Current Views of
Hip
Fracture
Gerald S. Laros, MD
in the treatment of hip fracfrom recumbency enforced by sand bags, spicas, or traction to mobilization care. This advance was made possible primarily by the development of internal fixation devices. Refinement of these devices and of surgical techniques has continued because problems and complications associated with treatment still remain. The articles in this symposium deal with current thinking on the treatment of fractures about the hip and how we may continue to improve our results. The major residual problems are found in two general areas. (1) Medical complications: The age and general medical condition of patients suffering from hip fractures predispose them to complications of recumbency such as thromboembolic disease, urinary tract infections, pneumonia, senile psychosis, and decubitus ulcers. (2) Technical complications: The forces acting about fractures in the region of the hip tend to produce varus at the fracture site. These forces lead to complications of fixation that may limit the stability of the hip, interfere with bone healing, or produce functional problems in ambulation and thus de¬ feat or compromise our efforts for mobilization care. In fractures of the femoral neck, a third problem still haunts us. Poor local blood supply may lead to avascular necrosis of the femoral head and/ or nonunion of the frac¬
The greatest improvement change tures
was
the
ture.
RECUMBENCY
The main reason for internally fixing a hip fracture in debilitated patients is to reduce complications of re¬ cumbency. Stabilizing the fracture by internal fixation re¬ duces pain and makes it possible to mobilize the patient. Accepted for publication July 25, 1974. From the Section of Orthopedics, University of Chicago Hospitals and Clinics, Chicago. Reprint requests to Section of Orthopedics, University of Chicago Hospitals and Clinics, 950 E 59th St, Chicago, IL 60637 (Dr. Laros).
Early mobilization protects against thromboembolism, pneumonia, urinary tract infections, senile psychosis, and decubitus ulcers. Major surgery in an elderly or debili¬ tated patient is certainly more risky than in young and healthy patients, but clinical studies1 indicate an even greater morbidity and mortality if these patients are treated nonoperatively. In most cases, treatment of hip fractures in the elderly by surgery is the conservative course in that it carries less risk than prolonged bed rest. If surgery is absolutely contraindicated, it is generally preferable in the aged, debilitated patient to ignore the fracture and mobilize the patient as early as pain permits. This means changing the position of the patient in bed or moving the patient from bed to chair without particular regard for immobilizing the fracture. INFECTION of operation, and possibly ana¬ contribute to an infection rate of 5% to 10% in surgically treated hip fractures. This is higher than the usual infection rate following orthopedic surgical proce¬ dures and makes infection a matter of special concern in hip fractures. Boyd and associates,- using prophylactic an¬ tibiotics before, during, and after surgery, reduced the in¬ fection rate in hip fractures from 4.8% to 0.8%. Other clini¬ cal3 and experimental' studies emphasize the importance of adequate tissue levels of antibiotic during surgery for effective prophylaxis. Properly administered antibiotics (before, during, and after surgery) are, therefore, recom¬ mended as an adjunct to reducing infection rates in con¬ cert with good surgical technique.
Age, debility, duration
tomic
area
THROMBOEMBOLISM
Clinical signs failed to identify 80% of postoperative thromboses diagnosed by phlebogram in a study of elective hip surgery by Evarts and Feil.8 Using specific diagnostic techniques such as phlebograms or radioactive venous
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Iowa User on 06/17/2015
fibrinogen scan, a true incidence of venous thrombosis in hip fractures and elective hip surgery is found to run be¬ tween 40% to 55%.'7 The corollary of this high incidence of venous thrombosis is pulmonary embolism. In autopsies of 247 patients who died after hip fracture, 38% died of pul¬
tively also offers reduced incidence of thrombotic com¬ plications comparable in effectiveness to low molecular weight dextran and dicumarol, but with substantially fewer bleeding complications.
Although the problem of thromboembolism is large and real, the solution is less clear. Prophylactic anticoagulation can be beneficial in reducing thromboembolic problems. Lowered incidences of venous thromboses have been reported using preoperative dicumarol, dicumarol be¬ ginning several days postoperative, full anticoagulant doses of heparin sodium given intravenously, low dose subcutaneous heparin, low molecular weight dextran, high molecular weight dextran, and aspirin. Unfortunately each regimen has its failings as well. Some are difficult to control and unpredictable; some cause significant bleeding complications; some produce fluid overloads; some add to
The predominant site of pressure ulcération in patients with hip fractures is not the sacrum, but the posterior as¬ pect of the heel. Patients with a painful hip, who may, in addition, be confused or weak, tend to let the weight of their leg press the heel against the bed. After a few hours it ceases to be painful because blood supply is lost and nerve endings necrose. Even if the patient is "mobilized" by spending some time in a chair or on crutches, the larg¬ est percentage of time will be spent in bed and specific measures must be directed at relieving pressure on the heel to avoid necrosis and ulcération. Pressure should be distributed more proximally around the calf using pillows or rolls of sponge rubber. Unless used with care, heel pads may serve not to relieve the pressure, but to cover up the fact that a sore is developing. The back of the heel should be examined regularly by the nurses and daily by physi¬ cians. With the preceding information as background common to all fractures about the hip, the following articles discuss in more detail the problems associated with specific frac¬ tures about the hip as reflected in the experience of the authors against the background of past and current litera¬
DECUBITUS ULCERS
monary emboli.8
wound
sepsis
or
may
delay fracture healing.
