Physiotherapy and fractured neck of femur
Fractured neck of femur is a common injury, with more than 25,000 older adults hospitalised each year—a figure that is expected to continue to rise. Emma Blake, Brett Baxter and Thomas Petrie from the Orthopaedics national group present five discussion points about the associated risk factors and management of these fractures.
1. Hip fractures frequently lead to a decline in functional status and mobility in older adults
Hip fracture survivors experience significantly worse mobility, health and quality of life, have less independence of function and have higher rates of institutionalisation than age-matched controls.
Hip fractures reduce the mobility, health and quality of life of older people and lead to lower rates of independent living.
A study undertaken by the Fragility Fracture Network Rehabilitation Research Special Interest Group and published by BMC Geriatrics in 2016—‘A critical review of the long-term disability outcomes following hip fracture’—found that only 40–60 per cent of patients recovered their pre-fracture level of mobility and ability to perform instrumental activities of daily living.
Hip fractures in older people were shown to reduce functional outcomes in a five-year follow-up study.
There was a significant increase in the number of patients using walking aids at five years (56.8 per cent) compared to pre-fracture (29.7 per cent).
Patient-reported overall health status decreased by 44.7 per cent and there was a significant decrease in the number of patients living at home five years after a hip fracture (60.5 per cent compared to 84.2 per cent prior to fracture).
There is also a significant increase in mortality at 30 days, one year and five years after a hip fracture of 7.9 per cent, 37 per cent and 69.4 per cent respectively (de Joode et al 2019).
2. Key predictors of discharge destinations help facilitate post-acute care
Data from the Australian and New Zealand Hip Fracture Registry was recently analysed to examine patient and facility factors predictive of discharge destination from acute care for people who came from a private residence on admission.
The authors found that as well as advancing age, impaired cognition, reduced walking ability and poorer preoperative health, there are other factors that influence discharge destination.
The odds of discharge to a rehabilitation unit are higher for individuals with extracapsular fractures and for those treated at major trauma centres or at hospitals with home-based rehabilitation.
The authors argue that understanding the key predictors of discharge destination can facilitate earlier planning for post-acute care.
Data analysed from the Irish Hip Fracture Database also found that increasing age and preoperative mobility were predictors of discharge destination.
In addition, early postoperative mobilisation made patients 24 per cent more likely to be discharged directly home.
Patients who waited longer than 72 hours after injury for surgery were 30 per cent less likely to be discharged directly home (Ferris et al 2022).
3. All patients should follow the Hip Fracture Care Clinical Care Standard
The Australian Commission on Safety and Quality in Health Care developed the Hip Fracture Care Clinical Care Standard, which defines the evidence-based best practice management of all patients following a hip fracture in Australia.
The Hip Fracture Care Clinical Care Standard prescribes optimal treatment throughout the management of a hip fracture.
The aim of the Clinical Care Standard is to ensure that all patients sustaining a hip fracture receive optimal treatment, from presentation to the emergency department through to the completion of their treatment in hospital.
The goal is to optimise outcomes and reduce the risk of further fractures developing.
The Hip Fracture Care Clinical Care Standard describes seven individual care standards: care at presentation, pain management, orthogeriatric model of care, timing of surgery, mobilising and weight-bearing, minimising risk of another fracture and transition from hospital care.
It includes patients who sustain a hip fracture while in hospital and is appropriate for patients with a suspected hip fracture due to osteoporosis or osteopaenia.
Outcome indicators are used across all seven care standards to ascertain how the individual care of the patient compares to the recommended care standards as well as to provide information to patients and clinicians on the quality of their care.
4. Early mobilisation results in a reduction in postoperative complications and mortality and improved function
Early mobilisation is an essential component of postoperative management following hip fracture surgery.
Early mobilisation after a hip fracture improves mobility function, lowers mortality rates and reduces postoperative complications.
It has been shown to reduce postoperative complications such as venous thromboembolism, pneumonia, wound breakdown, pressure ulcers and delirium.
All patients sustaining a hip fracture should be offered mobilisation without weight-bearing restrictions the day after surgery and at least once a day thereafter if clinically appropriate.
This includes bed mobility, standing and walking with an aid and sitting out of bed.
Early mobilisation has been associated with lower mortality rates at six months and one year compared with patients who mobilised later independent of early time to surgery (Aprato et al 2020).
There is also evidence that patients with poor premorbid health have a reduced risk of developing postoperative complications following early mobilisation (Kenyon-Smith et al 2019).
Mobilisation on the day of or the day after surgery has been shown to improve mobility function 30 days following discharge and is associated with 30-day survival.
The association between early mobilisation and 30-day ambulation recovery was stronger for those whose pre-fracture mobility was indoor only when compared to those with outdoor mobility pre-fracture (Goubar et al 2021).
5. Multidisciplinary team management leads to better outcomes
Multidisciplinary teams involving medical, nursing and allied health professionals, including physiotherapists, occupational therapists and dietitians, are considered essential for effective management of many conditions.
Patients who have sustained a hip fracture are certainly no different and evidence suggests that multidisciplinary teams that include a regular geriatrician review lead to a reduction in in-hospital mortality and complications (Duncan et al 2006, Shyu et al 2016).
There is also a tendency towards better functional outcomes at four weeks (Crotty et al 2019), with studies showing improved mobility and reduced fear of falling (Prestmo et al 2015).
