Don’t Delay Hip Fracture Surgery. Here’s Why

Don’t Delay Hip Fracture Surgery. Here’s Why

Seniors with a fractured hip need surgery as soon as possible or they could suffer life-threatening complications, a new Canadian study concludes.

Having surgery within 24 hours decreases the risk of hip fracture-related death. It also lowers odds of problems such as pneumonia, heart attack and blocked arteries, the researchers found.

“We found that there appears to be a safe window, within the first 24 hours,” said lead researcher Daniel Pincus, a doctoral student with the University of Toronto.

“After 24 hours, risk began to clearly increase,” Pincus said.

U.S. and Canadian guidelines recommend hip fracture surgery within 48 hours of injury, but it’s likely that many people don’t receive care that quickly, he noted.

In the United Kingdom, guidelines call for surgery within 36 hours, but hospitals often fail to get patients promptly into the operating room, Pincus added. Rates range from 15 percent to 95 percent among U.K. hospitals, according to the report.

Oftentimes, there’s no operating room or surgeon available, or other patients are awaiting surgery, Pincus explained.

“There’s a triage system and these patients historically were not prioritized,” he said. “Sometimes there’s medical reason for the delay, but that’s very rare. We’re starting to realize there’s almost no reason why a patient should be delayed.”

Delay also likely occurs because doctors approach these elderly patients with a good deal of caution, said Dr. Harry Sax. He is executive vice chair of surgery for Cedars-Sinai Medical Center in Los Angeles.

“The perception is that if you’re old and you’ve broken your hip, that you’re going to have a lot of other [health problems],” said Sax, co-author of an editorial accompanying the new study. “Therefore, I need to spend several days running tests on you to try to make sure I can get you through the hip fracture surgery. ”

To see how this delay affects the health of patients, Pincus and his colleagues evaluated data on over 42,000 people treated for hip fracture at 72 hospitals in Ontario between April 2009 and March 2014. The patients’ average age was 80.

The investigators compared patients based on whether they had surgery before or after 24 hours.

Overall, about 12 percent of hip fracture patients died within the month following their surgery.

However, patients who got surgery within 24 hours were 21 percent less likely to die during the following month, compared with those who had a delay in surgery, the findings showed.

Those patients also had lower complication rates. They were 82 percent less likely to develop a blood clot in the leg veins (deep vein thrombosis); 61 percent less likely to have a heart attack; and 49 percent less likely to suffer a blood clot in the lung (pulmonary embolism). They were also 5 percent less likely to develop pneumonia during the month following surgery.

“The problem is the longer you sit in bed, the more likely you are to get pneumonia and blood clots. The unfixed bone is continuing to flick off little bits of fat, which can go to the lungs,” Sax said. “The delay doesn’t necessarily make things better. It could make things worse.”

People with an elderly relative facing hip fracture surgery should ask the health care team to get their loved one into surgery as soon as possible, with as little additional testing as possible, Pincus and Sax said.

“A prompt evaluation to make sure there’s nothing quickly correctable should be done, but otherwise the patient should move to the operating room as quickly as possible,” Sax said.

Families should ask doctors about every test, scan or screen that delays the surgery, Sax said.

“The question needs to be, what is the information that you’re going to gain and how would that change your management of this patient,” Sax said. “There are very few things you find with all this expensive testing that you can do anything about.”

The patient would be best off in a hospital that has a specific program to manage elderly people with hip fractures, Sax added. These programs have a team of surgeons, geriatricians, anesthesiologists and other professionals well-versed in the procedure.

“If you can find a hospital that does that, the chances are your outcomes are going to be better,” Sax said.

The study was published Nov. 28 in the Journal of the American Medical Association.

More information

For more on hip fractures, visit the American Academy of Orthopaedic Surgeons.

SOURCES: Daniel Pincus, doctoral student, University of Toronto, Ontario, Canada; Harry Sax, M.D., executive vice chair, surgery, Cedars-Sinai Medical Center, Los Angeles; Nov. 28, 2017, Journal of the American Medical Association

Ditch the Throw Rugs, Seniors!

Ditch the Throw Rugs, Seniors!

Icy winter weather may lead to fewer hip fractures than many believe.

Most fall-related hip fractures among elderly people in a New England study occurred in warm months and indoors — with throw rugs a common culprit.

“Given the results of this study, it appears that efforts to decrease fall risk among the elderly living in cold climates should not be preferentially aimed at preventing outdoor fractures in winter,” said study author Dr. Jason Guercio.