Unless labo¬ very good, no currently be given
ratory controls and medical supervision
potent anticoagulation regimen
unqualified
recommendation.
can
are
Thrombi probably begin to form during surgery when surgery is elective. In hip fractures, thrombi probably be¬ gin to form after initial trauma and continue to form un¬ til surgery permits mobilization of the patient. If the pa¬ tient is medically stable, early surgery (within 24 hours)
offers a reasonable means of reducing thrombotic compli¬ cations. The use of aspirin preoperatively and postopera-
ture.
References 1. Evans FM: Trochanteric fractures: A review of 110 cases treated by nail-plate fixation. J Bone Joint Surg 33-B:192-204, 1951. 2. Boyd RJ, Burke JF, Colton T: A double-blind clinical trial of prophylactic antibiotics in hip fractures. J Bone Joint Surg 55\x=req-\ A:1251-1258, 1973. 3. Fogelberg EV, Zitzmann EK, Stinchfield FE: Prophylactic penicillin in orthopedic surgery. J Bone Joint Surg 52-A:95-98, 1970. 4. Wilson FC, Worchester JN, Coleman PD, et al: Antibiotic penetration of experimental bone hematomas. J Bone Joint Surg 53-A:1622-1628, 1971.
5. Evarts CM, Feil EJ: Prevention of thromboembolic disease after elective surgery of the hip. J Bone Joint Surg 53-A:1271\x=req-\ 1280, 1971. 6. Hamilton HW, Crawford JS, Gardner JH, et al: Venous thrombosis in patients with fracture of the upper end of the femur. J Bone Joint Surg 52-B:268-289, 1970. 7. Freeark RJ, Boswick J, Fardin R: Posttraumatic Venous Thrombosis. Arch Surg 95:567-575, 1967. 8. Tubiana R, Duparc J: Prevention of thrombo-embolic complications in orthopedic and accident surgery. J Bone Joint Surg 43\x=req-\ B:7-15, 1961.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Iowa User on 06/17/2015
Hip
Fracture
Gerald S. Laros, MD
in the treatment of hip fracfrom recumbency enforced by sand bags, spicas, or traction to mobilization care. This advance was made possible primarily by the development of internal fixation devices. Refinement of these devices and of surgical techniques has continued because problems and complications associated with treatment still remain. The articles in this symposium deal with current thinking on the treatment of fractures about the hip and how we may continue to improve our results. The major residual problems are found in two general areas. (1) Medical complications: The age and general medical condition of patients suffering from hip fractures predispose them to complications of recumbency such as thromboembolic disease, urinary tract infections, pneumonia, senile psychosis, and decubitus ulcers. (2) Technical complications: The forces acting about fractures in the region of the hip tend to produce varus at the fracture site. These forces lead to complications of fixation that may limit the stability of the hip, interfere with bone healing, or produce functional problems in ambulation and thus de¬ feat or compromise our efforts for mobilization care. In fractures of the femoral neck, a third problem still haunts us. Poor local blood supply may lead to avascular necrosis of the femoral head and/ or nonunion of the frac¬
The greatest improvement change tures
was
the
ture.
RECUMBENCY
The main reason for internally fixing a hip fracture in debilitated patients is to reduce complications of re¬ cumbency. Stabilizing the fracture by internal fixation re¬ duces pain and makes it possible to mobilize the patient. Accepted for publication July 25, 1974. From the Section of Orthopedics, University of Chicago Hospitals and Clinics, Chicago. Reprint requests to Section of Orthopedics, University of Chicago Hospitals and Clinics, 950 E 59th St, Chicago, IL 60637 (Dr. Laros).
Early mobilization protects against thromboembolism, pneumonia, urinary tract infections, senile psychosis, and decubitus ulcers. Major surgery in an elderly or debili¬ tated patient is certainly more risky than in young and healthy patients, but clinical studies1 indicate an even greater morbidity and mortality if these patients are treated nonoperatively. In most cases, treatment of hip fractures in the elderly by surgery is the conservative course in that it carries less risk than prolonged bed rest. If surgery is absolutely contraindicated, it is generally preferable in the aged, debilitated patient to ignore the fracture and mobilize the patient as early as pain permits. This means changing the position of the patient in bed or moving the patient from bed to chair without particular regard for immobilizing the fracture. INFECTION of operation, and possibly ana¬ contribute to an infection rate of 5% to 10% in surgically treated hip fractures. This is higher than the usual infection rate following orthopedic surgical proce¬ dures and makes infection a matter of special concern in hip fractures. Boyd and associates,- using prophylactic an¬ tibiotics before, during, and after surgery, reduced the in¬ fection rate in hip fractures from 4.8% to 0.8%. Other clini¬ cal3 and experimental' studies emphasize the importance of adequate tissue levels of antibiotic during surgery for effective prophylaxis. Properly administered antibiotics (before, during, and after surgery) are, therefore, recom¬ mended as an adjunct to reducing infection rates in con¬ cert with good surgical technique.
