Orthopaedic Surgery - Hip Fracture

Introduction 

Hip Fractures – What are they?

Fractures occur to the upper of the end thigh bone (femur). This is usually associated with a fall and can indicate thinning of the bone which is called osteoporosis

Do I need to have an operation?

If you sustain a hip fracture and do not have an operation you will require prolonged bed rest (2 or more months) to allow healing. Without surgery your risk of death, chest and water infections, blood clots and pressure sores increases. The operation reduces these risks, reduces pain and allows you to walk again.

Operation

What will happen before my operation?

After you are admitted via Accident and Emergency (or the ward) you will be admitted to the Trauma Unit as soon as a bed is available. The doctors will obtain a detailed history, carry out an examination and the nurses will perform assessments for your planned care. You will have blood tests, heart tracings (ECG) and other tests such as a chest xray if required. You will be prescribed pain killers and fluids to maintain hydration and will be started on anti-thrombosis (blood clot) medication in the form of an injection.

Once you are stable the doctors will discuss the diagnosis and the most appropriate treatment with you. They will ask you to sign a “Consent Form” saying that you agree to have the operation and it has been explained to you. This can also be discussed with your relatives/carers if you wish and any questions will be answered.

The consultant surgeon whose care you will be under will meet you on the following day’s morning ward round.

What anaesthetic will I have?

We aim to perform your operation within 36 hours of your admission depending on available surgeons and theatre space. Your operation may be delayed to improve your medical condition to reduce the risk of the anaesthetic and surgery.

The anaesthetist will visit you before your operation to discuss what sort of anaesthetic is the most suitable for you and to answer questions about risks. They may also talk to your close family if you wish.

It is common to perform hip fracture surgery under a spinal anaesthetic. This involves an injection in your back which numbs your hips and legs. With this sort of anaesthetic you might be awake or given medication to feel drowsy (sedation) for your surgery.

It is also common to have a general anaesthetic, where you are completely asleep for the surgery.

You may also receive a nerve block from the anaesthetist to help with the pain relief after surgery. Some patients may also require a blood transfusion during or after their operation if their blood count becomes low (anaemia).

What happens when I am taken to theatre?

You will be escorted from the ward with a staff member. In the reception area of the theatre complex you will asked a few questions and several check lists are completed for your safety.

You will be asked to confirm what you are having done. You will be placed on monitors for your heart and breathing and may require another drip to be placed in your arm. Everything will be explained to you as it happens.

What happens after the operation?

If you have been unwell or unstable during the operation you may need a higher area of care such as the high dependency unit or intensive care.

Your observations will be regularly monitored and you will be provided with pain killers, fluids and food when you are ready to eat.

You will be started on blood thinning medicine to prevent a blood clot and laxatives as constipation is very common after such an injury and with taking strong pain killers.

Post-Operative Care

What should I expect in the post-operative period?

Day 1 & 2 – If you are well enough you will be assisted out of bed by the ward staff or physiotherapists. You will be shown some exercises to perform and will have a formal physiotherapy session at your bedside. Blood tests and x-rays may be performed. You will be encouraged to walk for a few steps around your bed under supervision using a zimmer frame.

Day 4 – Most patients are medically stable by this stage. If fit enough and you need some more rehabilitation you will be assessed for intermediate care. If you have medical issues requiring review you will receive rehabilitation on the Orthopaedic Ward (I5) (or possibly at Fairfield General Hospital if you live in Bury). Social work assessment will be performed before you retun home to ensure you have the correct support.

Will I make a full recovery?

Suffering with a hip fracture is a serious condition particularly in elderly frail patients. Many patients will regain their independence to a certain level. Some patients will require care and help in coping with their activities of daily living and may have an element of reduced mobility afterwards.

How long will I be in hospital?

Recovery after a hip fracture is a very personal thing. Some patients recover very quickly and regain mobility early, however if you have other medical problems you may require a longer time to regain confidence and strength to rehabilitate from this injury. In patients with good pre-injury level of independence we estimate 7 days; if we estimate a longer period then we refer patients early to social workers and rehabilitation, to allow patients to be discharged within approximately 14 days after admission from the acute ward.

Where will I be discharged to?

A full social work, physiotherapy and occupational therapy review will have been performed to assess the best area of care for you to progress to. We will not transfer you home until it is safe to do so. Some patients will require a period of time at an Intermediate Care Centre. Here you will have your own room and will be encouraged to mobilise and care for yourself with help at hand if required. Some patients will be admitted to a care home for a period of time. If you were admitted from a nursing home you will be transferred back there when medically stable.

Will I have stitches that need taking out?

You will have either metal clips or stitches that require removal 12-14 days after the operation. This will be arranged for you if you have already been discharged from the hospital.

How can I reduce the risk of a blood clot?

Compression stockings will be provided if your skin is in good condition and should be worn for 6 weeks. You will also have clexane blood thinning injections for four weeks in total after the operation.

Will I be reviewed in clinic?

