Chapter 7: Hip Fractures: Treatment and Prevention 2 CCHs
By: Katherine Rush, PT Learning objectives
After completing this course, the learner will be able to: Distinguish the difference between the three major types of hip fractures, their characteristics and the indications for treatment of each. Summarize the similarities and differences between the physical strategies for rehabilitation for the surgical candidate, versus the non-surgical candidate. Discuss the issues associated with each. Identify the different approaches to hip surgery; discuss the advantages, disadvantages and the treatment strategies and rehabilitation outcomes for each of these surgeries. A hip fracture is a break in the upper quarter of the femur, or the thigh bone. These types of fractures occur most commonly from falls, although some conditions like cancer, osteoporosis or stress injuries can weaken bones and make them more susceptible to breaking. Other factors, including multiple medications, diminished vision, as well as balance problems can also make older individuals more likely to fall. Each year, over 250,000 people are hospitalized for hip fractures, and some of these individuals will never fully regain their prior level of function: they may require assistance to walk, and a few will even need to go to a nursing home (CDC, 2015). It is also likely that a large percentage of them will die. Types of hip fractures There are three major types of hip fracture: Intracapsular fracture, intertrochanteric fracture, and subtrochanteric fracture. ● Intracapsular fracture : Occurs at the level of the neck and head of the femur. As the name suggests, this fracture occurs within the capsule that surrounds the hip and can often impair circulation to the head of the femur, causing avascular necrosis. While these fractures can often be repaired with a pin or a screw, some surgeons will instead decide to replace the head of the femur (hemiarthroplasty) or will replace both the head of the femur and the acetabulum with a total hip replacement. A complete hip replacement can help prevent the arthritis that often results from the avascular necrosis. ● Intertrochanteric fracture : Occurs between the neck of the femur and the lesser trochanter. This fracture can be repaired PT for the nonsurgical candidate Only a very small percentage of patients with hip fractures are not considered surgical candidates. Patients not considered surgical candidates are typically those with severe dementia, poor life expectancy, were non-ambulatory prior to the hip fracture, or who have one of the above conditions and are relatively comfortable. The goal in these cases is not necessarily to improve mobility; rather, it is to improve patient comfort. PT is likely to consist of passive range of motion (PROM) of the other extremities, and educating caregivers about turning, positioning and transferring the patient with the least amount of pain, as PT after surgery The physical therapy type and treatment will vary somewhat, depending on the type of surgery (or lack of surgery) that was performed to correct the hip fracture. A variation of an ORIF (open reduction internal fixation) surgery is most common; however, as discussed in an earlier section, a total hip replacement may be completed to prevent arthritis due to
Discuss the reasons for a total hip replacement, what challenges this procedure might present and the unique implications of the anterior versus the posterior approach. Discuss the progression of physical therapy to maximize progression to each patient’s either prior level, or maximum level, of functioning. Relate practical and effective preventative measures that patients can take to prevent future falls.
INTRODUCTION
A thoughtfully designed physical therapy program is vital for the treatment, as well as the prevention, of hip fractures. The physical therapist is an essential partner to assist patients in preserving, improving and maintaining the current levels of functioning within their daily lives. This course will provide an overview on the three main types of hip fractures, the differences between the approaches to surgical and non-surgical candidates for physical therapy, and prevention techniques that the physical therapist can share which will ensure a patient is knowledgeable about how to prevent future fall occurrences. either by a compression hip screw (a screw fixed to the outer side of the bone with a lag screw directed into the neck and head of the hip) or with an intramedullary nail (a nail set into the marrow canal of the bone with a lag screw directed into the head and neck of the hip). The outcomes of these two treatments are virtually the same and will depend on which surgeon is performing the surgery. ● Subtrochanteric fracture : Refers to a fracture below the lesser trochanter, generally within about 2.5 inches. It is often repaired with an intramedullary nail and various types of screws (depending on the location and extent of damage) to stabilize the nail (The American Academy of Orthopedic Surgeons, 2009). well as for positioning the patient to reduce the risk of pressure ulcers. A surgeon will rarely decide that surgery is not indicated when a hip fracture is nondisplaced. In these cases, PT will focus on mobility, following weight bearing precautions (most likely non- weight bearing), and the strengthening - as tolerated - of both the affected and non-affected sides. These patients may be on bed rest; PT management will then focus on the prevention of issues associated with bed rest, such as blood clots, weakness, and ulcers. avascular necrosis. Total hip replacements may be completed with cement, without cement, and also from an anterior approach or from a posterior approach. While each of these variations presents different precautions and challenges for the treating therapist, the goal of each is to return every patient to his/her prior level of function. This has been found to be most
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