"Hip fracture"

 

Hip fracture
IN THE ELDERLY

     Fractures of the hip region correspond to those in the upper end of the femur, and, together with the doll, they are most common in the elderly.

     Although they are classically divided into two groups: the neck of the femur and the region trochanteric two together are going to very similar problems, since it is usually seen in older people. Banal occur from falls, are largely tied to osteoporosis as usual at this age, occurring in a region that supports load equivalent to three times the body weight, and also, with rare exceptions, they all have to operate if you want to achieve more effective results. 

     It is precisely in this region (in the young is very strong) where the effects of osteoporosis are going to be very marked in the elderly, the disappearance of bone trabeculae at times in significant proportions in areas covered by the neck Trochanteric femur and the region.

     These fractures are more common in women (more than twice that of men), and this is largely due to the intensity of the amount of bone loss (osteoporosis) is greater in them than in men. 

     The frequency of these changes in response to different countries and geographical environments, and its highest incidence in the countries of northern Europe and USA in relation to the "Mediterranean", suggesting that increased exposure to the sun (ultraviolet radiation) of the inhabitants of the latter could be a determining factor for these differences. It also found that the incidence is lower in rural areas, where houses tend to be broader and more elderly develop physical activity and more time being exposed to sunlight.

     Could be the "robot portrait" of the subject with hip fracture risk that corresponds to that of "white women, older than 70 years, slim, sedentary life, prone to repeated falls, which have illness or chronic diseases, medications subject to the type of sedatives, antidepressants, antihypertensives, etc.., with a family history of osteoporosis and fractures in this region, which has been or is smoking or drinking, and accustomed to a diet rich in proteins. "

     In general, one can say that the number of hip fractures has increased significantly in recent years, coinciding with the aging population. In the USA produces about 220,000 cases annually in the United Kingdom increased from 50,000, and in Spain are around 30,000. It is estimated further that by early next century the number of cases will be double those in 1980, suggesting that by then almost 30% of the beds of Trauma Services of the hospitals will be occupied by elderly people with this condition.

PREVENTION OF FRACTURE

     The problem of prevention of these fractures is now regarded as a key point in the health programs of the countries, which are lesions that produce a high morbidity and mortality with major economic implications. At present, the mortality for a population of hip fracture operated with an average age of 75 years, is six times higher than in the general population.

     One of the main objectives is to achieve more effective action on osteoporosis, measures that would delay its onset or give rise to larval forms. Thus, a balanced diet with a diet rich in protein and vitamin D, calcium is the daily dose and administering sufficient estrogen action that are, in principle, intervene positively in terms of halting the loss of bone mass.

     By the same token, it is very important for the elderly to maintain a daily physical activity, walking with some frequency within its means, and avoiding long periods in bed or even sitting. You can also assess a program of treatment with estrogen, which must consult with a specialist in gynecology. This type of treatment should be done from the beginning of menopause.

 
     Preventing falls in elderly people should be in the minds of not only the health personnel responsible for your care, but also the families with whom they live. The trauma required to produce a fracture in the elderly after suffering a fall it is often more important than usually thought because it requires a considerable mechanical strength to be a hip fracture, even at advanced ages. Therefore, we must put aside the idea that sometimes the first thing that occurs is the fracture and then fall.

     It is known that the chances of falls increase with age, so that 30% of the population over 75 years falls at least once a year and this figure rises to 50% in those older than 80. As most of the time older people spend it at home or in institutions where they are welcomed, it is in those places where they usually occur in the fall, and within them in the bedrooms, sitting-rooms and toilets . In these places should be systems or devices such as handrails or handrails and seats.

      Carpets are a danger to the elderly and many of the crashes occur when you stumble or slip on them so they should be well attached to the soil or, better yet, dispense with them. Another risk is the existence of dark areas, so we need good lighting in the places where the elderly are moving, especially as very often have decreased visual acuity.

     Also important is the implementation of measures for coordination and scheduling of controlled exercises, as well as the use of protective systems (pads) to act as buffers in case of falls. Be cautious taking sedative drugs and all those that cause orthostatic hypotension in patients who are predisposed to falls. Will prevent the consumption of alcohol and snuff, as both are favoring osteoporosis.

