As people age, the number of people who experience hip fractures is increasing. A pelvic fracture in an older adult is not just an ordinary fracture. It is a life-threatening condition. Pelvic fracture in older adults is not a condition that is always difficult to manage. But once a fracture occurs, it brings with it all the potential medical complications that can arise when an elderly patient is bedridden for long periods of time. It is these complications that can turn a simple illness into a life-threatening one.

Hip fractures in children and young adults are much different. The information in this leaflet is focused on hip fractures in older adults.

This guide will help you understand it;

1. How hip fractures occur
2. How doctors diagnose the problem
3. What treatment options are available
4. Post-surgery recovery

Pelvic Anatomy

The hip joint is a ball-and-socket joint. The socket of the pelvis is called the acetabulum and forms a deep cup surrounding the ball of the upper femur (thigh) bone, or femur head. The femur head connects to the femur bone through a short section of bone called the neck of the femur. The area below the neck is a bulge called the trochanter, where the muscles of the buttocks and pelvic drive attach.

Gambar 1. Blood flow within the bones forming the hip joint (google image source)

All blood supply to the head of the femur (the rounded part of the pelvis) comes through the neck of the femur bone. If this blood supply is damaged by a fracture, there is no backup. One of the problems with pelvic fractures is that damage can occur to these blood vessels when the pelvis is broken. This can cause the bone head of the femur to completely die due to the cut off of blood flow. This can lead to one of the complications of hip fracture called avascular necrosis (AVN).

Causes of pelvic fracture

Injury is an obvious cause of hip fracture. In the elderly, injuries can result from loss of balance and falling to the ground.

Osteoporosis can weaken the neck of the femur to the extent that increased stress can cause the neck of the femur to break suddenly. An unsteady step or slip can cause the hip joint to twist, putting too much pressure on the neck of the femur. The neck of the femur breaks, and the patient falls to the ground. This happens so quickly that it is unclear to the patient whether the fall or the break occurred first.

Gambar 2. Falls due to loss of balance in the elderly are the most common cause of fractures in the pelvic area. (google image source)

Symptoms of pelvic fracture

A pelvic fracture, like any other fracture, causes pain. Fractures make standing or walking very difficult. If a pelvic fracture occurs in an elderly person who lives alone, it may take hours before anyone can find the patient. The patient sometimes cannot pick up the phone to alert anyone. This is the first life-threatening situation. This situation can lead to dehydration and the condition can be fatal.

Diagnosis of pelvic fracture

Diagnosis of pelvic fractures usually occurs in the emergency room. Diagnosis begins with a history and physical examination. It is important for the doctor to be informed of any other medical problems the patient is experiencing so that treatment of the pelvic fracture can be planned. Most of the information from the history and physical examination will be used to try to evaluate the patient's overall physical condition. Tests such as chest x-rays, blood work, and electrocardiograms may be done to assess the patient's overall condition.

X-rays are usually used to determine if a pelvic fracture has occurred and the location of the fracture. The orthopedic surgeon will use X-rays to determine if a surgical procedure is required and to decide on the type of procedure recommended.

In some cases, X-rays may not show a fracture. If the pelvis continues to hurt and the doctor suspects a pelvic fracture, magnetic resonance imaging (MRI) or CT scan may be recommended.

This test is done to ensure there is no fracture before the patient is allowed to put weight on their leg. Walking on a pelvic fracture can cause both sides of the fracture to shift, or move away. A non-displaced fracture is much easier to treat than a displaced fracture. A displaced fracture in the neck area of the femur also increases the risk of damage to the blood supply to the head of the femur causing AVN.

Gambar 3. MRI can detect fractures that are not detected by X Ray (image source: google)

Pelvic Fracture Treatment

What can be done to solve the problem?

Pelvic fracture treatment begins immediately by ensuring that the patient is medically stable. Once the doctor is convinced that the patient's condition is stable, a decision regarding the fracture treatment can be made.

Non-Surgical Therapy

Rarely is a fracture considered stable, meaning that it will not shift if the patient is left sleeping or sitting in a chair. The problem, however, is that the patient must be bedridden for eight to 12 weeks. Keeping an older adult in bed for that length of time carries a much greater risk of serious complications than the surgery required to repair a hip fracture. This is the main reason why surgery is recommended for almost all patients with pelvic fractures.

Operation

Almost all hip fractures in the elderly are treated with some type of surgery to repair the broken bones. Ideally, surgery is usually performed within 48 hours of the fall.

The goal of any surgical procedure to treat a hip fracture is to keep the broken bone in position, so that the patient can get out of bed as soon as possible. Many methods have been invented to treat different types of fractures. Most pelvic fractures are treated in one of the following three ways: with metal screws, with nailing, atau mengganti kepala femur yang patah dengan implan buatan.

Metal Screws

A fracture that occurs through the neck of the femur, if it is still in the correct position, may only require two or three metal screws to hold the two broken pieces together. This procedure, called hip pinning, cukup sederhana dan memungkinkan pasien untuk mulai berjalan segera setelah operasi.

Gambar 4. Metal screw for fixation of fractured neck of femur forceps not to shift (image source: google)

Nailing

Some pelvic fractures, especially those that occur in the trochanter area or below the trochanter can be stabilized with a nailing technique, this technique can be done in a surgical manner. minimal invasive, sayatan kecil, perdarahan minimal sehingga pasien bisa segera berjalan pasca operasi tanpa rasa nyeri yang bermakna.

Femur head replacement

Fractures that occur in the area of the neck of the femur that has shifted, causing impaired blood flow to the head of the femur, resulting in the replacement of the head of the femur by implant membuat pasien bisa segera berjalan tanpa risiko terjadinya AVN

Gambar 5. The left side (L) is a trochanter area hip fracture stabilized with nailing, the other side is a femoral neck fracture with femoral head replacement. The photo is an example that implant selection for the same patient can differ depending on the type and location of the fracture. Tidak semua patah area panggul perlu dilakukan penggantian sendi atau penggantian kepala tulang femur. (sumber gambar: google)

Gambar 6. Pelvic stabilization surgery with minimally invasive techniques to insert the nailing into the bone

Postoperative Recovery

Most patients can get out of bed and start physical therapy the day after surgery. It is important to start moving as soon as possible. This helps prevent medical complications, such as blood clots, pneumonia, and blisters from lying down. For older patients, it also helps prevent disorientation and delirium.

Immediate movement and rehabilitation has been shown to improve long-term outcomes from hip surgery.

During recovery, the patient will be assisted by a physiotherapist to get out of bed and walk with assistance. walker. Patients need several weeks to practice walking and daily activities after hip surgery.

Is it necessary to postpone surgery in patients taking blood thinners?

Many studies have shown that patients taking blood thinners such as aspirin or clopidogrel do not need to postpone surgery. This is in line with our experience at Santo Borromeus Hospital that blood thinning medications being taken by patients do not increase the risk of bleeding during and after surgery.

Complications that can arise after surgery

Several complications can occur as a result of surgery, including :

• Complications related to anesthesia
• Inflammation of the lungs (pneumonia)
• Surgical wound infection
• Thrombophlebitis or the occurrence of blood clots in blood vessels
• Postoperative confusion or disorientation
• Implant-related complications: such as dislocation, implant patah
• Leg length difference
• Bones do not connect as expected

Getting the patient out of bed and moving around immediately can reduce the risk of all these complications occurring.

Article by : dr. Andre Yanuar, SpOT(K)PL, M.Med.