Hip Fracture

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Hip Fracture

Topic Overview

Picture of the skeletal system

What is a hip fracture?

A hip fracture is more than a broken bone. If you are older, breaking your hip can mean a major change in your life. You will likely need surgery, and it can take as long as a year to recover. Activity and physiotherapy can help you get your strength and mobility back. You are likely to need support from family or a caregiver as you recover.

Most hip fractures happen to people who are 65 or older. If you are in this age group, you need to be extra careful to avoid falls. Most people break their hip near the upper part of the thigh bone (femur). It usually happens near where the thigh bone fits into the hip joint.

What causes hip fractures?

Falls cause most hip fractures in older adults. As you get older, your bones naturally lose some strength and are more likely to break, even from a minor fall. Children and young adults are more likely to break a hip because of a bike or car accident or a sports injury.

Other things that increase your risk of breaking your hip include:

  • Being female.
  • Your family history—being thin or tall or having family members who had fractures later in life.
  • Poor eating habits. Not getting enough calcium and vitamin D can weaken bones.
  • Not being active. Weight-bearing exercise, such as walking, can help keep bones strong.
  • Smoking.
  • Medical conditions that cause dizziness or problems with balance, or conditions such as arthritis that can interfere with steady and safe movement.
  • Taking certain medicines that may lead to bone loss.

What are the symptoms?

It is hard to miss the symptoms of a hip fracture. You will most likely have severe pain in your hip or lower groin area. You probably will not be able to walk or put any weight on your leg.

These symptoms would be most likely after a fall. But if you have very thin bones from osteoporosis or another problem, you could break your hip without falling. In rare cases, people have only thigh or knee pain. They may be able to walk.

How is a hip fracture diagnosed?

Doctors use X-rays to diagnose a broken hip. If your doctor thinks that you have a fracture but cannot see it on an X-ray, you may need an MRI, a CT scan, or a bone scan.

How is it treated?

You will probably need surgery to fix your hip. Surgery usually works well, but you will need to be patient. Getting better will probably take a long time. And you may never be able to get around as well as you could before.

The type of surgery you have will depend on where the break is and how bad it is. Your doctor may put metal screws, a metal plate, or a rod in your hip to fix the break. Or you may need to have all or part of your hip replaced.

Your doctor will want you to start moving as soon after surgery as you can. This will help prevent problems such as pneumonia, blood clots, and bed sores. These things may happen because you have to stay in bed so long.

After your surgery, it will be hard for you to do things yourself. You may need to go to a nursing home or rehabilitation centre for a while after your surgery. But the more active you can be in your care, the faster you will get better.

How can you prevent a hip fracture?

There are many things you can do to prevent a hip fracture. One of the most important is to prevent osteoporosis. This disease can happen to men or women. But it is more common in women.

To slow or prevent osteoporosis:

  • Get plenty of calcium and vitamin D. Eat foods high in calcium. Milk, cheese, yogurt, and other dairy foods have lots of calcium. Dark green vegetables, some seafood, and almonds are also good. If you want to take calcium and vitamin D supplements, talk to your doctor about how much you need to take.
  • Avoid alcohol, and do not smoke.
  • Do weight-bearing exercise that puts pressure on bones and muscles. Walking is a good choice.
  • Some people need to take medicine to slow osteoporosis.

Preventing falls is also very important.

  • Arrange furniture so that you will not trip on it.
  • Get rid of throw rugs, and move electrical cords out of the way.
  • Be sure you have good lighting where you are walking.
  • Put grab bars in showers and bathtubs.
  • Outside of your home, avoid icy or snowy sidewalks.
  • Wear shoes with sturdy, flat soles.
  • Get your eyes checked.
  • Avoid too much alcohol.
  • Exercise to help keep your strength and balance.
  • Take medicines only as directed and periodically review your medicines with your primary care doctor, especially if you have more than one doctor. Some medicines, such as sleeping pills or pain relievers, can increase your risk of falling.

Frequently Asked Questions

Learning about fractured hips:

Being diagnosed:

Getting treatment:

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  Aging Well: Making Your Home Fall-Proof

Symptoms

The most common symptom of hip fracture is severe pain in the hip or lower groin. Your leg may be rotated to the outside, feel more comfortable when moved away from your other leg, and be a little shorter than the other leg. You usually can't walk or even put weight on the injured leg. But in rare cases, there may be only thigh or knee pain. Walking may still be possible, although painful, with impacted fractures, where the ball at the top of the thigh bone is pushed down onto the rest of the thigh bone.

You typically notice symptoms after a fall. But a fracture can also occur without a fall, especially if the bone has been thinned through osteoporosis or other health conditions.

