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OCR for page 61
10
Hip Fracture
David G. Murray
Although a fracture of the hip is not in and of itself potentially fatal, the
mortality associated with the occurrence of this injury in the elderly is
significant, and the associated morbidity and negative effect on quality of
life are important. Moreover, the incidence, which increases rapidly in the
Medicare population, places a major demand on health resources, social
institutions, and the budget for health care. Any changes that could be
brought about to decrease the incidence of hip fracture, facilitate improved
treatment, reduce hospitalization, and increase the number of individuals
restored to their prefecture lifestyle would have impressive benefits for
society.
PREVENTION
Prevention of fracture of the hip in the elderly involves an increased
understanding of etiological factors. Osteoporosis, which to some extent is
a natural accompaniment of aging, is an obvious predisposing condition.
The extent to which the normal decrease in bone density that occurs during
aging plays a role in the predisposition is poorly understood and requires
further study. Pathological osteoporosis (itself poorly understood) is an
obvious predisposing condition. The various factors affecting this condition,
such as alcoholism, smoking, steroids, sedatives, anticoagulants, and diet,
need further study. Mechanisms for modifying osteoporosis through diet,
activity, or drug therapy are currently being investigated.
The vast majority of fractured hips are associated with falls. It has never
been clear whether the individual falls because the hip fractures or the hip
fractures as a result of the fall. Probably both play a role. Falls in the
elderly are influenced by external and internal factors. The external environment,
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EFFECTIVENESS AND OUTCOMES IN HEALTH CARE
which includes obstacles to ambulation such as furniture, slippery floors,
and carpets, can obviously be modified once the relationship to falls is
clearly understood. The internal factors such as Parkinsonism, malnutrition,
Alzheimer's disease, balance problems, and visual impairment may be more
difficult to modify. On the other hand, once such internal factors are clearly
identified as being associated with an increased incidence of falls and frac-
ture, some modifications of the external environment may be able to compensate
for them.
Data also suggest that there is a geographic variation in the incidence of
fracture of the hip. Whether this is due to dietary differences, differences in
demographics, or some other factor remains to be explained and deserves
further investigation.
TREATMENT
The diagnosis of fracture of the hip is straightforward. The history of a
fall with associated disability in an elderly person is suggestive. X-ray
examination confirms the diagnosis and characterizes the fracture as either
a fracture of the femoral neck or an intertrochanteric fracture (one involving
the upper end of the femur just below the femoral head). The location of
the fracture influences the treatment and the prognosis. Fractures of the
femoral neck may impair the blood supply to the bone of the femoral head
and therefore compromise the results of treatment that retains the femoral
head. Intertrochanteric fractures may be complex, and the damage to the
bone may preclude replacement with a prosthetic device.
Since the 1930s, surgery has been the preferred method of treatment for
fractures of the hip. Fixing the fracture in some manner has been shown not
only to diminish the length of hospitalization but also to lower significantly
the mortality rate and improve the chances of the patient's returning to the
prefecture lifestyle. At this point, nonsurgical treatment is reserved for
those patients who cannot undergo surgery for medical reasons.
Initially, fractures of the hip were treated surgically by internally fixing
the fracture with a nail, plate, screws, or some other means of holding the
bone ends together. Because the bone ends frequently failed to unite, a
prosthesis was introduced to replace the femoral head. Subsequently, total
hip replacement was used to treat certain fractures of the hip.
At this point no ideal treatment for hip fracture has been established. The
method used varies with the preference of the individual surgeon. To some
extent economics enters the picture as well. Simply fixing the fracture with
a nail or plate carries the previously mentioned risk of nonunion or loss of
position of the fractured fragments. Replacement of the femoral head with
a prosthesis is sometimes associated with persistent pain in the hip and
gradual erosion of the bone of the pelvis by the metallic femoral head.
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IOM CLINICAL CONDITION WORKSHOPS
63
Total hip replacement is a somewhat more complex procedure and is more
expensive, both in terms of operating time and equipment and device costs.
There is a definite need for outcome studies to clarify the relative advantages
and disadvantages of each treatment method. Such outcome studies would
include length of hospitalization, in-hospital complications, rate of reoperation,
and the overall recovery of the patient.
IN-HOSPITAL CARE
In addition to the surgical procedure itself, a number of other factors are
associated with the initial hospitalization of a patient with a fractured hip.
These factors need to be reviewed in terms of their impact on the outcome
or effectiveness of treatment. Preoperative evaluation by consultants, including
internists, geriatricians, family physicians, cardiologists, urologists, and so
on, may have a beneficial effect on the mortality or morbidity associated
with the surgical procedure. Following surgery, the involvement of a rehabilitation
team has been shown in other countries to have an effect on the length of
hospitalization. Hospitalization in the United States is significantly shorter
than in other countries, but similar studies should be done to clarify the
impact of associated special services on the outcome of the patient's hospital
treatment.
REHABILITATION
A multitude of factors are associated with the ultimate rehabilitation of
the patient. Currently it is known that the mortality associated with a
fractured hip is elevated over that of a matched population group during the
first 6 to 12 months after fracture. In addition, the percentage of individu-
als who are converted from independent to dependent lifestyles is sizable.
This has been well documented in the literature, along with other factors
that may play a role in this conversion. Obviously, the number of persons
who become dependent upon the institutions of society affects the overall
costs associated with the problem of hip fracture. Mechanisms need to be
developed to reduce the number of such individuals. Further data are needed
to characterize this group and to show modification of outcome by intervention.
This will require improved data collection, including collection of information
after hospitalization, and an effective method for assessing function.
CONCLUSION
The Medicare data bank already provides a mechanism for accumulating
information concerning the effectiveness of various types of treatment for
hip fracture. By extrapolation, information may be derived concerning epi
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EFFECTIVENESS AND OUTCOMES IN lIEALTlI CARE
demiology, predisposition, and prevention. Many factors that may play a
role in predisposition occur far in advance of the age of 65, however. Clarification
of some of these factors depends upon expanding the data collection to
younger people. If worthwhile data on long-term functional outcome are to
be gathered, the data set must be augmented. Ways of doing this have been
identified and appear feasible.
If the occurrence of hip fracture is reduced significantly and treatment
and rehabilitation of persons with fractures are improved, the quality of life
of a large number of elderly persons will be improved. The commensurate
savings in health care dollars will more than justify the cost of the effectiveness
studies.
Representative terms from entire chapter:
femoral head
