Hip fracture treatment 5297328 217299913 2008-06-05T13:08:37Z Herbythyme 2420168 Reverted edits by [[Special:Contributions/Doctorveklich|Doctorveklich]] ([[User talk:Doctorveklich|talk]]) to last version by 69.137.218.163 [[Hip fracture]]s are treated in one of two ways: [[Traction (orthopedics)|Traction]] or [[orthopedic surgery]]. ==Non-operative treatment== If operative treatment is refused or the risks of surgery are considered to be too high the main emphasis of treatment is on pain relief. [[Traction (orthopedics)|Skeletal traction]] may be considered for long term treatment. Aggressive chest [[physiotherapy]] is needed to reduce the risk of [[pneumonia]] and skilled nursing to try to avoid [[Bedsores|pressure sores]] and [[Deep vein thrombosis|DVT]]/[[pulmonary embolism]] Most patients will be bedbound for several months. ==Operative treatment== Most hip fractures are treated by [[orthopedic surgery]], which involves [[medical implant|implanting]] an [[orthosis]]. The surgery is a major stress on the patient, particularly in older people. Pain is significant, forcing the patient to remain immobilized. Since prolonged immobilization can be more of a health risk than the surgery itself, post-op patients are encouraged to become mobile as soon as possible, often with the assistance of [[physical therapy]]. ===Surgery for fractured neck of femur=== For low-grade fractures (Garden types 1 and 2), standard treatment is fixation of the fracture in situ with screws or a sliding screw/plate device. This treatment can also be offered for displaced fractures after the fracture has been reduced. In elderly patients with displaced fractures many surgeons prefer to undertake a [[Hemiarthroplasty]], replacing the broken part of the bone with a metal implant. The advantage is that the patient can mobilize without having to wait for healing.<br clear="all" /> ===Surgery for intertrochanteric fracture=== An intertrochanteric fracture, below the neck of the femur, has a good chance of healing. Treatment involves stabilizing the fracture with a lag screw and plate device to hold the two fragments in position. A large screw is inserted into the [[femoral head]], crossing through the fracture; the plate runs down the shaft of the femur, with smaller screws securing it in place. The fracture typically takes 3-6 months to heal. As it is only common in elderly, removal of the [[dynamic hip screw]] is usually not recommended to avoid unnecessary risk of second operation and the increased risk of re-fracture after implant removal. The most common cause for hip fractures in the elderly is osteoporosis; if this is the case, treatment of the osteoporosis can well reduce the risk of further fracture. Only young patients tend to consider having it removed; the implant may function as a [[stress riser]], increasing the risk of a break if another accident occurs.<br clear="all" /> ===Prognosis post operation=== Among those affected over the age of 65, 40% are transferred directly to long-term care facilities, long-term rehabilition facilities, or [[nursing home]]s; most of those affected require some sort of living assistance from family or home-care providers. 50% permanently require [[walker (tool) |walker]]s, canes, or some other such device for mobility; all require some sort of mobility assistance throughout the healing process. Among those affected over the age of 50, approximately 25% die within the next year due to complications such as [[thrombus|blood clots]] ([[deep venous thrombosis]], [[pulmonary embolism]]), [[infection]]s, and [[pneumonia]]. Patients with hip fractures are at high risk for future fractures including hip, wrist, shoulder, and spine. After treatment of the acute fracture, the risk of future fractures should be addressed. Currently, only 1 in 4 patients after a hip fracture receives treatment and work up for osteoporosis the underlying cause of most of the fractures. Current treatment standards include the starting of a [[bisphosphonate]] to prevent future fracture risk by up to 50%. ==Complications== ===Complications of the injury=== [[Nonunion]], failure of the fracture to heal, is common (20%) in fractures of the neck of the femur, but much more rare with other types of hip fracture. The rate of nonunion is increased if the fracture is not treated surgically to immobilize the bone fragments. [[Malunion]], healing of the fracture in a distorted position, is very common. The thigh muscles tend to pull on the bone fragments, causing them to