Examinations and Tests

Hip fractures usually are diagnosed with a physical examination and X-rays. Signs of hip fracture include pain in the groin, thigh, and knee, being unable to move the leg, and the leg being shorter than the other and rotated to the outside.

In some cases a fracture is not visible on the first X-ray. But your doctor will still suspect a hip fracture because of your hip pain or recent fall. In these cases, your doctor may suggest other tests, such as:

  • An MRI, which provides better images of bone and soft tissues.
  • A CT scan, another way of getting more specific images than X-ray.
  • A bone scan, which involves injecting a dye, then taking images that show hairline fractures (the bone is cracked, but all pieces are still in place).

Fractures that were not clearly visible on an X-ray may show up on an MRI, a CT scan, or a bone scan.

Women who have been through menopause and have a hip fracture also may have osteoporosis or be at a higher risk for it. A bone mineral density test for osteoporosis may provide early detection and lead to treatment that can help prevent future fractures.

To prevent hip fractures, doctors should ask older people at least once a year whether they have fallen. If a single fall has occurred, a simple test should be done to assess the risk of more falls. Your doctor will watch you stand up from a chair without using your arms, walk several paces, and return (called the "get-up-and-go test"). If you have any trouble or unsteadiness, you need further assessment. This includes a detailed medical history, a review of your medicines, and an examination of vision, balance, and muscle strength.

Treatment Overview

The goal of treatment for hip fractures is to allow you to do, without pain, most of the things you did before your fracture. The most common and almost always the best treatment for a hip fracture is surgery. Surgery helps make sure that the bones are lined up to heal correctly.

After your hip fracture is diagnosed, you may have a pillow placed under the knee of your injured leg. Or you may be placed in gentle skin traction to help keep you more comfortable until surgery. Skin traction attaches a light weight to your leg using tape, straps, or a special boot. And this weight provides a constant pull on your leg.

Surgery is done as soon as possible after a diagnosis of hip fracture, often within 24 hours. Having surgery right away can help shorten your stay in the hospital and may decrease pain and complications.1 But in some cases, surgery may be delayed for 1 to 2 days for treatment of other medical problems, such as heart or lung conditions, so that surgery will be less risky.

There are different types of surgery for hip fractures, depending on the location of the break, the position of the bone fragments, and your age. Surgery for a hip fracture may include one of the following:

  • Internal fixation. Internal fixation involves stabilizing broken bones with surgical screws, rods, or plates. This type of surgery is usually for people who have fractures in which the bones can be properly aligned. See Hip Fracture Repair (Hip Pinning) for more information.
  • Hip replacement surgery (arthroplasty). Arthroplasty involves replacing part or all of the joint with artificial (usually metal) parts. A partial hip replacement may be done to replace the broken upper part of the thigh bone (femur) with artificial parts. In some cases, a total hip replacement can be done if the hip joint area was already damaged before the fracture by arthritis or an injury and the joint was not working correctly. Arthroplasty is often done for femoral neck fractures when the blood supply to the top of the thigh bone is damaged and there is a chance that the bone might die (avascular necrosis). And arthroplasty is often done when the fractured bones cannot be properly aligned. See Hip Replacement Surgery for more information.

Reduction (getting the bone lined up correctly) and internal fixation (stabilizing broken bones) often are done on younger, active people. Hip replacement surgery often is done on older, less active adults. In deciding which of these methods to use for repairing a hip fracture, your surgeon will consider the type of fracture, your age and activity level, and also the possible trade-offs. Research on displaced hip fractures (where the bones are not aligned) shows that, in the long term, total hip replacements may need to be redone less often than internal fixation, but there is also more time in surgery, a greater chance of infection, and possibly a greater chance of death from hip-replacement complications.2

Surgery usually is the most effective treatment for a hip fracture, although in most cases you will not regain all of the mobility that you had before the hip fracture. In general, if you were healthy and active before the fracture, then you will recover faster after surgery than a person who was not. If you have other health problems and have not stayed active, there is a greater chance of complications after surgery.

In rare cases, surgery is not done. For example, surgery is not done in people who are at high risk for complications during or after surgery and who may not benefit significantly from surgery, such as those who were unable to walk before the hip fracture and who have minimal pain. In these cases, your doctor will use medicine to manage your pain.

What to expect after surgery

There are many issues to consider after hip surgery. Older adults often need extensive care, including physiotherapy and help with cooking, taking medicine, and personal care. Anticoagulant medicines are prescribed to reduce the risk of blood clots and associated stroke, pulmonary embolism, or thrombophlebitis. You will probably keep taking this medicine until you are walking frequently and well. This often takes at least 3 weeks.

