the same time, recovery processes worsen: with a fracture, the risk of avascular necrosis increases.

Fracture of the femoral neck is more likely to occur with an adduction injury - that is, during a lateral fall. The peripheral segment is adducted and displaced upward and outward. Abductive trauma - emphasis and falling with divorced limbs - is less common in the elderly. At the same time, the peripheral segment remains in the retracted state, with an upward displacement, and in some cases enters the central fragment, forming an impacted fracture.

Negative conditions for adequate fracture closure in the elderly are insufficient blood supply to the proximal fragment, the absence of a periosteal layer in the neck area, a vertical fracture plane, complex alignment of fragments and their loose contact, tissue demineralization.

Symptoms of the hip fracture in the elderly

Because of the extreme prevalence and danger of hip fractures in the elderly, most medical professionals can easily identify an injury if the following symptoms are present:

• Prolonged constant pain in the groin, not intense, but continuous. The victim is able to endure such pain for several days, hoping for its self-elimination, or taking it for a manifestation of arthrosis or arthritis. However, without appropriate treatment, the pain syndrome gradually increases and becomes especially noticeable when trying to actively walk or when placing the foot on the heel.
• The foot changes somewhat, as if turning outwards: this is easy to determine if you compare both feet and compare their position relative to the knee joint.
• In some patients, there is a slight shortening of the affected limb, not exceeding 40 mm. The cause of this symptom is the contraction of the muscles in the area of damage, which is especially typical for varus injury.
• A characteristic symptom of a “stuck heel” appears: it is expressed in the fact that the limb cannot be put from a position on weight to a horizontal plane, since it seems to slide. At the same time, the function of flexion and extension of the leg was preserved.

The first signs of a fracture of the femoral neck can reveal themselves with a crunch, which is especially noticeable when trying to turn a leg that is horizontal. Pain can also be felt when probing the damaged area: then you can also notice a strong pulsation in the area of the femoral artery. 

Other characteristic features are:

• if you press or tap on the calcaneus of the patient, then there are uncomfortable or even painful sensations;
• if there is a violation on the part of the greater trochanter, then the shift of the Shemaker line attracts attention - this is an imaginary line connecting the tip of the greater trochanter with the anterior-superior iliac spine.

Some time after receiving a fracture of the femoral neck, a hematoma may form in the injured area, provoked by a violation of the integrity of deeply located vessels.

Forms

Fracture of the femoral neck in the elderly is divided into several types, depending on the location of the damage, on its level, on the type of displacement and on the nature.

For example, with a varus fracture, the head moves downward and inward, with a valgus fracture, the head moves up and out, and with an impacted fracture, the fragments are displaced into each other.

According to statistics, the impacted form of an intra-articular fracture has the most unfavorable prognosis: if left untreated, the damage can transform (bone fragments separate and diverge, which can only be corrected by surgical intervention).

We will look at other common types of fractures in more detail.

• The impacted fracture of the femoral neck in the elderly often has an intra-articular character. Severe pain and limited mobility are not typical for him, so the victims do not immediately seek medical help. Often this leads to the fact that fragments and fragments continue to move, leading to even more damage, and the impacted fracture is transformed into a non-impacted form. Interestingly, with a timely visit to the doctor, this type of fracture is the most favorable.
• Lateral fracture of the femoral neck in the elderly is the most rare: the line of damage runs clearly along the lateral border, penetrating the base of the neck and not reaching the area of the trochanters. Damage usually does not involve displacement; outward rotational bending and varus position are possible. When viewed from the side, the position of the axis is normal, however, anterior or posterior curvature of varying severity is possible. The lateral fracture has much in common with trochanteric fractures in terms of clinic and treatment, and some experts even identify these types of injuries.
• A pertrochanteric fracture of the femoral neck in the elderly is an injury that covers the bone segment from the subtrochanteric line to the cervical base. The injury is usually caused by overloading the greater trochanter or by twisting the leg. A fracture may be accompanied by severe blood loss, external tissue edema and hematoma.
• Basal fracture of the femoral neck in the elderly is characterized by the location of the fault line at the base of the neck. Injury occurs when falling or due to a direct blow to the thigh.

