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Providing evidence-based practices for patients with hip fractures

Hohler, Sharon, E., BSN, RN, CNOR

doi: 10.1097/01.NURSE.0000531895.31558.55
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Current standards and best practices for a common injury in older adults.

Sharon E. Hohler is a team coordinator in orthopedics and a CN IV at Saint Francis Healthcare System in Cape Girardeau, Mo.

The author has disclosed no financial relationships related to this article.

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MS. H, 78, lived independently at home until the day she turned to open the refrigerator door and found herself lying on the floor with severe pain in her left hip. Fortunately, her cell phone was in her pocket and she called her son for help. At the hospital, X-rays showed Ms. H had a left intertrochanteric fracture. She was admitted and prepped for surgery.

In older adults, intertrochanteric fractures generally occur as the result of a fall.1 (See Impact of falls.) As the U.S. population ages, nurses can expect to see more older adults with hip fractures because of osteoporosis and a tendency to fall due to balance issues, environmental hazards, and adverse reactions to medications.1

According to the American Academy of Orthopaedic Surgeons (AAOS), a hip fracture sustained during a fall usually indicates the patient has advanced osteoporosis and is also at risk for future fractures.2 This article discusses the pathophysiology and treatment of hip fractures and reviews evidence-based practices that support optimal patient outcomes. (See Looking into normal hip anatomy.)

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Hip fracture classification

Hip fractures are classified by anatomic location and by fracture type. The general categories include intracapsular (femoral neck and head) and extracapsular (intertrochanteric and subtrochanteric) fractures:1

  • An intracapsular (or subcapital) fracture occurs at the femoral neck between the femoral head and the greater trochanter. (See Types of fractures.)
  • An intertrochanteric fracture occurs between the greater trochanter and the lesser trochanter.
  • A subtrochanteric fracture occurs below the lesser trochanter.3
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Clinical manifestations

One classic symptom of hip fracture is the sudden onset of groin pain that occurs before or after the patient falls. The leg may also appear shorter and externally rotated. Most patients can't bear weight or walk on the affected leg.1

  • Intracapsular (femoral neck) fractures: Classic symptoms of a hip fracture are usually present in intracapsular fractures. Because any bleeding is contained in intracapsular fractures, ecchymosis is uncommon. If the intracapsular fracture is impacted, it's possible for the patient to bear weight and walk.1
  • Intertrochanteric fractures: Intertrochanteric fractures are extracapsular. Besides the classic symptoms of a hip fracture, these fractures are associated with edema and ecchymosis in the thigh. In fact, a large amount of blood loss from the fracture may cause hemodynamic instability; these patients must be monitored closely. Another significant symptom of intertrochanteric fracture is tenderness over the trochanteric area.1
  • Trochanteric fractures: Patients with lesser trochanteric fractures experience classic hip fracture symptoms, but the pain may involve the knee or posterior thigh and increases with hip flexion and rotation. Patients with greater trochanteric fractures may find that pain increases with abduction and have tenderness over the greater trochanter.1
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Diagnosis

For patients with suspected hip fractures, anterior-posterior (AP) X-rays with maximum internal rotation and lateral X-rays are obtained. The AP view with supported external rotation will help to identify lesser trochanteric fractures while greater trochanteric fractures are well demonstrated on AP views. Often an AP pelvis X-ray is taken to compare both hips. Magnetic resonance imaging can be used for older adults with diminished bone density to identify hip fractures.1

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Management

Because most older adults have comorbidities, many are admitted to the hospital for preoperative management of complex multiple health issues before surgery. Initial management of patients with a hip fracture consists primarily of pain management and orthopedic surgeon consultation.1

Surgical procedures and internal fixation implants are determined based on the patient's overall health status and the fracture location. For a select few patients with comorbidities who aren't candidates for anesthesia and surgery, a nonsurgical option such as compassionate care and hospice may be necessary. Most patients with hip fractures can undergo surgery to stabilize the fracture and reduce pain.3 When patients are older, it's especially important to search for the cause of the fall, such as syncope or stroke, and assess for any other injuries, including additional fractures and internal damage.1

  • Intracapsular fractures are usually treated with open reduction with internal fixation (ORIF) or total or partial hip arthroplasty. Nonoperative management may be reasonable in patients with stable, impacted fractures.1
  • Intertrochanteric fractures may be treated with arthroplasty or internal fixation.1
  • Trochanteric fractures: Most trochanteric fractures with 1 cm or less displacement can be managed with nonoperative care. Non-weight-bearing for 3 to 4 weeks is the usual time frame. After healing occurs over 2 to 3 months, many patients return to full activity. Patients with displaced trochanteric fractures greater than 1 cm should be referred to an orthopedic surgeon for surgical repair (ORIF).1

Surgical treatment of Ms. H's hip fracture occurred within 2 days. The timing of hip surgery has been debated. Many surgeons perform the surgery as soon as possible after the patient has been medically cleared. Evidence-based clinical practice guidelines from the AAOS say that “moderate evidence supports that hip fracture surgery within 48 hours of admission is associated with better outcomes.”4

One study involving 40,000 patients found that surgery for hip fracture within 24 hours of admission was associated with lower 30-day mortality than hip fracture surgery that occurred later than 24 hours after admission.5 However, the frail older adults who suffer most hip fractures often have multiple comorbidities that increase their surgical complication risk. For these patients, the healthcare providers perform a thorough evaluation and stabilization before proceeding with surgery as soon as possible.5

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Preventing complications

Preoperative preparation focuses on the goals of preventing complications and supporting the patient's health status. These same goals continue through the patient's postoperative period.

