Rehabilitation

What happens as I recover?

The course of recovery from a hip fracture depends on many factors, the nature of the fracture, the treatment selected and the patient's overall medical condition. For all types of fracture there is no need for casts or braces but walking aids such as crutches or a walking frame may be needed for a period of time. Part of this is to reduce the forces placed through the hip but avoidance of another fall is also a concern. Most patients benefit from progressive exercises for strength, balance and endurance. This may need the supervision of a physical therapist. Much of the exercise program can be done at home.

Femoral Neck Fracture treated by joint replacement

The result of surgery is to remove all the broken parts and there is no need to wait for healing. The metal prosthetic components are usually well fixed into the bone with cement or by a tight interference fit. Weight bearing is protected by the use of crutches for the first few weeks. This is mainly to allow the muscles time to heal and recover strength. It is also important to avoid movements and posture that might cause a dislocation of the artificial hip. After six weeks the rehabilitation exercises are directed to recovering strength, balance, normal walking patterns and endurance. After a hip replacement people continue to improve for many months.

Femoral Neck Fracture treated by internal fixation with screws

This method of treatment is an attempt to preserve a normal hip joint and it has a higher risk of failure than replacement arthroplasty. While the bone heals, it is advisable to minimize the forces acting through the hip joint by using crutches or a walker. Most surgeons recommend "feather weight-bearing" in which the weight of the leg is passed to the floor but no more. The nursing and physical therapy staff will explain this to the patient during the hospital stay.

As the discomfort lessens or if the patient is confused it is inevitable that more weight will be placed through the hip and this may contribute to shortening of the fracture or displacement. During the follow-up period x-rays will be taken to determine the extent of bone healing and evaluate any loss of position or fixation. Callus (early bone healing) may be seen at six weeks. If so the restrictions on weight bearing may be partially eased.

A cane or some form of walking aid is usually needed for a minimum of three months. The exercises for strengthening, balance and recovery of normal walking patterns must wait until the fracture is healed. This means that the patient is weak and has a long way to go to get back to normal. All in all it is easy to see why many surgeons prefer to undertake a joint replacement in elderly patients with this fracture.

Intertrochanteric Fracture & Subtrochanteric Fracture treated by internal fixation

The intention of surgery is to allow the patient to move in bed, sit and walk short distances with crutches so as to avoid the most dangerous consequences of being immobile. The fixation holds the bone fragments in place to allow this to happen.

Early rehabilitation consist of getting mobile again using crutches or a walker to prevent too much force going through the fracture. The amount of weight-bearing that is suggested depends on the exact configuration of the fracture and the type of fixation used. Sliding Nail fixation allows for some collapse of the fracture but it is not desirable for the fracture to shorten too far. In these cases minimal weight-bearing is recommended until the fracture shows signs of healing.

Follow-up x-rays at the six week mark often show evidence of new bone formation (callus) and this may be the signal to allow more weight through the hip. Healing and consolidation of the fracture takes three months at least and the strength of the new bone continues to increase for up to 18 months.

Another important consideration is the recovery of muscle from this type of hip fracture. The thigh muscles must be split to expose the thigh bone to do the surgery. They are sore and weak after the surgery and take some time to recover, particularly as strengthening exercises cannot be too aggressive at first. Physical therapy as needed in hospital to assist with mobilization and may be needed later to supervise a program for the recovery of strength, balance and endurance.

A hip fracture is such a major injury that about a third of patients do not fully recover to reach the level of independence they had before the injury. If they were walking without support before the fracture they may find that afterward they need a cane, a walker or even a wheelchair. If they were only just managing to live an independent life, the injury may change that. Many patients require a prolonged period in hospital or rehabilitation before they can go home.

Preventing Hip Fractures

Numerous studies have shown that a patient who has suffered a fragility fracture, like a hip fracture, is at risk of further fractures in the future. The fact that a hip fracture has occurred places the patient in a high risk category. The subject of prevention of further fractures and treatment of osteoporosis is receiving a great deal of attention.

There are three parts to the prevention of further fractures:

• Falls prevention
• Hip protectors
• Osteoporosis treatment

Falls prevention

It is obviously of the utmost importance to reduce the risk of falling. A complete strategy may require assessment of the home environment to reduce risk, provision of walking aids, review of medication to reduce dizziness and an exercise program to promote strength and balance.This is often a factor in changing the patient's living arrangements and can lead to some loss of independence.

Hip protectors

These are plastic shields which are worn over the sides of the hip and cushion the impact of a fall. If these are worn they do reduce the incidence of hip fracture per fall. The problem lies in getting people to wear them.

Osteoporosis treatment

The pharmaceuticals industry has promoted the idea that medication is needed to treat osteoporosis. Numerous studies are under way to determine if taking certain medication slows or reverses the process of bone loss and whether that actually translates
into less fractures in the future. There is consensus that something should be done, but no consensus on what.

Related Document: A Patient's Guide to Osteoporosis