Mom Fell And Broke Her Hip – Now What?!
by Marel Ver, MD
In 2016, I wrote a Hawaii Filipino Chronicle article about falls being the number one killer in Hawaii’s older population.
As the previous Trauma Medical Director of my hospital, Hawaii’s trend of falls being the number one type of trauma remains. With nearly 21,000 emergency room visits and over 2700 hospitalizations yearly, falls are the leading cause of non-fatal injuries in the state, and nationwide.
Hawaii averages about 114 fatalities from falls yearly. Most of the falls are “ground-level falls,” and over 70% of these falls occur at home. Hawaii hospital charges for falls cost $100 million annually, and in the US, healthcare costs relating to falls surpass $50 billion annually.
The majority of those falling is our kupuna 65 years and older, with age increasing the associated risks and complications. In the US, over 300,000 older people are hospitalized with hip fractures yearly, of which 95% are caused by falling, usually sideways.
The top three injuries resulting from falls that I see in my trauma center are head bleeds, hip fractures, and wounds, all of which are consistent with other Hawaii trauma centers. For older patients with traumatic brain injuries, over 70% of deaths and 80% of hospitalizations are caused by falls.
As a trauma surgeon, it is routine for me to evaluate and take care of the trauma patients who come to the Emergency Room. Depending on the types of injury, I then consult the appropriate specialist who would contribute to the overall treatment plan.
Despite all the medical training, it is always difficult when the one who is injured is a member of your own family.
Last summer, my mother was at home and had a ground-level fall backwards after tripping over my dog. When she called my phone, she was crying in extreme pain and stated she could not get up from the floor.
My mother is in her mid-60s, appears much younger than her age, and was very active otherwise. I rushed from work to the house worried, not just about her, but also about my baby who was now unattended since Mom was immobile.
When I arrived, my Mom was on the floor in obvious pain. When I examined her, I already had a very high suspicion of a hip fracture, which would be a surprise to me since I didn’t think that this “could happen to my Mom.”
My colleague and I were unable to lift my Mom due to her severe pain. Therefore, we called 911 and the ambulance came several minutes later. Before loading her to the stretcher, the paramedics had to give her strong IV pain medications to help make transport comfortable and safer.
She was taken to the nearest trauma hospital and was evaluated in the emergency room. The workup by the Emergency doctor and on-call Trauma surgeon confirmed a right hip fracture. Fortunately, that’s the only injury that she had.
The on-call Orthopedic surgeon was consulted and recommended urgent hip repair surgery. Therefore, my Mom was admitted to the hospital under the Hospitalist (inpatient medical doctor) service to prep her for surgery the next morning.
Recovery from a hip fracture may be difficult and many people lose some of their independence. Hip fractures are the most expensive fracture to treat on a per-person basis.
The hip is comprised of the femur bone in the thigh that connects to the pelvis with a ball-in-socket joint (femoral head into the pelvis acetabulum). The nature of the fall affects the type of breaks in the bone. The location of the break affects healing potential. The most commonly fractured area is the femoral neck, which connects the femur shaft to the head.
Treatment options for hip fractures are basically whether to fix them surgically or not.
Non-operative management may be recommended for those with mild fractures where the hip joint is still stable and therefore causing minimal pain. Also, if the patient has conditions that make them too high of a risk for surgery, then the risks can outweigh the benefits.
If the patient is able to walk prior to the fracture and no operation is planned, then the physical therapist gets involved early to help mobilize and get the person walking again. The Hospitalist will prescribe a pain control regimen to help make the pain manageable.
Most Orthopedic surgeons argue that all hip fractures are operative. They operate to repair these fractures, even on the elderly patient, as the immobility itself has high complications.
These complications include pneumonia from breathing shallow, urinary tract infections from holding in urine, and pressure ulcers from being bedbound. The infections themselves, especially in an older patient, can be deadly. Immobility also can result in blood clots and general deconditioning.
It is alarming that the mortality rate of a hip fracture is 30% within 90 days. This percentage increases if we wait over 48 hours for surgery. Therefore, the benefits of operating urgently outweigh the risks.
Fixing the hip fracture stabilizes the joint for weight-bearing, decreases the pain, and allows for an earlier return to standing and walking. Surgery options include ORIF (Open Reduction Internal Fixation using rods, plates, and screws), screw fixation, and partial or full hip replacement (hemiarthroplasty/total hip arthroplasty). The hardware used is made of titanium; a special metal that the body adapts well.
The average operative time for a hip repair surgery is two to four hours, performed under general or spinal anesthesia. Once the surgeon clears the patient to walk (usually in one to two days, but as early as the same day), then the physical therapists start working with the patient.
In my center, hip fracture surgery accounts for 20% of all orthopedic surgeries. The average time in the hospital for a hip fracture patient is about four days. The physical therapists and occupational therapists (PT&OT) will assess if the patient is safe and ready to go home. The hospital Case Management team gets involved by helping families get ready for discharge home versus to another facility.
If the patient is safe and able to go home and has proper social support for help, then the case manager will set up PT&OT services to come to the house (home health) or set up visits at an outpatient facility.
