Hip Fractures

Many older people worry about fracturing a hip. Hip fractures can have serious consequences. A person may be unable to do daily activities, may be unable to live independently, or may develop a serious disorder leading to death. To help prevent hip fractures, people can become or continue to be active. Being active strengthens muscles and bones. It also improves the chances of a good recovery if a hip fracture occurs. Other precautions can also help.

In the United States, about 350,000 people fracture a hip each year. About 9 out of 10 hip fractures occur in people over 60. Hip fractures are much more common among women.

Types and Causes

Most hip fractures occur at or near the upper end (head) of the thighbone (femur). (The head of the thighbone fits into the pelvic bone to form the hip joint—a ball-and-socket joint.) There are two common types of hip fractures. Femoral neck (subcapital) hip fractures occur just below the thighbone's head, in the neck of the thighbone. Intertrochanteric hip fractures occur in the area just below the neck, where the thighbone broadens. There are two large bumps (called trochanters) in this area. They provide a sturdy place for the muscles of the legs and buttocks to be attached to.

The bones may be broken in different ways. The broken bone may remain in place (aligned or nondisplaced) even if the bone is cracked all the way through. The ends of the broken bone may be separated (displaced). Or one end may be jammed (impacted) into the other.

Most hip fractures result from a fall. However, when osteoporosis or another disorder has weakened the bone, a hip fracture may result from the stresses of ordinary activity (such as getting in and out of a chair).

Symptoms and Diagnosis

Hip fractures almost always cause pain, weakness in the affected leg, or both. Pain occurs partly because the ends of the broken bone move around, injuring the surrounding tissue. Most people with a displaced hip fracture cannot walk or stand. When they are lying on their back, the affected leg may appear shorter than the other leg, and the foot of the affected leg turns out (rather than pointing straight up). Some people with an impacted hip fracture can walk, although with pain.

People with an intertrochanteric hip fracture may become light-headed or weak or even go into shock. These symptoms indicate that blood pressure has fallen: Blood pressure falls if a fracture damages blood vessels and causes bleeding inside the hip. Large bruises may develop around the hip.

The stress of having a hip fracture can lead to other problems. Pain due to a hip fracture, the drugs used to control pain, and the experience of hospitalization and surgery may cause an older person to become confused, disoriented, forgetful, and anxious. A change in living arrangements, if needed, can be upsetting. A person may become depressed, especially if a fracture disrupts normal activities and requires a lot of time and adjustments while healing. Family members should report changes in mental function after a hip fracture to a health care practitioner.

After a femoral neck hip fracture, severe, painful arthritis may develop. Arthritis can develop if the fracture disrupts the blood supply to the head of the thighbone. Without a good blood supply, the bone heals slowly or incompletely, and it may eventually die and collapse.

Most hip fractures can be seen on x-rays. However, if the fracture is small, a second x-ray (taken a day or two later), computed tomography (CT), or magnetic resonance imaging (MRI) may be needed to detect it.

Prevention and Treatment

Preventing hip fractures involves preventing falls, strengthening bones to prevent osteoporosis, and protecting bones. One way to protect bones is to wear a specially designed hip protector (a thigh-length undergarment with padding along its sides). Many hip protectors can be worn comfortably under clothing.

Treatment usually consists of surgery. Surgery prevents the ends of the broken bones from moving and thus relieves pain. Surgery also enables most people to get out of bed and begin to walk again almost immediately. At first, almost everyone uses a walker. For people who have a serious disorder, such as a recent heart attack, surgery may be too risky. For these people, bed rest is continued until they recover enough for surgery to be safe. Rarely, surgery is not done—for example, for people who were permanently unable to walk before the fracture and who are not experiencing pain.

The type of surgery depends on the type and severity of the fracture and on the person's activity level.

See the figure Repairing a Broken Hip.

For some femoral neck hip fractures, metal pins can be inserted surgically to hold the bone together. For intertrochanteric hip fractures, a different type of metal implant is used. A plate is attached to the top part of thighbone with compression screws. The screws allow the fragments to move closer to each other and grow together. These procedures, which are types of internal fixation, preserve the person's own hip joint.

For more severe femoral neck hip fractures, the head and neck of the thighbone are removed and replaced in a procedure called partial hip replacement (hemiarthroplasty). They are replaced with a smooth metal sphere on a metal stem. The stem is inserted into the center of the thighbone's shaft and usually cemented in place. The sphere is made to fit into the person's hip socket.

See the figure Replacing a Hip.

Sometimes, especially if arthritis has damaged the hip socket, total hip replacement is necessary. In this operation, the hip socket is replaced as well as the head and neck of the thighbone. The pelvic bone around the socket is shaped so that a metal cup can be inserted to replace the opening of the socket.

Traditionally, hip surgery involves a 9-inch incision at the hip joint. Afterward, people must stay in the hospital 3 to 5 days. They may be able to put full weight on the hip in a few days, or they may have to wait up to 6 weeks. New techniques that cause less pain, involve much smaller incisions (about 2½ to 3 inches), and result in a quicker recovery are being developed. However, whether the new techniques are as safe and effective as traditional surgery is not yet known.

After surgery for a hip fracture, rehabilitation is begun in the hospital as soon as possible.

Outlook

Many people recover reasonably well after a hip fracture. But full recovery may take up to a year. Being healthy, able to move (mobile), and active before the fracture makes a good recovery more likely. However, hip fractures may lead to serious problems, primarily because they limit a person's mobility. Only about one third of people regain the same amount of mobility they had before the fracture. After a hip fracture, about 2 out of 5 people 65 and over need to stay in a nursing home for at least a while. Some of them stay there indefinitely. A year after a hip fracture, some older people still need a walker or another aid to walk. Some people need home care. During the year after they have a hip fracture, about 1 out of 4 people aged 50 and over die. Most of the people who die are over 80.