For appointments and enquiries, please call the CGH Appointment Centre at Tel: (65) 6850 3333 CGH Appointment Centre operating hours: 8.30 am to 8.00 pm (Monday to Friday) 8.30 am to 12.30 pm (Saturday & Sunday) Closed on Public Holidays For more information, please visit http://www.cgh.com.sg all about Hip Fracture 2 Simei Street 3 Singapore 529889 Tel: 6788 8833 Fax: 6788 0933 www.cgh.com.sg Reg No 198904226R All information is valid at the time of printing (April 2010) and subject to revision without prior notice. Organisation Accredited by Joint Commission International 16
What is a Hip Fracture? A fracture at the top end of the femur near the hip joint Three common types of fracture 1. Femoral neck fracture A fracture at the neck of the proximal femur, usually from a fall or minor trauma in osteoperotic bones. 2. Intertrochanteric fracture A fracture between the greater and lesser trochanter; usually heals well in healthy people. 3. Subtrochanteric fracture A fracture below the lesser trochanter and may extend further down the femur. ILIUM ILIAC CREST POSTERIOR SUPERIOR ILIAC SPINE Who gets Hip Fractures? Typically elderly people (aged 70 years and above), for several reasons: Increased risk of falling, especially low impact falls (i.e., falls from standing height or less) Reduced bone strength due to osteoporosis Occasionally, people with severe osteoporosis or other bone disorders sustain a fracture with no history of a fall. ANTERIOR SUPERIOR ILIAC SPINE (HIP BONE) FEMORAL HEAD FEMORAL NECK GREATER TROCHANTER ACETABULUM PUBIS A high percentage of hip fracture patients are aged above 80 years. Understanding Osteoporosis Osteoporosis is a systemic skeletal disease, characterised by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture. LESSER TROCHANTER FEMUR ISCHIUM ISCHIAL TUBEROSITY (SITTING BONE) BONES OF THE HIP AND PELVIS Factors influencing the risk of having osteoporosis: Post menopausal women, due to decreased oestrogen levels Age - risk increases with age Low dietary intake of calcium Low vitamin D levels - diet and sunlight exposure Low body weight Lack of exercise, particularly weight bearing exercise Smoking 2 3
Alcohol Genetic factors history of mother or father having a hip fracture Some diseases and drugs also cause accelerated bone loss: Renal dysfunction Respiratory diseases Rheumatoid arthritis Haematological conditions Treatment with corticosteroids or anticonvulsants How is a Hip Fracture diagnosed? X-ray of the affected hip will usually show the site and type of fracture. A repeat X-ray or a Magnetic Resonance Imaging (MRI) scan of the hip is performed if the fracture is not clearly seen on X-rays. Treatment Options Surgery is the best way to repair a hip fracture. The type of surgery depends on the type of hip fracture, Non-surgical alternatives, such as prolonged immobilisation on traction, are considered only if a patient has a serious illness that makes surgery high risk or unlikely to be of benefit. How do I know if I have suffered a Hip Fracture? Signs and symptoms of a hip fracture may include: Severe pain in your hip, groin or thigh; pain may intensify with movement Inability to apply weight on your leg on the side of your injured hip Bruising and swelling in and around your hip Shorter leg on the side of your injured hip Outward turning of your leg on the side of your injured hip Prolonged immobilisation on traction is associated with several complications: Blood clots in the veins of the legs which may spread to the lungs causing blockage of blood, flow to lung tissues. This is called a pulmonary embolus and can be fatal. Bedsores Constipation Urinary retention and urinary tract infection Pneumonia Muscle wasting and loss of strength 4 5
Types of Surgery Femoral neck fractures: Cancellous screws- If the broken pieces of bone are still well aligned, the surgeon will insert 3 metal screws into the bone to hold it together whilst the fracture heals. Cancellous Screws Hemiarthroplasty Hemiarthroplasty- If the pieces of bone are not properly aligned and the blood supply to the head of the femur is likely to be damaged, the surgeon will remove the head and neck of the femur and replace them with a metal prosthesis. Total hip replacement- This operation involves replacing the upper part of the femur and the socket in the pelvic bone with prosthesis. This operation is a good option if arthritis or prior injury has damaged the joint. All types of surgery are usually performed under a regional anaesthetic, a spinal injection that numbs the body from the waist down. Sedation is also used, sometimes a general anaesthetic is appropriate. The operation usually takes about 1 hour to perform. What are the benefits I can expect from surgery? Pain relief Early mobilisation and best opportunity to regain mobility Avoidance of complications associated with prolonged immobility i.e. constipation, urine retention, urine infection, pneumonia, confusion, pressure sores, de-conditioning and general loss of strength. What will happen to you during your hospital stay? Stage 1: Accident and Emergency (A&E) Department A doctor will assess you, check your history and do a physical examination. Total Hip Replacement Intertrochanteric fractures: Dynamic Hip Screw Dynamic Hip Screw- This operation involves the insertion of a metal screw and plate which keeps the pieces of bone stable and allow the pieces of bone to unite as the fracture heals. You will be offered some pain relief medication. - The following investigations will be ordered on you: Blood tests X-rays of your pelvis, hips and chest ECG These tests will enable the doctors to make the correct diagnosis and ensure that there are no other medical conditions that need to be corrected prior to surgery. 6 7