Instead, preventive efforts should focus on conditions present year-round, and especially on indoor risk, said Guercio. He’s with North American Partners in Anesthesiology at the Hospital of Central Connecticut in New Britain, Conn.

The researchers analyzed details about hip fractures suffered by 544 patients treated at the Hospital of Central Connecticut between 2013 and 2016.

More than 55 percent of the hip fractures occurred during warm months, with the highest rates in May, September and October (around 10 percent each). In addition, the investigators found that more than three-quarters of the hip fractures occurred indoors.

Moreover, 60 percent of outdoor fractures occurred from May through October, not in the depths of winter.

The most common cause of both indoor and outdoor hip fracture? Tripping over an obstacle. Indoors, throw rugs were the most common obstacle cited.

Falling out of bed was the second leading cause of indoor hip fractures.

Outdoors, the other leading causes of hip fractures were being struck by a vehicle or falling from a vehicle, followed by accidents on stairs.

The study was scheduled for presentation Monday at the annual meeting of the American Society of Anesthesiologists, in Boston.

“Falls are one of the most common health concerns facing the elderly today. And this population is the fastest growing segment of the U.S.,” Guercio said in a meeting news release.

“Falls leading to fracture can result in disability and even death. Understanding the risk factors for fractures can help to focus efforts on decreasing them, and guide resources and appropriate interventions to prevent them,” Guercio said.

“It is counterintuitive that the risk for hip fracture would be higher in warm months, as ice and snow would appear to be significant fall risks,” he added.

Research presented at meetings should be considered preliminary until published in a peer-reviewed medical journal.

More information

The U.S. Centers for Disease Control and Prevention has more on hip fractures among older adults.

SOURCE: Anesthesiology annual meeting, news release, Oct. 23, 2017

Preventing Sports Injuries

Preventing Sports Injuries

Exercise is good for the body and with the proper precautions, sports injuries can often be prevented. The quality of protective equipment – padding, helmets, shoes, mouth guards – have helped to improve the safety in sports. But, you can still be susceptible to injury. Always contact your healthcare provider before starting any type of physical activity, especially vigorous types of exercises or sports.

Causes of sport injuries may include:

  • improper or poor training practices
  • wearing improper sporting gear
  • being in poor health condition
  • improper warm-up or stretching practices before a sporting event or exercise

Common sports injuries include:

  • Sprains and strains
  • Joint injuries (knee)
  • Muscle injuries
  • Dislocations
  • Fractures
  • Achilles tendon injuries
  • Pain along the shin bone

How can I prevent a sports injury?

The following are some basic steps to prevent a sports injury:

  • Develop a fitness plan that includes cardiovascular exercise, strength training, and flexibility.  This will help decrease your chance of injury
  • Alternate exercising different muscle groups and exercise every other day.
  • Cool down properly after exercise or sports. It should take 2 times as long as your warm ups.
  • Stay hydrated. Drink water to prevent dehydration, heat exhaustion, and heat stroke.
  • Stretching exercises can improve the ability of muscles to contract and perform, reducing the risk for injury. Each stretch should start slowly until you reach a point of muscle tension. Stretching should not be painful. Aim to hold each stretch for up to 20 seconds.
  • Use the right equipment or gear and wear shoes that provide support  and that may correct certain foot problems that can lead to injury.
  • Learn the right techniques to play your sport.
  • Rest when tired, Avoid exercise when you are tired or in pain.
  • Always take your time during strength training and go through the full range of motion with each repetition.
  • If you do sustain a sports injury, make sure you participate in adequate rehabilitation before resuming strenuous activity.
Health Tip: Reduce Your Risk of Hip Fracture

Health Tip: Reduce Your Risk of Hip Fracture

Hip fractures are serious injuries, especially in seniors. Falls are a prime cause.

The American Academy of Orthopaedic Surgeons offers this advice on reducing your risk:

  • Keep your home clear of clutter, making sure it is well lit. Install grab bars in bathrooms.
  • Get regular exercise to strengthen bones and muscles, and improve balance.
  • Each year, get an eye exam and a complete physical.
  • Discuss all medications with your doctor, as some drugs can have side effects.
  • Know your risk factors for bone loss and fractures.
  • Eat a healthy diet rich in vitamin D and calcium. If needed, talk to your doctor about medication to improve bone health.
  • Maintain a healthy weight.

Injectable Corticosteroids

Corticosteroids are potent drugs used to reduce inflammation in the body’s tissues. They are different from anabolic steroids. These are illegally used by some athletes to increase muscle tone.

