Last updated: April 4, 2014
Hip fractures in the elderly are critical ailments, with
possible life-endangering complications. Surgeries to fix breaks
are common and consistently effective, while healing can take an
entire year. And once a senior suffers from a broken hip, his or
her health can take a downward spiral as the break can trigger
other problems and affect the elderly immune system.
Here is a scenario:
When Teresa Lang remembered a last-minute item she needed for
her trip to Europe, she jumped up from her couch. She tumbled over
a small suitcase on the floor, right into a wall. "The instant I
did this, before I hit the wall, I knew what had happened," says
the 88-year-old Lang. She had broken her left hip.
Hip fractures in the elderly are common. In fact, for every 10
hip fractures, about nine occur in people over the age of 60. "Hip
fractures double with every five-year increase in age [after age
50]," says Sandy B. Ganz, PT, DSc, GCS, the director of
rehabilitation at Amsterdam Nursing Home in New York City. By 90
years of age, one in four women and one in eight men will have
fractured a hip, according to a study done by the Center for
Disease Control and Prevention.
Causes and Risk Factors
Elderly people are at a high risk for falling,
the usual traumatic event that leads to hip fractures. "They fall
because they lose their coordination. They have difficulty with
their eye sight and they have difficulty with their balance, and
they become weak," says Dr. Charles A. Peterson, an orthopedic
surgeon at Seattle Orthopaedic and Fracture Clinic. "When they
fall, they tend to have a higher frequency of fractures due to
osteoporosis and weaker bones."
The risk factors for suffering a broken hip are numerous,
- Osteoporosis: This disease causes bones to
become weaker, making them more susceptible to fracture. In the
U.S., an estimated 10 million individuals already have osteoporosis,
and 80% of those affected are women. In this population, hip
fractures can occur during simple weight-bearing activities.
- Gender: Women lose bone density more quickly
than men due to a decrease in estrogen levels after menopause
- Heredity: Small-boned, slender-framed people;
Caucasians; and Asians have an increased risk of suffering from
- Nutrition: Poor nutrition in childhood
increases hip-fracture risk. Eating disorders such as anorexia
nervosa and bulimia damage bones.
- Tobacco and alcohol use: Smoking and drinking
too much can lead to bone loss.
- Medications: Taking four or more medications
at a time or taking any psychoactive medications are risk factors
- Home environment: Throw rugs and electrical
wires are tripping hazards, as are a lack of stair railings and
grab bars, unstable furniture, and poor lighting.
- Medical conditions: The following conditions
can increase the risk of hip fractures, either through bone loss or
by increasing the risk of falling: endocrine disorders, such as
type 1 diabetes; gastrointestinal disorders; rheumatoid disorders;
prolonged bed rest or immobility; nervous system disorders such as
Parkinson's disease or multiple
Signs and Symptoms
Most often, an individual knows right away that she has broken
her hip. For example, Lang was unable to stand up and was
discovered by her son who happened to stop by that day. Usually
severe pain is felt in the hip or groin areas and the person cannot
walk. Other symptoms include stiffness, contusions, or inflammation
in the hip area; the leg on the broken hip side is shorter or turns
outward. If the head of the hip bone is impacted onto the neck of
the hip bone, the person might not know he has a broken hip, as
this break can be less painful, according to Peterson.
Because hip fractures in the elderly are life-threatening, make
sure your loved one heads to a hospital immediately. Surgery to fix
the fracture is usually done within 24 hours. The examining doctor
can diagnose a broken hip simply from symptoms, but an x-ray or MRI
will verify the break and display the fracture type.
Treatment: Surgery for Hip Fractures in the Elderly
There are two main types of hip fractures, and older people
almost always undergo surgery to repair these breaks:
Femoral Neck Fracture
The femoral neck is right below the ball (or head) of the
ball-and-socket hip joint. Because this type of fracture diminishes
and can sometimes stop the flow of blood to the broken part of the
bone, surgery is almost always done to correct it. Partial hip
replacement, called hemiarthroplasty, replaces the ball and femoral
neck with a metal prosthesis, usually made from stainless steel or
chrome cobalt alloy. While the patient is under general or spinal
anesthesia, the surgeon makes an incision. The broken head is
removed, and the surgeon clears out cartilage and damaged bone from
the hip socket. The new socket, which includes a ball and stem, is
cemented in place. Muscles and tendons are positioned around the
prosthesis and the incision is closed.If the patient has arthritis
or a previous injury that has damaged the joint and they are
physiologically sound, a total hip replacement may be done for a
femoral neck fracture.
Intertrochanteric Region Fracture
Just below the femoral neck, this is where the thigh bone juts
out. The fracture runs between two bumps called trochanters. While
the patient is under general or spinal anesthesia, the surgeon
makes an incision on the side of the thigh. The patient's bones are
manipulated to correct their position. A large screw called a hip
nail is placed along the break and up into the femoral head. This
screw is held to a metal plate that is attached to the outside of
the thigh using several smaller screws. This plate and screw helps
the bones heal, compressing them so they grow together.