Patients under a multidisciplinary team also tend to have fewer nutritional problems, are more likely to be on appropriate osteoporosis management and are more likely to show cognitive improvement compared to usual care.
Continued, coordinated orthogeriatric and multidisciplinary review is recommended by the Australian Commission on Safety and Quality in Health Care and by similar guidelines in both the United Kingdom and the United States.
Click here for an infographic poster version of this article.
>> Emma Blake APAM, chair of the Orthopaedic national group, is a senior physiotherapist in orthopaedics at Hollywood Private Hospital in Perth. She has been the clinical team leader in orthopaedics at Sir Charles Gairdner Hospital in Perth and has held teaching positions within the physiotherapy orthopaedic unit at Curtin University. Emma was involved in establishing the inaugural accelerated rehabilitation program for joint replacement surgery at Osborne Park Hospital and has a keen interest in pain management and complex revision joint replacement surgery.
>> Brett Baxter APAM has been the clinical team leader in orthopaedic physiotherapy at the Princess Alexandra Hospital, Brisbane, since 2000, specialising in orthopaedic trauma. Brett is a past chair of the Orthopaedic group and is the APA representative to the Australian and New Zealand Hip Fracture Registry steering committee. He assisted in establishing patient safety officer roles at the Princess Alexandra Hospital.
>> Thomas Petrie APAM is the chair of the Queensland Orthopaedic group. He has specialised in trauma and orthopaedics for over 10 years, including work at the Nuffield Orthopaedic Centre and the Royal London Hospital (both in the UK), and currently works at the Princess Alexandra Hospital.
Aprato, A., Bechis, M., Buzzone, M. et al. No rest for elderly femur fracture patients: early surgery and early ambulation decrease mortality. J Orthop Traumatol 2020; 21, 12. https://doi.org/10.1186/s10195-020-00550-y
Crotty, M., Killington, M., Liu, E., Cameron, I. D., Kurrle, S., Kaambwa, B., Davies, O., Miller, M., Chehade, M., Ratcliffe, J. Should we provide outreach rehabilitation to very old people living in Nursing Care Facilities after a hip fracture? A randomised controlled trial. Age & Ageing 2019; 3: 373-380
Deakin DE, Wenn RT, Moran CG. Factors influencing discharge location following hip fracture. Injury. 2008; 39(2): 213- 218.
de Joode, S.G.C.J., Kalmet, P.H.S., Fiddelers, A.A.A. et al. Long-term functional outcome after a low-energy hip fracture in elderly patients. J Orthop Traumatol 2019; 20, 20. https://doi.org/10.1186/s10195-019-0529-z
Duncan, D. G., Beck, S. J., Hood, K., Johansen, A. Using dietetic assistants to improve the outcome of hip fracture: a randomised controlled trial of nutritional support in an acute trauma ward. Age & Ageing 2006; 2: 148-53
Dyer SM, Crotty M, Fairhall N, Magaziner J, Beaupre LA, Cameron ID, Sherrington C; Fragility Fracture Network (FFN) Rehabilitation Research Special Interest Group. A critical review of the long-term disability outcomes following hip fracture. BMC Geriatr. 2016 Sep 2;16(1):158. doi: 10.1186/s12877-016-0332-0. PMID: 27590604; PMCID: PMC5010762.
Ferris, H., Brent, L., Sorensen, J. et al. Discharge destination after hip fracture: findings from the Irish hip fracture database. Eur Geriatr Med 2022; 13, 415–424. https://doi.org/10.1007/s41999-021-00556-7
Goubar A, Martin FC, Potter C, Jones GD, Sackley C, Ayis S, Sheehan KJ. The 30-day survival and recovery after hip fracture by timing of mobilization and dementia : a UK database study. Bone Joint J. 2021 Jul;103-B(7):1317-1324. doi: 10.1302/0301-620X.103B7.
Hip Fracture Care Clinical Standard (2016)
Kenyon-Smith T, Nguyen E, Oberai T, Jarsma R. Early Mobilization Post-Hip Fracture Surgery. Geriatr Orthop Surg Rehabil. 2019 Apr 7;10:2151459319826431. doi: 10.1177/2151459319826431.
Nanjayan SK, John J, Swamy G, Mitsiou K, Tambe A, Abuzakuk T. Predictors of change in ‘discharge destination’ following treatment for fracture neck of femur. Injury. 2014; 45(7): 1080- 1084.
Prestmo, A., Hagen, G., Sletvold, O., Helbostad, J. L., Thingstad, P., Taraldsen, K., Lydersen, S., Halsteinli, V., Saltnes, T., Lamb, S. E., Johnsen, L. G., Saltvedt, I. Comprehensive geriatric care for patients with hip fractures: a prospective, randomised, controlled trial. Lancet 2015; 9978: 1623-33
Ryder, T, Close, J, Harris, I, et al; on behalf of the ANZHFR Steering Group. Patient and hospital factors influencing discharge destination following hip fracture. Australas J Ageing. 2021; 40: e234– e243.
Shyu, Y. I., Liang, J., Tseng, M. Y., Li, H. J., Wu, C. C., Cheng, H. S., Chou, S. W., Chen, C. Y., Yang, C. T. Enhanced interdisciplinary care improves self-care ability and decreases emergency department visits for older Taiwanese patients over 2 years after hip-fracture surgery: A randomised controlled trial. International Journal of Nursing Studies 2016; 0: 54-62
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