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should the fracture be fixed?

Should the fracture be fixed?

This year, in the United States, approximately 400,000 people over the age of 65 will be admitted to the hospital with a hip fracture.  Often the hardest question for the family to grapple with is whether or not the fracture should be fixed.  In times past, a hip fracture was often referred to as an “old person’s friend”, usually because a hip fracture was seen as an end of life event.  If the fracture is not operated upon and the patient is confined to bed, there is a very high chance that the patient will develop pneumonia, bed sores, or a urinary tract infection that could overwhelm the patient and end their life.  The mortality rate of untreated hip fractures in the elderly is quite high, probably higher than 85% within a month of the hip fracture, and the most effective way to reduce this mortality rate is to fix the fracture so that the patient can get out of bed and start moving again.

In my experience, most families opt to have the fracture fixed, even if the patient has evidence of age-related dementia and has a hard time participating in the decision-making process.  Typically, the most common patient who does not have their hip fracture fixed is an individual who knew that they were developing a major illness such as cancer that couldn’t be treated or early onset Alzheimer’s disease, and they created a living will that specifically states that they do not want to have surgery if they should fracture their hip.

However, even if the fracture is fixed, it is important to realize that these fractures typically occur toward the end of life.  Medical research shows that more than 50% of the elderly will pass away within 2 years of a hip fracture.  The cause of death is usually unrelated to the hip fracture surgery, but it is important to realize that by the time the bones have weakened to the point where they will fracture as the result of a simple fall, the heart, lungs, and other organ systems are starting to fail as well.  The most common reason why people pass away within the first two years after surgery is pneumonia or another infection, often caused by a urinary tract infection.  This is because the body’s immune system is weakened with age, fracture healing takes a lot of energy and calories, and the patient is often already in a relatively tenuous state.

In my discussions with families, the most commonly stated reason why people want their loved ones to have surgery is because they don’t want them to experience pain that can be effectively treated with surgery.  I think that this is a VERY reasonable motive.  Hip fracture surgery stabilizes the broken bones, it takes away most of the pain associated with simple movements such as moving around in bed, using a bed pan or a commode, and it makes it possible to get out of bed again and tolerate physical therapy and rehabilitation if the patient is strong enough.

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