After hip fracture surgery, your doctor will encourage you to participate in a rehabilitation (rehab) program. Research shows that 6 months of outpatient rehab that includes strength training can improve quality of life and reduce disability.3 Following a rehab program is very important because it will speed up your recovery and allow you to return to daily activities sooner.

If your hip fracture was from bone thinning of osteoporosis or another cause, your doctor may suggest that you take medicines such as bisphosphonates to help prevent another fracture.4

After a hip fracture, some people can never again be as independent as they were before the fracture. They may need to use a walker or cane to walk. They may need help with daily activities such as dressing and bathing. And many can no longer live on their own. It is hard to recover from a hip fracture. So be sure to do all you can to keep your bones strong and to avoid falls that can lead to a fracture. And if you do break your hip, work hard to get your strength and mobility back so you can be as independent as possible.

Prevention

There are steps you can take to help prevent a hip fracture.

Keep your bones strong

Eat nutritious foods that include adequate amounts of calcium and vitamin D. Both are needed for building healthy, strong bones. Vitamin D is vital for calcium absorption in bones and to improve muscle strength. Getting more vitamin D may help prevent falls in older people who are low in vitamin D.5 And some studies show that taking vitamin D may reduce the chances of breaking a bone.6 Talk to your doctor about measuring your vitamin D to be sure you are getting enough. The best source of vitamin D is exposure to sunlight. Vitamin D is also added to milk, some calcium supplements, and many multivitamin supplements.

Exercising and staying active help you keep your bone strength. Weight-bearing exercises such as walking, jogging, and light weight training help to minimize bone loss. Talk to your doctor about an exercise program that is right for you. Begin slowly, especially if you have been inactive. One study showed that moderate physical activity, such as walking, was linked to a substantially lowered number of hip fractures in post-menopausal women.7

Don't drink more than 2 alcoholic drinks a day if you are a man, or 1 alcoholic drink a day if you are a woman. Drinking more than this puts you at higher risk for osteoporosis. Alcohol use also raises your risk of falling and breaking a bone. See pictures of standard alcoholic drinks.

Don't smoke. Smoking puts you at a higher risk for osteoporosis and increases the rate of bone thinning after it starts.

Talk to your doctor about taking hormone replacement therapy or other medicines if you are at risk for osteoporosis. Some doctors recommend hormone therapy for osteoporosis, although its risks and benefits should be considered. Other medicines such as bisphosphonates, including alendronate (Fosamax) and zoledronic acid (Aclasta); raloxifene (Evista); and calcitonin (Calcimar or Miacalcin) are also used to prevent or treat osteoporosis. Studies show that the bisphosphonates, in particular, significantly reduced the risk of hip fracture in older women who have osteoporosis.8 For more information, see the topic Osteoporosis.

For more information, see the topics Fitness and Healthy Eating.

Avoid falls

Almost all hip fractures in older adults happen because of a fall. Things that increase your chance of falling include:

  • Having poor balance and coordination.
  • Having weakness in one or both legs.
  • Using certain medicines that may cause sleepiness, weakness, or dizziness.
  • Having vision problems.
  • Drinking too much alcohol.
  • Feeling confused or having impaired reasoning (caused by age or conditions such as dementia).

You can reduce your risk for falls by:

  • Removing anything in your house that may cause you to fall. Household hazards that can cause falls include slippery floors, cords, poor lighting, cluttered walkways, furniture placement that does not allow a clear pathway for walking, and throw rugs.
  • Using non-slip mats and grab bars in the bathtub and shower.
  • Making sure stairways have handrails. Having rails on both sides of the stairs is best. Also be sure to turn on the lights when you use the stairs.
  • Making sure you have enough light to see obstacles or pets as you move around your home.
  • Exercising to help you keep your strength and balance.
  • Taking medicines only as directed and periodically reviewing your medicines with your primary care doctor, especially if you have more than one doctor. Some medicines, such as sleeping pills or pain relievers, can increase your risk of falling.
  • Wearing low-heeled shoes that fit well.
  • Using walking aids correctly.

For more information, see the topic Preventing Falls.

Home Treatment

To help you recover from hip fracture surgery, your doctor will recommend a rehabilitation (rehab) program based on what part of your hip was fractured and the type of surgery done to repair it. A rehab program will include exercises to help you regain your strength and your ability to move around, retraining in simple daily activities, and ideas for staying active. Your doctor may recommend that you:

  • Begin balance training (with a physiotherapist from your hospital or local community centre).
  • Avoid movements that may strain your hip (or your new artificial hip parts).

After hip fracture surgery, you may need to learn new ways to do simple daily activities.