The department arranges follow up for fractures according to their treatment and this will be arranged prior to your discharge. Most patients who have had fixation of the fracture will be reviewed in fracture clinic at 3 months. Some patients may receive an earlier appointment if the team of doctors request this.

Patients having a total hip replacement will be followed up as per individual surgeon protocol. Some patients do not require another clinic appointment unless they specifically request one.

When can I drive again?

Usually after 6 weeks. Ensure you can perform an emergency stop and inform your insurance company of your injury prior to driving again.

Ward information

On admission to the ward you will be introduced to the different staff members. The team looking after you wear uniforms with the nurses in blue, healthcare assistants in purple, physiotherapists in blue trousers and occupational therapists in green trousers. You will meet various team members during your admission at different stages.The ward usually has a female and a male bay with separate toilets. There are side rooms that are either sex.

Mealtimes are protected and are between 12:00-13:00 (Midday - 1:00pm) and 17:00-18:00 (5:00pm - 6:00pm) on all wards.

Visiting times for relatives in all hospitals is open, however we ask if you can avoid mornings and mealtimes as noted above and to vacate at about 20:00 (8:00pm).

We suggest that only children over 12 years should visit.

Rehabilitation – Physiotherapy, Occupational Therapy

Will my hip be as good as new after the operation?

A hip fracture can be a life changing event. Few patients return to their usual ability and there can be long term mobility issues. This can be due to muscle or ligament damage as a result of the fracture.

Hip fractures tend to occur in people who have several medical conditions or are otherwise frail. The effects of these conditions or the overall frailty can affect your overall recovery.

How will I get back on my feet again?

We will try to get you out of bed on the day or the day after the operation. To start with this may be with the Physiotherapist.

Getting up sooner helps to reduce the risks of complications that can occur from lying in bed too long. In some fractures the surgeon may restrict how much weight you can put on your hip until the bone heals.

What help will I have with rehabilitation?

Getting back to a normal life is a very personal experience. Some people need more time than others. You are the key person in promoting your return to your usual ability. You may find it helpful to set small goals, gradually increasing the amount you do each day. Within the ward the physiotherapists, occupational therapists and nurses will support your progress.

We will encourage you to start putting your clothes on as soon as you are able to sit out again. Please ensure that your relatives/ friends bring some loose fitting day clothes. There is no personal laundry service on the ward.

Some patients will be able to return home with the support of the local community rehabilitation team and/or carers. There may be a charge for carer support. The team will continue rehabilitation in your own home or in the outpatient setting.

The home team can help with washing and dressing until you are more independent and can arrange for meals to be delivered until you are able to manage again.

Other patients may need a period of hospital rehabilitation which may be at a different hospital from admission. There are some rehabilitation facilities in the community setting called intermediate care.

In order to avoid delay in returning home we assess the help you may need at discharge soon after you are admitted.

The occupational therapists (OT) need to know information on heights of your furniture at home and your family/friends will be given paperwork to complete, particularly in the case of hemiarthroplasty or total hip replacement patients. If your furniture is at the correct height there is less chance your hip will dislocate. The OT may arrange for adaptive equipment to be delivered.

Orthogeriatrics Assessment

You will be seen by a doctor from the Orthogeriatrics Team. They will:

• Help with the treatment of any medical problems
• Assess why you fell and whether there is anything that can be done to reduce the risk of falls in the future. This may include changing medication

The results of these help us decide with you whether you need an osteoporosis medication, to help strengthen your bones and reduce the risk of future fractures.

Specialist nurses for Osteoporosis

You may be assessed by a Specialist Nurse who will assess your risks of having a condition which can cause thinning of the bones (Osteoporosis) and help you decide which treatments are most appropriate.

Bone Strengthening Treatments for Osteoporosis

There are treatments which can significantly reduce the risk of you having a broken bone (fracture) in the future.

There are 3 main treatments available.

• Once weekly tablet
• Once a year intravenous infusion for 3 or 5 years. This is usually used for people with heartburn
• Twice a year injection under the skin. This is usually used for people whose kidneys do not function well enough for the other treatments

Vitamin D is also important for healthy bones. If your Vitamin D levels are low, we will arrange treatment with tablets for this.

Letters

We will send you copies of the letters that we send to your GP.

If you have any suggestions about how we can improve our communication (including letters) with patients please let us know.

Contact information

If you have any questions or concerns please contact:

North Manchester General Hospital
Alison Clarke – Trauma co-ordinator and Hip Fracture link nurse - 0161 625 8285
Ward I5 - 0161 720 2552/0161 922 3392
Dr Gibson's Secretary - 0161 720 2789

Royal Oldham Hospital
Julie Walton/Amanda Woodall - Trauma Co-ordinators and Hip Fracture link nurses – 0161 778 5833
Ward T7 – 0161 778 5825
Dr Parikh’s Secretary – 0161 627 8480

Other information
NHFD website - http://www.nhfd.co.uk
Osteoporosis website - https://theros.org.uk/