You have been admitted to hospital as you have broken (fractured) your hip, this may also be referred to as a “Fractured Neck of Femur”

This fact sheet is designed to give you information about your injury, operation and the different aspects of care you can expect during your hospital stay and when you return home. If you have any questions please do not hesitate to ask any member of staff and they will happily answer any questions you may have.

What is a hip fracture?

Falls are common in older people and as we get older our bones become weaker, therefore a simple fall from standing or sitting can result in a broken hip. 

The hip joint is a ball and socket joint at the top of your thigh bone which connects to your pelvis. When you break this area it can be extremely painful and the vast majority of people will be unable to put any weight through the leg, making walking around very difficult.

You will usually require an operation to fix the fracture in order to relieve the pain and to help you get back up on your feet again. A hip fracture is a serious injury that can have a life changing impact on people.

According to the National Hip Fracture Database, in England, Wales and Northern Ireland there were over 65,000 people over the age of 60 years who sustained a hip fracture in 2016.

Out of this number only 67% of these had returned to their original residence at four months after surgery, those that return home generally require some form of formal support initially. Due to the age and frailty of people with hip fractures up to a third will die within a year following injury.  - (National Hip Fracture Database. 2017)

Your operation

The type of operation you will need often depends on where the hip is broken. Your surgeon will discuss this with you and your family prior to surgery.

The common operations used to fix a hip fracture include:

  • Hemiarthroplasty, when a partial hip replacement is done to replace an area of the fractured bone (the ball of your hip joint only).
  • Dynamic Hip Screw, (compression screw) where screws and a plate are inserted to hold the fracture together. 
  • Cannulated screws, where screws are inserted to hold the fracture together.
  • Intra Medullary Nailing, where a rod is inserted through the middle of your thigh bone.
  • Total Hip replacement, where the ball and the socket of the hip joint are replaced.


                      Hip fracture 1.jpg                     Hip fracture 2.png

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Fig 1 - shows common areas in the hip where a fracture occurs.

Fig 2 - shows some examples of surgical procedures

Our aim, if you are well enough, is for you to have your operation within 36 hours as per the NICE guidelines, however your operation may need to be delayed if you need

  • Further blood tests or correction of any abnormalities with your blood results or if you are on blood thinners.
  • Further discussion of your x-rays by the consultant.
  • Further investigations e.g. a heart scan or CT scan.
  • If you are unwell on admission and require medical treatment prior to undergoing your operation.
  • If there are a large amount of trauma patients requiring operations at the same time.

A delay in your surgery will not cause any further damage to your hip. However prolonged bedrest does increase risk of complications (see below).

Occasionally a person will be too unwell for surgery. If this is case they will be treated with prolonged bedrest with or without traction and regular pain relief.

Occasionally a hip fracture will not require any surgery and you will be able to get up and mobilise, further x-rays may be needed as you progress. 

Possible risks/complications

Any injury or operation has risk. It is important that you understand the following information and remember that everybody’s needs are different. Your recovery will vary depending on the general health, age and mental state prior to admission.

Venous Thromboembolism (VTE)

This is the name given to a deep vein thrombosis (DVT) or pulmonary embolism (PE). A DVT is a serious condition where a blood clot forms in a deep vein, commonly in the legs or pelvis, causing swelling, redness and pain. Occasionally the blood clot can dislodge and can pass through the blood stream to the lungs causing a PE. Symptoms of PE include coughing, shortness of breath and chest pain.

If you develop any of these symptoms either in hospital or at home you need to seek immediate medical advice. It is important you reduce the risk of VTE by doing lots of leg and deep breathing exercises to keep the blood circulating.

You will be prescribed a daily injection to thin the blood that you will have to continue for four weeks in total. In addition you may have mechanical compression garments applied to your lower legs or feet and these will stay on until you are mobile again. These are attached to a pump and they squeeze the muscles in your legs to encourage blood flow.

However one of the best ways to prevent VTE is to get up and start moving and walking as soon as you are allowed.