  • You will probably need to use a walking aid (such as a walker, cane, or crutches) for several months. For more information on how to use walking aids, see:
  • Cooking and other simple daily activities, such as bathing, may be difficult for you to do alone. There are devices such as dressing aids, raised toilet seats and bath benches, and handrails that may be helpful for you. Your local chapter of the Arthritis Society or a medical supply company may be able to help you find assistive devices in your area.
  • You may need to make changes to your home to reduce your risk for falls. Household hazards that can cause falls include slippery floors, cords, poor lighting, cluttered walkways, furniture placement that does not allow a clear pathway for walking, and throw rugs. For more information, see:
    Click here to view an Actionset. Aging Well: Making Your Home Fall-Proof.

Take care of yourself:

  • Stay active, and exercise a little every day.
  • Eat nutritious foods and have a balanced diet.
  • Limit alcohol use.
  • Don't smoke.
  • Take the correct medicine at the correct time.
  • Get your eyes checked on a regular basis.

Other Places To Get Help

Organizations

Arthritis Society of Canada
393 University Avenue
Suite 1700
Toronto, ON  M5G 1E6
Phone: (416) 979-7228
Fax: (416) 979-8366
Email: info@arthritis.ca
Web Address: http://www.arthritis.ca/
 

The Arthritis Society provides funding for arthritis research and offers information on patient care, public education, and self-management of arthritis.


Canadian Orthopaedic Association
4150 St. Catherine Street West
Suite 360
Westmount, QC  H3Z 2Y5
Phone: (514) 874-9003
Fax: (514) 874-0464
Web Address: www.coa-aco.org

Osteoporosis Canada
1090 Don Mills Road
Suite 301
Toronto, ON  M3C 3R6
Phone: 1-800-463-6842
(416) 696-2663
Fax: (416) 696-2673
Email: info@osteoporosis.ca
Web Address: www.osteoporosis.ca
 

Osteoporosis Canada works to educate and support individuals and communities in the prevention and treatment of osteoporosis. Services to individuals with osteoporosis and the public include free publications, a bilingual toll-free information line, educational programs, and referrals to self-help groups and community resources.


References

Citations

  1. Orosz GM, et al. (2004). Association of timing of surgery for hip fracture and patient outcomes. JAMA, 291(14): 1738–1743.
  2. Bhandari M, et al. (2003). Internal fixation compared with arthroplasty for displaced fractures of the femoral neck. Journal of Bone and Joint Surgery, 85-A(9):1673–1681.
  3. Binder EF, et al. (2004). Effects of extended outpatient rehabilitation after hip fracture: A randomized controlled trial. JAMA, 492(7): 837–846.
  4. Qaseem A, et al. (2008). Pharmacologic treatment of low bone density or osteoporosis to prevent fractures: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 149(6): 404–415.
  5. Gillespie LD, et al. (2009). Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews (2).
  6. Bischoff-Ferrari HA, et al. (2009). Prevention of nonvertebral fractures with oral vitamin D and dose dependency. Archives of Internal Medicine, 169(6): 551–561.
  7. Feskanich D, et al. (2002). Walking and leisure-time activity and risk of hip fracture in postmenopausal women. JAMA, 288(18): 2300–2306.
  8. Ettinger MP (2003). Aging bone and osteoporosis: Strategies for preventing fractures in the elderly. Archives of Internal Medicine, 163(18): 2237–2246.

Other Works Consulted

  • American Academy of Orthopaedic Surgeons and American Academy of Pediatrics (2010). Fracture of the proximal femur. In LY Griffin, ed., Essentials of Musculoskeletal Care, 4th ed., pp. 563–567. Rosemont, IL: American Academy of Orthopaedic Surgeons.
  • American Academy of Orthopedic Surgeons (2007). Minimally Invasive Hip Replacement. Available online: http://orthoinfo.aaos.org/topic.cfm?topic=A00404&return_link=0.
  • Fiechtner JJ (2003). Hip fracture prevention. Postgraduate Medicine, 114(3): 22–32.
  • Goldstein WM, Branson JJ (2004). Posterior-lateral approach to minimal incision total hip arthroplasty. Orthopedic Clinics of North America, 35(2): 131–136.
  • Lyles KW, et al. (2007). Zoledronic acid and clinical fractures and mortality after hip fracture. New England Journal of Medicine, 357(18): 1799–1809.
  • Mercier LR (2008). Fractures of the hip section of The hip. In Practical Orthopedics, 6th ed., pp. 207–211. St. Louis: Mosby Elsevier.

Credits

By Healthwise Staff
Primary Medical Reviewer William H. Blahd, Jr., MD, FACEP - Emergency Medicine
Primary Medical Reviewer Andrew Swan, MD, CCFP, FCFP - Family Medicine
Specialist Medical Reviewer Kenneth J. Koval, MD, MD - Orthopedic Surgery, Orthopedic Trauma
Last Revised June 27, 2011

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