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Thread: Hip fracture

  1. #1
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    Hip fracture

    Jake's nurse was doing some range of motion last week and put a little too much pressure on his hip and it 'popped'. He said it was broken, but it was awfully hard to tell if that was the case or if he was just afraid because of the noise. (He's got limited sensation, plus the short-term memory loss makes it hard for him to describe something after a few minutes.) Then, he ended up in the hospital for a pneumonia a couple of days later, and during a ct scan of his abdomen and lungs, a hairline fracture showed up in the hip, just beginning to heal.

    His activity isn't much restricted, just can't do a frog position...but we need to see a bone doctor soon. We're afraid to put him in the hoyer at present.

    I haven't seen the pictures yet, and this was a weekend admission, so the docs weren't familiar to us and not as communicative...(maybe afraid the fracture had happened there and didn't want to get too involved in discussion. Maybe.) So, I don't know exactly what fractured--the long bone or the pelvic part--but now I'm really concerned about his upcoming one-year rehab follow-up at UWMC, as we were going to ask his physiatrist to recommend a standing frame. I guess I'm hoping that if it is just hairline, and if the weekend doc was telling me the whole story of what they saw, maybe it will heal enough to be weight-bearing before too long...?

    Has anyone else had this kind of (sigh...) experience? I know his regular doctor will do the right thing...tests, referrals, whatever is needed...but we have a couple of weeks to go before we see her, and I'm feeling terribly discouraged about this. I lost it, yelled at the scheduler for our home health agency about a nurse not being scheduled the night he came home...then apologized for taking out my overwhelm on him, and then he ended up finding us a nurse at the last minute, so I felt bad about blowing up. But this is just a final straw after a screaming-meemies two weeks, and I need some hope.

    Anyone have any to offer...?

    Thanks, Tana

  2. #2
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    Woops--maybe this should have gone in Care. ??? Sorry!

  3. #3
    The type and location of the fracture, and the degree of osteoporosis is critical for determining a correct treatment. Unfortunately fractures like this are fairly common. Whether treated surgically or with rest, there will be a period of time when weight bearing will not be allowed, and this can vary from a few weeks to several months. For your lift, if you have a sling that goes only under the thighs, you may need to use a different sling for now. An amputee sling lifts under the buttocks, not under the thighs and would protect the femur more. It is extremely unlikely that this is a pelvic fracture. It is most likely a high femur fracture (trochanter or neck).

    (KLD)

  4. #4
    Hi Tana,
    This past May while my wife was doing range of motion exercises on my left leg we heard a load snap. It turns out that I had fractured the left Femur, just below the ball were it goes into the hip socket. A contributing factor to my situation is the HO (calcium build up) I have in both hips which puts pressure on the hip joint. I had to have surgery to put a rod through the femur bone, from the hip to just above the knee to support it. I was able to transfers as soon as I felt comfortable. The doctor made me wait a few months before using my standing frame. I probably could have done so sooner but he was being cautious. I am a C-5 incomplete for the past 6 years and do not walk. Any other ? please feel free to ask. good luck!

    Joe

  5. #5
    Tana,

    I agree with KLD. When they found the hairline fracture of the hip, did they say where? It is likely to be in the femur neck just below the trochanter and unlikely to involve the pelvis. Does Jake get autonomic dysreflexia when his legs are moved?

    Most orthopedic surgeons are unwilling to do hip replacement in patients who have osteoporosis from spinal cord injury and, in their opinion, may not use their hips. Because of the osteoporosis, most orthopedic surgeons will not use a plate with screws because the screws may not hold. Some orthopedic surgeons use rods, as described below by Riz (Joe). A vast majority of such fractures are treated conservatively by orthopedic surgeons. Healing should occur in 3-4 weeks. The main risks of conservative therapy are increased atrophy (due to inability to stand or exercise during the healing period) and deformity due to healing of the fracture in an inappropriate position. My guess is that Jake's orthopedic surgeons will recommend conservative treatment for a hairline fracture since the risk of deformity is minimal.

    Fractures are very common in people with spinal cord injury and generally acknowledged to be underestimated because most people who get leg or hip fractures after spinal cord injury are either treated conservatively or in places other than spinal cord injury centers that collect the data. Thus, the incidence of hip/leg fractures in people with chronic spinal cord injury has been estimated to be 2-6%, the Model Spinal Cord Injury System recently suggested that the incidence may be as high as 14% at 5 years, 28% in 10 years, and 39% at 15 years post-injury. They are 10 times more frequent in patients with "complete" spinal cord injury than in those with incomplete injuries and who are walking.

    There is some evidence that bisphophonates may help reduce the rate or severity of osteoporosis in people with spinal cord injury. After he heals, if he is not already taking it, he probably should take Pamidronate, etidronate, clodronate, and/or terparatide. For more information see http://www.emedicine.com/pmr/topic96.htm



    Wise.
    Last edited by Wise Young; 12-27-2005 at 10:40 PM.