Pain

Your hip will be painful after the operation. You will be offered regular pain killers to reduce the pain; however it is important that you tell the nurse if you feel they are not effective as stronger pain killers may be needed.

Bleeding

Some people will have increased blood loss as a result of the injury and surgery and you may require a blood transfusion. Your bloods will be checked regularly after your operation to monitor this.

Your wound may also leak after your operation and the staff will monitor your wound dressing for this. You may require further surgery if this does not subside. You may also find you have a large bruise around your hip, groin and thigh area, this will usually resolve over time.

Infection

This is a risk of any surgery and is taken very seriously.  Every effort will be taken by staff to prevent you from getting an infection.  However there are a small number of people that may develop a wound infection following surgery. In this case antibiotics may be needed and in some cases further surgery may be required.

Chest infection / Pneumonia

You may develop chest infection or any respiratory problem as a result of prolonged bedrest. This risk is reduced by getting up and mobilising as soon as possible after your operation. Deep breathing exercises are encouraged as this a good way of keeping the lungs working well.

Pressure ulcers

When on bedrest and when your mobility is reduced your skin can become sore, typically at the bottom, heels and elbows. Your skin condition will be monitored regularly by the staff and if you feel any discomfort please tell someone. Again early mobilisation is the best way you can reduce your risk of developing a pressure sore.

Catheterisation

You may struggle to pass urine either before or after your operation therefore a tube can be inserted into your bladder temporarily.

Constipation

This is a common problem associated with reduced mobility, also some pain killers can cause you to become constipated. You may require a laxative and your bowel habits will be monitored. Again if you feel constipated please inform a member of the staff and they will be able to offer treatment. By drinking plenty of water, eating healthy diet and exercise you can reduce the risk of constipation. If you normally do suffer from constipation please inform a member of staff.

Dislocation / failed metalwork

If your operation consists of the ball of the hip joint being replaced (Hemiarthroplasty), there is a small risk of this dislocating- where the ball slips out of the socket. It is also possible for the metalwork used in other operations to fail or displace. You may need an additional operation to address this.

Acute confusion / Delirium

Some patients may experience a period or periods of confusion after their operation. This can be caused by a number of factors such as, simply just being away from home, medications used for pain and from anaesthetic, low oxygen levels, infections such as chest or urine, an imbalance in your blood results, pain and constipation.

Whilst this can be distressing for relatives, it is usually short term and will be monitored, investigated and treated if necessary.

Nutrition / lack of appetite

Due to the nature of injury and proceeding surgery, it is common for you to lose your appetite; however it is important to ensure you maintain a healthy balanced diet, this is essential for wound healing and to ensure you gain strength to mobilise and recover from your operation. Snacks are available at any time of day/night. Please ask a member of staff. Your dietary intake may be monitored and if required you may be referred to the dietician. If you have trouble with swallowing, a referral to the Speech and Language Therapist may also be required.

Dehydration

Poor fluid intake can be caused by many things, including emergency surgery and pre-op fasting, some medications; refusal to drink for fear of needing the toilet or incontinence, increasing age, physical weakness, infections and underlying cognitive impairment. You are advised to drink plenty of water in order to prevent dehydration. Your water jug will be replenished throughout the day, but please do ask a member of staff if you run out or need assistance with this.

Again your oral fluid intake may be monitored closely and intravenous fluids will be given while you are awaiting surgery and post operatively to prevent dehydration. Blood tests will also be taken to monitor this regularly.

The team looking after you

During your stay on the Orthopaedic ward you will come across many people and teams who may be involved within your care. These may include:-

  • Orthopaedic Consultants, Registrars and Orthopaedic Junior Doctors
  • Anaesthetic team
  • Ortho-geriatric Doctors 
  • Matron for Orthopaedics
  • Specialist Nurse in Ortho-geriatrics
  • Nurse Practitioners
  • Ward Managers & Deputy Ward Managers
  • Staff Nurses and Healthcare Assistants from A&E, the Ward, Theatre and Recovery departments
  • Surgical Site Infection Nurse (SSI)
  • Physiotherapy team (PT)
  • Occupational Therapist team (OT)
  • Pharmacy team
  • Phlebotomists
  • Dietician
  • Speech and Language Therapists
  • Porters
  • House Keeper
Involvement of relatives/carers, your relatives can help by:-
  • Bringing in any belongings you may need
  • Your own medication or an up to date list of what you take
  • Your own toiletries
  • Suitable footwear and clothing, day clothes are encouraged rather than nightwear. (please note there are no washing facilities for patient laundry)
  • Helping and encouraging you to do your exercises
  • Encouraging you to eat and drink

Please avoid bringing anything valuable into hospital and be aware that space is very limited. Flowers are not permitted.

