Osteoporotic Hip Fractures: Trauma Calls Revisited

During your EMS career, you may have seen an elderly patient with a fractured hip. You provided excellent emergency care and properly placed the traction splint or other immobilizing device as you learned in EMT class. You assisted your patient with his needs and arrived at the hospital without incident. It’s more than likely that you never thought about the potential for serious consequences or the impact of the injury on the patient’s quality of life. Yet, hip fractures can result in enormous negative influences for victims, their families and for society as a whole.

Case Study

At 1300, Mrs. Smith dials 9-1-1 because she has not heard from her elderly mother who lives alone in another town. A police unit arrives a few minutes before your ambulance to find 79-year-old Mrs. Bishop on the kitchen floor, unable to move. They radio that she appears weak and is complaining of pain in her left hip.

Upon arrival, you find a small, pale, diaphoretic Caucasian woman in a great deal of pain with obvious external rotation and shortening of her left leg. Her skin is cold and clammy with poor turgor. Her blood pressure is 90/50, pulse 110 and respirations 24. Pulse oximetry reveals a saturation of 96%. The patient reports no pertinent medical history and no fracture history, but says she takes antihypertensive medication. She has been incontinent of urine and reports that she tripped over a kitchen throw rug and fell yesterday afternoon. Due to severe hip pain, she has been unable to move or get to a phone to seek help.

Hip Fracture Epidemiology

Hip fracture is a serious problem among the elderly of both sexes who experience a fall. These falls can occur anywhere, however, they mainly happen in the home. Although people of all ages fracture hips in car crashes and other types of accidents, according to the American Academy of Orthopedic Surgeons, 90% of the 350,000 hip fractures that occur each year in the U.S. result from falls.1 The probability of a hip fracture is greatly increased by the presence of osteoporosis (OP), which results in decreased bone strength due to loss of calcium.2 Only one-quarter of the victims of osteoporotic hip fracture achieve full recovery.3

Statistics project that between the years 2000–2040, the number of people age 65 and over will more than double to over 77 million. This will result in an estimated 650,000 hip fractures annually, or nearly 1,800 hip fractures per day.4

Injuries like these place enormous burdens on the healthcare system. Most hip fracture victims are elderly and require months of rehabilitation, if they survive the first year. Fifty percent will require an assistive device for ambulation and up to a quarter of those over age 50 will die in the first year following the injury.5 Mortality rates in the first year following a hip fracture are the highest in older populations. Causes of mortality include blood clots, pneumonia, infection and others.6

Women have two to three times as many hip fractures as men, and Caucasian, post-menopausal women have a one in seven chance of hip fracture during a lifetime. The rate of hip fracture increases at age 50, doubling every five to six years. Nearly one-half of women who reach age 90 have suffered a hip fracture.7

These figures mean that hip fracture is among the most pervasive, expensive and harmful of all of the health problems of our society. Most health professionals, let alone the lay public, fail to appreciate the significance of hip fracture to our socioeconomic well-being.

Anatomy of the Hip

The hip is the joint between the femur and pelvis and is made up of the femoral head (ball) and the acetabulum (socket), which is a shallow depression in the iliac bone of the pelvis (see Figure 1). This type of joint allows extensive range of motion while providing structural strength for supporting much of our total body weight. Two iliac bones each make up the major part of one half of the pelvis; the rest is comprised of the single sacral bone in the back. Major arteries and nerves enter the femoral head in the acetabulum. The hip joint’s normal structure is essential to maintain normal ambulation.

The femoral neck, the short length of bone that connects the femoral head to the shaft of the femur, is a structural weak point. Femoral neck fractures cause more disability and complications than fractures anywhere else in the hip, because discontinuity between the femoral head and the shaft of the femur destroys the hip’s weight-bearing ability. In addition, this area is richly supplied with blood, and serious bleeding can result from fractures of the femoral neck.

As a critical component of both structure and motion, the hip is not only a target for injury but is also a source of major disability when compromised—for example, when it is fractured.

The pubic ramus, the part of the pelvis connecting the acetabular area with the symphysis pubis (where the left and right halves of the pelvis are joined anteriorly), is also prone to fracture. This area, however, is not as structurally critical as the femoral neck, and fractures here are unlikely to result in instability unless due to major trauma. Osteoporotic fractures of the pubic ramus are painful but rarely lead to serious complications.