overlap and reunite incorrectly. [[bone shortening|Shortening]], [[varus deformity]], [[valgus deformity]], and [[rotational malunion]] all occur often because the fracture may be unstable and collapse before it heals. This may not be as much of a concern in patients with limited independence and mobility. [[avascular necrosis|Avascular necrosis]] of the femoral head occurs frequently (20%) in fractures of the neck of femur, because the blood supply is interrupted. It is rare after intertrochanteric fractures. Hip fractures rarely results in [[neurological]] or [[Blood vessel|vascular]] injury. ===Surgical complications=== Deep or superficial wound infection has an approximate incidence of 2%. It is a serious problem as superficial infection may lead to deep infection. This may cause infection of the healing bone and contamination of the implants. It is difficult to eliminate infection in the presence of metal foreign bodies such as implants. Bacteria inside the implants are inaccessible to the body's defence system and to antibiotics. The management is to attempt to suppress the infection with drainage and antibiotics until the bone is healed. Then the implant should be removed, following which the infection may clear up. Implant failure may occur; the metal screws and plate can break, back out, or cut out superiorly and enter the joint. This occurs either through inaccurate implant placement or if the fixation does not hold in weak and brittle bone. In the event of failure, the surgery may be redone, or changed to a [[total hip replacement]]. Mal-positioning: The fracture can be fixed and subsequently heal in an incorrect position; especially rotation. This may not be a severe problem or may require subsequent [[osteotomy]] surgery for correction. ===General medical complications=== Many of patients are unwell before breaking a hip; it is not uncommon for the break to have been caused by a [[falling|fall]] due to some illness, especially in the elderly. Nevertheless, the stress of the injury, and a likely surgery, does increase the risk of medical illness including [[myocardial infarction|heart attack]], [[cerebrovascular accident|stroke]], and [[pneumonia|chest infection]]. [[Thrombus|Blood clots]] may result. [[Deep venous thrombosis]] (DVT) is when the blood in the leg veins clots and causes pain and swelling. This is very common after hip fracture as the circulation is stagnant and the blood is hypercoagulable as a response to injury. DVT can occur without causing symptoms. A [[pulmonary embolism]] (PE) occurs when clotted blood from a DVT comes loose from the leg veins and passes up to the lungs. Circulation to parts of the lungs are cut off which can be very dangerous. Fatal PE may have an incidence of 2% after hip fracture and may contribute to illness and mortality in other cases. [[Mental confusion]] is extremely common following a hip fracture. It usually clears completely, but the disorienting experience of pain, immobility, loss of independence, moving to a strange place, surgery, and drugs combine to cause or accentuate [[dementia|dementia]]. [[Urinary tract infection|Urinary Tract Infection]] (UTI) can occur. Patients are immobilized and in bed for many days; they are frequently [[urinary catheterization|catheterised]], commonly causing infection. Prolonged immobilization and difficulty moving make it hard to avoid [[bedsores|pressure sores]] on the sacrum and heels of patients with hip fractures. Whenever possible, early mobilization is advocated; otherwise, [[alternating pressure mattress]]es should be used. == References == * {{cite web |url=http://www.wheelessonline.com/ortho/fractures_of_the_femoral_neck |title=Fractures of the Femoral Neck |author= |work=Wheeless' Textbook of Orthopaedics|publisher=[[Duke University School of Medicine]]|accessdaymonth=27 January |accessyear=2008}} * {{cite web |url=http://www.wheelessonline.com/ortho/intertrochanteric_fractures |title=Intertrochanteric Fractures |author= |work=Wheeless' Textbook of Orthopaedics|publisher=[[Duke University School of Medicine]]|accessdaymonth=27 January |accessyear=2008}} * {{cite web |url=http://www.medicalnewstoday.com/articles/63321.php |title=Damage Control Orthopaedics: Patient Stabilization, Early Mobilization |author= |work=74th Annual Meeting of the [[American Academy of Orthopaedic Surgeons]] briefing |date=18 Feb 2007 |publisher=[[Medical News Today]]|accessdaymonth=27 January |accessyear=2008}} [[Category:Orthopedics]] [[Category:Medical treatments]]