Hip Fractures Rehabilitation
The hip is a ball and socket type joint that has an influence on the pelvis and lumbar spine. The hip joint helps control and stabilize the lower limb, and plays an integral part in lower limb mechanics including walking and climbing stairs. The hip joint is formed by the head of the femur and the acetabulum area of the pelvis. The femoral head sits deep into the concave acetabulum and is bound firmly by ligaments, a joint capsule, and muscles. The muscles around the hip act to move the lower limb. An example would be the moving of one's thigh (femur) forward by contracting the muscles that flex the hip. Muscles act to stabilize the hip but also provide mobility and control (i.e. walking). It is quite apparent that through contraction of muscles and weight-bearing there can be large forces generated on the hip joint. Therefore, it is very important that hip musculature be strong and flexible to resist forces encountered during activities such as walking and stair climbing, resulting in minimized stress on the hip joint.
As individuals age into late adulthood, muscle strength declines. Due to decreased strength in older individuals, the forces on the hip joint once taken up by the surrounding musculature are now placed more on the weight-bearing surface of the hip. Osteoarthritis (OA) and osteoporosis further compromise the hip joint. Both diseases are common in the elderly adult. As the aging process continues the effects of decreased strength, OA and osteoporosis can lead to a less stable hip joint. With decreased stability, an individual can be at an increased risk for falling. Unfortunately, fractures are a possible outcome of falling in older adults. Hip fractures are one of the most common fractures associated with falling.
The hip joint is a very stable ball and socket joint. Because of this inherent stability, the hip rarely dislocates. There are also numerous muscles around the hip that move the lower limb forward, backward, and to the side. These muscles aid in stabilizing the hip by further compressing or "holding" the femoral head in place. As stated previously, as the age of an individual increases, the stability of the hip joint can decrease. This decreased stability can lead to gait and balance problems, thus increasing the risk for falling. Moreover, other factors such as dementia, medication, and vision can also increase the risk for falling. Barriers in the environment can also make a surrounding place unsafe for the elderly. It becomes quite clear that older adults are at risk for falling, and a serious complication can be fracture.
There are disorders that effect the hip, and one of the most common in older adults is hip fracture. There is an area in the hip joint that is located approximately midway between the femoral head and the shaft of the femur.
Acetabulum—The cup-shaped socket in the pelvis.
Dementia—A deterioration of mentality usually with marked apathy.
Isometric exercises—A mode of exercise where there is contraction of muscle fibers, yet there is no movement of the limb.
Lumbar—Pertaining to the vertebrae in the lower back.
Pelvis—A basin-shaped group of bones that form the pelvic girdle.
Osteoarthritis—Degeneration of cartilage and bone of joints.
Osteoporosis—A condition that is characterized by decrease in bone mass with decreased density and enlargement of bone spaces.
Progressive resistive exercises—The mode of training that involves increasing intensity of exercise over time.
Prosthesis—An artificial implant or device that replaces a part of the body.
This area is called the femoral neck. Within the femoral neck there is a zone of weakness that is inherent to the bony structure. Unfortunately, as aging occurs and OA progresses, this area (or zone of weakness) becomes weaker and loses the ability to handle stress. There is a greater risk for fracture secondary to trauma or degeneration particularly in the area of the femoral neck.
There are many factors that can lead to falling and subsequent hip fracture. There are ways in which older adults can minimize the risk of falling and thus, decrease the possibility of fracturing the hip. Steps that can be taken by the older adult to minimize the risk of falling are:
- Removing slippery or tiled surfaces in the home.
- Improve the lighting in a home.
- Removing small or loose rugs.
- Minimize height differential between rooms; use ramps when necessary.
- Make sure floor is free from small objects.
- Have vision checked.• Have a physician evaluate medicines for side-effects such as dizziness.
- Use handrails when needed, especially in toilet and shower areas.
- Exercise regularly to promote wellness, increase strength, and improve balance.
A hip fracture usually refers to a disruption of either the proximal femoral shaft or femoral neck. If a femoral fracture were to occur, it usually happens in the area of the zone of weakness. Hip fractures in young athletes are not common and usually occur secondary to large forces due to trauma. The older individual who has hip osteoarthritis or osteoporosis is at risk for hip fracture.
Two common fractures in the elderly are intertrochanteric and femoral neck. Intertrochanteric fractures usually occur in the elderly. These fractures occur between the greater and lesser trochanters of the proximal femur, thus the term intertrochanteric (inter: between) and trochanteric, referring to trochanters. When there is a fracture between the trochanters, the most common procedure is an open reduction with internal fixation or more commonly known as ORIF. The goal of the ORIF is to provide a strong and stable fixture for the proximal femur. Femoral neck fractures usually occur in the zone of weakness described previously in the area between the femoral head and the trochanters and are also common in the elderly. Usually the age of an individual determines the mode of treatment. For example, in a displaced fracture in a younger individual, the mode of treatment may be an open reduction with internal fixation. In an elderly individual, a displaced fracture usually results in either a partial or total hip replacement. In non-displaced fractures of the femoral neck, internal fixation with pins and/or screws is the treatment of choice.
Hip fracture can lead to impaired function and disability. Therefore, rehabilitation is important to minimize impairment and restore function. Rehabilitation should include early ambulation (walking), stabilizing the individual medically, breathing exercises to minimize risk of pulmonary embolisms, frequent changes in position to minimize formation of pressure ulcers, and regular walking.
Specific physical therapy treatments include range of motion, resistive exercises, flexibility, transfer training, balance exercises, bed mobility, and walking.
Complications after hip fracture can be related to the fracture, effects of bed rest, and the internal hardware. In a femoral neck fracture a serious complication is avascular necrosis. In either type of fracture (femoral or intertrochanteric) there could be poor reduction or possible re-fracturing. Extended bed rest could lead to muscle wasting, development of pressure ulcers, lung problems such as pneumonia, and other medical anomalies. Complications of hip arthoplasty may include infection, dislocation, and loosening of the prosthesis. Usually, a standard protocol for individuals with total hip replacement are no hip internal rotation, adduction past midline, and no hip flexion beyond ninety degrees (no leaning trunk over hips while sitting). Passive range of motion should be avoided if there was a reduced fracture. Hip fractures occurring in older adults often results in deteriorating health due to compounding complications. There is a statistically high rate of mortality due to complications directly resulting from hip fractures in patients over the age of seventy.
After hip fracture most individuals are full weight-bearing and independent in activities of daily living, i.e. walking, by four to six months post-surgery. Full passive and active range of motion exercise can be done; progressive resistive exercises should be continued to strengthen the hip and surrounding musculature.
Health care team roles
Unfortunately, individuals in their mid-80s and older who have a hip fracture are at a much higher risk of not regaining prior level of function. Furthermore, almost 20% of individuals with hip fracture will require nursing home care. Thus, the cost of hip fracture for the individual, family, and society is quite high. Considering the aging of the United States population, it would seem reasonable to assume that the incidence of hip fracture and complications associated with this condition will increase over time. Thus, the importance of prevention and education in our society.
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Mark Damian Rossi, Ph.D., P.T.