The joint capsule of the hip extends from the acetabulum to the intertrochanteric line anteriorly and then to the middle of the distal third of the femoral neck posteriorly. In other words, the femoral neck is contained entirely within the capsule of the hip joint. Therefore, femoral neck fractures are considered to be intracapsular injuries. It is important to understand this concept, as intracapsular fractures are more prone to posttraumatic complications than are fractures occurring outside of the joint capsule.

Blood supply to the hip originates from the circumflex femoral artery, which has branches stretching along the joint capsule and supplies blood to the femoral neck. Obviously, fractures to the femoral neck and/or any damage to the joint capsule can disrupt blood supply. Inadequate blood supply and pressure within the capsule from bleeding into the joint space can compromise circulation.8

Types of Hip Fractures

The term “hip fracture” refers to any of several different types of fractures that occur in the general vicinity of the true hip joint. Fractures can occur in various parts of the joint itself or in nearby areas. Following are the most common types of hip fractures:

• Femoral neck
• Pubic ramus
• Other parts of the iliac bones
• Greater trochanter
• Intertrochanteric fracture
• Shaft of femur.

Just like any other fracture, hip fractures can be displaced or nondisplaced, complete or incomplete, or comminuted. The relative seriousness of any fracture depends on many factors, such as location and whether significant bleeding or dislocation has occurred, or whether the skin has been broken. These types of complications are more unusual in hip fractures due to osteoporosis than to those due to trauma.

Risk Factors

As in many other areas of medicine, the risk of sustaining a hip fracture is determined on the basis of whether an individual has one or more of a number of risk factors. In general, the more risk factors one has, the more likely it is that a hip fracture will occur and vice versa. Some risk factors are modifiable (able to be changed) and some are not. Risk factors for hip fracture include:

• Osteoporosis
• Pre-existing physical disability (arthritis, CVA, chronic disease)
• Use of potentially sedating medications (tranquilizers, antidepressants, sleep aids)
• Dementia
• Physical hazards in the home
• Poor vision/poor lighting in the home
• Previous osteoporotic fractures
• Poor physical fitness
• Family history of hip fracture
• Neuromuscular or musculoskeletal problems
• Cognitive impairment and sensory deficits
• Slender/tall small-boned women
• Flimsy or unstable furniture
• Inability to rise from a chair without using the arms.9

Most of these risk factors are common, which helps explain the alarming frequency of hip fractures in the elderly.

Osteoporosis

Osteoporosis, the major underlying risk factor for hip fracture, is a condition characterized by loss of bone mineral matrix and calcium. The formal medical definition of OP is a numerical rating derived from a radiographic test called a DEXA (dual x-ray absorptiometry, or “bone density” test) scan.10 A DEXA scan (see Figure 2) is performed simply and quickly in an office setting with no invasive maneuvers required. The scored definitions, called “T-scores,” were created by a committee of the World Health Organization (WHO).11 A score of 2.5 or more standard deviations below normal is defined as osteoporosis.12

OP is in turn made more likely by the presence of one or more of its own risk factors, which are separate from the risk factors for hip fracture. Like the risk factors for hip fracture, some of the risk factors for OP are modifiable and some are not. Although space precludes a complete discussion of OP, many of its risk factors include:

• Age
• Female
• Nulliparity
• Small body size
• Light complexion
• Excessive alcohol or caffeine intake
• Prolonged bed rest, sedentary lifestyle or immobility due to illness
• Race (Caucasian or Asian higher risk than African)
• Family history of OP
• Poor calcium intake
• Chronic disease (rheumatoid arthritis, chronic obstructive pulmonary disease, cancer, chronic renal failure)
• Some medications (steroids, antiseizure drugs, sedating medications)
• Some endocrine disorders (hyperparathyroidism, diabetes).13

The OP patient has lost so much bone that the skeleton is unable to adequately perform its weight-bearing function, which is one of its main purposes. Normal activities can stress osteoporotic bone to the point of fracture even without trauma. The most common complications of OP besides hip fractures include fractures of the vertebrae, wrists and ribs.

Vertebral fractures, also called compression fractures, are the most common type of fracture seen in OP and can lead to kyphosis—loss of height or a bowed back (see Figures 3 and 4).

While female menopause is the main underlying risk factor for OP, there are other significant risk factors, some modifiable and some unchangeable. For example, poor calcium intake, lack of vitamin D or use of certain medications can all be changed, but one’s genetic make-up or history of previous fractures cannot be changed.

Since OP is the major risk factor for hip fracture, controlling or preventing OP is the best way to prevent hip fractures in the elderly. This is a major public health issue for Americans, and educating ourselves and the public in areas like this should be a part of every health professional’s job. EMTs and paramedics can be educators in their own communities.

