Hip Fracture

Introduction

Hip fracture is one of the classic inpatient rehabilitation diagnoses: one of the 13 medical conditions that meet CMS compliance threshold. According to the current CMS requirements, 60% of the patients admitted to an inpatient rehabilitation facility (IRF) need to have one of these thirteen diagnoses. With the increased proportion of aged population, by 2030 incidence of hip fractures is projected to reach 289,000, a 12% increase from 2010. Although IRF level of rehabilitation is more costly than SNF level of care when evaluating the cost of stay at rehabilitation facility itself , inpatient rehabilitation level of care was shown to incur less overall costs of care at 18 months follow up.   This finding may be due to lower rate of re-hospitalization to acute care facilities , shorter length of stay  or higher functional status at discharge from IRF  which may decrease costs by decreased need for home care.

Definition

A hip fracture can be classified as either intra-capsular or extra-capsular. Femoral head fractures and femoral neck fractures are intra-capsular fractures. Intertrochanteric fractures and sub-trochanteric fractures are extra-capsular fractures.

Etiology

Over 95% of hip fractures are due to falling. Elderly are at higher risk of hip fractures due to decreased bone resilience and higher risk of falls, especially to the side, often due to slower gait pattern with decreased forward momentum making falls to the side more likely. Postmenopausal women are at a particularly high risk due to estrogen deficiency contributing to risk of osteoporosis.   Unfortunately osteoporosis is a common disease with over 10 million of age 50 and up affected in the U.S. and another 34 million are at risk. However, there is a smaller but steadily growing population of young patients with hip fractures who survive motor vehicle accidents and present with high energy injuries.

Risk Factors

Additional risk factors to hip fracture include:  osteoporosis, age >75, gait instability, foot deformities, muscular weakness, sensory impairment, polypharmacy, impaired cognition, depression, use of alcohol or benzodiazepines, orthostatic hypotension, home environmental hazards (loose rugs, loose cords).

Epidemiology

Data shows that incidence of hip fractures increases from 22.5 per 100,000 at age 50 to 630 per 100,000 for men, and from 23.9 in 100,000 at age 50 to 1289per 100,000 by age of 80 for men and women. In 2010, there were 258,000 hospital admissions for hip fractures in people aged 65 and older and three quarters of hip fractures occurred in women. Postmenopausal women are at a particularly high risk due to estrogen deficiency contributing to risk of osteoporosis. Osteoporosis weakens the bones’ ability to resist trauma and increases the risk for hip fractures. Costs for falls to Medicare totaled over $31 billion in 2015.

Primary Prevention

First-line treatment to prevent fractures includes fall prevention, smoking cessation, moderation of alcohol intake, and management of osteoporosis (bisphosphonate therapy). Many of the deaths due to falls are associated with hip fractures. 20% of hip fracture patients die within a year of injury. As part of an individualized multifaceted approach to fall reduction there’s an expected relative risk reduction of 24% in this patient’s risk of falls at three months.

The CDC has developed the STEADI (Stopping Elderly Accidents, Deaths & Injuries) Initiative for Health Care providers to reduce an individual’s risk of falling by utilizing an algorithm to identify patients at low, moderate, and high risk for fall, identify modifiable risk factors, and provide effective interventions (such as behavioral approach, education, foot-care, medication simplification, etc…). Refer to the CDC STEADI website for the algorithm (http://www.cdc.gov/steadi/pdf/algorithm_2015-04-a.pdf).

A few caveats should be noted regarding the CDCs Vitamin D and Calcium supplementation recommendations.  Current publications show no increased benefit of calcium supplementation (as oral supplement, this does not modify the dietary calcium intake recommendations)  and new evidence has been emerging implicating calcium supplementation with increased adverse effects, e.g. risk of strokes and myocardial infarction by possibly potentiating atrial fibrillation. The U.S. Preventive Services Task Force does continue to recommend vitamin D supplementation to prevent falls in community-dwelling adults 65 > years or older with increased risk for falls  despite recent reports disputing its efficacy and even safety.

Osteoporosis is a common disease with over 10 million of age 50 and up affected in the U.S. and another 34 million are at risk. The U.S. Preventive Services Task Force recommends using dual energy x-ray absorptiometry to screen all women 65 years and older, and younger women who have an increased fracture risk as determined by the World Health Organization’s FRAX Fracture Risk Assessment Tool.

Patho-Anatomy/Physiology  

Hip fractures can be classified by location and stability, stable or unstable based on their propensity to be compromised after the surgery of the fracture. Fractures located within the hip joint are called intra-capsular and those outside are called extra-capsular. The hip is a ball and socket joint.  The femoral head, a ball-like structure connects to the acetabulum, and is covered by a fibrous tissue making up the hip joint capsule.

