Breaking Bones

Sixty-five-year-old Jane was helping her daughter prepare for a garage sale when she tripped over a cardboard box and fell, landing on her left hip. She cried out in pain and grabbed at the injured hip. After sitting for a few minutes, Jane asked her family to lift her into a chair.

After resting for 20 minutes, Jane was still in pain, but needed to use the bathroom. As she was helped into the house, she could bear a little weight on her left leg, but she suddenly heard a crack, her leg gave out, and she collapsed to the floor in agony. In that moment, her partial hip fracture became a complete hip fracture. For Jane, a simple fall at home turned into a severe injury, with a complex treatment program and uncertain recovery.

Introduction
According to the Centers for Disease Control and Prevention, more than one-third of adults over age 65 fall each year.1 Falls are the leading cause of injury-related deaths in elderly patients and the death rate from falls increased steadily from 1988-2000.2

In 2001, more than 1.6 million seniors were seen in emergency departments for fall injuries, resulting in 388,000 hospitalizations. Most of the fall-related hospitalizations were related to hip fractures. It is estimated that 98% of hip fractures are in the elderly.3

Hip fractures in children, adolescents and adults under age 65 are rare and are most likely a result of high-speed sports collisions, motor vehicle collisions or falls from a significant height. This article focuses on hip fractures in the elderly.

Hip Anatomy and Physiology
The hip is a ball and socket joint with a wide range of motion and is where the femur meets the pelvis. A hip fracture is actually a fracture of the proximal femur, including the head or neck of the femur, which angles inward towards the pelvis. The head of the femur is the ball that fits in the socket created by the acetabulum in the hip bone.3 The femur consists of the head, neck, greater trochanter (a palpable bony prominence that is even with the wrist of a supine patient's extended arm), lesser trochanter and intertrochanteric line, or ridge.

The acetabulum is composed of all three pelvic bones.5 Acetabulum fractures are primarily the result of high-energy trauma mechanisms, and not simple falls. In elderly patients, the proximal femur is more likely to fracture from a simple fall before the acetabulum fractures.

Several arteries branch off the femoral artery to bring oxygenated blood to the neck and head of the femur. This blood supply is often described as tenuous because fractures of the femoral neck can disrupt the blood supply to the femoral head.6

It is easy to see how a hip fracture could cause nerve impairment. The sciatic nerve--the major nerve of the body--innervates the muscles of the leg and foot, and also controls movement of the hip and knee.7

Motion of the hip joint is controlled by three major ligaments and several large muscles.6 The iliofemoral ligament attaches the ileum of the pelvis to the intertrochanteric line of the femur. The pubofemoral ligament attaches the pubis to the intertrochanteric line of the femur, and the ischiofemoral ligament attaches the ischium to the greater trochanter.8

A hip fracture is any break in the proximal end of the femur, from the head of the femur to the first 4 cm to 5 cm of the subtrochanteric area.6 After physical examination and x-ray study, hip fractures are classified, based on the location of the break, as either head, neck, intertrochanteric, trochanteric or subtrochanteric.6 Most hip fractures are displaced, meaning the head of the femur stays in the socket and the femur repositions to the anterior or posterior. Displacement leads to the injured extremity being shortened and externally rotated.

Fracture Classifications
Different fracture locations present with different physical exam findings.6

Femoral head fracture
A femoral head fracture is single or multiple fractures in the head of the femur. Femoral head fractures are commonly associated with hip dislocations.

Femoral neck fracture
In a femoral neck fracture, the affected extremity is a slightly shortened, abducted and externally rotated position.6
Femoral neck fractures can cause a significant disruption of the blood supply to the femoral neck, which can result in significant healing problems.3

Intertrochanteric fracture
In an intertrochanteric fracture, the affected extremity is held in a markedly shortened and externally rotated position.6

Trochanteric Fracture
Trochanteric fractures produce no obvious physical exam findings.6

Subtrochanteric fracture
For a subtrochanteric fracture, the affected proximal femur is usually held in a flexed and externally rotated position.6

Significance of Hip Fractures in the Elderly
There are a number of reasons why hip fractures in the elderly are so significant:

• They cause more deaths than fractures from other falls.
• They lead to the most severe health complications during hospitalization and rehabilitation.
• They lead to reduced quality of life through prolonged hospitalization, institutionalization, loss of mobility and loss of confidence.
• After treatment and rehabilitation, about half of hip fracture patients are no longer able to walk independently.