Discharge planning

It is difficult to predict how well you will progress following your hip fracture and surgery. Many factors have to be taken into consideration, such as your present general health, previous level of mobility, fitness and independence.

Some patients may be well enough to leave hospital within 2-3 days; however some patients will need increased levels of support and recover at a slower pace.

The staff will start planning for your discharge straight away and your consultant will set you an ‘Expected Date of Discharge’ this is based on the average length of stay of patients with a fractured hip which is approximately 14 days.

We aim to transfer those who are admitted from West Cumberland Hospital (WCH) back to WCH at approximately 48hrs after their surgery. This is dependent on if you are medically fit and there is a bed available.

After discharge, most patients will require some form of support at home from a community support team, where they will continue your rehabilitation in your own home. If it is felt you will require longer rehabilitation before you return home, you will be listed for a bed in a community hospital. This will depend on the availability of beds in the community and may not be your local area.

On your admission to the ward
  • You will be on bedrest until after your surgery
  • You will be admitted by one of the nursing staff who will go through your details.
  • You will have your blood pressure and other observations checked
  • You may be nil by mouth (NBM) until we clarify when your surgery is planned
  • You will have swabs taken from your nose and groin/perineum to screen for infections such as MRSA
  • You will be commenced on infection eradication therapy for 5 days as a precaution and to reduce your risk of developing an infection.
  • You will have compression garments applied to your legs or feet to reduce your risk of VTE.
  • You will be offered a gutter type pillow to rest your affected leg in for comfort and support.
  • You will be prescribed a once daily injection into your tummy to thin your blood in the evening.
  • You may have further blood samples taken
  • You will need to use bed pans/urinals whilst on bedrest.
  • Fluids will be given to you via a drip to prevent you becoming dehydrated.
  • You may be seen by the consultant orthopaedic surgeon or their registrar to discuss your surgery and you will be asked to sign a consent form.
  • Dependant on your time of admission and theatre space you may have your surgery the same day or typically within 36hours unless there is a reason to improve your health prior to surgery.

You will be reviewed by the Ortho-Geriatrician, aiming to be within 72 hours of your admission, who will assess any medical issues you may have. Where possible we aim for this to take place before your operation. The Ortho-Geriatrician is a medical doctor who specialises in the care of people over the age of 60 with a hip fracture.