Fractures within the joint capsule are called intra-capsular, and most commonly involve the femoral neck. Since repair of these fractures often affects the fibrous capsular tissue in addition to bone tissue, intra-capsular fractures have a higher incidence of complications: nonunion (failure of bone fragments to join together after the surgery) and avascular necrosis (compromise of blood flow causing bone tissue death) of the femoral head than extra-capsular fractures.

Femoral neck is the most common location for hip fractures and is often compromised in women. Femoral neck fractures can be classified using the Garden Classification:  Stage I and II are stable, and Stage III and IV are unstable. In stable fractures, the fractured bone fragments are still aligned or non-displaced.  Since non-surgical management results in a secondary displacement rate of 40%, stable femoral neck fractures are generally best treated with surgical stabilization and immediate mobilization. Treatment is by operative pinning with three parallel cannulated screws placed adjacent to the femoral neck. Unstable or displaced fractures in young patients are similarly treated with fixation by cannulated screws, but in the elderly joint replacement procedures yield better results. The elderly often require hemi- or total joint arthroplasty. In hemiarthroplasty, the acetabular cartilage is left intact and the implant articulates with the acetabulum. Hemiarthroplasty requires less surgery and carries a smaller risk of dislocation, but total joint replacement is preferred in young active patients who would wear down the pelvic bone cartilage with overuse.

Inter-trochanteric fractures are the second most common type of hip fractures. The Evan Classification takes into consideration the number of fractured fragments. Fractures where the femur is broken in only two or three parts are stable, while those broken into four or more parts or have oblique fractures are unstable. Stable fractures are treated with a sliding screw and a side plate screwed onto the femoral shaft. An Intramedullary nail and a sliding hip screw are often used for unstable fractures.

Sub-trochanteric fractures are the least stable and fortunately least common type of hip fractures. They are treated with an intramedullary hip screw only.

Prognosis of Hip Fractures

Seniors with impaired ADLs prior to hip fracture had higher risk of ADL decline 6 months after surgery if they had sustained an intertrochanteric fracture vs femoral neck or sub-trochanteric fractures. Intertrochanteric fractures had also been associated with delayed recovery of pre-fracture mobility  and increased mortality.

Specific Secondary or Associated Conditions and Complications

• DVT
• Hardware failures
• Wound infection
• Delirium
• Pain
• Leg length discrepancy
• Immobility
• Falls
• Neuropathy
• Weight bearing and hip precautions incompliance

Refer to Section “Rehabilitation Management” for detailed description regarding management of comorbidities and complications.

2. Essentials of Assessment

History

Age and gender are predisposing factors for certain injuries. As mentioned earlier, most hip fractures occur in the elderly which are usually the results of low-energy trauma; whereas, in young individuals, hip fractures typically result from high impact injuries such as motor vehicle accidents. Other factors to take into consideration are history of cancer (history of chemo or radiation therapy), history of steroid use, metabolic disorders. History of comorbidities such as cardiovascular disease, alcohol abuse, polypharmacy.  Also consider secondary injuries, such as knee injuries vertebral body fractures or distal radius fracture.

Physical Examination

After the patient has been stabilized and life threatening conditions have been addressed, evaluate the injured extremity. Visual inspection:  pallor, ecchymosis, asymmetry, or deformity, abrasion, laceration, open wounds. Position of the limb:  displaced femoral neck fracture, the leg will be externally rotated, abducted, and shortened. With intertrochanteric fractures, the leg typically is in external rotation with shortening. Note that shortening of limb-length can be found with fractures, dislocations, and osteoarthritis.  Limb shortening or rotation is usually not seen with non-displaced fractures; however, pain is elected with internal and external rotation. It is recommended to defer range of motion testing with obvious deformities until imaging is completed.  Location of pain is important; true hip pain radiates to the groin.

Neurovascular compromise must be considered; therefore assess femoral, popliteal, dorsal pedis, and posterior tibial pulses and perform ABI if needed while completing a thorough neurological exam. The femoral nerve and/or artery can be injured with sub-trochanteric and femoral shaft fractures; while the sciatic nerve can be injured with hip fractures.

Diagnosis

Radiographic Assessment

Imaging evaluation should begin with anterior-posterior (AP) image and a cross-table lateral projection of the hip. Three studies showed that a “limited” MRI of the hip could identify occult hip fractures. These data have led the current recommendations to be plain film radiography followed by MRI in patients older than the age of 50 years. In younger patients who typically have high-energy fractures, CT scanning is probably more useful for preoperative planning.

