Mention "hip fracture," and the stereotypical patient who springs to mind is a frail, elderly woman. And, indeed, many who suffer a fracture are older women who have other medical problems that make them fragile.
But then came the news, earlier this year, that former President Ronald Reagan, now 90, fell at the Bel Air, California, home he shares with his wife, Nancy, fracturing his right hip. He was rushed to a nearby hospital, where he underwent surgery. Doctors released him a week later, saying he made remarkable progress even though like other hip fracture patients he faces an uphill recovery.
Reagan's tragedy shines a spotlight on a medical problem that annually affects about 300,000 Americans 45 and older, who are hospitalized with hip fractures, according to estimates from the National Osteoporosis Foundation. Osteoporosis -- literally, "porous bones" -- leads to fragile bones and an increased risk of hip, spine and wrist fractures. It is the underlying cause of most hip fractures, according to the NOF.
Older people often have less muscle mass than they did in their earlier years and are weaker, making them more prone to falls and injury. Senility and dementia can also make falls more likely, since older adults with these conditions may not always be fully aware of their environment.
The outlook can be dismal: 24 percent of hip-fracture patients 50 and older die in the year following their fracture, according to NOF estimates. Women's risk of hip fracture is two to three times higher than men's, but about 5.6 million men are at increased risk of hip fracture because of osteoporosis or low bone mass. (Osteoporosis is marked by low bone mass and structural deterioration of the bone tissue. Low bone mass, by itself, increases the risk of getting osteoporosis.)
There can be complications related to the injury and long recovery period, as well as the kind of complications often seen in the elderly after any major surgery, such as infection or pneumonia.
But there is hope. Experts say much can be done to reduce the risk of a second hip fracture. And for those who have not had a hip fracture, there is much they can do to prevent one.
How It Happens
"Typically, a hip is fractured when the person falls sideways," says Ethel Siris, M.D., the Madeline C. Stabile professor of clinical medicine at Columbia University College of Physicians and Surgeons, New York City, and osteoporosis specialist who serves as a spokeswoman for the National Osteoporosis Foundation.
"The hip is actually the upper part of the thigh bone, the femur," says Siris. "That is what breaks. It is very painful. It's not possible [after the fall] to stand up."
How It Is Fixed
Like Reagan, most who fracture a hip are taken by ambulance to the hospital, where surgical repair is done as soon as possible. How a physician repairs the fracture depends on the exact location and severity of the fracture. A surgeon might insert a metal pin or screw or, if the hip can't be repaired that way, insert a hip prosthesis.
What's the Prognosis?
Even if the surgery goes well, the postoperative course is not always smooth. Only a third of those who fracture a hip regain their pre-fracture level of independence, according to the NOF. After a year, more than 40 percent of patients cannot walk without aid such as a cane or a walker. Many patients end up in a nursing home.
In fact, the likelihood of discharge to a nursing home is greater now than it was more than a decade ago, according to a study of more than 100,000 hip fracture patients presented at the American Academy of Orthopaedic Surgeons' 2001 annual meeting Feb. 28-March 4 in San Francisco. In 1985, 20 percent of patients went to a nursing home, but in 1996 53 percent did. (One factor behind the increase, the researchers speculate, is the trend by healthcare providers to reduce the amount of time spent in acute-care hospitals.)
Another factor that slows recovery could be depression, which is common in the elderly. "Imagine lying in a hospital bed at age 80 and reflecting on how your life will be more limited now that you have broken your hip," says Peter Katona, M.D., a University of California, Los Angeles, assistant clinical professor of medicine. If other depressing events, such as the deaths of close friends, occur at about the same time, the outlook could get bleaker.
The Recovery Timeline
Physical therapy is an important part of recovery and often begins as soon as possible, says Renee Shpall, a physical therapist and physical therapy supervisor at Santa Monica-UCLA Medical Center, Santa Monica, California. "We usually get them out of bed the first postoperative day." The long-term goal is to get a patient back to his or her pre-facture level of functioning.
A typical timeline, Shpall says, is to keep a patient in the hospital for about 10 days. Sometimes a patient is discharged to a rehabilitation facility before returning home, if possible. Often, a patient will continue physical therapy at an outpatient facility. It is often two or three months before a patient is considered to be fully recovered, Shpall says. Even then, a walker may be needed.
During rehabilitation, the focus is on strengthening exercises such as gently pushing the back of the knee against the bed to strengthen the quadriceps (back of the thigh) muscles. Physicians prescribe the amount of weight a patient is able to bear.
"Some people bounce back," Shpall says. A lot has to do with their prior medical status. Those who were in good physical shape before the fracture generally do better.
"Patients who are generally healthy and have family support and a good attitude are likely to do better," agrees Siris. "People with dementia and no family support often do worse."
If depression seems to be a problem, family members or the physical therapist might suggest an appointment with the patient's family doctor, who can evaluate the need for antidepressant medications, counseling sessions or both.
Reducing the Risk of a Repeat
Once rehabilitation is progressing, the focus should be on preventing another fracture. "When someone breaks a hip, one of the tragedies is they don't [always] get counseling on vitamin D, calcium and bone-density tests," Siris says. All of these measures can help reduce the risk of a second hip fracture, she says.
So if the doctor doesn't discuss those measures, by all means ask, Siris suggests. The doctor might also discuss whether one of five medications approved by the U.S. Food and Drug Administration to treat (and in some cases prevent) osteoporosis might be wise to consider. Among the options are estrogen replacement therapy, alendronate (Fosamax), risedronate (Actonel), raloxifene (Evista) and calcitonin (Miacalcin).
To reduce the risk of falls, experts suggest increasing the amount of indoor light and removing hazardous objects such as slippery throw rugs. Hip protectors, undergarments that include shock guards to pad the hips, can reduce the risk of fracture, according to a study reported late last year in the New England Journal of Medicine.
Kathleen Doheny is a Los Angeles-based health journalist who writes for Apria.com, the Los Angeles Times, Web MD.com, Shape, Modern Maturity and other publications.
