Saturday, 23 July 2011

Treating Hip Fractures in the Elderly

Published in "Panorama"

Managing hip fractures in the elderly

Fall and Osteoporosis, are the commonest causes of hip fractures in the elderly and contrary to popular belief, they need be neither life threatening, nor, not amenable to surgery, says Dr.H.P.C.Khincha, Director and Head of the Department Orthopedics, Specialist in Joint Replacement, Arthroscopic Surgery & Sports Medicine, Sagar Apollo Hospital, Bangalore.

The fall itself may happen due to slipping on wet surfaces as in toilets, or on uneven surfaces, tripping over carpet edges, et al. Very often, poor vision may lead to these mishaps. Alternatively, when bones have weakened due to Osteoporosis, the elderly people can occasionally break the hip bone after a trivial twist, and then fall, explains Dr.Khincha.

Besides hip fractures, the other common sites of fracture, a break in the continuity of bone which may be partial or total, with or without displacement, include the wrist, spine, shoulder, ankle and around the knees.

Is it true that if old people have a fall, it could culminate in a fatality, if not immediately, at least within a few months? Dr. Khincha is reassuring and unequivocal in his response: “No. If the person who has fallen, has had some predisposing problem as a heart attack, weak heart, an underlying cancer, et al, a fall could pose a risk, not otherwise. If the person has been hale and healthy and walking about and he has had a fall due to any reason, then he can be up and about, walking well, with surgery. He can get back to normalcy within three months of surgery, get back his independence in 3 days as in the ability to get out of bed, sit at a dining table, use a commode, do his shaving and other simple routine chores.”

Is there any upper age limit to a person being considered suitable for surgery? “No age need be excluded from surgery if the person is healthy,” opines Dr.Khincha. “I myself have operated upon patients up to the age of 108 years! In fact, a few days back I operated upon an 85 year old with a hip fracture who had had a previous heart attack. He walked home after surgery, with a walker and the third day following surgery, he was even climbing a few steps!”

Dr.Khincha strongly advises surgical treatment of fractures where necessary, emphasizing that the risks of operating are much less than the risks of not operating! So what are the risks of not following up with surgical measures? Dr.Khincha enumerates:

Firstly, the fractures may not unite at all or unite in a wrong position if surgery is not done.
Secondly, the commonest, most debilitating and painful problems are bedsores which the victim may develop as a result of long bed rest of 6 – 12 weeks.

Thirdly, prolonged bed rest could give rise to pneumonia because there is no respiratory physio.
Fourthly, Deep Vein Thrombosis may result from prolonged bed rest.

The mental agony of being in bed and having to depend on others for simple chores of life, can be no less traumatic.

Financial burden of long hospitalization and disruption of routine of family members, bring with them their own set of problems.

These are all enough indications to fix or replace with hip prosthetics so that the patient can be up and about, back to the home environment, without a stick or walker after 3 months, says Dr.Khincha.

Is there something like prone-ness to fracture amongst the elderly? Dr.Khincha emphasizes, “As I said, osteoporosis is the commonest cause of a fall or a break. Secondly, many times you hear people say that they were walking and then they heard a click in the hip, following which they fell down. This implies the person has broken an osteoporotic bone and then fallen. Thirdly, elderly people, especially males, having prostatic problems, may trip and fall in the darkness or from sleep when they wake up to attend nature’s call at night. This is compounded by the fact they most of them have vision problem. These are prone conditions which can increase the risks of falls, leading to fractures.”

Is there any gender bias to hip fractures? Osteoporosis is more common and gross in females because of hormonal problems, reveals Dr.Khincha. “So the female population of hip fractures anywhere in the world is far higher than the male population.”

How does a person know he or she has a fractured hip? After a fall, generally the person is not able to move or get up if there is a hip fracture, explains Dr.Khincha. There is extreme pain on slightest movement of the affected leg.

What measures should be taken before medical help can be reached? “It is important,” says Dr.Khincha, “to comfort the patient and arrange for an ambulance to reach him to the hospital. It is equally important not the feed the patient anything orally, particularly fluids, in a lying down position since this may result in the food getting into the respiratory system rather than into the food pipe, thus causing harm.”

What are the diagnostic measures used once the patient reaches the hospital? An X-Ray of the hip is taken. This is followed by a routine check up of the patient to look out for any other injuries. Chest X Ray, ECG and routine blood tests are done. Thorough medical, cardiology and urological checks are done to rule out systemic problems. Traction is applied to the affected leg.

What kind of surgical procedure is involved in treating the fracture? Dr.Khincha explains, “Depending on the level of fracture, we have two types of procedures. If it is an intracapsular hip joint fracture, that is, fracture within the hip joint, we normally go for hip replacement. That is we put an articifical hip made of medical steel and sometimes titanium. Medical steel is an alloy which has been medically tested and found to be bio-compatible with the tissues of the body; it is non-allergic, non-infective and non-irritant. In the second instance where we have an extracapsular fracture, that is, fracture outside the hip joint, we fix it with a plate and screws or sometimes with other devices.”

Are the procedures contraindicated in certain patients? “No, not unless the patient is so moribund that even the anesthetist and physician will not give me a fit for the minimum anesthetic time to do the surgery,” says Dr.Khincha.

Is it true that the surgery is contraindicated in diabetics, osteoporotics and those with previous heart attacks? Dr.Khincha replies, “These conditions can be easily controlled and with improved anesthetic techniques and ICU care, it is now safer to operate even on these patients.”

What are the complications of the surgery itself? “Infection, though a possibility, is very rare these days because of the antibiotic cover, sterile and well equipped operation theatres and strict theatre protocol and discipline,” reveals Dr.Khincha. “However, if the bones are very, very osteoporotic, then the fixation of our implants are not that tight; it is like putting a screw in some wet cement and the screw can be easily pulled out. In such a situation, our fixation can fail. But of course there are ways and means of overcoming this by using either cement or the new technique called Locking Plates and Bolts, which does not depend on the osteoporosis; rather it depends on the mechanism of how we fix it.”

What is the prognosis for patients following surgery? “Much better than if they were not operated upon,” emphasizes Dr. Khincha. “In fact usually these patients don’t even have to use sticks and walkers beyond the initial 6 – 12 weeks following surgery.”

What about post surgical pain? For the first two to three days following surgery, pain is totally controlled by special techniques like epidural analgesia or controlled pumps. Pain normally reduces by the 3rd day and is completely gone by a week, explains Dr.Khincha.

Suppose the person has another fall later in life, how will the implant be impacted? Says Dr.Khincha, “I’ve seen that the victims don’t fracture in and on the area where we’ve operated upon; it’s usually below the lower most end of the plate, at the stress riders, whenever another fall and fracture happens. Of course, sometimes the plates can break because of the impact of the fall. Then we re-do the whole procedure with a slightly higher risk. But then again, these people would be better off with the surgery than getting laid in bed!”


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