Stage 2: Admission to the Orthopaedic Ward A doctor from Orthopaedic department will examine you. He/She will discuss your case with your surgeon-in-charge who will decide what type of operation you require. If you are elderly (> 70yrs old), a Geriatrician may review you to make sure that any other medical conditions are stabilised prior to surgery. A nurse will also speak to you about your usual level of mobility, your ability to care for yourself and your home circumstances. Stage 3: Preparing for Surgery Once you are medically fit you will be asked to give your consent for surgery to be performed. The plan for surgery will be explained to you. If you are unsure about what you have been told, please seek further clarification. If you are in pain, please request for some analgesia from the nurses. Your blood pressure and other vital signs will be closely monitored for the first 24 hours. The surgeons may put in a tube at the operation site to drain out any excess blood and the tube will remain for at least 24 hours. Blood tests will be taken to measure your haemoglobin level as some blood would have been lost due to the injury and also during the operation. If the blood loss is significant you may require a blood transfusion. You may begin to sit out of bed by the next day and the physiotherapist will start to see you on a regular basis. Our nurses will assist you with your personal hygiene and sanitary needs. Please do not hesitate to ask for assistance. Our nurse will approach you and your family to discuss plans for your transfer to a community hospital for further rehabilitation. Stage 4: On The Day of Surgery You will not have anything to eat or drink from midnight on the eve of your surgery until after the surgery. You will be given an intravenous drip to keep you hydrated. The nurses will change you into a special gown to be worn in the operating theatre. Your valuables will be kept safe by the ward nurses whilst you are in the theatre. Stage 5: After Surgery You will either return back to your own ward or be transferred to another ward for closer monitoring for a period of 24-48hrs. The doctor will review you approximately 4 hours after the operation and if there are no contraindications, you will be allowed to eat. Stage 6: Discharge Planning If you were able to walk before your fracture and you are allowed to weight bear on the injured leg after the operation, we would advise that you be transferred to a rehabilitation unit, usually in a community hospital after your surgery. If you were able to walk before your fracture, but due to the type of fracture and surgery, you are not allowed to put weight through the affected leg and you have a full time carer, you may wish to go home. You will then be referred for outpatient physiotherapy once the fracture has healed and to start to weight bear. If you do not have a full time carer then a transfer to a community hospital would be the recommended option. If you go home you will be shown a series of exercises that you should do in order to maintain your lower limb muscle strength whilst you are confined to a wheel chair. 8 9
Rehabilitation and advice from Physiotherapy Advice from Physiotherapy Early mobilisation (moving about) will help to maintain and improve movement and strength. It also reduces the risk of developing chest infection, deep vein thrombosis, constipation, urine retention and infection. Pre-operatively You may be referred to the physiotherapist for assessment. The physiotherapist will assess you and teach you exercises that you can do before you go to surgery. Post-operatively the recommendation for exercise will depend on the type of fracture and operation Rehabilitation for different types of Hip Fractures Fracture type - Femoral neck Operation Performed - Cancellous screw Following this operation there is no limit on the range of movement of your affected leg. You will be encouraged to move the affected leg Exercises will be re-enforced by the physiotherapist and gradually increased in intensity according to your level of comfort and physical ability The surgeon often requests for a period of non weight bearing on the affected limb, but you may be able to walk without taking weight through the affected leg. You will be taught how to use aids, e.g. crutches or walking frame to assist with ambulation. If you are unable to tolerate or safely perform non weight bearing ambulation you will be referred to the occupational therapist for wheel chair mobilisation. You will be given a series of non weight bearing exercises to perform to maintain your muscle strength until you are allowed to start to walk. Operation Performed - Hemiarthroplasty Moore s or bipolar You will be advised not to bend at the hip by more than 90 degrees or cross the affected leg over your midline as these movements may cause the implant to move out of place. With this operation you are usually allowed to place weight through the affected leg after the operation. Initially you will be taught to walk using a walking aid to make you more stable. With time you may change the type of aid or even become independent. The physiotherapist will decide what type of aid and exercise is suitable for you. The physiotherapist will gradually increase the intensity of exercise as your condition improves. 10 11