Mechanism of Injury
The mechanism of injury for a hip fracture can vary from a significant trauma to a simple fall. Patients with a major trauma MOI, like a motor vehicle collision, are also likely to have other musculoskeletal and soft tissue injuries, including head and neck injuries, spinal cord injury, pelvis fracture, and internal and external bleeding.6 In less than 2% of elderly patients, hip fractures are spontaneous without a fall, but may be from a sudden movement or twist.

Three factors--the fall itself, the force and direction of the fall, and fragility of the bones that absorb the impact--determine whether or not a bone fractures.10 Tall patients fall farther and thus have an increased risk. There is also a greater risk of fracture from falling sideways or straight down than falling backwards. Over time, bones become fragile and can snap from activities that were at one time done without thinking.10

Falls among elderly patients are most common in the home.11 Patients report tripping over a loose area rug, a newspaper lying on the floor or a pet; or they misjudge the location of a chair or bed and fall to the ground. Approximately 60% of falls occur in the home, usually from a standing position on a level surface;1 30% occur in public places, and 10% happen to patients in nursing homes.11

According to maps from the CDC that show unintentional fall death rates for men and women, the rate is much higher in the Upper Midwest and Rocky Mountain West.12 There are probably a number of reasons for this, including a greater proportion of population over age 65; months of icy and snow-covered driveways, steps and sidewalks; higher obesity rates; and higher rates of alcohol consumption.

Fall Risk Factors
Environmental hazards combine with gender, age, race, impaired or decreasing mobility, health problems like osteoporosis, and medications to increase the risk of falling. In the home, seniors face a variety of environmental hazards that include tripping hazards like rugs, electrical cords, loose shoes and clothing; a lack of railings or grab bars in stairs, bathrooms and tubs; slippery surfaces like icy sidewalks or shower floor; unstable furniture and poor lighting.1

Women sustain 80% of all hip fractures and are admitted to the hospital for hip fractures at much higher rates than men.1,2 By age 80, 15% of women and 5% of men have had a hip fracture.4

The rate of hip fractures increases exponentially with age. For example, patients over age 85 are 10-15 times more likely to sustain a hip fracture than a 60-year-old.1,13,14 Aging brings changes in vision--decreased acuity and peripheral vision, cataracts and decreased depth perception. Diminished hearing also increases the risk of falling.

Elderly patients generally lose strength, with an accompanying reduction in muscle mass. Thus, the consequences of a fall are more severe; a minor fall can cause severe injuries. Elderly patients have slower psychomotor skills and reduced hand-eye coordination, which can turn a minor slip into a full fall.

Finally, elderly patients counteract many body changes by changing their gait or stride, which can cause their feet to stick on the floor or result in tripping over a small object. Whites sustain two to three times more hip fractures than non-whites, because the rate of osteoporosis is greater among whites.6

Existing medical problems, like Parkinson's disease, history of stroke, arthritis or dementia, that increase the risk of a simple fall in turn increase the risk of a hip fracture.1 One common medical problem is orthostatic hypotension--a sudden drop in blood pressure from standing up. Many medications and medical problems can cause orthostatic hypotension.

Weakness and walking problems are among the most common causes of falls, especially for nursing home residents. Impaired mobility can also lead to falls when a senior attempts to move from a chair to a bed or from a toilet to a wheelchair.15 Poor foot care, poorly fitting shoes and incorrect use of canes and walkers also lead to an increased fall risk.15 Medications, especially psychoactive drugs and sedatives, increase the risk of falls and fall-related injuries in seniors as well.15

Hip Fracture Assessment
When EMS arrived, the patient in the opening scenario was entirely focused on her pain. Any movement, even subtle, caused an agonizing scream. The EMTs' findings included: a female patient, age 65, who had fallen on the garage floor 20 minutes before our arrival. The patient was on numerous medications. Her injured leg was shortened with the toes pointing out, and she rated her pain as 10 of 10. There was pain and tenderness upon palpation. All clues pointed to a hip fracture.

During your scene size-up, consider the type of fall: Was it from a height or a standing position? Are c-spine precautions indicated? Are additional resources needed to lift or move the patient off the ground and onto the cot? Are rescuers at risk of falling while assessing, treating and moving the patient?

