Background and Etiology (cause)
The hip joint is one of the largest joints in the body. It is composed of one osseous (contains bone) joint. The hip is built for weight bearing and movement in several different planes. The hip is a ball and socket joint. It is formed by the head of the femur (thigh bone), which sits in the acetabulum, a part of the pelvis.
A fracture is defined as a partial or complete crack in a bone. Fractures can be minor with little or no displacement of the bone, or more severe with complete displacement of the two ends of the bone that requires surgery to realign. There are closed fractures that do not break the skin, and open fractures that do break the skin.
A hip fracture is a break to the upper femur. A break of the acetabulum itself requires special consideration due to the involved structures of the joint, therefore it is not considered a “hip fracture.” When we say hip fracture we are referring to an injury of the femur.
The most common cause of a hip fracture is trauma from a fall or a direct blow to the hip. Hip fractures occur predominately in people over the age of 65, but it is possible to experience a hip fracture at any age. Common causes of hip fracture include:
- Trauma from a fall
- Direct blow to the hip (for example, from a car accident)
- Age related loss of minerals in the bone that causes weakness
- Osteoporosis, or a loss of bone density
A fracture is an acute injury therefore a patient may begin to experience symptoms immediately.
- Immobility when attempting to move the leg or hip
- Severe pain in the outer, upper thigh, hip and groin
- Difficulty placing weight on the leg on the affected side
- Stiffness, bruising or welling at the hip
- An outward turn to the leg (external rotation) on the affected side
- A complete break may make the effected leg appear shorter than the other leg
In the event that an individual suspects they may have sustained a hip fracture, a radiographic evaluation (X-Ray) will be essential to a proper diagnosis. Most hip fractures require surgery to realign and stabilize the injury. Other methods of realignment, like traction, are typically only used if the patient cannot undergo surgery.
There are several surgical options for the treatment of hip fractures. What type of surgery your doctor will recommend will be based on the severity of the fracture. Metal screws and plates for internal fixation are one way that a severe hip fracture can be repaired.
How much movement should be restricted following the fracture will depend on the severity of the break. Once cleared by the physician, a physical therapy program should be initiated to restore hip motion. In more involved fractures recovery can be long and arduous. Formal therapy and compliance with an extensive home program is the mainstay to restoring function of the hip.
Goals for physical therapy post hip fracture are optimal loading and restoration of normal tissue relationships to improve motion, strength and the ability to perform functional activities of daily living.
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, and joint mobilization by a physical therapist to modulate pain and reduce any soft tissue or tendon irritation and restore normal joint mechanics and range of motion.
- Therapeutic Exercises (TE) including exercises to improve strength and performance of the hip and surrounding muscles.
- Neuromuscular Reeducation (NMR) to restore stability, begin retraining the lower extremity, improve proximal joint stability and improve movement technique and mechanics (for example: running in use of the involved lower extremity in daily activities.
- Modalities that can include the use of ultrasound, electrical stimulation, ice, cold and laser to decrease pain, improve mobility and reduce inflammation of the hip joint and surrounding muscles and tendons.
- Home program development should include strengthening, stretching and stabilization exercises as well as instructions to help the person perform daily tasks and advance to the next functional level.
Most fractures can be diagnosed with X-Ray studies and when necessary a CAT scan. The use of pain medications, rest and ice are the first line of treatment. Surgical intervention is typically required to realign and repair the fracture.
Prognosis
Rate of recovery and the prognosis from a hip fracture will depend on a number of factors:
- Severity – Minor fractures do well with immobilization and physical therapy, while fractures that are more severe and require surgery or effect joint integrity take longer to recover. Patients may have residual motion and strength deficits, especially if the rotator cuff is involved.
- Age- Younger individuals recover faster and are less likely to have residual deficits. Younger individuals heal quicker, have better circulation, are stronger and usually their pre-injury tissue integrity is better.
- Prior activity level plays an important role in post-injury recovery. Those who exercise regularly are stronger and more flexible, and generally have an easier and more complete recovery.
- Compliance- Patients that are committed to their rehabilitation program and are compliant with their home program are more successful in returning to full function.