Patients undergoing surgical repair for hip fracture are at risk for complications such as malnutrition and protein deficit, venous thromboembolism (VTE), infection, pressure injuries, and delirium.6 Nursing care addresses these potential complications:

  • Malnutrition. According to the AAOS guidelines, 58% of patients with hip fractures qualify as malnourished when admitted with a hip fracture. Addition of a high-protein nutritional supplement with calcium significantly decreases complications.7

Ms. H was screened for malnutrition upon admission to the nursing unit and received nutritional optimization during the 2 days before her surgery.

  • VTE. Older age, immobility, and preexisting comorbidities increase the risk of VTE in patients with hip fracture. VTE is a major cause of postoperative morbidity and mortality in these patients.5 Research shows that patients with a hip fracture who receive VTE prophylaxis have significantly fewer thrombotic complications.12 Mechanical prophylaxis includes use of intermittent pneumatic compression devices, which can be used throughout the hospital stay. Low-molecular-weight heparin may be started preoperatively, as long as it's stopped in a timely manner to prevent surgical bleeding and then restarted after surgery.8 Post-op mobilization may begin immediately on day 1 or according to the surgeon's orders, depending on the type of hip implant and when weight-bearing is allowed.3
  • Infection. During the entire hospital stay, optimal hand hygiene is a basic but critically important staff behavior in the overall infection prevention strategy.5 Because Staphylococcus aureus was found to be the most common organism causing wound infections, rigorous sterile technique including prophylactic antibiotics help prevent surgical site infections. In addition, nasal methicillin-resistant S. aureus (MRSA) screening and decolonization with nasal mupirocin may be indicated. I.V. vancomycin may be added to the preoperative antibiotic regimen if the patient tests positive for MRSA to decrease the patient's infection risk.9

OR staff and anesthesia providers practice many established evidence-based interventions such as properly sterilized instruments, OR environmental cleaning, and preoperative skin preparation, which help prevent infection. In the perioperative setting, the patient should be kept normothermic, normoxic, and normoglycemic.10 These practices should continue postoperatively with the addition of standard infection prevention practices such as appropriately stopping preoperative antibiotics within 24 hours, turning the patient regularly to prevent skin breakdown, encouraging deep breathing and coughing to prevent atelectasis and pneumonia, and providing meticulous wound care.10

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Pressure injuries

Nursing interventions such as preventing skin breakdown by turning and proper repositioning of the patient according to facility policies and procedures help prevent pressure injuries.11 Pressure injury prevention bundles include comprehensive skin assessments, standardized assessments of pressure injury risk, and care plans and nursing interventions to address risk factors.

  • Delirium. Many older adults experience delirium while they're hospitalized. Besides impairing cognition, delirium affects perception, memory, and the sleep–wake cycle. This frequently unrecognized and misdiagnosed disorder affects up to 30% of hospitalized older adults and up to 61% of patients with hip fracture.5 For patients with mild to moderate dementia who experience delirium, the AAOS guidelines found that a multidisciplinary program produced positive results. This program, which includes geriatric assessment, rehabilitation services such as fall prevention strategies, and discharge planning with optional home health services, resulted in “better functional outcomes and fall prevention in postsurgical hip fracture patients.”6
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Rehabilitation

Physical therapy after hip fracture surgery helps the patient regain strength and a more normal gait and balance. Without physical therapy, a patient's weakness, gait, and balance issues can contribute to future falls and injuries. When older adults are afraid of falling again, they may limit their efforts to walk with resulting decreased mobility.12

Studies have found that home-based intensive physical therapy improves strength and gait for older patients with hip fractures. The AAOS guidelines strongly support home-based physical therapy.13

Occupational therapy helps patients regain the abilities they had before surgery. Studies have found that occupational therapy helps patients with their activities of daily living, instrumental activities of daily living, and health-related quality of life. To improve function and prevent falls, the AAOS guidelines recommend occupational therapy across the continuum of care, including in the home.14

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Fall prevention

Teach patients and their families that they can make their homes safer by decluttering floors, securing electrical wires, and adding skid-proof backing to rugs. Bathrooms are safer when grab bars and rubber mats are added. Stairways should have adequate lighting, sturdy handrails, and secure carpeting. Outdoor safety tips involve providing handrails on steps, wearing rubber-soled shoes or boots, and avoiding slick sidewalks.15 A full listing of fall prevention tips can be found at the National Osteoporosis Foundation website at www.nof.org/patients/fracturesfall-prevention.

