After your Hip Fracture Surgery

Information for Patients Who Have Had

Hip Fracture Surgery

Prepared by:

Interior Health Orthopedic Working Group

Draft –December 6, 2011

Introduction______

This booklet is to provide patients who have had Hip Fracture Surgery with the information needed for a comfortable and successful recovery.

The information in this booklet is intended solely for the person to whom it was given by the health care team. It does not replace the advice or directions provided to you by your surgeon.

Table of Contents______

Introduction - The Hip

About Hip Fractures

What is a fractured hip?

Causes

What is Osteoporosis?

Main Types of Fractures

Treatment Options

What is a An Artificial or Total Joint Replacement?

If you have had An Artificial Joint Replacement

Special Precautions After Surgery

Your Health Care Team and Clinical Pathway

Admission and Acute Care Stay

Clinical Pathway – see Appendix A

What to Expect Before Surgery

What to Expect Immediately After Surgery

Post-op Days One through Five

On the First Day After Surgery

Pain Control

Postoperative Exercises

Constipation

On the Second Day After Surgery

Sitting

Walking

On the Third Day After Surgery

On the Fourth Day After Surgery

On the Fifth Day After Surgery

Going Home

Checklist

Managing Your Pain At Home

Follow-up

While at Home After Your Surgery

Preventing Falls

Complications

Nutrition

Daily Activities

Home Exercise Program

Resuming Activities

How to Obtain Equipment

Home Support Services

The Hip______

The hip is a ball and socket joint where the thigh bone (femur) meets the pelvis (socket). The hip joint provides movement in all directions (forward, backward, sideways, and rotation). The femoral head is the “ball” (or top part of the femur) which fits into the “socket” (or acetabulum) which is located in the pelvis.

What is a Fractured Hip?______

A fractured hip is a partial or complete break in the upper portion of the thigh bone (femur).

About Hip Fractures______

Causes

Hip fractures are usually caused by:

  • an injury to the hip (i.e. a fall), or
  • a disease called osteoporosis

What is osteoporosis?

Osteoporosis is a disease characterized by low bone mass and deterioration of bone tissue. As you age, it takes your body longer to replace lost bone mass and this leads to increased bone fragility and risk of fracture (broken bones), particularly of the hip, spine, and wrist.

Osteoporosis is most common in people who:

  • are thin
  • exercise very little
  • smoke or drink alcohol
  • don’t have enough calcium in their diets
  • are post menopausal

If you have osteoporosis, it is important that you try to prevent bone loss. You can do this through diet, medication, and exercise. It is also important that you learn how to prepare yourself and your home so that you can prevent a fall that could result in a broken bone(s).

Main types of Hip Fractures

There are three main types of hip fractures:

  • Femoral Neck – a fracture occurring across the neck of the femur, just below the head (ball)
  • Intertrochanteric - a fracture occurring between the femoral neck and the shaft of the femur (most common type of hip fracture)
  • Subtrochanteric – a fracture occurring across the shaft of the femur (least common type of fracture).

Treatment______

Depending on the type of hip fracture that you have (see above), your fracture will be (or has been) repaired using one of the following special techniques:

  • Femoral Neck Fracture

Femoral neck fractures may be repaired using either:

a)Metal pins/screws- which are inserted across the fracture line to hold the femoral neck together and in proper alignment.

or,

b)An artificial hip prosthesis or component. This type of surgery is known as a “hemi-arthroplasty” and involves replacement of the “ball” portion of the hip joint with an artificial (metal) component. This may be done when the blood supply to the head of the femur has been interrupted or cannot be repaired using other methods.

  • Intertrochanteric Fracture

To repair this type of fracture, a special metal screw is inserted through a plate into the bone and across the fracture line. This plate and screw system helps to align the fracture and bring the edges of the bone back together so that it may heal.

  • Subtrochanteric Fracture

Subtrochaneric fractures may be repaired by inserting a metal nail down the shaft of the femur to hold the broken bone in place. Special screws (known as compression screws) are also inserted into the bone and through the nail which help to bring the fracture edges back together and ensure proper bone alignment.

What isAn Artificial Total Hip Joint Replacement?______

If your hip joint has been badly damaged due to trauma or arthritis, your surgeon may decide to replace all of the hip joint components (or parts) including the actetablum or “socket”. This type of surgery is called a “total hip replacement” or a “total hip arthroplasty”. It is similar to a hemi-arthroplasty (see above) except that all of the components (or parts) of the hip joint are replaced with artificial ones.

Your Health Care Team and Clinical Pathway______

The health care team has put together a Clinical Pathwaywhich will act as your guide so that you will know what will happen on a day-to-day basis. A summary of this Clinical Pathway is found in Appendix A of this booklet.

Please be sure to keep and read this information as the team members will refer to these instructions throughout your stay.

