Fractures in Older Adults
I recently had a routine follow up visit with one of my patients who sustained a hip fracture. He was recovering from surgery quite well and we were considering the best course for weaning him off his cane. His wife joined the conversation and said: “I am glad you did not say he is doing well “for his age.” Lately, all the docs we’ve seen point out how we are faring medically for our age and we don’t like that.”
When I meet a patient with a fracture – any patient really—my first question is: What activity that you enjoy has been limited by your current injury? My treatment approach takes into account the calendar age of the patient, but its main focus is restoring the person to their pre-injury activity level.
Half of the women and a quarter of the men over age of 50 will fracture a bone weakened by osteoporosis. Hip fractures are serious and increasingly common injuries. These injuries, unfortunately, can be the beginning of a cascade of events that ends one’s life. I take these very seriously.
There is never a good day to have a hip fracture, and often they occur during most inconvenient times – while on vacation or when friends and family travel away. There is a small window of time during which we can medically optimize the patient’s health, perform surgery and begin rehabilitation for a successful outcome.
Treatment and recovery vary due to several factors:
• What kind of patient has the fracture (medical health, support of nearby family, involvement of patient in treatment)?
• What type of fracture is it?
Here I outlined most common ways in which hip and pelvis can be injured.
Pelvic ring fracture, pubic ramus fracture, and sacral fractures can be sustained from a fall from standing height or a small step.
Most of these fractures are painful, but stable. All that is required is pain medication, encouragement of physical therapy, and time. I will routinely X-ray patients like this a short while after the injury to check for any shifting of the fragments (aka displacement) and to ensure that no surgery is required. Rarely, these become unstable and require major pelvic ring reconstruction in an orthopedic trauma center.
Femur fractures – when people speak about hip fractures that require surgery they speak of injuries involving various parts of the femur or thigh bone.
Fractures immediately adjacent or through the ball (femoral head) portion of the femur can sometimes be treated with weight-bearing restrictions but usually require either stabilization with screws to keep them from displacing while they heal or a hip replacement (arthroplasty).
Replacement may be the better option if the fracture is very unstable or if injury moves the ball sufficiently away from the rest of the femur that can tear arteries that feed the femoral head. Rarely do the screws work their way through soft bone which would require a revision to a hip replacement.
The type of hip replacement typically performed is partial arthroplasty also known as hemiarthroplasty. The procedure offers stability and immediate, unlimited weight bearing. However, this offers less range of motion to a younger, more active person.
Total hip arthroplasty is recommended for those active individuals who are closer to 60 years of age than to 80 and who are able to participate in more involved therapy. These typically result in return to more active lifestyle: horse-riding/golfing/even tennis! There has been a historically reported higher risk of hip dislocation in these patients. However, with improved understanding of hip mechanics and patient selection, dislocation after a total hip replacement in a hip fracture patient is less and less likely.
Inter-trochanteric, sub-trochanteric or per-trochanteric fractures refer to the region where femoral neck meets the shaft. These fractures in most cases can be repaired without replacement of the femoral head. Instead, a metal device (nail/rod) is inserted into the hollow canal inside the femur and a large screw is threaded through the nail into femoral head. This compresses the femoral neck and is quite stable and the patient is able to bear weight on it right away. Typically, these patients recover quite well and are able to keep their hip joint. Rarely does the nail work its way through soft bone and a second surgery to a revision hip replacement is required.
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