• Reference Number: HEY-1387/2023
• Departments: Orthopaedics
• Last Updated: 1 April 2023

Introduction

This leaflet has been produced to give you general information. Most of your questions should be answered by this leaflet. It is not intended to replace the discussion between you and the healthcare team, but may act as a starting point for discussion. If after reading it you have any concerns or require further explanation, please discuss this with a member of the healthcare team.

What is a broken hip?

The hip joint is a ball and socket joint between your pelvis and thigh bone (femur).

Hip fractures are cracks or breaks in the top of the thigh bone (femur) close to the hip joint. They are usually caused by a fall or an injury to the side of the hip, but may occasionally be caused by a health condition, such as cancer that weakens the hip bone.

Falls and hip fractures are common among older people as the bones become weaker with age and other bone diseases, especially in people aged 80 and over. Hip fractures are also more common in women.

How will the doctors fix my hip?

More than 98% of hip fractures need surgery before patients can walk again. About 70,000 of hip fractures are fixed by surgery each year in the UK. In Hull we operate on more than 500 patients with a broken hip each year.

Two main types of hip fracture occur. The break can be across the neck of the thigh bone or can be below the neck of the thigh bone. Each requires a different type of operation. The consultant will explain to you the type of operation that you need.

Surgery is usually the only treatment option for a hip fracture so that you can move again in comfort and begin your journey to recovery. The National Institute for Care and Excellence (NICE) recommends that someone with a hip fracture should have surgery within 48 hrs of admission to hospital.

Important: Occasionally, some patients are not well enough for surgery and the surgeon will decide to wait until their health has improved before repairing their hip.

The type of surgery you have will depend on several factors, including:

• The type of fracture (where on the femur it is)
• Your age
• Your level of mobility before the fracture
• The condition of the bone and joint ( for example, whether or not you have arthritis)

The orthopaedic team will explain the type of operation to you before you sign the consent form.

What are the risks of having a broken hip and of the surgery to fix it?

A hip fracture is a very serious injury and can be life threatening in some cases. Some patients do not survive the hospital admission and some decline in the months following discharge from the hospital. 10% of people with a hip fracture die within 1 month and one third of patients die within 12 months.

The fracture in itself is a sign that you are vulnerable and that your health may deteriorate in the short or longer term. The combination of fall and fracture often brings to light ill health and pre-existing conditions and this brings challenges and complications to the patient’s recovery back to health.

Common problems:

Pain

A fractured hip can be painful, so you’ll be offered painkillers to keep you as comfortable as possible. For some people, regular paracetamol is enough to keep the pain under control, but for most people find they need stronger painkillers.

Stronger painkillers can also cause constipation and they still may not relieve the pain enough to allow you to move around comfortably.

You may be offered a nerve block, which is an injection into the groin. This can be very effective and has less side effects.

After your surgery it is still normal to feel some pain and discomfort and this can continue for some time after your discharge but will get less and less each day. If you feel your pain is preventing you from moving after your surgery, let your doctor or nurse know.

Confusion, Delirium & Dementia

If you had a problem with your memory before you broke your hip, this may get worse for a while, confusion and agitation is also very common following a broken hip.

Hip fractures, surgery and medications can cause some people to experience a condition known as delirium, which is a state of mental confusion. This often starts suddenly and can be frightening and distressing, often it improves over time but in some cases the deterioration is permanent. If you or your family have any concerns then please speak to a nurse or doctor.

The hospital and the wards are working with the ‘Butterfly Scheme’ and ‘John’s Campaign’. The Butterfly Scheme reaches out to people with dementia, delirium and memory problems and it provides a system where care can be given to a patient based on their individual needs. Patients are identified with a ‘blue butterfly’ above the bed, on the wrist band and on the notes so that all healthcare staff know that they need to give the appropriate care for this patient group, including working with the carers and family.  John’s Campaign supports the right of people with dementia to be supported by their family and carers. There is information on the wards that explain more about the Butterfly Scheme and John’s Campaign so please take a look or speak to the nursing staff if you have dementia or you look after someone with dementia.

Chest infection

Reduced mobility and lying in bed puts you at risk of developing a chest infection or pneumonia. You will be encouraged to get out of bed to mobilise as you are able and to sit in your chair to minimise this risk.

Blood clots (thrombosis)

There is also an increased risk of blood clots developing when you are mobilising less. This can sometime move to the lungs and make you very unwell. When you are admitted to hospital the doctor will complete a risk assessment for developing clots and you are likely to be started on a blood thinning injection to minimise this risk unless you have a medical condition where you cannot have this injection. Wearing anti-embolic sticking also helps reduce the risk of clots forming.