A number of health care professionals may be involved in your care. These include:

  • Nurses
  • Doctors (family physician, surgeon and anesthesiologist)
  • Physiotherapists (PT)
  • Occupational Therapists (OT)
  • Others (Social Workers, etc)

If You Have Had An Artificial HipJoint Replacement ______

If you have had an artificial hip joint replacement (either partial or all components), the muscles and soft tissue of your surgical leg will be very weak after your surgery. Until they strengthen, your hip may “dislocate” (slide out of it’s socket).

It is therefore VERY important that you follow these special precautions:

For the first three (3) months after your surgery:

Do NOT:

  • cross your legs or feet.
  • twist at the waist.
  • sit on any surface lower than your own knee height
  • bend in the hip past 90 degrees or lean forward to reach things.

Do:

  • sit on a high chair or cushion and use a raised toilet seat.
  • use long-handled aids (such as a shoe horn and “reacher”) to help you dress and reach things.
  • sleep with pillows between your legs for the first three (3) months after your surgery.

What to Expect Before Surgery______

  • You will be interviewed by nurses, doctors, and other health care team members to find out about your overall health, past health problems,previous surgeries, etc. and the help that you may need when you go home.
  • You will have blood work done and x-rays taken of your hip and chest.
  • You will have a small tube or catheter (known as an IV) inserted into your hand or arm. Pain medication may be given to you through this small tube to help keep you comfortable. The anesthesiologist will also use this small tube to give you an anesthetic (medication which will put you to sleep for your surgery).
  • You will not be allowed to have anything to eat or drink before your surgery. This is an important safety measureto ensure that you do not choke (or aspirate). Please follow the directions given to you regarding eating and/or drinking before your surgery.

What to expect immediately after surgery ______

  • When you wake up, you will be in a special area (called “The Recovery Room”) where patients who have had surgery are monitored until they are awake and medically stable.
  • The nurse will check your temperature, heart rate, blood pressure, circulation, hip dressing, and movement of your operated leg. She will do this a number of times.
  • The nurse will also give you pain medication on a regular basis through the small tube (IV) in your hand/arm. Please tell your nurse if you begin to feel any pain or discomfort.
  • If you are feeling sick to your stomach, the nurse may also give you some anti-nausea medication.
  • Your nurse will help you turn from side-to-side every three (3) hours while you are in bed. This is important to prevent pressure areas and sores from developing on your skin and also helps your breathing and circulation.
  • You will be encouraged to do some deep breathing and coughing exercises to help clear your lungs.
  • Your family can visit with you when you are transferred to your in-patient bed (approximately 3-4 hours after your surgery).
  • For your diet, you will start with clear fluids (water, juice, tea) and slowly progress to a regular (high fiber) diet when you are feeling better.
  • You may also have had (or will wake up with) a small tube (or catheter) in your bladder to help empty your urine.
  • If you have had an artificial joint replacement, you may also have a large splint placed between your legs. This is to help keep your hip in proper alignment.

Pain Control______

After your surgery:

Most patients report moderate pain after their hip surgery. It is possible however to relieve much of the pain with medication and comfort measures such as ice, relaxation exercises, and repositioning.

It is important that you are comfortable so that you can rest, heal, and start some gentle exercises. Don’t be afraid to ask for pain medication. Some patient’s don’t ask because they do not want to bother the nurses; others fear becoming addicted to the drug. For most patients, there is virtually no chance of addiction. Preventing severe pain in the early stages after surgery will also prevent the pain from persisting later on, allows the body to relax and heal, and speeds overall recovery.

Pain management is therefore a priority.

Your nurse needs to know when you hurt and feel pain. Constant and severe pain can hamper your recovery and prevent you from moving, doing your exercises and sleeping – all of which could lead to severe complications and delayed healing.

Types of Pain Medication:

After your surgery, you may receive pain medication in a variety of ways: These include:

  • Through a special computerized pump and tubing called a PCA pump (Patient Controlled Analgesic Pump).This pump will allow you to safely manage your pain. By using a hand-controlled button, you can press the pump and it will deliver a safe pre-programmed dose of pain medication. The pump has special safety measures built in so that you cannot give yourself more medication than is safe.
  • Through the intravenous (IV) catheter and tubing
  • By epidural injection – medication is injected into the spinal column during surgery to provide pain relief for a number of hours
  • By injection
  • By mouth (i.e. pills)
  • By suppository

Managing your pain while in the hospital:

Your nurse will explain how your pain will be managed and how to use a pain scale. This scale helps you to identify or measure intensity of pain (i.e. no pain, a little pain, worst pain).

0 1 2 3 4 5 6 7 8 9 10

No pain Moderate pain Worst pain

It is recommended that you keep your pain at a level four (4) or lower (on the pain scale) or whatever level is most comfortable for you. You should be comfortable at both rest and with activity or movement.

Be sure to notify your nurse when you start to become uncomfortable or before any expected activity (i.e. post-op exercises/physiotherapy). Do not wait until the pain is severe. Pain medications work more quickly and effectively when taken at regular intervals and when you are relaxed (i.e. not in too much pain).