Early Prediction Outcomes

Hip fractures are associated with significant morbidity and mortality, and it is reported the 1-year mortality after sustaining a hip fracture is estimated to be 14 to 58%. It has also been shown that women with a hip fracture have a five-fold increase and men have about an eight-fold increase in relative likelihood of death within the first 3 months.

Environmental 

The home environment can have many hazards which may place an individual at risk for a hip fracture.  The CDC recommends the following to minimize fall hazard:

1. Remove tripping hazards
2. Add grab bars inside and outside the shower or tub, and next to the toilet
3. Add railings on both sides of the stairs
4. Utilize bright lights in the home

3. Rehabilitation Management and Treatments

Indications for inpatient rehabilitation for hip fractures

Although the continuum of hip fracture rehabilitation can be undertaken by an Inpatient Rehabilitation Facility (IRF), sub-acute rehabilitation (also known as SNF, skilled nursing facility), home based rehabilitation to outpatient rehabilitation, there is strong evidence supporting the superiority of IRF-based rehabilitation.

IRFs optimize hip fracture rehabilitation by a comprehensive team of physicians, nurses, physical & occupational therapists, social and case workers.  It ensures 3 hours of therapy a day for 5 days a week or at least 15 hours of therapy a week total to provide a concentrated rehab effort.  Patients are provided with around the clock medical and nursing care.

Superiority of Inpatient Rehabilitation 

Perhaps this is what accounts for the fact that IRF patients have the lowest rate of inpatient re-hospitalization compared to SNF, home discharge with and with-out home health care at 180 days after discharge. Also, patients discharged from IRFs required less home care than those from SNF. It has been shown that hip fracture patients undergoing rehabilitation in IRFs were more likely to be discharged home after rehabilitation than patients undergoing rehabilitation in SNFs. It has also been shown that patients at SNF level of rehabilitative care were more likely to be  re-institutionalized (i.e. return to some type of medical care) than those at IRF. Patients in IRF had shorter length of stay than those at SNF. Herbold et al report that “matched for age, gender, operative diagnosis, [morbidity] severity index, and admission ambulation FIM score, those who received rehabilitation in the IRF had shorter length of stay and superior functional outcomes than those in the SNF setting.”

Restore Function 

IRFs track patients’ functional status from admission to discharge by using FIM, functional independence measure, as a standardized method to measure function in IRFs. After adjusting for baseline characteristics and participation in rehabilitation, subjects in the IRF group were eight times more likely to regain 95% of their pre-fracture FIM motor score at 12 weeks, as compared to subjects in the SNF group.

Peer support

IRFs often provide peer support groups both during IRF stay and as an adjunct treatment following IRF stay for their patients. Peer support groups allow for better adjustment to the consequences of hip fractures and easier community reintegration. It has been shown that peer support groups provide advocacy, connecting to resources, experiential sharing, building community, relationship building, group facilitation, skill building/mentoring/goal setting, and socialization/self-esteem building as well as assist with education/awareness building and information gathering and verification. Group learning was shown to decrease the number of ADL items perceived to be performed with difficulties and increase perceived ability to participate in social life after hip fracture.

Mental Health

Depression, apathy, and cognitive impairments effect hip fracture patients’ participation in therapy. Depressed patients are not motivated to participate in therapy and due to lack of participation normally have less functional improvement. It has been shown that those who received rehabilitation at an IRF had significantly better functional outcomes than similarly impaired patients at SNFs. Similarly, evidence supports improved outcomes in patients with dementia undergoing rehabilitation in IRF facilities.

Patients at Higher Risk 

Obesity is a common comorbidity found among hip fracture patients. Nailing fixation of hip fractures in morbidly obese population resulted in increased incidence of wound infections, greater trochanter fractures and pulmonary emboli, and more rehab needs.

Diabetes may have profound effects on hip fracture patients. One study showed an increased mortality rate of diabetics after a hip surgery.

Cardiovascular disease is another important comorbidity in this patient population. A significant increase in proportion of hip fracture patients admitted with comorbid cardiovascular disease had been documented. Congestive heart disease, for instance, had been described as a potential risk factor for worse transfer and locomotion outcomes, but patients in this population demonstrated faster rate of ambulation function recovery than those without.