Age, debility, duration
tomic
area
THROMBOEMBOLISM
Clinical signs failed to identify 80% of postoperative thromboses diagnosed by phlebogram in a study of elective hip surgery by Evarts and Feil.8 Using specific diagnostic techniques such as phlebograms or radioactive venous
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Iowa User on 06/17/2015
fibrinogen scan, a true incidence of venous thrombosis in hip fractures and elective hip surgery is found to run be¬ tween 40% to 55%.'7 The corollary of this high incidence of venous thrombosis is pulmonary embolism. In autopsies of 247 patients who died after hip fracture, 38% died of pul¬
tively also offers reduced incidence of thrombotic com¬ plications comparable in effectiveness to low molecular weight dextran and dicumarol, but with substantially fewer bleeding complications.
Although the problem of thromboembolism is large and real, the solution is less clear. Prophylactic anticoagulation can be beneficial in reducing thromboembolic problems. Lowered incidences of venous thromboses have been reported using preoperative dicumarol, dicumarol be¬ ginning several days postoperative, full anticoagulant doses of heparin sodium given intravenously, low dose subcutaneous heparin, low molecular weight dextran, high molecular weight dextran, and aspirin. Unfortunately each regimen has its failings as well. Some are difficult to control and unpredictable; some cause significant bleeding complications; some produce fluid overloads; some add to
The predominant site of pressure ulcération in patients with hip fractures is not the sacrum, but the posterior as¬ pect of the heel. Patients with a painful hip, who may, in addition, be confused or weak, tend to let the weight of their leg press the heel against the bed. After a few hours it ceases to be painful because blood supply is lost and nerve endings necrose. Even if the patient is "mobilized" by spending some time in a chair or on crutches, the larg¬ est percentage of time will be spent in bed and specific measures must be directed at relieving pressure on the heel to avoid necrosis and ulcération. Pressure should be distributed more proximally around the calf using pillows or rolls of sponge rubber. Unless used with care, heel pads may serve not to relieve the pressure, but to cover up the fact that a sore is developing. The back of the heel should be examined regularly by the nurses and daily by physi¬ cians. With the preceding information as background common to all fractures about the hip, the following articles discuss in more detail the problems associated with specific frac¬ tures about the hip as reflected in the experience of the authors against the background of past and current litera¬
DECUBITUS ULCERS
monary emboli.8
wound
sepsis
or
may
delay fracture healing.
Unless labo¬ very good, no currently be given
ratory controls and medical supervision
potent anticoagulation regimen
unqualified
recommendation.
can
are
Thrombi probably begin to form during surgery when surgery is elective. In hip fractures, thrombi probably be¬ gin to form after initial trauma and continue to form un¬ til surgery permits mobilization of the patient. If the pa¬ tient is medically stable, early surgery (within 24 hours)
offers a reasonable means of reducing thrombotic compli¬ cations. The use of aspirin preoperatively and postopera-
ture.
References 1. Evans FM: Trochanteric fractures: A review of 110 cases treated by nail-plate fixation. J Bone Joint Surg 33-B:192-204, 1951. 2. Boyd RJ, Burke JF, Colton T: A double-blind clinical trial of prophylactic antibiotics in hip fractures. J Bone Joint Surg 55\x=req-\ A:1251-1258, 1973. 3. Fogelberg EV, Zitzmann EK, Stinchfield FE: Prophylactic penicillin in orthopedic surgery. J Bone Joint Surg 52-A:95-98, 1970. 4. Wilson FC, Worchester JN, Coleman PD, et al: Antibiotic penetration of experimental bone hematomas. J Bone Joint Surg 53-A:1622-1628, 1971.
5. Evarts CM, Feil EJ: Prevention of thromboembolic disease after elective surgery of the hip. J Bone Joint Surg 53-A:1271\x=req-\ 1280, 1971. 6. Hamilton HW, Crawford JS, Gardner JH, et al: Venous thrombosis in patients with fracture of the upper end of the femur. J Bone Joint Surg 52-B:268-289, 1970. 7. Freeark RJ, Boswick J, Fardin R: Posttraumatic Venous Thrombosis. Arch Surg 95:567-575, 1967. 8. Tubiana R, Duparc J: Prevention of thrombo-embolic complications in orthopedic and accident surgery. J Bone Joint Surg 43\x=req-\ B:7-15, 1961.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Iowa User on 06/17/2015