Relaxation techniques(such as deep breathing, distraction, and also imaging) help to control pain.

Notify your nurse immediately if:

  • your hip pain increases sharply, or if
  • your calves feel tender or painful

On the First Day After Your Surgery______

  • Your nurses will help you to turn and reposition yourself in bed.
  • You will be encouraged to do deep breathing and coughing exercises as well as some foot and ankle exercises.
  • You may have some more blood work done.
  • The incision on your hip will be examined and the dressing changed.
  • You will be encouraged to sit on the side of your bed (or in a chair). Before you do this however, your nurse will give you some pain medication so that you will be a little more relaxed and comfortable.
  • You may also be given a high-protein/high caloric drink twice a day to help your body tissues heal.

Getting out of Bed:

The nurse (or physiotherapist) will help you to get out of bed for the first few times.

To do this:

  • Move your body towards the same side of the bed as your surgical hip. (i.e. move towards the left if your surgery was on your left hip).
  • Slide your surgical leg to the edge of the bed.
  • Push up from your back, using your elbows and hands to get into a sitting position.

Getting into Bed:

Again, the nurse (or physiotherapist) will help you to do this the first few times.

  • Position yourself half way down the bed so that your surgical side (leg) will move/slide first on the bed.
  • Sit on the edge of the bed like you would in a chair.
  • Lean back on your elbows.
  • Slowly slide your surgical leg onto the bed until you are flat.
  • When moving, try to move your body as a whole (keeping your trunk straight and your legs apart).

Post-operative Exercises______

The following exercises will help to prevent post operative complications (such as fluid in the lungs, pneumonia, or blood clots) which can occur due to the anesthetic and prolonged bed rest.

Deep Breathing and Coughing

Deep breathing and coughing help to clear your chest after surgery. They also help to improve circulation, breathing, and prevent pneumonia.

  • Take 4 deep slow breaths, then cough loudly
  • Repeat 4 times

Practice deep breathing and coughing every hour for the first three (3) days after your surgery.

Exercising in Bed

After surgery, a physiotherapist will help you with simple exercises that can be done in bed (see page XX for post-op exercises). These exercises will help to restore circulation, prevent blood clots, and to strengthen your muscles.

Relaxation Exercise

This exercise will help you to relax. Relaxation will help your pain medication to be more effective and will also help you to sleep.

  • Breathe in and out slowly to the count of three (3)
  • Breathe in (1-2-3)
  • Hold (1-2-3)
  • Breathe out (1-2-3)
  • As you do this exercise, concentrate on feeling pleasantly warm and heavy. Let your jaw go loose and your head sway gently and slowly from side to side. Think about feeling loose and limp all over. Continue to breathe in and out slowly. As you breathe in, think relaxing, soothing thoughts. As you breathe out, blow pain, discomfort, or tension away.
  • Repeat 10-20 times.

Constipation______

While pain medication is important for your comfort and recovery, it may lead to constipation. Here are some suggestions to keep you “regular”.

  • Drink at least eight (8) glasses of water or juice a day (unless not recommended by your doctor)
  • Eat fibre (such as prunes, bran, fruit, and vegetables)
  • Move around as much as you can comfortably.

Be sure to let your nurse know if you are feeling uncomfortable or “full” as a laxative or stool softener may be necessary.

On the second day after your surgery______

  • You will be encouraged to get up and sit in a chair for at least 1 meal on this day.
  • If you have had an artificial joint replacement, you may have pillows placed between your legs to remind you not to cross your legs while in bed.
  • If you have a urine catheter, the nurse may remove it.
  • You may use a commode (portable toilet) or bedpan/urinal. Note: If you have had an artificial joint replacement, you will need to use a commode with a raised seat.
  • The physiotherapist will teach you appropriate exercises for your hip and legs.

Sitting:

For meals (and for short periods of time), you may sit in a firm and sturdy high-seated chair that has arm rests.

To Sit[ls1]:

  • Back up to the chair with your walker (or crutches) until you feel the back of your knees touching the chair.
  • Move your surgical leg forward, keep your trunk straight , and reach for the arm rests.
  • Lower yourself slowly into the chair.
  • Be sure to ask for help if needed.
  • If you have had an artificial hip joint replacement, sit only on a raised/high chair.

Walking:

The physiotherapist will show you how to use a walker (or crutches) and help you to walk short distances. Be sure to ask for help if needed.

On the third day after your surgery______

  • You will be offered pain medication (that is taken by mouth on a regular basis) for the rest of your hospital stay. Be sure to tell the nurse if you are feeling any pain or discomfort.
  • The nurse will check your dressing and will change it if needed.
  • You will be up and sitting in a chair twice for meals.
  • You will be up and walking twice a day (using a walker or crutches).
  • You will continue to do your hip exercises.
  • You may use a commode (portable toilet) during the day and a bedpan/urinal at night.
  • An Occupational Therapist may visit to discuss any home needs or equipment that you may require. These will need to be in place before you go home.

On the fourth day after your surgery______