Hip fractures represent a serious health event, particularly for older adults. These injuries often result from falls, which are a leading cause of injury and injury-related deaths in individuals over 65. Approximately 300,000 hip fractures occur annually in the United States, predominantly affecting older adults. The one-year mortality rate after a surgically repaired hip fracture is around 21%.
Immediate Medical Complications
Pulmonary embolism (PE) is a serious acute medical complication following hip fracture. Prolonged immobility due to the fracture and subsequent surgery can lead to deep vein thrombosis (DVT), primarily in the legs. If these clots detach and travel to the lungs, they can block blood flow, causing a PE, which can be fatal. PE is responsible for approximately 14% of deaths in hip fracture patients.
Cardiac events, such as heart attack or exacerbation of heart failure, are also common. The trauma of the fracture, combined with the stress of surgery and anesthesia, places strain on the cardiovascular system. Patients with pre-existing heart conditions are particularly susceptible. Myocardial injury, even without a full heart attack, is common and associated with a three-fold higher risk of mortality.
Sepsis and severe infection are another serious risk following hip fracture surgery. Infections can arise at the surgical site or in other areas such as the urinary tract or lungs, especially pneumonia. Sepsis occurs when the body’s immune response to an infection becomes overwhelming, leading to widespread inflammation and organ damage. Patients who develop sepsis after hip fracture surgery have a 30-day mortality rate of 16.2%, which increases to 40.8% for those with septic shock.
Acute kidney injury (AKI) can develop, sometimes progressing to multi-organ failure. AKI is a frequent complication following hip fracture surgery, affecting approximately 15.3% to 21.6% of patients. This condition is associated with longer hospital stays, increased treatment costs, and a higher risk of morbidity and mortality. The development of AKI can initiate a cascade effect, where dysfunction in one organ system can lead to the failure of others.
Underlying Contributing Factors
Advanced age and frailty increase an individual’s vulnerability to complications after a hip fracture. Older adults often have reduced physiological reserves, meaning their bodies are less able to cope with the stress of trauma and surgery. This diminished capacity makes them more susceptible to adverse outcomes. The likelihood of death within one year can be as high as 50% for someone in their 90s who breaks a hip.
Pre-existing chronic conditions predispose patients to complications. Cardiovascular diseases, such as coronary artery disease and heart failure, elevate the risk of cardiac events post-fracture. Conditions like diabetes, chronic lung disease, and kidney disease can impair the body’s ability to heal and fight off infections, making patients more susceptible to sepsis and other medical complications. Chronic kidney disease is associated with higher rates of AKI after hip fracture surgery.
Malnutrition and dehydration can complicate recovery and increase susceptibility to infection. Patients who are malnourished often have weakened immune systems and poor wound healing capabilities. Dehydration can exacerbate kidney dysfunction and affect overall physiological stability. Maintaining adequate nutritional support is recognized as beneficial for recovery.
Cognitive impairment, such as dementia, presents challenges in care and increases the risk of immobility-related complications. Patients with cognitive deficits may struggle to follow post-operative instructions, participate in rehabilitation, or communicate symptoms effectively. This can lead to prolonged immobility, increasing the risk of pneumonia, pressure sores, and blood clots. Postoperative delirium, a common complication, further amplifies the risk of poorer outcomes and increased mortality.
Medication use, particularly polypharmacy, can introduce interactions or side effects that complicate post-fracture management. Anticoagulants, while sometimes used to prevent blood clots, can also increase the risk of bleeding complications during and after surgery. The complex interplay of various medications can impact the body’s response to trauma and treatment, requiring careful monitoring and adjustment by healthcare providers.
Preventing Fatal Complications
Early surgical intervention is a primary strategy to reduce immobility complications following a hip fracture. Timely surgery, ideally within 24 to 48 hours of admission, helps stabilize the fracture and allows for earlier mobilization, which can significantly decrease the risk of blood clot formation and pneumonia. Studies indicate that surgical delay beyond 72 hours increases the risk of one-year mortality. Accelerating surgery has shown potential to reduce the risk of mortality and adverse cardiovascular outcomes in patients with myocardial injury.
Thromboprophylaxis is implemented to prevent dangerous blood clots. This involves using medications like anticoagulants, unless contraindicated, and mechanical compression devices to reduce the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE). Most major organizations advocate for at least 28 days of post-operative chemical prophylaxis. Early ambulation also serves as a beneficial measure to prevent venous thromboembolism.
Aggressive pain management is important for enabling early mobilization and rehabilitation. Effective pain control allows patients to participate more fully in physical therapy and movement exercises, which are crucial for preventing complications associated with prolonged bed rest, such as muscle weakness and respiratory issues. Regional anesthesia, such as spinal anesthesia, has been associated with a decrease in one-month mortality rates.
Early mobilization and rehabilitation are fundamental in preventing complications like pneumonia and blood clots. Encouraging patients to move and bear weight as soon as medically safe helps improve circulation, maintain lung function, and reduce muscle atrophy. Physiotherapy-driven lung expansion techniques, including deep-breathing exercises, have been successful in reducing mortality in abdominal surgery patients and warrant consideration for hip fracture patients.
Optimized medical management of comorbidities is also crucial. This involves carefully managing pre-existing conditions like cardiovascular disease, diabetes, and chronic lung disease throughout the perioperative period. Addressing these underlying health issues helps stabilize the patient’s overall condition, making them more resilient to the stresses of surgery and recovery.
Infection control measures and prophylactic antibiotics are employed to prevent surgical site infections and other systemic infections. Adhering to strict sterile techniques during surgery and administering prophylactic antibiotics can significantly lower the risk of post-operative infections that could lead to sepsis. Extending prophylactic antibiotic coverage for pneumonia in high-risk patients may also be considered.
Nutritional support plays a role in healing and recovery. Ensuring patients receive adequate calories, protein, and micronutrients supports tissue repair, immune function, and overall strength. Addressing malnutrition helps the body respond more effectively to the trauma and surgical recovery process.
Close monitoring in post-operative care allows for the early detection of complications. Intensive monitoring of vital signs, fluid balance, and laboratory values helps identify issues like cardiac events, sepsis, or acute kidney injury promptly. Early detection enables swift intervention, which can significantly improve outcomes and reduce the risk of sudden death.