Fall in hospital

Most patients that have a hip fracture have many risks for falling. The nurses will do a full assessment on your risk factors and put in a plan of care to try to prevent you having another fall whilst in hospital. The therapy team will assess your mobility and give you any walking aids that you need to move around safely. If you are at a higher risk of falls then you may wear a yellow wrist band, this is to tell everyone looking after you that you might fall so they can help you as you need it. The nurse call bell can be used to call for help if you need to mobilise. Although every effort is made to prevent falls, due to many contributing factors, unfortunately falls do still happen in hospital.

Pressure ulcers (pressure sores)

A lot of patients have fragile skin and reduced mobility and a lower intake of nutrition all put you at increased risk of a sore developing especially on your bottom or heels. The nurses will do a full assessment of your risk factors of getting a pressure ulcer. They will ask to have a look at your at risk pressure areas on a daily basis so they can identify any sores at the earliest stages to prevent serious damage happening and delaying your recovery. If you have any pain or numbness especially over any bony prominence or your heels and bottom please tell the nurses. The nurses will help you move around the bed if you are not able to do this yourself as this is the best way to prevent pressure ulcers developing. To help your levels of nutrition in addition to mealtimes you are likely to be offered high energy drinks and snacks. Please ask your family to also bring in other snacks and drinks that you may like.

Constipation and/or Diarrhoea

As mentioned earlier some medications, especially pain killers, can cause constipation. It is important to have your pain levels controlled so you will also be given laxatives to prevent constipation. If you have not had your bowels opened for some time or you find it difficult and painful to have them opened then please tell a nurse as there are other things you can have to help.

Some medications or viruses and infections can cause diarrhoea. If you do have diarrhoea then the nurse will usually take a sample to send to the lab for testing for infections that can be passed on to other people. Until the result of this is known you will be looked after in a single side room to prevent any potential spread of the infection. Often diarrhoea is not caused by an infection and will settle in a few days by itself.

It is important in both these cases to continue to drink plenty of fluids, especially water.

Wound infection

Sometimes you can have a leaking wound. This often settles over a few days with antibiotics or a special type of dressing attached to a vacuum. Sometimes if the infection is deeper and affects the metal work used in the hip repair you may need further surgery and a longer stay in hospital.

Dislocation

Sometimes the socket joint of the hip repair can become dislocated (moved out of joint), to put the hip back into position you would need to go back to surgery for another operation for it to be fixed.

Who will look after me during my hospital stay?

A multidisciplinary team of healthcare professionals will look after you during your hospital stay. The team includes:

Consultant Orthopaedic Surgeon and Specialist Registrars

This is the senior surgical team who are responsible for your care in the days before and after your operation. There is a large team of surgeons and it will be this team that will perform your operation.

Medical Ortho Geriatric Consultant

This is the senior medical doctor who is also responsible for your care. They look after your medical problems and review your medications.

Consultant Anaesthetist

This is the senior doctor who will assess you and explain about your anaesthetic. You will be given your anaesthetic by an anaesthetic doctor before your operation.

Junior Doctor and Advanced Care Practitioner (ACPs)

A team of orthopaedic doctors and ACPs are based on the ward daily and will work with your consultant.

Neck of Femur (NOF) Specialist Nurse

The Nurse specialist will see you in the first few days of your admission, and will follow you up along with the Ortho Geriatric Consultant.

Ward Nursing Team

There is a large team of nurses of different roles and responsibilities that will help you with your daily needs. The ward sister is the first point of contact if you have any questions or concerns. The nursing team will work with you and your family to help ensure a safe and timely discharge from hospital.

Therapy Team

There is a team of therapists including physiotherapy and occupational therapy that will work with you to progress your mobility, abilities and needs with everyday tasks. If you have any other needs you may also see other therapy staff such as Speech and Language therapy and dieticians.

Other health care professionals

There are many other professionals who you may see whilst in hospital to assist you in your recovery and progress to discharge.

What will happen to me before the operation?

You will be admitted by the nursing staff on the ward

Routine assessments of your falls risk whilst in hospital, nutrition and pressure care will all be completed.

You will meet the surgical team

Before your operation, the surgeon will explain to you what type of break you have, and what type of operation would provide the best fix.

The surgeon will mark the skin over your broken hip with a pen before surgery, and will ask for your permission to perform the operation. You will be asked to sign a consent form.

In order to get you ready for surgery, to make you comfortable and in a good fit state for the operation, the surgical team may arrange the following for you:

• Painkillers

Regular painkilling tablets will be prescribed. If you are in pain, ask the nurses for extra painkillers.

• Intravenous fluids (a ‘drip’)

You are not allowed to eat or drink for several hours before surgery. You will be given fluids into the veins to stop you getting dehydrated.

• Blood clot prevention

This will involve wearing elastic stockings and having small, daily injections under the skin or taking tablets.