Complications and consequences

According to statistics, a hip fracture in the elderly often causes the death of patients, despite the fact that death is not at all a direct consequence of the injury. Why it happens?

With a long forced lying position in the elderly, the risk of problems with the respiratory and cardiovascular systems increases many times over, the risk of vascular thrombosis, infection, and skin diseases increases.

Inflammation of the lungs associated with congestion and continuous bed rest is often the killer point for patients.

Among other unpleasant consequences of prolonged "lying" can be called depression, mental disorders. Many elderly people, due to trauma and immobility, lose the meaning of life, their perception of reality is disturbed, their consciousness is confused. Often, patients begin to abuse alcohol, take strong medications (for example, tranquilizers, antidepressants), which easily aggravates the deplorable situation. [2]

Diagnostics of the hip fracture in the elderly

Diagnosis is usually uncomplicated, as if appropriate symptoms are present, a diagnosis of a hip fracture can be made. But without confirmation, such a diagnosis is not valid, so first you should do an x-ray: this type of study will help detect a crack or displacement of the bones in the femoral neck.

Analyzes are prescribed as an addition to the main diagnostics:

• clinical blood test, ESR;
• Analysis of urine;
• if necessary - analysis of the joint fluid, examination of tissues taken during a biopsy.

As we have already said, the basic diagnostic method for detecting a femoral neck fracture is radiography: both cracks and fracture lines are visualized in the pictures. Additional instrumental diagnostics can be connected to clarify some details of the damage. For this, computed tomography is used - a diagnostic study that allows for a more accurate and detailed assessment of the condition of the bone. An alternative to CT can be magnetic resonance imaging.

Differential diagnosis

Differential diagnosis should be carried out with a bruise of the hip joint, dislocation of the hip joint. With a dislocation, characteristic symptoms are present: spring tension of the sore leg, displacement of the femoral head, and a noticeable shortening of the limb. With a bruise, pain, swelling, hematoma are observed; joint function is limited or severely impaired. The final diagnosis is made after an X-ray examination.

Treatment of the hip fracture in the elderly

You can’t let the situation take its course and leave a hip fracture without proper treatment: for older people, this attitude to the problem can be fatal. Treatment is mandatory - whether it be conservative methods or surgery.

Surgical treatment is considered the most effective and radical, but the need for it is not always present. For example, with an impacted fracture, or if the lower segment of the neck is damaged, the help of a surgeon may not be needed. In addition, surgery for an elderly person may simply be contraindicated - for example, due to old age, with severe disorders of the internal organs. [3]

Conservative treatment usually consists of the following mandatory steps:

1. Examination of the patient with further placement in a specialized orthopedic or trauma department.
2. Implementation of skeletal traction during the first 8 weeks after the fracture.
3. Manual therapy, massage procedures.
4. Mandatory use of crutches after removal of skeletal traction.
5. Attempts to involve the affected limb for walking and movement under strict medical supervision, not earlier than 4 months after the injury.

If we are not talking about an operation, then the first thing the doctor will offer is to ensure immobilization and skeletal traction of the affected leg. How does this procedure take place?

• The damaged articular area is cut off with local anesthetics (for example, based on novocaine).
• Set the traction for a period of up to ten days.
• After the specified time, the pull-out structure is removed.
• Turn the patient on one or the other side, raise the head, provide a semi-sitting and sitting position.
• Approximately three weeks later, under the supervision of a doctor, an attempt is made to move the patient on crutches.

Further, in a satisfactory condition, the patient is prepared for discharge. However, he should move only on crutches, accompanied by an assistant. Only the attending physician should decide on the abolition of crutches.

Surgery

Surgery is an important decision for both the doctor and the patient. The doctor must be sure that the elderly person will normally tolerate anesthesia and the intervention itself.