Patient education should also include evaluating the fall risk associated with medications.16 Other recommendations from the CDC include eye and vision evaluations and eyeglass updates once a year for best vision. Also, exercise programs such as tai chi will improve balance and strength, which helps to prevent falls.16

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Home again

Ms. H recovered from her hip fracture without complications. With the help of family, home healthcare nurses, and physical and occupational therapists, she was able to resume her busy lifestyle.

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Impact of falls

Falls rank as the number one cause of injury and accidental death in people over age 65.16 Every year, 2.8 million people visit EDs for treatment after a fall, with over 800,000 being hospitalized and 27,000 dying from fall injuries.12 Of those hospitalized, 300,000 sustained hip fractures. Women account for three-fourths of hip fracture falls.17

Research shows that 93% of American adults don't recognize that men face a risk of osteoporosis and fractures. Yet statistics show that one-third of all hip fractures worldwide affect men and that in the first year after fracture, these men face a mortality of 37%. This research points to the need for public education about the risk of falling and fractures and increased osteoporosis screening among men.18

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Looking into normal hip anatomy

The hip is a ball-and-socket joint in which the femoral head articulates deeply in the acetabulum. The proximal part of the femur consists of a head, neck, and greater trochanter. The vascular anatomy of the femoral head, which receives its main blood supply from the lateral and medial circumflex femoral arteries and the obturator artery, is of critical importance in any disorder of the hip. Disease or injuries that compromise blood flow may damage the viability of the femoral head and lead to avascular necrosis or osteonecrosis.

The figure below shows the blood supply of the head and neck of the femur (anterior view). A section of the bone has been removed from the femoral neck.

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Figure

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Types of fractures

The general hip fracture categories include intracapsular and extracapsular (intertrochanteric and subtrochanteric) fractures. Subcapital fractures are common intracapsular fractures.

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REFERENCES

1. Foster KW. Hip fractures in adults. UpToDate. 2017. http://www.uptodate.com.
2. American Academy of Orthopaedic Surgeons. Evidence-based clinical practice guidelines: osteoporosis evaluation and treatment. http://www.orthoguidelines.org/guideline-detail?id=1290.
3. American Academy of Orthopaedic Surgeons. Management of hip fractures in the elderly. http://orthoinfo.aaos.org/topic.cfm?topic=A00392.
4. American Academy of Orthopaedic Surgeons. Evidence-based clinical practice guidelines: surgical timing. http://www.orthoguidelines.org/guideline-detail?id=1233.
5. Morrison RS, Siu AL. Medical consultation for patients with hip fracture. UpToDate. 2017. http://www.uptodate.com.
6. American Academy of Orthopaedic Surgeons. Evidence-based clinical practice guidelines: interdisciplinary care program. http://www.orthoguidelines.org/guideline-detail?id=1284.
7. American Academy of Orthopaedic Surgeons. Evidence-based clinical practice guidelines: nutrition. http://www.orthoguidelines.org/guideline-detail?id=1283.
8. American Academy of Orthopaedic Surgeons. Evidence-based clinical practice guidelines: VTE prophylaxis. http://www.orthoguidelines.org/guideline-detail?id=1279.
9. Bratzler DW, Dellinger EP, Olsen KM, et al Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195–283.
10. Association for Professionals in Infection Control and Epidemiology. 2017 HICPAC-CDC guideline for prevention of surgical site infection: what the IP needs to know. 2017. https://apic.org/Resource_/TinyMceFileManager/Periodical_images/SSI_2017_Fall_PS.pdf.
11. Agency for Healthcare Research and Quality. Preventing pressure ulcers in hospitals. 3. What are the best practices in pressure ulcer prevention that we want to use? 2014. http://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/putool3.html.
13. American Academy of Orthopaedic Surgeons. Evidence-based clinical practice guidelines: intensive physical therapy. http://www.orthoguidelines.org/guideline-detail?id=1282.
14. American Academy of Orthopaedic Surgeons. Evidence-based clinical practice guidelines: occupational and physical therapy. http://www.orthoguidelines.org/guideline-detail?id=1281.
15. National Osteoporosis Foundation. Fractures/fall prevention. http://www.nof.org/patients/fracturesfall-prevention.
16. Centers for Disease Control and Prevention. Falls are leading cause of injury and death in older Americans. 2016. http://www.cdc.gov/media/releases/2016/p0922-older-adult-falls.html.
17. Centers for Disease Control and Prevention. Hip fractures among older adults. 2016. http://www.cdc.gov/homeandrecreationalsafety/falls/adulthipfx.html.
18. National Osteoporosis Foundation. New research shows 93% of U.S. adults unaware of men's risk for osteoporosis. 2014. http://www.nof.org/2014/10/20/new-research-shows-93-percent-of-u-s-adults-unaware-of-mens-risk-for-osteoporosis.
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