Critical Thinking Question: Do you think Mrs. Bishop was a prime candidate for hip fracture? Why or why not?

Complications

You and your partner took great care immobilizing Mrs. Bishop’s leg and hip. In fact, the orthopedist in the emergency department specifically mentioned that your work would help reduce her chance of developing the usual postsurgical complications.

You hadn’t even thought of that. Of course, you knew that the extent of the patient’s deformity meant that the hip would probably have to be replaced. Now that it has been pointed out, you realize that this could mean the possibility of further problems. You decide to delve into it a little deeper and follow the patient’s progress.

Hip fracture is a major illness, therefore there are numerous chances for serious complications. The initial event, whether mild or severe, results in considerable psychological trauma due to pain and the shock of suddenly being unable to move, or to even effectively call for help. This in turn can lead to anxiety-induced elevations of blood pressure or even to myocardial infarction.

If the period of time the victim is unable to procure help is prolonged, other medical side effects become more likely, due to the simple inability to obtain water or medications. For example, dehydration in the elderly can lead to worsening of pre-existing renal problems. If dehydration is severe enough, it can even lead to a new onset of kidney problems.

Diabetic complications can also result from dehydration, the inability to obtain food or the lack of medications such as insulin, oral hypoglycemic agents or other prescription medications.

Immobility, local trauma or pressure on extremities can lead to deep venous thrombosis (DVT), which in turn can lead to pulmonary embolism, a potentially fatal complication in which pieces of blood clots break off and travel to the lungs, blocking circulation.14

Significant blood loss can occur, leading to hypotension and its attendant ramifications, although this is unusual in osteoporotic hip fractures, as opposed to those caused by major trauma. Hypotension can also lead to shock, myocardial infarction (MI) or cerebrovascular accident (CVA).

Other events made more likely by the immediate posttraumatic immobility include development of pneumonia or urinary tract infections (UTI).

Osteoporotic hip fractures lead to total hip replacement (THR) in the majority of cases. Major surgery like this is made more difficult by advanced age, associated medical conditions and the increased probability of surgical complications.15 In addition, the emergency nature of the surgery further increases the possibility of complications, as opposed to the controlled, planned setting of elective procedures. Possible surgical complications include infection of the prosthesis or surgical wound, anesthesia reactions or acute cardiovascular problems, such as MI or CVA.

In the longer postoperative period, complications include UTI, DVT, with or without pulmonary embolization, and CVA. Healing is more difficult for the elderly and nonunion of the bone may occur. Skin breakdown with resultant decubiti (bedsores) may occur if ambulation is inadequate. The prolonged relative immobility serves to worsen the pre-existing OP, and many patients are left with various gait disturbances, ambulation difficulties and a major change in the quality of their lives.

It is not surprising that elderly hip fracture victims rarely recover to a fully functional pre-fracture state. Major fractures with surgical treatment, whether or not complications arise, are difficult for even young patients to overcome. It is that much more difficult for the elderly. Likewise, it is easy to see that some of the possible complications can lead to death, especially in the first year after fracture. Without prophylactic anticoagulation, the risk of death from venous thrombo-embolism in the first three months following elective hip replacement surgery is increased 17-fold.16

Prehospital Care and Transportation

Prehospital care varies, depending upon local protocols and patient presentation. All patients complaining of hip pain should have the hip immobilized. In addition to a rapid and thorough assessment and evaluation for additional injuries, attention should be paid to airway, breathing and circulation, which is always a priority in treating trauma victims.

When fractures or deformities are obvious, apply traction splints, spine boards or cervical immobilizing devices. If osteoporosis seems likely, the possible coexistence of vertebral fractures should be considered.

Pain is likely, so handle these patients gently. Don’t be surprised if patients cry out in pain while being moved or splinted. Always explain what you are going to do and how you are going to do it. Regardless of age, fractures hurt, and movement worsens pain. Do whatever it takes to avoid further injury and discomfort.

Monitor vital signs, neurovascular status, pulse and sensation before and after splinting. Fluid replacement may be necessary, especially in patients who are hypotensive and tachycardic. Assess oxygen saturation, treat for shock, if indicated, and administer oxygen.

Advanced life support may be indicated for serious falls and associated hip fractures with increased bleeding potential. Ask patients if they are taking medications like beta blockers, which may decrease the heart rate, or anticoagulants like Coumadin (warfarin), which may cause additional bleeding.