  6. #6
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    My gratitude to each of you--I was feeling somewhat depressed about this (helpless), but it's passing. We haven't seen the CT pics of this yet, as Jake was at UWMC for a pneumonia the last two weekends (home for a few days, then went back) and had weekend docs at ICU who only told us about the hip on the phone the day he was discharged, so we waited at home for him rather than driving down;(he did make it home on the 24th, and so was able to enjoy his first Christmas at home--that was so great!!) He's recovering from the pneumonia now, and by next week should be able to get the flu shot we've been trying to arrange for weeks now through our home health agency. Then, after giving that a few days to settle into his system, we'll make an appointment with the bone clinic for an x-ray and discussion with them. (They are associated with UWMC in Seattle.) I'll take this page along to include in the discussion.

    I suspect this fracture is in the femur--Jake is 2 1/2 years post and I don't think his osteoporosis is much advanced yet, or we've been told this in the past few months. But the location is still a mystery to us. His regular doc, Dr. Bell, is on vacation and will return Monday, so I'll see if she has a few minutes to take a look at this and describe it to me. Hopefully one of the meds you mention, Wise, will be prescribed and Jake will have a good result. He takes so many meds, and we're hoping to have this reviewed in the coming weeks and see if some of these might safely be reduced, and I am reluctant to keep adding without also subtracting, if it is safe. (Some, like Paxil, Zyprexa, and Klonopin were started way back when the coma/brain injury were still much more predominant, so we'd like to revisit those first.)

    We also learned that Jake has a hernia on the left side of his diaphragm and when his stomach is full (he has 4 cans of Nutren a day, one every four hours) the contents push it up into the cavity of his heart and left lung, and this has really scared me. He's been complaining of feeling sick for several weeks now (could this be the result of this hernia...?), and I can hardly bear to hear it as I don't know how to help or comfort him. I've given him anti-nausea medicine a few times (a PRN), but the best thing seems to be repositioning, as he constantly slides down on his bed and tilts over to his left, compressing the area even more. Sigh. I can't move him by myself, so always have to wait either until Bob is up or the day shift nurse arrives, (I have him by myself from 6 a.m. to 8 a.m., and whether or not the night nurse and I can reposition him depends on who it is, since I injured my back awhile ago and have very limited lifting ability for now). (I let Bob sleep in, since he stays up late to get Jake on the vent for the night and then comes to bed when the night nurse arrives, so I go to bed early and get up early and take him off the vent for the day. It works pretty well, though each of us has to 'man the fort' alone for a couple of hours each, and hope Jake is comfortable enough.)

    Jake's sling does go under his thighs, and we got him up yesterday (recovery from pneumonia always hits this space in which he is so restless and bored and angry at life, and all he wants is to go outside and see the sky...), so we put a cloth tie (not tight, but supportively snug with some space between his knees) just above his knees so the upper leg was stable but not forced into an unnatural position outward. (Like the frog position, which we avoid for now.) Lying in bed at this point is so not helpful for his breathing. I'll see if I can find the type of sling suggested by KLD--thank you, KLD. I did wonder if this sling was appropriate.

    Joe, thank you for describing your experience with this. I'm so glad you are improving and able to transfer and use your frame again! This greatly encourages me that all is not lost...we had big plans for this spring, especially as Jake has settled so well being at home (nearly six months now) and wants so badly to 'get up'. He is just now beginning to realize and remember that he has this injury--for the first time, he said, "I need a wheelchair." instead of, "I don't need a wheelchair--I can walk." (Well, we don't tell him he can't--only that it's going to take a lot of hard work and time to try...the point is his remembering it on his own. Short-term memory loss is so disorienting to work with! But it is slowly improving, and having accepted that he needs a chair for now was huge.)

    Well, life is an adventure, and we seem to have reached a plateau at which we might rest awhile and have a picnic or something. A deep breath here, and thank you each a thousand times for advice that is like fuel on our trip.

    Wise, I'm still not quite sure if I grasp 'complete/incomplete', but Jake has limited sensation and slight movement (his right foot) below the injury, which is the C5 split vertebra that swelled, the C6 that shattered with some bone frags penetrating the myelin, and most likely a stretched brain stem. (It was a multiple roll-over and he was wearing a seat belt.) I do hope that one day Jake will be walking. He is so motivated--he's always been very physical and athletic, and healthy, and I've never known him to give up on anything he wanted badly enough.

    Happy 2006 to each of you! May good things come your way this year!

    Tana

  7. #7
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    Wise--Jake doesn't seem to have AD reaction to his legs being moved, but has pretty strong spasms.