Since most falls happen in the home, they are usually unwitnessed. Look for clues about how the patient fell, like a cane or walker that is out of reach, a spilled bag of groceries or a phone pulled toward the patient's location.13

Pain is the most common prehospital complaint, and most hip fractures are painful. The pain is either constant, presents with movement or is noted on palpation. Most elderly patients who sustain a hip fracture only have an isolated fracture and are awake with no other problems. Nonetheless, some patients lie on the ground for hours or even overnight before they are found. Check and treat any ABC problems before proceeding with the focused history and physical exam.

In a typical presentation, the injured leg is externally rotated and may be shortened.3 Even when the MOI is a simple fall, conduct a full head-to-toe exam to find any other injuries and to look for evidence of previous falls.

During the exam, look for:

• Deformity: Is there obvious deformity of the hip joint?
  
• Symmetry: Are both legs of equal length?
  
• Flexion or extension of the affected leg
  
• Is the foot of the affected leg externally rotated, toes pointing outward?
  
• Ask the patient to point to where it hurts the most.

Listen to the patient's pain response when you palpate the greater trochanter, proximal femur and groin. Listen to the patient's pain response when you attempt to passively move her extremity, ask her to bend at the knee or to turn her toes in or out.

Feel for deformity. Is the greater trochanter where you expect it to be? A critical assessment component is to check circulation, sensation and motion distal to the injury.

When conducting the physical exam, assess range of motion. Check internal and external rotation of the extremity by asking the patient to point her toes inward and outward. Check flexion by asking her to bring her foot toward her bottom; check extension by asking her to straighten her leg. Stop the exam immediately if it causes pain or there is resistance to movement.

After falling, some patients feel some pain, are able to partially bear weight and continue to walk with the support of a companion, but, 20-30 minutes later, feel a pop and sudden severe, sharp pain. It is likely the patient had a partial or stress fracture of the femoral neck that became a complete fracture. If you suspect a patient has a hip fracture, do not ask him to walk or bear weight, as this could significantly worsen the problem and prolong recovery.6

A common set of findings for an elderly patient with a hip fracture includes:3

• Pain with passive motion: Attempting to move the patient's hip causes pain.
• A limited range of motion, especially external rotation--pointing the toes outward.
• Bruising may or may not be present, which is partially dependent on the time since injury.
• Pain and tenderness to palpation in the groin and the femoral neck.

During the physical exam, look for other injuries from simple falls, like other fractures; facial and scalp lacerations; abrasions to hands, elbows, knees and face; and bruises almost anywhere.

Patient History
SPLATT is a tool used to gather history about the fall.13

Symptoms
Inquire about the patient's signs and symptoms, including learning about pain using the OPQRST mnemonic.
Previous history
Ask if the patient has a previous history of falls. If yes, ask additional probing questions to learn more about those falls.
Location
Determine the location of the fall. Many patients are carried or crawl from the location of the fall before we arrive.
Activity
What was the patient doing at the time of the fall?
Time
How long ago did the fall occur? If the patient is disoriented or not awake, use clues like skin temperature, pressure sores, signs of hypoperfusion and bladder incontinence to estimate the time.
Trauma
Look for fall-related trauma.

Take note of any allergies, especially to medications, as the patient is likely to receive pain medication. Be alert for medications like estrogen, raloxifene, calcium and vitamin D, which may indicate your patient is being treated for osteoporosis.4

Document any pertinent medical history that is associated with increased risk of falls and fractures. Try to learn more about the fall from the patient and any witnesses.

Assessment
A hip fracture is capable of producing significant internal bleeding, with a potential volume loss of more than a liter.6 If the patient has increasing heart and respiratory rate and altered mental status, treat for shock with fluids, positioning, high-flow oxygen and high-priority transport.

Since most patients with hip fractures are elderly, there is a likelihood that the patient also has dementia and hearing or vision impairment that will complicate the assessment. If the patient is unable to report pain, does palpation elicit a pain response? Does passive range of motion elicit a pain response? Expose the skin to look at the hip for bruising and deformity. Expose the entire leg to look for shortening and rotation, and compare the injured to the noninjured leg. Ask any available caregivers what they observed before you arrived.

Hip Fracture Treatment
The general principles of hip fracture treatment after identifying and stabilizing any life threats include: stabilization of the injured hip and affected extremity; pain control; and lifting and moving the patient to the ambulance cot to minimize further injury and pain.