Hip Fracture Primary Complications 

Femoral Neck Fractures

Overall, osteonecrosis (23%) and nonunion (8%) are the most common complications of intra-capsular femoral neck fractures with 27% vs. 14% rate of necrosis in patients with unstable fractures.  Femoral neck fractures treated with screw treatment may be complicated by nonunion, failure of bone parts to heal together after the surgery or late vascular necrosis, failure of blood flow to the bone causing bone death, requiring a repeat surgery with hip replacement. A physician would suspect nonunion if patient complains of worsening groin or buttock pain and can detect lack of bone healing by ordering an X-ray that shows screws sliding out as the fracture collapses.

Intertrochanteric Fractures

Inter-trochanteric fractures may be complicated by nonunion, screw cut-out, nail breakage, malunion or limp most of which may be treated by total joint replacement.

Total or Hemiarthroplasty 

Patients with total or hemiarthroplasty may complain of hip pain and present with acetabular erosion (in hemiarthroplasty), prosthetic loosening, hip dislocation, fracture or infection, all of which may need a repeat surgery with total hip replacement.

Hip precautions are specific mobility restrictions instructed to patient during rehabilitation, in order to prevent dislocation.  For instance, those at risk for posterior dislocation can maintain hip precautions by keeping an abduction pillow between legs while in bed to keep the hip 15 degrees away from the midline, avoiding reaching forward by flexing at the hip, using adaptive equipment like reachers, sock-aids and dressing sticks for lower extremity care and raised toilet-seats/commodes and tub benches for toileting and hygiene. Patients in particularly high risk for dislocation: those with history of dislocation, poor compliance, impulsivity, altered mental status, and revision arthroplasty may benefit from a restrictive abduction hip brace.

Secondary Precautions   

Pain is common after hip surgery and associated with poor functional outcomes.  Pain management with opioid protocol has shown 9% risk reduction of chronic pain incidence and improved physical function at 6 months. Since opiates are commonly used to treat post-operative hip pain, hip fracture patients need to be closely monitored for a common opiate side effect of constipation.

DVT Prevention 

Thromboembolism is a common occurrence in hip fracture patients. Venous thromboembolism prophylaxis in hip fracture patients had been shown to decrease lower extremity blood clots by 40%. Despite high level of prophylaxis (97.6% of patients), still 1.34% developed symptomatic blood clots at 3 months with 0.25% affecting the lungs with 3/16 patients suffering fatality.

Wound Healing 

One study reports 1.2% of patients developing deep and 1.1% superficial wound infection after hip surgery.

Nerve Palsy 

The following nerve palsies have been described and should be screened for: sciatic, peroneal, femoral, obturator, superior gluteal nerves.

Leg Length Discrepancy 

Normally, post-operative discrepancy is due to pelvic obliquity from muscle imbalance and hip contractures and may be resolved with therapies. Discrepancy less than half an inch is normally well tolerated, but those more than ¾ of an inch may require a shoe lift.

Fall Risk 

Fall risk is due to post-operative weakness and mobility deficits. Fall precautions are ordered such that patient is instructed not to get out of bed unassisted and nursing staff assists the patient with transfers and mobility until fall risk is cleared. Multi-factorial fall risk assessment and intervention had been shown to decrease fall incidence.

Weight Bearing Precautions 

Weight bearing restrictions (e.g. non–weight bearing, toe-touch (<25% of body weight), or partial weight bearing) may sometimes be utilized after surgery. These restrictions may be difficult for some patients to comply with due to lack of comprehension, arm strength or overall bodily coordination. Furthermore, they may hinder rehabilitative efforts in a patient unable to comply with the restrictions as therapy treatments need to be halted until proper weight bearing is learned. Fortunately, studies show that after a hip surgery weight bearing as tolerated is well tolerated    and therefore encouraged except for in displaced femoral neck fractures fixed with cannulated screws where partial or toe-touch weight bearing is recommended.

Impaired Mobility 

Impaired mobility is relative decrease in ability to ambulate and transfer from surfaces and commonly occurs after hip surgery.

Non-Progression with Therapy

Non-progression with therapy is an unfortunate occurrence in rehab facilities.  Etiologies for non-progression include: 1) poor patient cooperation due to personality traits, psychological or cognitive issues; 2) reaching maximum currently achievable functional state; 3) worsening medical condition; 4) pain; 5) insomnia; 6) fatigue; and 7) patient’s family factors. Unless the patient has reached his or her functional improvement plateau underlying etiologies need to be investigated not only to facilitate patients’ rehabilitative course, but also to assess if there is an underlying subclinical medical condition that is now starting to resurface.  If non-progression etiologies have been sufficiently investigated and patient persistently fails to improve from therapies it becomes difficult to justify patient’s stay on IRF without measurable functional gain and it may be time to consider continuing rehabilitative services at a different level of care, transfer to subacute rehabilitation or home with outpatient therapy regimen.

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