Madrid
Updated:05/26/2022 08:36h
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The progressive aging of the population has increased the incidence of hip fractures, a type of injury that has a high rate of morbidity and mortality. “To reduce this risk, a surgical intervention is required as soon as possible,” warns Dr. Inmaculada Gómez Arrayás, head of the Traumatology and Orthopedic Surgery Unit of the Ruber Internacional Hospital and Ruber Internacional Centro Médico Habana.
It is one of the most frequent fractures that occur in the emergency room and orthopedic trauma teams. “Most are the result of a fall in elderly people,” says the expert.
There are numerous risk factors: history of falls, gait disturbances, use of walking aids, vertigo, dizziness, Parkinson’s disease, medication side effects, among others.
“To all this we must add that older people usually have a reduction in bone quality (osteoporosis), which is the fundamental cause of most hip fractures,” says Dr. Arrayás.
More infrequent are hip fractures that occur in young adults and are usually the result of high-energy trauma.
About 5% of hip fractures are pathological, “that is, the cause is not a fall, but rather that the bone had a previous pathology, a tumor, metastasis, use of medications that can alter bone metabolism, very advanced osteoporosis , etc.”, adds Dr. Gómez Arrayás.
The incidence of hip fractures is much higher in women (more than double) and the average age of patients who present a hip fracture is 80 years.
According to the doctor, as these patients are usually elderly with complex medical histories, it is very important to carry out a very complete medical history when admitted, rule out factors causing the fall (syncope, heart attack…) and carry out a cognitive evaluation.
“During the examination of a hip fracture, the patient presents pain in the groin when trying to move the limb and the most frequent deformity that we find is the shortening of the injured leg with the foot turned outwards. This is accompanied by an inability to get up and walk”, explains Gómez Arrayás.
Diagnosis is made, in most cases, by means of 2-projection radiographs. “But there is a small percentage (2-7%) that are not seen on the X-ray because they are trabecular fractures (they occur under the bone), incomplete, not displaced at all, which require a Magnetic Resonance Imaging (MRI) or a CT (Computed Tomography). ) to diagnose them. We must perform them as long as the symptoms are compatible and no fracture is seen on the X-rays, ”clarifies the Ruber Internacional traumatologist.
The treatment of hip fractures is surgical (except for some important contraindications), and the type of surgery will depend on where the fracture is located.
There are two types of fractures. “There are fractures that occur within the joint capsule of the hip (intracapsular, fractures of the femur neck, subcapital, basicervical), whose surgical treatment is a total or partial hip prosthesis and in some cases, if the fracture does not have displacement and there is good bone quality, an osteosynthesis is performed, that is, a fixation system with cannulated screws”, details the doctor Immaculate Gomez Arrayas.
And, for fractures located below the joint capsule (pertrochanteric and subtrochanteric), he adds, “the treatment is to fix the fracture while preserving its femoral head (intramedullary nails, screw-plate, etc.)” .
Patients with hip fracture can lose up to 1 liter of blood before undergoing surgery, so fluid replacement and transfusion if necessary are important from the emergency, especially in patients with previous anemia.
As indicated by the Gomez Arrayasa fracture of this type greatly destabilizes the body and for this reason it is important that a multidisciplinary team made up of Internal Medicine, Traumatology, Anesthesia and Physiotherapy evaluate the patient and monitor their treatment to minimize possible complications.
“The objective of treatment is to restore the patient’s state of mobility as soon as possible and, for this, the treatment of choice is urgent surgery, at least in the first 24-48 hours, always having previously optimized the patient’s conditions.” . Early surgery is related to better results and, therefore, it is recommended to operate within 48 hours after admission, as it has been shown in numerous studies that it reduces mortality and the rate of major complications,” says the expert.
Different systematic reviews and meta-analyses – the doctor continues – conclude that early surgery (within 24 to 48 hours) can reduce the risk of mortality from all causes in patients 60 years of age or older by 20%. . “Early surgery is also associated with a reduction in pressure ulcers (bedsores) and postoperative pneumonia. Another systematic review also showed that a delay in surgery beyond 48 hours was associated with an increased risk of mortality”, emphasizes Dr. Gómez Arrayás.
Conservative (non-surgical) treatment of fractured hips is associated with higher 30-day and 1-year mortality.
Postoperative rehabilitation is as important as surgery, highlights the expert. Regular intensive physical therapy is required to encourage rapid progression of mobility. «Patients should sit up and move around immediately after surgery. And they will be able to start walking, with partial load, the next day except for very unstable fractures or patients who, due to their comorbidity, require delaying their march, ”says the specialist.
Finally, Dr. Inmaculada Gómez Arrayás points out that the diagnosis and treatment of osteoporosis is essential to reduce hip fractures. “All patients over the age of 50 who experience a fracture should be evaluated for osteoporosis and should be treated appropriately to reduce the risk of subsequent fractures.”
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