Hip Fracture

Rehabilitation after surgery: Rehabilitation is started as soon as possible after hip fracture surgery. The first goals may be to increase strength and to prevent atrophy on the unaffected side. Initially, only isometric exercise of the affected limb while it is fully extended is permitted. Placement of a pillow under the knee is contraindicated because it may lead to flexion contracture of the hip and knee.

Gradual mobilization of the affected limb usually results in full ambulation. The speed of rehabilitation depends partly on the type of surgery performed. For example, after prosthetic hip replacement, rehabilitation usually progresses more rapidly, less rehabilitation is needed, and the functional outcome is better than after nail-and-plate or pin-and-plate fixation. Ideally, full weight bearing starts on the 2nd day after surgery. Ambulation exercises are started after 4 to 8 days (assuming that the patient has achieved full weight bearing and balance), and stair-climbing exercises after about 11 days.

Patients are taught to perform daily exercises to strengthen the trunk muscles and quadriceps of the affected leg. Prolonged lifting or pushing of heavy items, stooping, reaching, or jumping can be harmful. During ambulation, the amount of mechanical stress is about the same whether patients use one or two canes, but using two may interfere with certain activities of daily living. Patients should not sit on a chair, particularly a low one, for a long period and should use the chair arm for support when standing up. While sitting, they should keep their legs uncrossed.

Before the patient is discharged, the therapist should evaluate the patient's home to determine if additional training or assistive devices are needed.

Rehabilitation without surgery: Nonsurgical treatment of hip fracture generally results in a poor functional outcome and is therefore rarely advisable. The hip and leg are usually immobilized for 6 to 8 weeks. During immobilization, prevention of secondary disabilities (eg, pressure sores, muscle atrophy, joint contractures, general deconditioning) is important but often unsuccessful. After immobilization, the rehabilitation program is similar to that for postoperative patients; however, the program begins with general conditioning exercises, and rehabilitation progresses more slowly, in part because patients lose so much muscle mass during the prolonged immobilization.

Some physicians do not allow weight bearing until x-rays show union of the bone, which is rare before 8 weeks and usually occurs 10 to 12 weeks after fracture. Other physicians establish that healing has occurred by comparing x-rays taken under non-weight-bearing and under weight-bearing conditions; if no difference is seen, weight-bearing exercises can proceed. However, patients, even if told not to, often begin weight-bearing activities as soon as they feel no discomfort. The decision to allow weight bearing seems more reasonable when based on the patient's perception rather than solely on x-ray findings.