Hip Fractures in The Elderly Can Have Serious Consequences

19 June 2022

Fractures in the geriatric population are almost always caused by a combination of weak bones from osteoporosis and a fall. Of particular concern are hip fractures as they carry a high death rate, especially since the elderly often have multiple illnesses and functional impairments as well.

A hip fracture is a partial or complete break in the upper portion of the femur (thigh bone). The break often happens in the neck of the femur, i.e. the narrowest part. With younger patients, this fracture is typically the result of a fall from a ladder or a vehicle collision, but in the elderly, it is often due to a fall from a standing height. Those with severe osteoporosis can even suffer a fracture just by twisting their leg while standing.

Sunway Medical Centre, Sunway City Consultant Orthopaedic and Arthroplasty Surgeon Dr Suhail Suresh Abdullah explains: “If someone has a hip fracture and you want her to be pain-free, she will have to be totally in bed for three to six months.

 “This will probably heal the bone, but anatomically, it could be in a displaced position and cause a shortening of the leg; she will then be unable to walk properly and start falling again. For that reason, a hip fracture in elderly has to be operated on.”

Also, a younger person with a hip fracture who needs bed rest may not suffer from any lung problems, compared to an 80-year-old, whose lungs and heart are already not in the best of shape.

He says: “If we don’t operate and just leave them in bed, half will die within three months due to lung complications, pneumonia, blood clots, bed sores, etc. When they’re lying down, their torso will be in one plane and they cannot sit up. If they do, it might push the bone out of alignment. But they must sit up to prevent lung complications. Hence, we try to take them to the operating theatre as soon as possible to treat the hip fracture, even if the patient is 101.”

Dr Suhail’s oldest patient was a 99-year-old lady who fractured one hip, then six months later, fractured the other. She survived both surgeries.

Surgery a necessity

Depending on how and where the bone breaks, it can be repaired with the help of metal screws, plates and rods. If the bone is completely broken at the femoral neck area, then an artificial replacement (prosthesis) may be necessary.

“For those above 70, no matter how healthy they are, if they go to sleep tonight, they may not wake up tomorrow simply because they are elderly. Now, we are taking this body and putting it under a lot of stress for surgery. Putting them under anaesthesia also has its own risks. I always tell these elderly patients needing surgery that it’s like taking them to the deep sea and bringing them back to shore again alive. If they don’t end up in intensive care, I probably will because of the amount of stress involved!” says Dr Suhail, laughing.

If a patient falls at night, the surgeon knows that it is inevitably going to be a case of hip fracture. The most common type of fall is landing on the buttocks, which leads to either the hip or spine getting fractured.

“If they use their hand to break the fall, they might break the wrist. If they are in a narrow space, i.e. toilet, and want to prevent their head from hitting the wall when they fall, they will flex their hips to sit down and end up landing on the buttocks. Most elderly people do not have very good hip control, which is why when we do rehabilitation for this group, the emphasis is on hip flexion exercises,” explains the Malaysian Orthopaedic Association president.

In most hip fracture cases, the surgeon’s intention is to get the patient to be mobile quickly. But usually, family members are reluctant to proceed with surgery because their parent is already old and they’re concerned with the outcome. And perhaps, finances as well.

“They think the doctor is gung ho to operate, but when I sit down and explain to them, they understand why surgery is necessary. Sometimes, when we do all the pre-surgery investigations, we may discover that they have a major block in the artery and the cardiovascular risk for hip replacement is very high. In those cases, we probably have to say no to surgery. There are also others who are completely unfit for surgery and no matter what we do, we cannot get them ready,” he points out.

These segments of patients are then pumped with painkillers and blood thinners so that they don’t end up getting a stroke or deep vein thrombosis – potential side effects of a hip fracture. They’re also recommended optimal nursing care and advised to sleep on mattresses that can prevent bed sores.

