Management of Hip Fractures in Elderly Patients

Introduction

Elderly patients are at higher risk of developing hip fractures as their age compromises their bone health as well as their medical condition of the patient. The fracture is first diagnosed, and the treatment intervention depends on the fracture type. Considering the patient's medical condition also forms the basis for gaining better treatment outcomes. This article elaborates on the various aspects of the management of hip fractures in elderly patients.

What Are Hip Fractures?

Fractures in the hip bone are called hip fractures, primarily osteoporotic in elderly patients. Osteoporotic fractures occur due to a decrease in the mineral content of the bone.

Along with the increasing age, elderly people are prone to increasing co-morbidities, which hampers the patient's clinical condition, leading to accidental falls.

Depending on the location and extent of the fracture, hip fractures are classified into the following types:

• Intracapsular Fractures - Intracapsular fractures occur inside the capsule of the hip.

• Extracapsular Fractures - Fractures occurring on the outside of the capsule are termed extracapsular fractures.

What Are the Symptoms of Hip Fractures in the Elderly?

Symptoms usually depend on the degree of displacement and the extent of the fracture. The following are the symptoms of hip fractures in elderly patients:

• Pain.

• Altered function.

• Swelling.

• Inflammation.

• Tear on the overlying skin.

• Abnormal positioning of the limbs.

• Modified walk and posture.

How Can Hip Fractures Be Diagnosed?

The following are the methods for diagnosing hip fractures:

The clinical condition and symptoms of the patient first lead to the basic idea of fracture.

• X-ray: An X-ray is advised to confirm the presence of a fracture and to locate it.

• MRI (Magnetic Resonance Imaging): At times, the X-ray does not show the fracture location; hence, an MRI (Magnetic resonance imaging) or bone scan is advised.

• CT (Computed Tomography) Scan: It is an advanced imaging procedure than the conventional X-ray.

What Are the Various Management Protocols for Hip Fractures?

Better treatment outcomes are also based on considering the patient's medical state. Management of hip features in elderly patients involves surgical and nonsurgical intervention therapies.

• Non-surgical Management:

Adequate and proper analgesia forms the basis of the treatment as it provides immediate relief and reduces discomfort, which allows the patient to take up diagnostic investigations.

Use of regular Paracetamol, unless it is contraindicated, is advised.

If required, opioids are also prescribed, and care is taken to avoid most non-steroidal anti-inflammatory drugs in the elderly.

Preoperative and intraoperative use of local anesthesia is suggested to provide adequate effect and to reduce the use of opioids, which can cause delirium. It should be noted that analgesia is not preferred as a substitute for surgery.

It becomes challenging to relieve pain in patients suffering from mental health issues.

• Surgical Management:

Hip fractures need emergency surgery as they can be associated with the occurrence of pressure sores and also the risk of death.

Almost half of the hip fractures are displaced intracapsular fractures. The blood supply for this kind of fracture is questionable, and the healing of the fracture after the surgery also cannot be relied on.

• Hip Hemiarthroplasty: It is a process that is advised in treating displaced intracapsular fractures in which the femoral head of the bone is replaced. Bone cement can also be used without risk in patients with an increased mortality risk.

• Cemented Total Hip Replacement: Patients who can walk independently outside with medically fit conditions and undergo lengthy surgery can be treated with cemented total hip replacement.

• Sliding Hip Screw Fixation: It is a process used to treat extracapsular hip fractures, which allows stability that can aid in the union of the fracture.

• Use of Modern Implants: It is an evolving technology used in the surgical management of hip fractures

Rehabilitation and Multi-Disciplinary Care:

Specific programs such as the orthogeriatric model of care and the hip fracture program recognize the importance of multidisciplinary care. The shared care approach for the patients undergoing treatment helps improve the treatment outcome. An orthogeriatrician is a specialist who is involved in the rehabilitation process. The specialist optimizes the medical condition of the patient to increase the recovery process and early discharge of the patient.

It is recommended to complete mobilization soon after the surgery. Intensive surgeries are effective in improving the condition of the patient. The best intervention to enhance the patient's recovery still needs to be determined.

Nutrition also plays a vital role in improving the patient's overall clinical condition.

What Is Geriatric Hip Fracture Surgery?

The location and severity of the fracture, whether the cracked bones are misaligned or displaced, the age, and any underlying medical issues will all likely affect the type of surgery required. Choices consist of:

Internal Screw Repair: To hold the bone together while the fracture heals, metal screws are placed into the bone. There are occasions when a metal plate that runs along the thigh bone (femur) has screws fastened to it.

Total Hip Replacement: Artificial components (prostheses) are used for the replacement of the pelvic bone socket and the upper femur. High number of studies indicate that in otherwise healthy, independent individuals, total hip replacement proves more economical and has superior long-term results.

Partial Hip Replacement: There are various circumstances in which replacing the hip's socket is not necessary. Adults no longer live independently and have other health issues that may benefit from a partial hip replacement.

What Is the Importance of the Prevention of Hip Fractures in the Elderly?

Elderly persons are more likely to develop co-morbidities as they age, which impairs their clinical state and increases their risk of accidental falls. The most important part of caring for elderly patients starts with preventing fractures.

Strategies to prevent fractures include:

• Decreasing the risks of falls.

• Preventing bone health.

Falls can be assessed by identifying the medical issues for falling, such as syncope, postural hypotension, and arrhythmia. Mechanical causes, including poor mobility, impaired vision, and balance, are assessed to prevent falls and fractures by installing bath equipment, rails, stairs, lifts, etc. Bone health profile is taken by laboratory blood tests evaluating the vitamin D or calcium deficiency and reviewing the medications and associated medical conditions such as renal and liver disease. Oral bisphosphonates are initiated in elderly women to prevent osteoporotic fragility fractures (low trauma fractures) occurring due to a decrease in the mineral content of the bone.

Conclusion

Hip fractures in elderly people are usually occurring at an increased rate. With the increased advancements in the treatment of hip fractures, there is significant scope for complications related to the healing of the fracture, nonunion, or implant failure. Recognizing the potential complications and treating them also is necessary to improve the treatment outcome for the patient. A proper assessment of the fracture is done by the orthopedist, and surgical intervention therapy is advised when necessary. On the whole, hip fractures present complex challenges to both patients and treating physicians. Improving the quality of life and preventing fractures, along with a multi-disciplinary approach, helps improve patient outcomes.