My Mom had ORIF hip surgery. She stayed longer in the hospital due to intolerance to the strong pain medications, which also limited her ability to participate in PT&OT. It was recommended that instead of staying at the hospital longer to get better at home, that she be discharged to a short-term rehabilitation (STR) facility.
At the STR, she had a room with a hospital bed and nurses/aides to tend to her needs. PT&OT services were of higher intensity compared to those in the hospital. The Rehabilitation doctor (rehab inpatient doctor) checked on her daily to address her medical needs and pain control regimen. We visited her daily and encouraged her efforts to participate in her recovery.
In Hawaii, of those patients hospitalized after a fall, more than half are discharged to a skilled nursing facility. When falls result in a hip fracture, 70% are discharged to a skilled nursing facility and 11% to a rehab facility. Only 11% are discharged to home. Home health services are often arranged.
My Mom was eventually discharged home from rehab after two weeks. My dad and my brother received the teaching necessary to assist my Mom with using her walker and cane, and to help with transfers.
A list of needed supplies was given to them to prepare the house for Mom’s return. This list included a shower chair, handrail and grips for the shower, a commode, bed rail, and guidance on proper shoes.
PT&OT services were arranged to come to the house to continue therapy. My Mom improved daily and was up walking with a cane by three months.
Aside from my rascal dog, the main reason for my Mom’s hip fracture was her undiagnosed osteoporosis; a condition that is common as we age where our bones become brittle and break.
All post-menopausal women are at risk of osteoporosis due to low estrogen levels. Low estrogen levels can also be seen in pre-menopausal women with hormone disorders or those who participate in extreme physical activity. Low testosterone in males is also a risk for osteoporosis. Women do fall more often than men with about 75% of hip fractures occurring in women.
Unfortunately, osteoporosis is a “silent disease” as there are often none to minimal symptoms until a bone breaks. The top three reasons for causes of osteoporosis are estrogen deficiencies, low calcium, and inactive lifestyle.
Some medications like tamoxifen and anastrozole for breast cancer treatment are designed to lower estrogen levels. We cannot control our natural hormonal changes over time, but we can focus on preventing low calcium and vitamin D levels through diet or supplements and incorporating exercise activities, like a brisk walk into one’s routine to encourage bone strengthening.
The most widely prescribed medications to treat osteoporosis are bisphosphonates like Fosamax. There are newer medications like Prolia on the market in addition to other bone-building medications currently under development.
There are ways to assess your own bone density and associated risk for fractures. A DEXA Scan is a bone density test that measures the mineral content of your skeleton. This scan can help diagnose osteoporosis as well as osteopenia, which is low bone mass.
Your PCP or specialist may consider a DEXA scan if you have one or more risk factors including advanced age (65 years old in women, and 70 years old in men), family history, previous fractures (especially if the injury occurred after 50 years old), medications, and overall health.
The report will show bone density scores and provide a percentage risk for injury. Your doctor can use these results to determine the next steps for prevention/treatment, and timing for your next surveillance scan.
The medical course of treatment for a hip fracture is not easy. Moreover, it is worth mentioning the emotional toll that it takes on the patient and caregivers, as this fracture, although treatable, is indeed life-changing.
My Mom has and continues to spend a significant amount of time rehabilitating. I can sense her frustration, anger, and sadness, that she cannot move the way she did before her injury. She has lost part of her independence. She loves to go out and travel, and now she is mostly homebound.
These events impact others in the family as well. I had to hurry and arrange for alternate childcare, as Lola/Lolo daycare (the best that there is!) was no longer available. I worry about my dad and brother who continue to take time off from work and other parts of their lives to aid my Mom with her needs.
This one injury has affected all of us and our daily routines, but my Mom most of all. We continue to be positive and adjust daily.
I realize that we don’t expect bad things to happen to us or our family members; but we can’t have a “bahala na” attitude and have a passive approach to our health, especially as we age.
It is important to be aware of our overall health risks, be prepared for the just-in-case, and focus on prevention. With special regard to hip fractures, if you suspect injury after a fall, it is important to go to the ER for evaluation since timely treatment decreases overall mortality.
It is important to acknowledge the risks and make efforts to be safer. Speak up to your doctor about falling concerns, check your medications, and assess risks. Check your eyes and feet. Wear proper footwear. Keep moving with activities like Tai Chi and walking to strengthen your legs and balance. Make your home safe by removing clutter, having handrails, increasing lights, and being mindful of kids and pets. Start conversations with your family about contingency plans and advanced care directives for if and when something should happen.
For more information about preventing falls as a core focus of Hawaii’s Injury Prevention Plan, please visit health.hawaii.gov/injuryprevention/home/preventing-falls/information/.
I’d like to thank my mother Agnes Rustia Ver for allowing me to share her story. We hope that you are more informed on what to expect and prompted to take action. I’d also like to acknowledge my orthopedic surgeon colleagues Dr. Mariya Opanova and Dr. Tim Fei who contributed their expertise to this article and very thankfully to my mother’s care.
DR. MARIA “MAREL” VER is a board-certified general surgeon for Hawaii Pacific Health, previous Trauma Medical Director of Pali Momi, and past PMAH president.