Follow local protocols for stabilizing a suspected hip fracture. Most awake and oriented patients will be self-stabilizing in a position of comfort when you arrive. Notice what the patient is doing and assist her in maintaining that position. If necessary, help the patient find a position of comfort with the right combination of pillows and blankets.

Any splint applied to a hip fracture should be complete, compact and comfortable. A complete splint immobilizes the hip by limiting movement of the affected joint. Unless the patient has a significant trauma MOI--like a motor vehicle collision--full spinal immobilization is not necessary. A compact splint has appropriate bulk to immobilize the injury, but still allows the patient to fit on the ambulance cot. A comfortable splint does not cause the patient any additional pain.

Hip fractures are painful. Begin pain management with non-pharmacological techniques, including helping the patient achieve a position of comfort, reassurance, and splinting or binding the injured area. Consider using a few pillows, blankets and triangle bandages to bind the injured leg to the uninjured leg in a position that is most comfortable for the patient.

For many elderly patients with an isolated hip fracture, an ALS on-scene response or intercept is indicated, primarily for pain management. If the patient is stabilized in a position of comfort, request an ALS service to administer IV pain medication, which will make it easier to assess and move the patient and make the bumpy ambulance ride more comfortable.

Always consider IV pain medication for a patient with a suspected hip fracture.3 A patient who has received pain medication is better able to answer history questions, test range of motion ability and assist in moving to the ambulance cot. Follow local protocols for indications, contraindications and dosages for pain medications. Reassess physical exam findings after administering pain medications, as you might get additional information.

Lifting and Moving
The goals of lifting and moving a patient with a hip fracture are to minimize the chance of a lifting-related injury to rescuers and minimize movement and stress on the patient's injured hip.

To meet these goals, first explain the plan to all rescuers and the patient before lifting. Administer pain medications a few minutes before lifting, waiting until the patient has experienced some pain relief before moving him. Also, splint the injured hip before moving the patient.

Select a method that will minimize patient movement. A method I have seen work well is one rescuer lifting under the patient's armpits and two rescuers supporting the weight of the legs. The patient is rolled onto a blanket and lifted by three or four rescue personnel onto the ambulance cot. If you use a backboard or scoop stretcher to transfer the patient from the ground to cot, remove the backboard after the patient is on the cot.

An isolated suspected fracture does not make a patient a high-priority transport. A hip fracture becomes a high priority if: other injuries are causing ABC life threats; circulation, sensation and motion are compromised distal to the injury; and vital sign trends indicate hypoperfusion from internal bleeding.

Lasting Consequences
The high mortality rate associated with hip fractures is due to problems related to immobilization after hospital interventions, such as deep vein thrombosis, pulmonary embolism, pneumonia and muscular atrophy.6 Permanent decreased physical functioning is a common physical consequence.15 Surviving the fall is easy; recovering mentally and physically is very difficult.

In addition to the lingering physical effects, many patients experience some or all of the following psychological consequences that result from impaired mobility and loss of independence: depression, shame, fear, anxiety, loss of confidence, loss of motivation, social isolation and feelings of helplessness.13,15

Osteoporosis as a Risk Factor
During the SAMPLE history, the patient may tell you she has osteoporosis, which is a degenerative problem of low bone mass and loss of bone tissue.4 Osteoporosis leads to an increased risk of fractures of the hip, spine and wrist. There are 10 million patients in the United States with osteoporosis and another 18 million at risk.4 Eighty percent of patients with osteoporosis are female.4 Osteoporosis causes more than 1.5 million fractures per year, of which 19% are hip fractures.16

Osteoporosis is primarily due to a lack of estrogen in women and androgen in men.4 Additional causes include low calcium intake, low vitamin D, low exercise and other hormonal changes with age.4 Like many medical problems, cigarette smoking, eating disorders, heavy alcohol consumption and a sedentary lifestyle increase the risk.4 Osteoporosis initially has no symptoms. As bone tissue is lost and bone density decreases, bones become so fragile they can break under the slightest strain.10

Osteoporosis is not the same as osteoarthritis. Osteoarthritis is a chronic disease that affects the weight-bearing joints. It is common in geriatric patients, with nearly 100% of patients over age 75 having some symptoms of osteoarthritis. Patients often complain of aching and throbbing pain that is worse with activity and improves with rest early in the disease process.17 As it worsens, the pain is always present.