    Would any of these meds cause a heightened risk of stones? He's had both lithotripsy and surgery to control kidney and bladder stones, and we have an x-ray about every 3-4 months so he can get a lithotripsy if needed (and hopefully avoid needing another surgery to remove 'gravel'.)

    Thank you,

    Tana

  8. #8
    I would not lift him with any sling that goes primarily under the femur (thigh bone) regardless of whether it is high near the hip or low near the knee. Either could displace an unstable fracture. A amputee sling will lift under the buttocks. You can use a full body sling (without the butt cut-out) alternatively, but this is very difficult to get out once you have him sitting in the chair.

    Depending on his insurance, you may want to look into temporary rental of a turning mattress (either foam or low air loss). We often use these when our clients have fractured hips as it prevents the need for manual turning.

    Obviously his hiatal hernia is another problem that will need to be addressed in the future. Surgery for this used to be horrendous, but now it can often be done laproscopically. You should have him see a good thoracic surgeon who does this procedure.

    (KLD)

  9. #9
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    Thank you, KLD. I called MSI yesterday, the company that provides Jake's DME and asked about an amputee sling. The woman I spoke with wasn't sure of what that was...sigh. So, I e-mailed a page of pictures of different slings from my 'favorites' web list, and while I can picture what you are describing, I don't see anything that looks like that. Wouldn't this include a harness of some kind so he won't pitch forward?

    If we get a full body/butt cut out sling, he could keep it on during time in the chair, as he doesn't tolerate a real long period yet--even an hour up would be better than staying in bed all day. The sling he has now, which was provided by WA State Medicaid (he has Medicare now as primary), can't be removed when he's in the chair. It's a blue mesh and full body...(head to knees.)

    We did get him up the day before I wrote to you guys. We tried to be very careful of his legs not getting tweaked, but now I wish we hadn't even done that. I hope we haven't made it worse. Sigh. But we won't get him up now until we know it's not going to hurt him. He's almost done with antibiotics for the pneumonia, and we plan to get him a flu shot a few days after that's done. No fever today... Then we will take him down to the bone clinic in Seattle (UWMC associate) for an x-ray. The thing is, I'm really feeling nervous about whether or not we've caused a displacement by getting him up the other day--he keeps tilting over to his right (at the waist) while he's in bed and his hip juts out, but then it looks straight once we get him straightened back up. It doesn't feel abnormal, but sure looks weird when he tilts over.

    His doctor should be back at work on Tuesday, and I've sent her a copy of these posts.

    He just got a new mattress rented from Pegasus bed company called a Trinova, as he's been trying to recover a rt. scapula decub for 1 1/2 yrs now, and this mattress was the consensus choice between our home health RN and Visiting Nurses wound nurse. Also, I guess, Medicare chooses this one for this purpose. It has small alternating air channels (as opposed to fewer, large ones in his own air mattress) and alternates about every 6 or 7 minutes, every 3rd channel, in a sequence. It doesn't go side-to-side. We've been told that a barrel roll is safe...the weekend doc at ICU told us this. That's what we've been doing to reposition...and he is hard to turn because of the decerebrate contractures. Foam or low air loss...hmm. Would the purpose of that be to prevent him from sliding around? He slides down into the most uncomfortable positions during the night with this bed. He ends up in a Z position, legs to his left, waist to his right, shoulders and head back to his left. And complains of feeling sick every minute. (I don't know if it's because he forgets that he just told me or if it's an overwhelming feeling of feeling sick. It's hard to determine. But he stops complaining once we get him straightened out.) (I suspect the hernia may be part of the feeling sick when he slumps over on it.)

    Thank you so much, KLD. This stuff is really hard. I go from being Mom to being Nurse, from empathy and private tears, frustration, to being competent and reassuring for Jake. I just hope I don't get them mixed up at the wrong moment! You guys all are a tremendous boost to my ability to keep going. It's been an overwhelming couple of weeks--thank God these are the exception lately!

    The hernia is definitely a big priority, and I am eager to discuss this with Dr. Bell on Tuesday. I think it's been behind a lot of his discomfort, and it is scary so close to his lung and heart. Now I think it's been misunderstood for the last few weeks, when the Pulmonologist who saw him at the local hospital couldn't figure out what he was seeing on the outside of the lung in an x-ray. It was the ct scan at UW that made this clear. So, from here forward.

    Happy 2006!! I expect good things for all of us this year!!

    Gratitude...Tana

  10. #10
    A full body sling without cut-outs is better than one with cut-outs when transferring someone with a hip fracture. A turning mattress would allow him to be rolled 30 degrees side to side with the mattress. He still has to be manually turned with the Pegasus you describe. If you keep the head of the bed less than 30 degrees it is better for his skin and less risk of him sliding down.

    (KLD)

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