Fractured neck of femur

You have been admitted to Addenbrooke’s Hospital with a hip fracture. You will be cared for by a team of specialists, whose roles will be described later.

The goal of this team is to return you to your previous levels of independence, mobility and confidence. To achieve this, we need you and your relatives/ carers to work with us. Our aim is to perform any necessary surgery within 36 hours of your admission to hospital.

'From Me to You' – A patient testimonial

Dear Friend,
On the first day you can feel so weak, you feel as though you are helpless but the nurses are there to help you, they are wonderful. My worst worry was wetting the bed at night, but to the nurses this was no problem.
All the physio was a must, after the exercises you begin to feel a bit stronger and the strength begins to come back each day. Each day you feel a bit more human.
I had a bad night’s sleep and feel a little tired today, having a walk with physio will be good I thought. My head was not feeling very clear and the steps seemed hard but thinking about it after, it was easy.
Going up the stairs I felt was good, but coming down I thought was harder, having the feeling of falling was there but once I did it, I was very proud and thought, I can do this.
On reaching the age of 80 years, this is the first time I have been in hospital. It is a huge experience. I have found it good to try not to get too stressed and to try to keep calm. I have been told it’s a long job, 6 months to a year to get fully better, so it’s quite a long time, but I will get there with some help and determination.
Rita.

What is a hip fracture?

Hip fracture is another term for a break at the top of the thigh bone. It is a very common injury with about 75,000 people breaking their hips in the UK each year but this is likely to increase due to our ageing population. About 8 out of 10 people who sustain a hip fracture are women, and it is the main reason for older people to be admitted to an orthopaedic ward. The average age of someone breaking their hip is 80 years. We call a hip fracture a fragility fracture because there is usually some underlying osteoporosis (thinning of the bones). The hip can be broken in different places. The position of the break is described as intracapsular (inside the joint capsule) or extra capsular (outside the joint capsule). The fragments of bone may be displaced, which means the pieces of the bone have moved and need to be re-aligned. Most people need an operation to fix this.

The specialist team

You will be under the joint care of an orthopaedic consultant (surgeon) and an ortho-geriatric consultant (physician).

Surgeon

The orthopaedic surgeon will arrange for your operation to be performed after discussing the best fixation and possible complications with you. They will also ask you to sign a consent form. It may not be the consultant who admitted you that does your operation but it will be one of their orthopaedic colleagues.

Ortho-geriatric consultant

The team is led by two consultant physicians who specialise in the care of older people and have a specific interest in hip fractures. They will be responsible for your day-to-day medical care.

Specialist support nurse

The team is co-ordinated by this specialist nurse who works closely with the ortho-geriatric consultants. The role is to facilitate communication between the team members, patients, relatives and carers.

Physiotherapist

Working with the physiotherapy team is key to regaining your mobility and confidence. Our aim is to work with you seven days a week and whilst we appreciate you will be tired, research shows that the quicker you get back on your feet the better your future mobility is likely to be.

At the end of this booklet you will find some basic exercises that you can do independently or with the assistance of relatives and friends to help speed up your recovery.

Occupational therapist

The role of the occupational therapist is to assess you for any aids or equipment which will assist you in regaining your previous levels of independence. They will issue you with a form to be completed with measurements from your home.

Ward nursing team

Your day-to-day needs will be met by the ward nursing team led by the senior charge nurse. They will support you during recovery and encourage independence wherever possible.

Many other people will be involved in your care; they are all part of the Addenbrooke’s team who are here to make your experience Kind, Safe and Excellent.

What to expect before your operation

You will probably have been admitted to our specialist hip fracture unit, but there are times when this is not possible. However, you will still be cared for by the specialist team.

Same sex bays and bathrooms are offered in all wards except critical care and theatre recovery areas where the use of high-tech equipment and/or specialist one-to-one care is required.

The majority of our patients will be seen by the ortho-geriatric consultant before surgery. The doctor will take a full medical and social history. This will enable us to identify any potential issues that may need addressing prior to surgery and to assist us in making a plan for a safe and timely discharge.

You will not be allowed to eat or drink for at least four hours before your operation. You may need a drip setting up to prevent dehydration. If you are having difficulty passing urine you may have a catheter inserted into your bladder. On the day of your operation you will be seen by an anaesthetist.

There are different types of anaesthetics available. The anaesthetist will discuss the best option for you.

The anatomy of your hip

The hip is a ball and socket joint. The ball of the thigh bone (head of femur) sits in the socket in the pelvis (acetabulum). There is a strong capsule surrounding the joint that gives stability and provides lubrication to help hip movement.

Here are some examples of different fixation methods for a fractured neck of femur.

After surgery

Immediately following surgery you will be cared for in the recovery area of the Operating Department until you are ready to return to the ward. A drip will be set up to give you intravenous fluid. Oxygen will be administered via a face mask or nasal cannulae. You may also have a catheter to drain your bladder. These will be removed as soon as they are no longer required; usually 24-48 hours following surgery.

Some types of injury can lead to blood loss that may require a blood transfusion.

Pain relief

All fractures are painful. This pain can become worse on movement. Recent evidence shows that early mobilisation helps to reduce the risk of complications following surgery. It is therefore essential you have adequate pain relief. Please do not be afraid to raise any concerns about pain to a member of the team.

Your journey to recovery

Discharge planning will begin immediately following admission. We know that most people are keen to return home as soon as possible. To achieve a safe and timely discharge from hospital we need the help of you and your relatives/ carers.

The occupational therapist will issue you with a heights form which gives them information about your home environment. This needs to be completed accurately and returned to us as soon as possible, preferably within 48 hours.