Day of operation - Pre op
  • You are encouraged to do leg and deep breathing exercises in bed to prevent blood clots and pressure sores occurring.
  • You will be nil by mouth for surgery. Your nurse will advise you on when you have to stop eating and drinking oral fluids. Mouth wash can be used if required.
  • To prevent you becoming dehydrated, fluids will continue to be given to you via a drip.
  • The consultant and their team will see you on the morning trauma round where they will discuss your planned surgery with you. In some circumstances they may also want to discuss your care with your next of kin if appropriate.
  • You may be assessed by the Ortho-geriatrician
  • You will need to be warm before surgery so a ‘warming blanket’ will be placed over you to raise your temperature.
  • Your nurse will assist and escort you to theatre
Post op
  • You will be kept in the theatre recovery area until you are comfortable and recovered from the anaesthetic before being transferred back to the ward.
  • On return to the ward you will continue to be regularly monitored by the staff.
  • Your pain will be assessed and pain relief medication given as required.
  • You may start to eat and drink again gradually, once you’re awake.
  • If necessary a catheter may have to be inserted into your bladder. This will be removed as soon you move your bowels.
  • You will have stitches or metal clips to your wound and this will be covered by a surgical dressing. These will be removed 14 days after your surgery. You are advised not to bath or shower until then.
  • If you are well enough you may get out of bed and sit in the chair.
Day 1
  • You will be reviewed by your consultant on the morning trauma round to discuss your surgery and answer any questions.
  • You will be helped by the physio to sit out in a chair and take a few steps with a walking frame. You may feel weaker than usual and you may feel some pain and discomfort when you start to mobilise.
  • You will be offered regular painkillers but please tell your nurse if these are not sufficient.
  • You are encouraged to eat and drink and once you are taking adequate fluids by mouth your drip will be removed.
  • You will have your bloods taken.
  • You may require a blood transfusion; staff will discuss this with you if needed.
  • You may require a check x-ray of your hip (only needed in certain operations)
  • You are encouraged to wear your own clothes.
Day 2
  • You are encouraged to sit out in the chair for longer periods and especially for meals.
  • You will continue with physiotherapy and be helped to walk with a frame.
  • You are encouraged to practice sitting and standing.
  • You will have further blood tests.
  • If applicable – if you are medically well enough for transfer and there is a bed available you will be transferred back to West Cumberland Hospital.
  • Any cannulas may be removed if not required.
  • The Occupational Therapist (OT) may come and discuss your home circumstances with you.
  • You will keep the compression garments on your legs until you are mobile around the ward.
Day 3 onwards
  • You will continue your physiotherapy until your mobility improves. You may progress to using crutches. You are encouraged to practice walking with supervision as much as possible. The distance you go will increase every day. The nurses and healthcare assistants will encourage you to walk to and from the bathroom as part of your on-going rehabilitation.
  • The OT may start/continue their assessments, and may begin assessments such as looking at how you manage with personal care and assess for the support you may need.
  • If required, the OT may also take you to the kitchen area where you will be assessed on how you manage when completing tasks such as making a cup of tea. They will also assess how you manage to get on/off bed/chair/toilet to see what equipment you may need for discharge home.
  • If you have stairs at home the physio will teach you to negotiate them. If stairs are thought to be problematic, you may be asked about the possibility of moving a bed downstairs to facilitate a safe environment for you discharge.
  • A home visit will only be carried out if deemed necessary by the OT and is not routine.
  • A referral may be sent for community rehabilitation at your home or to the local community hospital.
  • You will be discharged home once you are medically fit and deemed safe with the Nursing, Physiotherapy and Occupational therapy teams.
Other information

Wound care - You will either have skin staples/clips as wound closure or dissolvable stitches and your wound will be covered with a dressing. Staples and non-dissolvable stitches and will be removed 14 days after your operation.

If you are at home you are advised to make an appointment with your practice nurse at you GP surgery to have them removed. The dressing will stay on for the whole 14 days and will only be changed if your wound leaks through this. You are encouraged to keep this dry until your wound is fully healed.

Follow up – the majority of operations do not require orthopaedic follow up. If you do need an appointment, it will be made at the time of discharge or posted to your address. You will be contacted by the surgical site infection nurse with regards to your wound soon after surgery and again at around four months to see how you are managing. 

The National Hip Fracture Database collects information about hip fracture care and they release annual reports regarding each hospitals performance. If you would like more information on hip fracture and how this trust is performing nationally, you can visit National Hip Fracture Database website www.nhfd.co.uk 

Confidentiality

‘The Trust’s vision is to keep your information safe in our hands.’ We promise to use your information fairly and legally, and in-line with local and national policies. You have a right to understand how your information is used and you can request a copy of the information we hold about you at any time.

For further information on confidentiality contact the Information Governance Team:

Information.Governance@ncic.nhs.uk | 01228 603961

Feedback

We appreciate and encourage feedback, which helps us to improve our services. If you have any comments, compliments or concerns to make about your care, please contact the Patient, Advice & Liaison Service:

pals@ncic.nhs.uk | 01228 814008 or 01946 523818

If you would like to raise a complaint regarding your care, please contact the Complaints Department:

complaints@ncic.nhs.uk | 01228 936302