Hip Fracture Setting Priorities for Effectiveness Research (1990) / Chapter Skim
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THE KNOWLEDGE BASE FOR KEY CLINICAL ISSUES IN HIP FRACTURE
THE KNOWLEDGE BASE FOR KEY CLINICAL ISSUES IN HIP FRACTURE
Pages 8-20
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From page 8... ...
One group involves the femoral neck, which is just below the head of the femur. Another involves fractures around the intertrochanteric crest; this bane links the greater and lesser trochanters, which are prominent bony eminences situated essentially between the femoral neck and the upper part of the main shaft of the femur, to which the major skeletal muscles are attached.
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From page 9... ...
Least Severe \ 30° / Femoral Neck Fracture Intertrochanteric Fracture to=, ~ Greater A Trochanter <' // \ Lesser Trochanter ~V: / Subtrochanteric Fracture FIGURE 1 Examples of Main lopes of Hip Fracture 9 Most Severe ~\N )
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From page 10... ...
Epidemiology Frequency Hip fracture causes significant morbidity and mortality. There are 260,000 hip fractures in the United States each year, and they occur almost entirely among elderly people.2 The medical, social, and economic consequences for hip fracture victims are severe, for instance, resulting in an excess 1-year mortality of 12 to 25 percent, impaired ambulation, and institutionalization for 33 percent or more of hip fracture survivors.
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From page 11... ...
At the other extreme, hip fracture may signal an "end of the beginning," a clinical manifestation of aging and frailty that was previously subclinical or the cumulative effect of small declines reaching a threshold that precipitates the hip fracture. Most clinicians suspect that both perspectives are valid.
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From page 12... ...
Data are not yet available to allow a simultaneous assessment of both bone density and fall severity; this is a critical question because its answer influences the potential efficacy of intervention efforts aimed at maintaining bone strength, reducing falls, or reducing the severity of falls that do occur. Intervention efforts aimed at either maintaining bone strength or reducing the number of falls have not conclusively shown significant reductions in hip fracture incidence.
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From page 13... ...
Bone Mass and Osteoporosis Fracture pathogenesis is complex and involves abnormalities that are intrinsic and extrinsic to the skeleton. Low bone mass is the most critical skeletal abnormality relating to hip fracture.
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From page 14... ...
Anticonvulsants, corticosteriods, and replacement thyroid hormone may increase bone loss and, thus, increase fracture risk. Clinical trials and other research efforts are needed to quantify the risk of hip fractures associated with use of these medications, assess potential prophylaxis, and identify less hazardous alternative therapies.
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From page 15... ...
Surgical Treatment Options Although several surgical treatment options are available, clinicians generally agree that open reduction and fixation of the fracture fragments are the appropriate treatments for intertrochanteric and subtrochanteric fractures. A major controversy relates to defining objectively the appropriate treatment options for 'femoral neck fractures.
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From page 16... ...
Furthermore, both problems, singly or in combination, produce a poor result and may require further surgery, leading to replacement of the femoral head. For these reasons, many orthopedic surgeons elect to treat femoral neck fractures of the Garden III and Garden IV stages almost routinely with some form of prosthetic replacement.
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From page 17... ...
Controversy exists in use of the treatment options available for the more severe Garden stage III and IV fractures. Few useful criteria exist to assist a practitioner in determining when and under what circumstances a particular displaced femoral neck fracture should be reduced and internally fixed, treated by primary hemiarthroplasty (replacement of the femoral head with a prosthesis as the primary procedure)
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From page 18... ...
Nonsurgical Treatment Issues With the many advances in medical care and technology over past decades, physicians are now confronted with a group of very elderly, infirm patients with moderate to severe mental and functional impairments who sustain hip fractures. These injuries frequently occur in protected environments such as nursing homes and hospitals.
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From page 19... ...
It also concerns their opportunity to live independently; to function within the community; to participate in social activities; and to continue other activities they might wish to perform. Many services can be offered: effective limb and joint mobilization and alignment; passive resistive exercises of nonaffected joints; other physical therapy and occupational therapy to regain mobility and independence; restorative nursing services (e.g., range-of-motion exercises)
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From page 20... ...
Nevertheless, both historical and clinical experience suggests that active rehabilitation that focuses broadly on the various needs of an individual results in better outcomes than does more limited services. At present, most rehabilitation professionals believe it is preferable for an individual to receive comprehensive services in a setting somewhat more intense than necessary, rather than risk having a patient fail to receive comprehensive services because of efforts to reduce short-term costs.
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