Fracture type - Intertrochanteric fracture Operation Performed - Dynamic hip screw Following this operation there is no limit on the range of movement of your leg, however many patients will not be allowed to put weight on the affected leg for several weeks The therapist will assess you and teach you exercises that you can do whether you are allowed to weight bear or not. Following a period of approximately 6 weeks you will be reviewed by the surgeon and if you are allowed to put weight on the affected leg you will be referred to a physiotherapist to regain your walking ability. The physiotherapist may be in a community hospital or out patient rehabilitation centre. If you have any questions about your rehabilitation, please speak to our ward nurses and physiotherapists. If you are discharged home from the ward, you should be provided with a clear set of exercise instructions for you to do at home. It is important to try to do these as they will improve your chances of walking again following your fracture. Please ask the ward nurses if you have not received a set of instructions. Rehabilitation Options LIST OF COMMUNITY HOSPITALS IN SINGAPORE St. Andrew s Community Hospital 8 Simei Street 3, Singapore 529895 Tel: 6586 1000 Fax: 6586 1100 Ang Mo Kio - Thye Hua Kwan Hospital 17, Ang Mo Kio Avenue 9, Singapore 569766 Tel: 6453 8033 Fax: 6454 1729 St Luke's Hospital 2 Bukit Batok Street 11, Singapore 659674 Tel: 6563 2281 Fax: 6560 7041 Bright Vision Hospital 5, Lorong Napiri, Singapore 547530 Tel: 6248 5755 Fax: 6881 3872 Referral to a community hospital is started immediately after your operation. You will be transferred to the community hospital when you are medically stable and a bed is available. The community hospital staff will contact you/your family for further information about finance, means testing and long term care planning. If you have concerns about the cost of rehabilitation or other financial difficulties, please request for a medical social worker to help you. Please contact the ward nurses if you need further clarification. 12 13
St. Andrew s Community Hospital St. Andrew s Community Hospital (SACH) offers rehabilitative care, sub-acute and continuing medical care for adults and paediatric patients. It is the first community hospital to be located next to an acute-care general hospital Changi General Hospital (CGH). This close proximity between SACH and CGH facilitates better integrated and continuum of care for the patients. INPATIENT SERVICES Adult Rehabilitative Care (e.g. stroke, hip fracture rehabilitation) Rehabilitative Care for Children (e.g. brain injuries, fractures) Sub-Acute Care (e.g. heart failure, chest infections) Continuing Medical Care (e.g. wound care, diabetic care) Respite Care (full-paying service) OUTPATIENT SERVICES Day Rehabilitation Centre Specialist Clinic in Rehabilitation Medicine General Outpatient Clinic for adults and children Home Nursing ADMISSION Admission is through referral from: Other hospitals or nursing homes; General practitioners and medical specialists; or St. Andrew s Community Hospital outpatient clinic. HOSPITAL CHARGES Ward charges and treatment fees vary depending on the level of government subsidy accorded based on the outcome of a means test conducted and the condition of the patient. A list of hospital charges can be obtained from SACH s Business Office or from the hospital s website at http://www.sach.org.sg. For more information, please call the Business Office at 6586 1033/34. VISITING HOURS Visiting hours are from 2:00pm to 8:00pm daily. CAREGIVER TRAINING SACH encourages active partnership between a patient s family and the medical team in caring for the patient. It is important to plan early for a caregiver to help the patient with his/her activities of daily living after he/she is discharged. SACH provides training for caregivers on ways to carry out rehabilitation exercise and to cope with the patient s condition. Do discuss with the nursing or therapy staff with regards to caregiver training. COUNSELLING AND SOCIAL SERVICES SACH s medical social workers and case managers can offer assistance to the patient and his/her family if there are psychological and social needs. The staff will coordinate the patient s discharge care plan based on the progression of the patient s condition. If you require help, you can approach the nursing staff to make an appointment with a medical social worker. HOME NURSING SERVICES INPATIENT CARE Each ward comprises four cubicles with 8 beds each. Wards facilities are similar to that of a C-class ward in a restructured hospital. 24-hour medical coverage. SACH provides home nursing services to discharged patients. For assistance or more information, please call 6586 1053. Consultation and ward rounds by CGH specialists, if required. 14 15