To promote dignity we encourage independence and expect you to be up, wearing lightweight day clothes and comfortable, well fitting shoes or slippers within 48 hours of surgery. Relatives, carers and friends will be asked for their help in supplying and washing these as there are no personal laundry facilities available within the hospital. They also need to supply you with personal toiletries, tissues and so on.

You will be encouraged to sit out in your chair for all meals. This aids digestion and helps to prevent constipation which can be a problem due to your decreased mobility and the painkillers you are taking.

Your relatives/ carers can bring in any food or drinks you particularly like as long as no re-heating is required. Many people in hospital have a decreased appetite, so anything that improves this will be welcomed.

Osteoporosis

As mentioned earlier, most hip fractures in the elderly are associated with osteoporosis, a condition which thins the bones. To reduce the risk of further fractures, the ortho-geriatrician will assess you and, after further discussion, prescribe some sort of bone protective medication. This will usually be a daily dose of calcium and vitamin D as well as a once weekly tablet. The doctor or pharmacist will discuss with you how to correctly take this. Other types of medication can be given if this treatment is not appropriate for you. Some additional investigations may be suggested at this time.

Your discharge from Addenbrooke’s

Most of our patients will be able to go home directly from hospital. If the multidisciplinary team feel it is necessary we can arrange some support for you in your own home. The support will vary depending on where you live and how long you are likely to need it. The team will discuss your individual circumstances with you and, if required, you will be referred to one of our care managers. Occasionally, patients require additional therapy prior to going home. Assessment will be made on the ward. This may lead to a referral to a local inpatient rehabilitation facility.

Some of our patients will already be frail and were struggling to manage at home before they broke their hip. For this reason we will sometimes suggest going to a residential or nursing home. Such a major change in lifestyle will only be considered following extensive discussions with the patient and any other relevant parties.

Occupational therapy

Occupational therapy aims to help people carry out activities that they need and want to do, such as personal care, domestic tasks and leisure activities. After sustaining a fractured neck of femur, people sometimes find such activities difficult. In these circumstances you may benefit from having rehabilitation either as an inpatient or in your own home and/or being provided with equipment to enable you to carry out your daily activities more easily.

Physiotherapy

The physiotherapist will aim to treat every patient every day, including Saturdays and Sundays. This will help to increase your confidence and abilities, to enable you to regain your independence and return home as quickly as possible. The physiotherapist works closely with all members of the multidisciplinary team to ensure you are offered the best and most appropriate treatment for your individual needs.

We expect your stay to be between 5 to 14 days following your operation. Before the operation, you will be given some exercises to practise in bed to help maintain your circulation and to help reduce the risk of complications.

On the first day after the operation, you will be assisted out of bed. You will probably require a frame to help you stand and walk.

The physiotherapist will teach you exercises to regain the strength and mobility in your leg. You will be encouraged to continue these exercises regularly, either on your own or with the help of family and friends. You will be offered regular sessions in the rehabilitation gym.

Before you are discharged home the physiotherapist will check that you can safely manage basic activities such as:

• get in and out of bed
• sit to stand from a chair
• walk a suitable distance to manage in your home environment
• balance safely, unsupported if required
• negotiate a step and/or stairs as required.

If you are worried about managing the stairs at home, you could consider having a bed downstairs for a few weeks until you feel stronger.

We expect you to need the use of a walking frame or crutches for about six weeks following the operation.

On discharge home, the physiotherapist will refer you on for further physiotherapy, to progress your walking and activities at home. This may take place either in your own home or at a local physiotherapy department.

Please see the exercises printed on the following pages. Aim to repeat each exercise 10 times.

This exercise is for your circulation. Lying or sitting with your back supported, bend and straighten your ankles briskly.

This is a further circulation exercise. Whilst lying or sitting with your back supported, now circle your ankles in each direction.

Lie in a comfortable position. Tighten your thigh muscles by pushing your knee down on to the bed and pulling your toes up towards you, keeping your knee straight. Hold for five seconds, then repeat.

Lie on your back or sit in a comfortable position. Squeeze your buttock muscles tightly together. Hold for five seconds, then repeat.

Lie in a comfortable position. Bend your knee up towards you, keeping your heel close to the bed. Lower slowly.

Lie in a comfortable position. Keep your knee straight and slide your leg towards the edge of the bed and back again. Your toes should always point to the ceiling.

Sit on a chair with your thigh fully supported. Tighten your thigh muscle and raise your foot until the leg is fully straight. Lower slowly.

Operated leg only

Stand on the un-operated leg and hold onto a firm support. Move the other leg forwards and upwards bending at both the hip and the knee towards a 90^o angle, but no further. Slowly lower the leg to the ground, and repeat.

Operated leg only

Stand on the un-operated leg in the same position as the previous exercise. Keep your knee straight. Move your other leg directly backwards as far as comfortably possible and then back to the starting position. Keep your upper body still throughout.

Operated leg only

Stand in an upright position with your upper body still. Hold onto a firm support. Move your operated leg sideways away from your body and then back to the centre. Move in a controlled manner keeping your kneecap facing forwards.

Most people will not require any outpatient follow-up. If you are concerned at any time after discharge please contact your general practitioner (GP) or any of the following numbers for advice.

Ward D8: 01223 217282

Specialist support nurse: 01223 245151 – ask for bleep 157 187

Physiotherapist: 01223 216104

Occupational therapist: 01223 216880

The information in this booklet follows the NICE guidelines for treatment of fractured neck of femur in England, Wales and Northern Ireland.

NICE Guidance Hip fracture: management Overview (opens in a new tab)