Corticosteroids can come in several forms: pills, liquids, creams, ointments, medicines sprayed into the nose, and injectable medicines.

Photo of syringe and needle

Corticosteroid injections can treat a variety of skeletal, muscular, and spinal conditions. Some of these injections can be performed by your health care provider during a routine clinic visit; others need a referral to a pain or other specialist.

Here are some of their most common uses:

  • Osteoarthritis. People with osteoarthritis often develop pain and inflammation in their joints. An injection of corticosteroids into the affected joint can give temporary pain relief for several weeks or months. After the treatment, your health care provider may recommend avoiding strenuous activity for at least 24 hours for the best results.
  • Low back pain. Lower back pain from ruptured disks, spinal stenosis, and some other conditions may be treated with injectable corticosteroids to provide some relief. Lumbar radiculopathy is pain in the buttocks, hips, or legs that comes from a pinched nerve in the lower back. This type of pain can often be treated with corticosteroid injections near the pinched nerve. Sometimes other drugs like local anesthetics are given with the corticosteroid.
  • Cervical radiculopathy. This is neck pain that radiates to the shoulder, arm, or hands. It happens when the vertebrae in the spine move closer together or a disc bulges or ruptures, pinching a nerve in the neck. Injecting corticosteroids near the pinched nerve may reduce swelling and relieve pain. This gives the nerve some time to heal.
  • Bursitis and tendonitis. Bursitis is a common condition that happens when the fluid sac that normally cushions spaces between bones, muscles, and skin becomes inflamed and painful. Tendonitis is a common condition in which the tendons around muscles and bones become inflamed. The areas that are commonly affected are the elbow, knee, shoulder, wrist, hand, and hip. Injected corticosteroids can reduce the inflammation. But you must be careful because repeated steroid use can cause the tendon to weaken or even rupture.
  • Carpal tunnel syndrome. This condition happens when a nerve in the wrist becomes compressed or pinched, causing pain, numbness, tingling, and possibly weakness in the hand. Injecting a corticosteroid into the wrist can give immediate, though temporary, relief. An anesthetic like lidocaine may also be given with the steroid.

Cautions about corticosteroids

Corticosteroids can have a number of side effects, including high blood sugar levels. For this reason, people with diabetes are advised to tell their health care providers about their condition before taking any steroid medicines.

Using injectable corticosteroids for a long period of time is not suggested because of additional side effects. These include osteoporosis, cataracts, delayed growth, stomach ulcers, skin atrophy and depigmentation, and high blood pressure. You may experience short-term side effects like local pain or infection at the injection site. Your health care provider will usually limit your total number of corticosteroid injections to 3 to 4 a year.

If you are considering taking corticosteroids to treat a muscular or skeletal condition, be sure to talk with your health care provider about all the benefits and risks.

Bursitis

What is bursitis?

Bursitis is inflammation of a bursa. A bursa is a closed, fluid-filled sac that works as a cushion and gliding surface to reduce friction between tissues of the body. The major bursae (this is the plural of bursa) are located next to the tendons near the large joints, such as in the shoulders, elbows, hips, and knees.

Shoulder Bursitis

Bursitis is usually a temporary condition. It may limit motion, but generally does not cause deformity.

Bursitis can happen in any bursa in the body, but there are some common types of bursitis, including:

  • Retromalleolar tendon bursitis. This type of bursitis is also called Albert disease. It’s caused by things like injury, disease, or shoes with rigid back support. These put extra strain on the lower part of the Achilles tendon. This attaches the calf muscle to the back of the heel. This can lead to inflammation of the bursa located where the tendon attaches to the heel.
  • Posterior Achilles tendon bursitis. This type of bursitis, also called Haglund deformity, is in the bursa located between the skin of the heel and the Achilles tendon. This attaches the calf muscles to the heel. It is aggravated by a type of walking that presses the soft heel tissue into the hard back support of a shoe.
  • Hip bursitis. Also called trochanteric bursitis, hip bursitis is often the result of injury, overuse, spinal abnormalities, arthritis, or surgery. This type of bursitis is more common in women and middle-aged and older people.
  • Elbow bursitis. Elbow bursitis is caused by the inflammation of the bursa located between the skin and bones of the elbow (the olecranon bursa). Elbow bursitis can be caused by injury or constant pressure on the elbow (for example, when leaning on a hard surface).
  • Knee bursitis. Bursitis in the knee is also called goosefoot bursitis or Pes Anserine bursitis. The Pes Anserine bursa is located between the shin bone and the three tendons of the hamstring muscles, on the inside of the knee. This type of bursitis may be caused by lack of stretching before exercise, tight hamstring muscles, being overweight, arthritis, or out-turning of the knee or lower leg.
  • Kneecap bursitis. Also called prepatellar bursitis, this type of bursitis is common in people who are on their knees a lot, such as carpet layers and plumbers.