A third type of break, called asubtrochanteric fracture, occurs
in the thigh bone or femur, and is quite rare. The surgical repair
is similar to the plate and screw system used in intertrochanteric
fractures, although the recovery period is much longer.
In rare instances, people who have hip fractures do not have
surgery. If someone is too sick for surgery to occur, traction or
other methods are used to repair the break.
Recovery and Therapy
Although surgeries to repair fractures are straightforward and
relatively simple fixes, complications after surgery can be
dangerous. Mortality rates in the year following a hip fracture are
about 25 percent. Complications include blood clots, infection, and
With a partial hip replacement, the patient can also dislocate the
prosthesis before it stabilizes. If an individual has fragile
bones, the hip nail or screw may pull out of the bone. Post-surgery
complications more often lead to death if a patient already suffers
from another serious medical condition.
Recovery after hip surgery is a lengthy process. The typical
hospital stay lasts four days to a week, but a longer stay isn't
unusual. Lang remained in the hospital for about a week, and then
moved to a sub-acute rehabilitation center for a month. Now she is
at home, receiving assisted care from her family, and two
therapists work with her twice a week. After a hospital stay,
patients can follow many different routes, depending on insurance,
age, and complications. According to Ganz:
- Some live in acute rehabilitation centers, which offer a
minimum of three hours of physical and occupational therapy each
- Some patients live in a skilled nursing facility for sub-acute
rehabilitation, which offers a minimum of 30 minutes per day of
- Others go straight home and receive in-home
assisted care and therapy;
- Others go home with no home care, but receive therapy as an
out-patient in a private practice or hospital.
Up to 25% of community-dwelling seniors who sustain hip
fractures remain in an institutional assisted care setting such as
a nursing home for at least a
Physical and occupational therapists begin to work with
recovering patients right at the hospital, helping them begin
walking with assistance usually the day after surgery. "Physical
therapy intervention for a hip fracture usually consists of muscle
re-education, strengthening exercises, balance retraining, bed
mobility, and transfer and gait training," says Ganz. "Occupational
therapy focuses on the activities of daily living: dressing,
grooming, bathing, as well as balance retraining and strengthening
The amount of therapy a patient receives depends on insurance.
"Unfortunately, right about the time therapy typically ends, about
four to six months post operatively, is when the patient is first
physically and physiologically able to receive more intensive
therapy," says Ganz.
While a patient may recover from surgery quickly, there is a
difference between healing and recovery. "After recovery, they can
continue doing everything on their own to get stronger," says Jill
Heitzman, PT, DPT, GCS, FCCWS, a physical therapist at Mary Greely
Rehab and Wellness in Ames, Iowa. "When they are actually healed,
they are back to doing everything they want to do." Healing, she
says, typically takes nine months to a year.
About 25% of people with hip fractures will experience a full
recovery and return to a semblance of their post-fall life.
However, 50% will need to use a cane or walker, and about 20% of
individuals who break their hip will permanently live in a nursing
home. Caregivers can help ensure the best outcome by helping their
loved ones adhere to their therapy regimens and taking some
preventive measures such as fall-proofing their homes.
Ideally, one can prevent hip fractures in the elderly in the
first place. People who have broken a hip also have a good chance
of falling again. You can help by making sure your loved one's home
environment is safe, as well as seeing that she stays as healthy as
Homes, rehabilitation centers, and nursing homes all need to be
fall-proofed. Ganz includes the following recommendations in a
- Lighting should not be too dim or too direct, and light
switches should be accessible.
- Carpets and rugs should be tacked down.
- Bathrooms should have a chair for bathing or skid-resistant
mats, grab bars should be placed where needed and the toilet seat
needs to be tall enough for easy transferring.
- Chairs need to be stable (without wheels) and have arm
- Kitchen items that are frequently used should be at waist level
or on low shelves, a rubber mat should be placed in front of the
sink and non-slip wax should be used on the floor.
- Stairways need handrails and steps should not be slippery.
There are several other simple suggestions that can help prevent
falls and hip fractures. People need to have regular eye-checkups;
wear sensible, hard-soled flat shoes; and be mindful of
medication's side effects. Individuals can also wear hip padding to
minimize the impact of a fall. A doctor can talk with your loved
one about how to increase her bone density through taking
supplements, including bisphosphonates for osteoporosis sufferers,
calcium, vitamin D, or starting estrogen or hormone replacement
therapy, says Ganz.
Exercise is imperative for preventing falls. Heitzman recommends
that a regimen includes:
- an aerobic workout that elevates heart rate and increases
- a strength-training program that involves lifting against
- exercising on different surfaces-such as carpets, stairs, and
gravel-to challenge one's balance.
Healing from a hip fracture takes time and patience. Seven weeks
after her fall, Lang uses a walker to move around her apartment and
the world outside. Before her accident, she occasionally used a
cane for outings, saying she found it elegant. Now she looks
forward to just using her cane. "They say you'll never be exactly
how you were, but you will be a pretty good facsimile of that!"