In many cases of hip fractures, the help of a surgeon is mandatory. The nature of the operation itself depends on the type of bone damage, on its scale. Most often, the fracture site is reinforced with a special design, which includes spoke-shaped or rod-shaped fasteners and / or screws. In severe cases, joint replacement may be required.

If the question is raised about the operation, then it is recommended to carry it out as soon as possible. The only factor in which the intervention can be postponed is the presence of temporary contraindications.

The general principles of surgical treatment are as follows:

• such treatment is always performed under anesthesia;
• in the presence of bone fragments, their reposition is preliminarily carried out;
• in case of simple fractures of the femoral neck, the intervention can be carried out without resorting to articular opening, using X-ray control;
• in complex fractures, the joint capsule is opened.

Endoprosthetics is used mainly in elderly patients, whose injury was accompanied by displacement of fragments, as well as in case of necrosis of the head of the bone.

Care for a hip fracture in the elderly

Proper care and good attitude of close people are important conditions for the speedy recovery of an elderly person who has received a hip fracture. In addition to stabilizing the state of the psyche, in order to accelerate the restoration of bone tissue, it is also necessary to perform special therapeutic exercises. It is important to prevent and eradicate the development of depression, depression: if necessary, you can additionally connect a psychotherapist to the treatment.

Close people should provide the victim with a healthy sleep, a complete diet. It is also recommended to conduct a course of massage procedures, to treat existing chronic pathologies. All activities in the complex will help to quickly deal with the problem.

You can not leave a sick person alone: he should always feel the support and participation of his relatives. To prevent the development of depression, doctors recommend spending time together, making plans for the future. It is good if the patient is able to perform feasible housework, as well as independently serve himself (for example, on crutches or sitting on a bed). And performing simple physical exercises to music will allow the patient to be distracted and improve his mood.

Rehabilitation

The duration of the rehabilitation period for a hip fracture in the elderly is difficult to accurately determine. This period depends on many factors, such as the complexity, type of fracture, age and general health of the victim. However, doctors believe that the duration of rehabilitation cannot be less than six months. [4]

In general, the recovery period can be figuratively divided into the following stages:

1. Starting from the third day after the plaster is applied, the patient is recommended to start massage procedures: first, the lumbar area is massaged, gradually moving to a healthy leg. Only after 7-10 days they begin to massage the damaged limb, not forgetting about caution and accuracy.
2. After removing the cast, it is allowed to gradually move the knee joint, making light movements under the supervision of a medical specialist. After 4 weeks, such exercises can be done independently, bending and unbending the leg at the knee. Extra movements that are not provided for by the medical instructions should not be performed.
3. After about three months, the doctor may allow the patient to get out of bed using crutches. At the same time, leaning on the injured leg is still not allowed.
4. The load is gradually increased, and after six months the patient is allowed to try movement without crutches.

Prevention

To prevent such severe injuries as a hip fracture, it is first necessary to:

• ensure that a sufficient amount of calcium is supplied with food (for the elderly, the daily norm is 1200-1500 mg of calcium, taking into account possible impaired absorption);
• provide the body with the necessary vitamins and mineral components - in particular, retinol, ascorbic acid, vitamins D and K, zinc, phosphorus and magnesium are needed;
• give the body regular and feasible physical activity, provide motor activity, strengthen muscles.

In addition to general strengthening of the body, it is necessary to minimize the possibility of falls and injuries. For example, at home, measures must be taken to prevent an elderly person from falling and hitting himself. It is necessary that the floors and floor coverings are non-slip, the thresholds are low (or it is better to get rid of them altogether). In the bathroom, it is desirable to install special handrails for which a person can hold on.

If the injury already exists, then efforts must be made to avoid the development of complications and speed up recovery. Seek medical attention and treatment should follow as soon as possible.

Forecast

Although a hip fracture in the elderly is considered a very difficult injury, the chances of a cure are still high. Pathology is completely curable, however, it is necessary to spend more than one month on rehabilitation. It is important that the effectiveness of treatment and the quality of recovery largely depend on the positive attitude of the patient and his environment. An injured old man cannot do without the help of loved ones.