Fall-Prevention Programs
If you have not yet cared for a patient with a hip fracture, you will soon. Researchers estimate that, given the aging population, the number of hip fractures will exceed 500,000 per year by 2040.1

EMS agencies can partner with other healthcare providers to deliver formal and informal injury-prevention programs to reduce the risk of falls. Things you can do include:

• If you are in a home and see a risk factor like poor lighting or a loose area rug, point out the risk to the patient and family bystanders.
  
• Encourage patients to stay physically active.
  
• Ask your patients if they have a home medical alert service they can use to call for help.
  
• Encourage the patient and family to install grab rails in the bathroom.
  
• Instruct the patient on proper use of assistive devices, like canes and walkers.

Formal programs to decrease hazards in seniors' homes include site visits to remove tripping hazards like throw rugs and clutter in walkways; install nonslip mats in the bathtub and on shower floors; install grab bars next to the toilet and in the tub or shower; install handrails on both sides of stairways; and improve lighting throughout the home.

References
1. Centers for Disease Control and Prevention National Center for Injury Prevention and Control. Falls and Hip Fractures Among Older Adults. www.cdc.gov/ncipc/factsheets/falls.htm.
2. Centers for Disease Control and Prevention National Center for Injury Prevention and Control. A Tool Kit to Prevent Senior Falls: Figures. www.cdc.gov/ncipc/pubres/toolkit/figures.htm.
3. Bhatti NS, Ertl JP. Hip Fracture. Emedicine.com. www.emedicine.com/sports/topic48.htm.
4. Smith HR. Osteoporosis Overview. Emedicine.com. www.emedicinehealth.com/articles/5516-1.asp#.
5. Thornton DD. Acetabulum, Fractures. Emedicine.com. www.emedicine.com/radio/topic5.htm.
6. Winkley G. Fractures, Hip. Emedicine.com. www.emedicine.com/emerg/topic198.htm.
7. Giunti Editorial Group. Atlas of Anatomy. Cobham, Surrey: TAJ Book Ltd, 2002.
8. Zlidenny A, Vaca FE. Hip Dislocation. Emedicine.com. www.emedicine.com/sports/topic47.htm.
9. Senisi S, et al. Functional Anatomy for Emergency Medical Services, Ed. Richard Beebe. Clifton Park, New York: Delmar Thomson Learning, 2002.
10. NIH Osteoporosis and Related Bone Diseases National Resource Center. Falls and Related Fractures: The Risk of Undiagnosed Osteoporosis. www.osteo.org/newfile.asp?doc=r613i&doctitle=Falls+and+Related+Fractures%3A+The+Risk+of+Undiagnosed+Osteoporosis&doctype=HTML+Fact+Sheet. 11. Kopito J. Falling Injuries and the Elderly. Glen Cove Volunteer Emergency Medical Services. www.glencoveems.com/InjuriesElderly.html.
12. Centers for Disease Control and Prevention National Center for Injury Prevention and Control. Tool Kit to Prevent Senior Falls: Maps. www.cdc.gov/ncipc/pubres/toolkit/maps.htm.
13. Teel L, Cason D. Falls and the Elderly: The Role of EMS in Treatment and Injury Prevention. Texas Department of Health Bureau of Emergency Management. www.tdh.state.tx.us/hcqs/ems/SO03CE.htm.
14. Newton RA. The Fall Prevention Program Manual. Temple University. www.temple.edu/older_adult/fppmanual.html.
15. Centers for Disease Control and Prevention National Center for Injury Prevention and Control. A Tool Kit to Prevent Senior Falls: Falls in Nursing Homes. www.cdc.gov/ncipc/factsheets/nursing.htm.
16. NIH Osteoporosis and Related Bone Diseases National Resource Center. Osteoporosis Overview. www.osteo.org/newfile.asp?doc=r106i&doctitle=Osteoporosis+Overview+%2D+HTML+Version&doctype=HTML+Fact+Sheet.
17. Stitik TP, Foye PM. Osteoarthritis. Emedicine.com. www.emedicine.com/pmr/topic93.htm.

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Greg Friese, MS, NREMT-P, WEMT, is president of Emergency Preparedness Systems LLC. EPS helps clients rapidly deploy emergency education. Greg and EPS associates have authored and edited dozens of online education programs for first responders, EMTs and paramedics. Friese is a paramedic, Wilderness Medical Associates lead instructor and EMS author. Contact him at gfriese@eps411.com.