What causes bursitis?

The most common causes of bursitis are injury or overuse. Infection may also cause it.

Bursitis is also associated with other problems. These include arthritis, gout, tendonitis, diabetes, and thyroid disease.

What are the symptoms of bursitis?

The following are the most common symptoms of bursitis. However, each person may experience symptoms differently.

  • Pain
  • Localized tenderness
  • Limited motion
  • Swelling and redness if the inflamed bursa is close to the surface of the skin

Chronic bursitis may involve repeated attacks of pain, swelling, and tenderness. These may lead to the deterioration of muscles and a limited range of motion in the affected joint.

The symptoms of bursitis may resemble other medical conditions or problems. Always see a healthcare provider for a diagnosis.

How is bursitis diagnosed?

In addition to a complete medical history and physical exam, diagnostic tests for bursitis may include:

  • X-ray. A diagnostic test that uses invisible electromagnetic energy beams to make pictures of internal tissues, bones, and organs on film.
  • Magnetic resonance imaging (MRI). An imaging test that uses a combination of large magnets, radiofrequencies, and a computer to make detailed pictures of organs and structures within the body.

MRI Scan

  • Ultrasound. An imaging test that uses high-frequency sound waves to look at the internal organs and tissues.
  • Aspiration. A procedure that involves using a thin needle to remove fluid from the swollen bursa to check for infection or gout as causes of bursitis.
  • Blood tests. Lab tests may be done to confirm or rule out other conditions.

How is bursitis treated?

The treatment of any bursitis depends on whether or not it involves infection.

  • Aseptic bursitis. This inflammation results from local soft-tissue trauma or strain injury. The bursa is not infected. Treatment may include:
  • R.I.C.E. This stands for rest, ice, compression, and elevation
  • Anti-inflammatory and pain medicines, such as ibuprofen or aspirin
  • Injection of a steroid into the affected area to help decrease pain and swelling
  • Splints or braces to limit movement of the affected joint

RICE_infographic

  • Septic bursitis. The bursa becomes infected with bacteria. This causes pain and swelling. Treatment may include:
  • Antibiotics
  • Repeated aspiration of the infected fluid (a needle is used to take out the fluid)
  • Surgical drainage and removal of the infected bursa. This is called a bursectomy.

What can I do to prevent bursitis?

Try the following measures to prevent bursitis:

  • Warm up before exercising or before sports or other repetitive movements.
  • Start new exercises or sports slowly. Gradually increase the demands you put on your body.
  • Take breaks often when doing repetitive tasks.
  • Cushion “at risk” joints by using elbow or knee pads.
  • Stop activities that cause pain.
  • Practice good posture. Position your body properly when doing daily activities.

When should I call my healthcare provider?

Call your healthcare provider if you have any of the following:

  • Pain or trouble moving affects your regular daily activities
  • Pain doesn’t get better or gets worse with treatment
  • A bulge or lump develops at the affected joint
  • Redness or swelling develops at the affected joint
  • You have fever, chills, or night sweats

Key points about bursitis

  • Bursitis is inflammation of a bursa, a closed, fluid-filled sac that works as a cushion and gliding surface to reduce friction between tissues of the body.
  • The most common causes of bursitis are injury or overuse, but it can also be caused by infection.
  • Pain, swelling, and tenderness near a joint are the most common signs of bursitis.
  • Bursitis can be treated with rest and medicines to help with the inflammation. Antibiotics are used if infection is found. If needed, surgery can be done to remove the bursa.
  • You can help prevent bursitis by doing things like warming up before exercise or sports, increasing activity slowly, padding joints, taking rest breaks often, and stopping activities that cause pain.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

  • Know the reason for your visit and what you want to happen.
  • Before your visit, write down questions you want answered.
  • Bring someone with you to help you ask questions and remember what your provider tells you.
  • At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
  • Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.
  • Ask if your condition can be treated in other ways.
  • Know why a test or procedure is recommended and what the results could mean.
  • Know what to expect if you do not take the medicine or have the test or procedure.
  • If you have a follow-up appointment, write down the date, time, and purpose for that visit.
  • Know how you can contact your provider if you have questions.