Fractures involving the upper portion of the femur, what we commonly refer to as hip fractures, are one of the most common and serious orthopedic injuries that occur in the elderly population. These injuries, of course, are usually the direct result of a fall onto a hip that has relatively low bone mineral density (osteoporosis). In 2014, the incidence of falls among people older than 65 years was 672 per 1000 population in the U.S., and the incidence increases with age. Among people older than 85 years, the fastest growing segment of the US population, fall incidence was 820 per 1000 population in 2014. Falls are the leading cause of both fatal and nonfatal Injuries in people 65 and older. A fall is often a life-changing event.
Osteoporosis (low bone mineral density) causes more than 8.9 million fractures annually worldwide, resulting in a fracture every 3 seconds. Osteoporosis affects 1/10 of women aged 60, 1/5 of women aged 70, 2/5 of women aged 80 and 2/3 of women aged 90. Overall, 61 % of osteoporotic fractures occur in women but 20-25% of hip fractures do occur in men.
Osteoporosis can cause fractures of the forearm, humerus, spine and hip, but hip fractures are generally considered the most worrisome of all. Hip fractures are invariably associated with chronic pain, decreased mobility, disability, and an increasing degree of dependence. After sustaining a hip fracture, 10-20% of previous community dwelling patients require long term nursing care. Up to 40% of patients are unable to walk independently after injury and less than half of those that survive regain their previous level of function. Mortality rates remain frustratingly high; 14-36% of patients will die within 1 year after injury.
Previous efforts to reduce the incidence of hip fractures have focused on prevention. Specifically, efforts have been made to strengthen bone mineral density. Supplementation with calcium, vitamin D or a combination of both has usually been considered 1st line treatment. Unfortunately, a recent meta-analysis of 33 studies involving more than 51,000 patients has shown that the use of these supplements, either alone or in combination, made no meaningful difference in the prevention of hip fractures, at least in those individuals living outside of a nursing home. Alternatively, other medicines that can increase bone mineral density, such as bisphosphonates, can be expensive and have serious side effects.
Despite these concerns, prevention of falls and osteoporosis remain the cornerstones of hip fracture treatment. First, regular physical activity and exercise for older individuals will not only boost bone mineral density but also help prevent future falls. Initially, a sedentary individual may need to start off slow and gradually increase activity level and duration. Assessing for visual impairment and treating appropriately will also help prevent falls. Identification of individuals with high fall risk and properly referring to a fall prevention program is also essential.
Efforts made at preventing osteoporosis focus on changing the modifiable factors. This includes: maintaining ideal body weight, smoking cessation, decrease alcohol intake, limit steroid usage and increasing physical activity. Additionally, once an osteoporosis-related fracture occurs, it is imperative to refer these individuals for bone mineral density testing and initiate appropriate treatment to prevent another fall or fracture.
Despite our best efforts at prevention, falls and hip fractures do occur. In this setting, prompt admission, early fall and nutrition assessment, surgery within 24-48 hours of admission and early postoperative physiotherapy are standards of care in the hospital setting for hip fracture treatment. Rest assured, Guthrie County Hospital is ready and prepared to provide all facets of hip fracture prevention and treatment!
Dr. Jeffrey Wahl, DO