Remember that orthopedic decisions vary significantly among different medical control physicians, whether they are orthopedists or not. Some physicians do not favor immobilization with traction splints, especially if the fracture is located in the femoral neck or trochanteric areas. Some frail, elderly patients cannot tolerate traction splinting and hard spine boards, which may cause additional trauma to their already weakened bones. Use your own discretion. If you are not sure, it is best to contact medical control for direction and consultation.

Transportation should be slow and gentle, because osteoporotic bones can be fragile enough that a rough ride on a hard spine board should be of concern. Preventing further injury is a gold standard of care. Of course, “priority one” calls may necessitate rapid transport to avoid further complications.

After the Fall

The fall and fracture changed Mrs. Bishop’s life drastically. She was quite shaken by the events, feeling helpless, humiliated and out of control. Unfortunately, no one took responsibility for contacting her family in the first few hours.

After assessment in the emergency department, she was medicated for pain. Being unused to such medications, she became confused. Laboratory studies were obtained. X-rays revealed a femoral neck fracture that would require surgery, so an orthopedic surgeon was called in for further evaluation and treatment.

Anxiety and stress increased as Mrs. Bishop gave permission for the first major surgical procedure of her life. She was tired, weak, tearful and worried about her future. She finally asked someone to call her daughter, who arrived after an hour or two—an interminable wait for the frightened 79-year- old. She was now in a hospital johnny-shirt, naked underneath, making her feel even more vulnerable and out of control. Her daughter tried to comfort her as she prepared herself mentally for surgery. All she had with her was a purse, an insurance card and her glasses. All her worldly possessions were at home unattended.

Mrs. Bishop was finally taken to the OR around 1700 for what would turn out to be a three-hour procedure. After six hours in the recovery room, she was transferred to an orthopedic unit. She suffered no major medical or surgical complications in the peri-operative period, but she was quite slow to regain ambulatory abilities. Even with daily physical therapy, she was not walking for almost four days due to weakness and balance problems.

After seven days in an acute-care hospital, Mrs. Bishop’s transfer to a rehabilitation facility was all set, but she developed a fever. A work-up revealed a urinary tract infection (UTI). Intravenous antibiotics necessitated a delay in transfer and she lost the extended- care facility bed. A change in antibiotics was mandated due to an allergic reaction, and the itchy rash drove her crazy.

The antihistamines used to treat the allergy disoriented her for a few days, until the consulting neurologist figured it out. The second antibiotic led to an opportunistic intestinal infection that caused severe diarrhea and dehydration. This was finally diagnosed as pseudo-membranous colitis, a fairly common condition caused by certain antibiotics that may suppress normal intestinal flora, allowing the overgrowth of others, and is characterized by severe diarrhea. This further delayed transfer of the patient.

Mrs. Bishop’s medical complications were finally controlled, and after 24 days in the hospital and a 14-lb. weight loss, she went to the extended care facility almost too weak to walk. Her life had changed from full independence to full dependence, even to the point of having to use a bedpan. Her depression was overshadowed by the medical complications until after transfer, when her daughter called her family doctor and pointed it out to him. Antidepressants were required to lift her feelings of hopelessness.

She had lived alone for 10 years after her husband died, and now she was not sure if she would ever return to her home. She needed assistance to get out of bed, as well as to use a walker. She was not able to walk independently and received daily physical therapy, which focused on functional training, safety aspects of ambulation, range of motion and muscle strengthening.

After three months at the rehabilitation center, she was transferred to a nursing home. Independent ambulation was still problematic, and Mrs. Bishop was not able to care for herself independently. She never returned to the home she had lived in for 40 years.

Critical Thinking Question: Can you list all the complications that Mrs. Bishop sustained throughout her course of treatment?

Lifestyle & Home Safety Tips

Knowing the risk factors for OP and hip fracture can help us make choices or changes that can hopefully reduce the possibility of this potentially devastating event.

Priority should be given to the prevention and treatment of OP. Everyone, including the elderly, should consume at least 1,200 milligrams of calcium daily, whether through dietary or supplemental sources. Adequate vitamin D is essential for effective absorption of calcium but is frequently missing from the diets of the elderly, as well as younger people.

Bone density testing to assess bone status should be performed on a DEXA scanner in all women over age 65, in all women under 65 with at least one OP risk factor, and in men with any risk factors. Testing should be repeated at least every two years and more frequently in specific circumstances, such as in those with predisposing illnesses or those using some of the medications known to cause OP.

