Older people are especially afraid of falling! If they fall, they may never get up again. This is related to aging bones and osteoporosis in the elderly. So, what should I do if I break a bone? Based on the current medical level and treatment model, we can tell patients and their families that fractures are not terrible, but the key is to treat them actively. In many cases, it is the bed rest that is scary, because bed rest can lead to many complications and can even be a direct threat to life.
Geriatric hip fracture refers to the fracture of the proximal femur (including femoral neck, intertrochanteric fracture and subtrochanteric fracture) that occurs in elderly people over 60 (or 65) years of age, of which femoral neck and intertrochanteric fracture account for about 50% each. The proportion of intertrochanteric fractures is higher in elderly people (>80 years old).
1. Incidence of hip fracture in the elderly
According to the National Committee on Aging, with the rapid development of population aging, China’s elderly population aged ≥60 years old reached 202 million at the end of 2013, and the national aging level reached 14.8%, especially the elderly aged above 80 years old are increasing at a faster rate. The national aging population will exceed 300 million by 2025 and 400 million by 2033. Shanghai has 3,477,600 senior citizens aged 60 and above, accounting for 24.5% of the registered population, nearly twice the national average; 629,200 senior citizens aged 80 and above are now in Shanghai.
The elderly have a high rate of hip fractures due to osteoporosis and the tendency to fall to. Although there are no exact statistics, it is estimated that the number of elderly hip fractures occurring in China is 300,000-500,000 per year. Among the elderly hip fracture patients who are hospitalized, it has been common to see elderly people over 80 or 90 years old.
2.Characteristics of hip fracture in the elderly
Compared with fractures in young people, hip fractures are a huge blow to elderly people with weakened vitality and have 5 characteristics.
(1) High mortality rate. Due to the weakening of the body in old age, the function of the organ system is weakened; at the same time, the combined medical diseases, especially the cardiovascular system diseases, and the general condition is poor, which makes the reserve power of the body decrease. Therefore, hip fracture is a severe test for the vitality of the elderly, and sometimes it becomes the last straw in life and has a high mortality rate.
(2) High disability rate, the rehabilitation ability of the elderly is limited, only about 1/2 of the hip fracture can return to the functional state before the fracture, so the disability rate is high.
(3) The failure rate is high, because the elderly have severe osteoporosis, low hip bone mass and poor bone quality, and the fractures are mostly comminuted, the stability of the fracture after internal fixation is poor, and the internal fixation is prone to failure.
(4) More complications, when people reach old age, the body often has a variety of medical diseases combined, which significantly increases the risk of treatment and the chance of medical complications.
(5) Heavy burden. The large population base of the elderly in China and the large number of fracture patients impose a huge economic and mental burden on individuals, families, communities and even the whole society.
3. Hazards of bed-ridden conservative treatment
The hip (the root of the thigh) is the joint part of the trunk and the thigh, and the hip is very important to daily life. Not only is the hip indispensable for standing and walking, but even when a person is bedridden, some basic activities, such as sitting up to eat, rubbing oneself, turning over, and cleaning up urine and stool, are also indispensable for hip activities.
After the fracture, only after the fracture end is strictly fixed (braking), the fracture can be healed after “100 days of injury”. Strictly immobile bed rest for 3 months will bring great harm to the vitality of the elderly, and many bed rest complications will directly threaten the life of the elderly
(1) prolonged suffering from pain.
(2) Decrease in lung capacity and complications of lung infection.
(3) afraid to turn over, the skin is pressed and broken, forming bedsores and infected wounds.
(4) Urinary tract infections due to incomplete urination
(5) constipation, eczema and erosion of perineal skin
(6) deep vein thrombosis, pulmonary embolism
(7) non-healing fractures.
(8) The best outcome is deformed healing of the fracture, wheelchair mobility, and difficulty for the patient to stand and walk.
The current view is that conservative treatment should only be used for the elderly who are extremely debilitated, cannot afford surgery, and are extremely risky. That is, the treatment of the fracture is abandoned without strict bed rest, and upper body activities are encouraged to preserve the life of the patient.
4. Methods and advantages of surgical treatment
Depending on the type of fracture, different surgical methods are used. For elderly femoral neck fractures, artificial femoral head replacement or hollow screw fixation is mostly used, and for elderly intertrochanteric fractures, closed reduction cephalomedullary nailing or lateral nail plate system fixation is mostly used. These minimally invasive procedures can be completed in about 30 minutes and are tolerated by most elderly patients.
The advantages of surgical treatment include.
(1) the effective elimination of pain after fracture fixation or joint replacement, which creates prerequisites for early activity.
(2) the ability to sit up and turn around after surgery, which is conducive to the recovery of the heart and lungs and other vital organs and reduces complications.
(3) It facilitates bowel and skin care.
(4) If physical strength allows, they can stand and walk under protection in the early postoperative period.
(5) About 1/2 of the patients can basically return to their pre-fracture activities in 2-3 months after functional exercise.
5.How to ensure the safety of surgery
The elderly are physically weak, and the functions of important organs such as heart, lung, liver, kidney and brain are decreasing. Statistics found that about 70% of the elderly have 1-2 and 20% have 3 or more medical comorbidities, which bring higher risk to surgical treatment. The current study concluded that the following measures can be taken to reduce postoperative complications and mortality.
(1) Early surgery and shortening the preoperative bed-rest waiting time, preferably within 24-48 hours after the patient’s admission, when the patient’s overall function has not yet suffered the blow of bed-rest and bed-rest complications such as infection have not yet appeared.
(2) Careful communication between the doctor and patient, and good risk assessment, including medical comorbidities, ability to take care of themselves, and ability to walk, etc.
(3) Rapid minimally invasive surgery to reduce the blow to the organism from surgery.
(4) Postoperative analgesia, early and active full rehabilitation.
(5) Multidisciplinary collaboration, timely detection and management of complications.
6. The main factors affecting the treatment effect
The effect of restoring function after surgery will be reduced if the following factors are contained
(1) Advanced age of the patient, over 80 years old, low physical reserve and reduced rehabilitation ability.
(2) High number of medical comorbidities, with important vital organ comorbidities (cardiopulmonary) or number of comorbidities greater than 3.
(3) Persons with intellectual disability (dementia) who have difficulty cooperating in functional rehabilitation.
(4) Independent living ability (eating, dressing, bathing, toileting, etc.) before the fracture, the more independent the person can be, the better the physical condition.
(5) The ability to walk before the fracture, such as being able to go out and move around in the community, is better than the physical condition of those who cannot go out and can only move around indoors.
(6) Nutritional status (hematocrit, albumin).
(7) Other bone and joint diseases, such as with severe lower limb knee, will also affect the patient’s walking function rehabilitation.
7.Outlook
Hip fracture in the elderly is one of the most serious public health issues facing today’s society, affecting not only individuals and families, but also the community and even the whole society, and must be taken seriously from various aspects such as medical model, society and economy.
In recent years, Yangpu Hospital of Tongji University has carried out a multidisciplinary collaborative treatment model in response to the characteristics of hip fractures in the elderly and their physical conditions, conducted a rapid assessment of body functions before surgery, predicted the risks of surgery by using a scoring scale, tried its best to shorten the bed-rest waiting time from admission to surgery, carried out minimally invasive surgical treatment, etc., which effectively reduced postoperative complications and mortality, improved the treatment effect and Patients’ ability to take care of themselves, and achieved better results.