Dr Suhail says: “Within three to four days, we try to sit them up and do a lot of chest rehabilitation to enable them to breathe well. We keep them propped up at 30 to 45 degrees, and by day five, we transfer them to a wheelchair. However, imagine the pain they have to go through. If we cannot sit them up, we are going to lose them.”

When they can sit, the bone will heal in three months, but it will be in an abnormal position. The limb will be shortened and rotated, so the patient will have to be confined to a wheelchair, although he can stand with assistance.

Osteoporosis is inevitable

As women are more predisposed to osteoporosis, they tend to suffer fractures more than men, with the ratio being five to one. After menopause, the decline in the female hormone oestrogen makes the bones thinner as there is no more protection, unless the individual is on some form of anti-osteoporotic treatment.

“When I see patients in the perimenopausal age and ask them to do a bone density test, they will ask if it is necessary as they don’t have any problems. When they do and we pick up osteoporosis, they are shocked,” he says.

Thus, women are advised to build their bone mass to a high level when they are in their 20s to 40s, so that when they reach menopause, the bone mass does not drop to a critical stage.

Dr Suhail explains: “Your bone density drops drastically in the first five years post-menopause, and the area that usually gets a significant reduction of bone is at the hip joint, end of wrist and the spine – all these bones are of the same calibre (spongy bones).

“Osteoporosis will always happen after menopause – it could be at 53, 80 or 100, depending on how you take care of your body. So, if you live long enough, you will get osteoporosis and the only way to delay it is to load the bone.”

Compare a dog bone and a fish bone – the land mammal is standing on its feet all the time so the bones are hard, whereas the fish is swimming and its bones are much softer.

“To avoid the bone from getting soft, walk or exercise instead of sitting down,” he advises.

Once the hip fracture is sorted out surgically, the patient needs to be on medications to rebuild the bone. Back then, only calcium and vitamin supplements were available; now, there are tablets, infusions and injections to strengthen the bone and slow down bone loss (i.e. bisphosphonates). Bone renewal is a slow process, but it has to be combined with proper diet and exercise to work. Many don’t realise that there is a 40-50% risk of another hip fracture occurring within a year.

Dr Suhail cautions: “These anti-osteoporotic drugs take at least a year to work. If the hips are not strong and you are not changing your lifestyle or not doing physiotherapy, then it is going to happen again.”

Men recover faster because they have larger bone volume and more muscle mass.

“When it comes to recovery from any surgery, we used to talk about the heart being strong, but now it’s all about muscle mass and preventing sarcopenia among the elderly. In intensive care, the patient with more muscle mass will survive better than a patient without, assuming everything else is the same. So work on building muscles,” he says.

How they fall

Dr Suhail shares: “The common story is that a woman will wake up to urinate at night because she has a weak bladder.

“Not wanting to wet herself, she will get up quickly from lying to a standing position to rush to the toilet, and this will cause a drop in blood pressure (orthostatic hypotension). She might get dizzy and fall. Or the bedroom lights would be off and she might trip over something and fall.”

To prevent falls, he offers some tips.

  • Have a potty in the room

“Many people cannot accept this, but it is so convenient.

“Get a commode chair so that when you get up in the middle of the night, you just have to transfer yourself to the potty and pee.

“The next morning, empty the bucket.

“Running to the toilet is a big price to pay.”

  • Install a dim floor light or keep the toilet light on at night

“If patients have cataracts and they don’t solve the eye problem, they cannot see clearly and there is a higher risk of falling.”

  • Keep the bedroom free from obstacles so that you can move unobstructed

“Patients always tell me they tripped over their grandchild’s toy and fell – that’s an entire drama!

“Older people are accustomed to where the furniture is usually placed, so don’t move around the furniture too much or the person gets confused.”

  • Get anti-slip floor mats
  • Take your medications properly

“Often, the elderly may forget to take their diabetic or blood pressure medications, or they get constipated and spend a long time straining in the toilet.

“This causes their blood pressure to drop so that when they are done, they get up and fall.”

Source: The Star