Routine preventive medical practices should be maintained. Sedatives and benzodiazepines should be eliminated or their dosages reduced. Vision or hearing problems should be addressed, blood pressure monitored and hip protectors worn, if indicated.

Other home-safety tips to prevent the falls that can lead to insufficiency fractures include but are not limited to:

• Grab bars in the bathroom
• Non-slip mats in the bathtub or shower
• Removal of loose throw rugs or floor coverings
• Good lighting to avoid bumping into things and falling
• Proper footwear
• Arising slowly after awakening or resting to avoid blood pressure changes
• Use of ambulatory aids such as canes or walkers to maintain balance
• Daily exercises to strengthen muscles
• Night light and flashlight by the bed
• Cell phone or medical alert alarm system
• Keeping pets away from pathways
• Holding on while using stairs.

Are You At Risk for Osteoporosis?

All healthcare professionals, including EMS personnel, should reflect upon their own risk factors for osteoporosis. Although calcium intake is most important in childhood and adolescence, adequate intake at all ages is essential to prevent OP. Food labels will help concerned consumers meet the recommended daily requirement of 1,200 milligrams. It is better to have a glass of milk while on duty than to have soft drinks or fast foods.

A dosage of at least 125 IU (international units) of vitamin D is required for adequate calcium absorption. This can be found in cereals, milk or multivitamin tablets. Reading food labels will help ensure adequate intake of both of these nutrients.16

Weight-bearing exercise is necessary to stimulate bone to lay down calcium. Conversely, a sedentary lifestyle is a major risk factor. While posting at a street corner or sitting in an ambulance bay, try to think of novel exercises, use handheld weights while watching television or otherwise be creative.

Analyze the potential risk factors of your family members of several generations. Determine if you are at risk for osteoporosis and begin an early prevention program. It is never too late to begin taking care of your health. After all, your patients need healthy prehospital providers who can care for them effectively. Optimum health can be assured by no one but you. Watch what you eat and take in adequate amounts of calcium.

Conclusion

EMS is frequently dispatched to the homes of the elderly, where falls are common occurrences. Most victims are women who have fallen and are unable to get up by themselves. While en route to such calls, EMS crews can consider the possibility of hip or vertebral fractures and the multitude of potential complications. “Simple” hip fractures can ultimately change the lives of victims and their families in a split second.

It is essential that rescue personnel consider all possibilities that may evolve from a simple fall, including death. Protect your elderly loved ones and do everything possible to prevent osteoporosis and the fractures that may result. Early diagnosis and intervention are key to hip fracture prevention. ?

References

1. American Academy of Orthopedic Surgeons. “Hip Fractures.” October 2000, p. 1. www.orthoinfo.org.
2. Cluett J. Hip Fracture: Information about a Broken Hip at: https://orthopedics.about.com, p. 1.
3. American Academy of Orthopedic Surgeons. Falls and hip fractures. April 2001, www.orthoinfo.org.
4. Ibid, p. 1.
5. Ibid.
6. Cluett J. Hip Fracture: Information about a Broken Hip. https://orthopedics.about.com, p. 1.
7. Winkley G. Fractures: Hip. www.emedicine.com.EMERG/topic198.htm. pp. 14–17.
8. Stoutt G. Just for the health of pilots. The Federal Air Surgeon’s Medical Bulletin: Spring 2003: Hip fracture, p. 1.
9. Winkley G. Fractures: Hip. www.emedicine.com.EMERG/topic198.htm. p. 14–16.
10. Peck B. The Baby Boomer Body Book: The Complete Health Reference for Our Generation, p. 309. SourceBooks, Inc., Ill. 2001.
11. World Health Organization.
12. Peck B, Bruce ML. Breaking bones: Prehospital care of the osteoporosis patient. Emerg Med Serv 32(4):83, 2003.
13. Seagrott V, et al. Elective total hip replacement: Incidence, emergency readmission rate, and postoperative mortality. BMJ 303:1431–1435, 1991.
14. Warwick D, et al. Death and thromboembolic disease after total hip replacement. A series of 1162 cases with no routine chemical prophylaxis. J Bone Joint Surgery Br 77: 6–10, 1995.
15. Seagrott V, et al. Elective total hip replacement: Incidence, emergency readmission rate, and postoperative mortality. BMJ 303:1431–1435, 1991
16. Peck B, Bruce ML. Breaking bones: Prehospital care of the osteoporosis patient. Emerg Med Serv 32(4):83, 2003.