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Geriatric Hip Fractures

  • When a trauma or fall causes a hairline break in the upper quarter of the thighbone
  • Types include ones sustained from high-intensity trauma and those resulting from falls
  • Treatments include nerve blocks for pain, blood-clot prevention, and surgery
  • Involves Orthopedics

Overview

More than 300,000 people over 65 years old fall and break their hips each year in the United States, and it can be a painful and scary experience. “Most are aware that they will need an operation, which is frightening for people of advanced age,” says Marc J. Shapiro, MD, medical director of the emergency department at Yale New Haven Hospital’s Saint Raphael Campus.

Yale Medicine specialists in the Fragility Hip Fracture Program are committed to reducing mortality and dramatically improving the prospects of elderly people with hip fractures.

What is a hip fracture?

Most hip fractures fall into one of two categories—those caused by a high-intensity trauma, such as a fall from a high place or a motor vehicle accident, and those that result from a fall, especially in someone with age-related osteoporosis. The Fragility Hip Program focuses on the latter, says Dr. Shapiro.

What are the unique challenges of a geriatric hip fracture?

“A hip fracture is a very traumatic event for an elderly person,” says Dr. Shapiro. “They know they are looking at the loss of their mobility and independence. Plus, they have severe pain in the hip, the pelvis or even the leg, depending on where the fracture is located."

Most patients are in so much pain that they can’t walk or bear weight. Many find movement excruciating, which presents challenges for the emergency medical technicians, nurses, and doctors trying to diagnose and treat them. Their immobility and other related medical conditions leave them at high risk for a wide range of other medical challenges that can contribute to the high fatality rate in the months after a hip fracture.

How is hip fracture diagnosed and treated?

The Fragility Hip Fracture Program has redesigned treatment for geriatric patients with a hip fracture, starting with the very moment someone calls 911, says Dr. Shapiro. Because the vast majority of people who fracture a hip will arrive by ambulance, emergency medical technicians have been trained to take them to Yale New Haven Hospital’s Saint Raphael Campus. “In the emergency department we are really the front line of the program,” Dr. Shapiro says. “Our goal is to make sure each patient gets exactly the workup that is needed and that care is initiated as early as possible.”

Priorities include:

  • Identifying hip fracture patients quickly: Most geriatric hip fractures are diagnosed in the emergency department, based on the patient’s description of symptoms, a physical exam and X-ray.
  • Managing pain with immediate delivery of a nerve block: As part of the multidisciplinary fragility hip fracture team, an on-call anesthesiologist delivers a nerve block injection as quickly as possible. This provides pain control while minimizing the use of opioid pain medications. “Seniors often have adverse events associated with opioid drugs, including delirium and respiratory problems, that contribute to the high mortality associated with hip fracture,” Dr. Shapiro says. 
  • Preventing blood clots: “When patients are lying around waiting to be treated, there is a grave risk that a life-threatening blood clot will develop,” Dr. Shapiro says. “Preventive heparin dosing (an anti-clothing medication) in the emergency department is a way to stay ahead of the curve.”
  • Faster surgical care: Research shows that hip fracture patients do better when surgery is performed within 24 hours of the injury. The new program streamlines the process of admitting and preparing patients for surgery, and has a dedicated daily operating room time slot, so hip fracture surgeries can be done quickly.

What makes Yale Medicine’s approach to treating geriatric hip fracture unique?

The Fragility Hip Fracture Program has resulted in a “dramatic improvement in care,” says Dr. Shapiro.  “It improves quality because it’s now easier for us to take better care of hip fracture patients. They are prioritized, given rapid pain control, standardized workups and excellent preventive care.”

The program also draws upon the expertise of a variety of specialists in such areas as emergency medicine and orthopedic surgery who address different issues from the moment the patient arrives through post-surgery rehabilitation. “We believe we are setting a new standard for care of the fragility hip fracture patient because we have not only the clinical expertise, but  physician and institutional commitment to excellence in the care of our patients with musculoskeletal and geriatric conditions," Dr. Shapiro says.