MANAGEMENT OF ELDERLY WITH HIP FRACTURE

     When an elderly person suffers a fall, and as a result of it is broken hip usually will feel intense pain that is often referred to in principle in the inguinal region. If the fracture is complete will not be lifted from the ground or move the injured member, taking a position on this external rotation at times very sharp (the tip of the feet is diverted outwards), and appear shortened in relation to the healthy side.

     It should be remembered that in some cases the fracture is incomplete at the beginning, which would then move the old man could even rise with the risk of becoming full immediately, or even past few days. Can also be found in 10% of cases, areas of contusion or injury located at the head, elbows or hands, which are produced by striking against objects or the ground at the time of the fall. Sometimes, depending on the intensity of the trauma, there are categories of shock (loss of) more or less passengers.

     In this situation, family members or people who take care of the elderly must consider the possibility of a fracture of the hip region, and proceed to place the patient in the position most comfortable, warm and, in principle, no attempt to lift or move if they do not have sufficient means and staff. Shall immediately notify the nearest health center or the appropriate assistance, to be sent an ambulance to transfer him to it.

      Once it has reached the corresponding center in the Emergency Department will be to collect basic data on the history and exploration will be conducted for radiological studies that confirmed the fracture and its location. Given that these patients are elderly and many have alterations of their general, as vectors of processes such as cerebrovascular diseases, dementia, Parkinson's disease, infections, diabetes, etc.., Surgical intervention (although almost always an indicator), risks and complications such as thrombus embolism, infection and pneumonia. Therefore, there is a general assessment of the condition of the patient before deciding surgery, and report such risks to relatives.

TREATMENT OF FRACTURES OF THE HIP

    Surgery is the primary indication of treatment of these lesions, as only it is possible that the patient can return to walking and integrate their activities. In the case of a femoral neck fracture, excision of the femoral head, followed by placement of a stent, is the most common and is used far more so with the older patient. This is, by the fact that keeping the head (which has always tried to younger subjects) would lengthen the time of discharge of the member, which tolerate the evil old man, and also assume the risk that occurred as a complication ischemic necrosis of that segment. However, if patients are not excessively higher, with good general condition and with good bone quality, can be assessed by fixing the fracture with screws and therefore the preservation of the femoral head. With the stent, the patient may begin an immediate functional recovery and even walk within the first week. It is clear that the sooner mobilize and walk, the results will be better to avoid many complications.

     In cases of fractures of the trocantérica region (area below the neck), the treatment goal is to reduce them and their metallic fixation devices (plates, screws and nails) that give stability to a large outbreak and allow the patient to get up and charge too soon. Be taken also into account that the results will be better if these patients had before the fracture, a good general and an appropriate functional activity.

    Stay with an elderly hip fracture in the hospital can take up to two weeks, and during this time has to be the subject of attention. Postoperative care are essential, and depends in large measure not only the functional recovery of the patient but also their survival. Hygiene care from the first moment of their income are very important and, within them, it is remarkable changes in posture and skin care to prevent decubitus ulcers.

    Placement in an appropriate place from the day following the intervention, as well as support to their wandering from the very moment the old man can endure.

     The patient should also perform exercises for as long as you stay in bed, appearing as a significant extension and flexion of the ankles and the contraction of the quadriceps, with forze pressing the back of the knee (Corvo) from the plane bed. Regardless of which antibiotic prophylaxis is carried out, will also take place almost always an prophylaxis of thromboembolic disease through appropriate medication anticoagulant, in fact now very routine and it can still be done and controlled at home.

 
    For all these measures is essential to be effective collaboration between the medical staff, nursing assistant and also of the patient's family, because they must keep control of it from moving to his home.

     For this reason should be well informed before departure of the hospital on the basic aspects of management of the elderly and therapeutic elementary lines.

     In summary, one can say that hip fractures in the elderly, but pose a serious problem both individual and social and public health due to their increased incidence, with its high rate of morbidity and mortality, as well as significant economic burdens that result, no longer have in recent years the ominous and the devastating effect that meant before, due mainly to improved management of patients who suffer these injuries, which is given by a greater and more serious attention, both pre and postoperative, as well as

     the implementation of more sophisticated surgical procedures (osteosynthesis material and stent) to which it is possible a rapid incorporation of the elderly to their normal lives.