• Blood tests and scans

You might need more tests in addition to the ones you had in the Accident and Emergency department.

• A catheter

If you find it too difficult or uncomfortable to use a bed pan, the nurse might fit you with a plastic tube to drain your urine.

You will meet the Anaesthetic Team

Before your operation you will be visited by an anaesthetist. There are two main types of anaesthetic used. You will be advised which is the most suitable for you.

1. General anaesthesia

This is where drugs are given that make you sleep during the operation. Local anaesthetic injections to the groin or lower back may be offered to you, to provide additional pain relief. These relieve the pain for 4-6 hours after the operation.

2. Regional (‘spinal’) anaesthesia

After receiving some sedative drugs to make you feel sleepy, you will be given a small injection in the middle of the lower back which will numb your body below the belly button during and after surgery (for several hours). You do not sleep with this type of anaesthetic, which allows you to recover quicker after the operation.

What will happen to me after the operation?

When you leave the operating theatre, you will be taken to a recovery area in the theatre suite, where you will be looked after by a special nurse until you come round from your anaesthetic/sedation. The nurse will check that you are warm and comfortable, and that your blood pressure and heart rate are normal, before you are taken back to your ward bed.

You may feel sick or groggy for several hours after the operation. Drugs can be given to stop you feeling sick.

With the break fixed, you should feel more comfortable. A nurse will check your pain level regularly, and will give you painkillers if you need them.

All patients lose some blood during a hip operation. Depending on your blood tests and general health, you may need a blood transfusion before, during or (more commonly) after your operation.

Constipation is common after a hip operation. Ask your nurse for laxatives (bowel medicine) if you are having trouble opening your bowels.

You may feel confused after the operation. Usually this is mild and gets better by itself, but your doctor may need to do further tests or give more treatment if you become very confused.

You will be encouraged to build up your strength after the operation by eating regularly. Additional ‘build-up’ drinks may be given to you if you are having difficulty swallowing more solid food.

You will be seen after your operation by the physiotherapist, who will show you some deep-breathing exercises and help you get up and out of bed if you are well enough. This helps to reduce the risk of chest infection and dangerous blood clots forming in your legs.

If you have a catheter tube draining the bladder then this will be removed as soon as possible after the operation. The catheter is removed to reduce the risk of a urine infection.

You will be reviewed and seen most days by a member of the surgical team, who will monitor your operation wound and general health.  You may also be seen by the Consultant Ortho-geriatrician who will monitor your overall medical condition.

Please ask a member of staff if you are uncertain about what has happened to you, what is planned for your recovery or, indeed, if you have any questions about your care.

How will I get back on my feet?

Unless your surgeon advises otherwise, the physiotherapists will help you get up and out of bed the day after your surgery. They will support you to begin with until you feel more confident, they will work with you and the nursing team with a safe plan to enable you to build up your mobility.

You will be encouraged to practise walking up and down the ward, before being shown how to cope with stairs. Recovery can take several days or weeks, and sometimes longer, but the key is to be patient and practise the exercises that the physiotherapists show you.

The physiotherapists, nursing staff and occupational therapists will give you help and advice for the safest place for you to be discharged to, as this may not be back to your home address from hospital. You may need some respite, more rehabilitation in the community or support at home with help from carers. 10–20 % of patients admitted from their own home with a fractured hip move to a care home on discharge from hospital.

If you had dissolvable stitches, these will not need to be removed. If you had metal clips, these will be removed 10-12 days after the operation. You will be able to get the scar wet after this time, providing the wound is closed and dry, but you should only have a shower after advice from your nurse.

A broken hip is a serious injury and life changing event. You will have undergone a major operation to fix your hip. Even when you are ready to go home you will not be back to your normal movements and walking as a full recovery takes a long time.

For some patients unfortunately they never get back to their normal. Most people find that their walking is not as good as it was before they broke their hip. Many patients need extra walking aids and extra help at home.

Twelve months after hip fracture about 60% of patients still are limited in at least one type of activity (e.g. feeding, dressing, toileting). 80% of people are unable to do more complex activities such as gardening or shopping.

What happens when I leave the hospital?

Hull University Teaching Hospitals NHS Trust is committed to providing patient centred care, ensuring consistency in delivery of high quality, safe care.  The Trauma Orthopaedic wards (12 and 120) are within Hull Royal Infirmary which provides dedicated care to trauma orthopaedic patients.  There are 50 inpatient beds across the two wards based within the Tower Block at Hull Royal Infirmary.

In order to ensure you are discharged to the safest place, once your medical care on ward 12 or 120 is completed, the ward team, nurses, discharge assistant, social workers and hospital discharge team all work together with yourself and your family to ensure your needs can be met when you leave the hospital.

When the acute phase of your admission is over and you are no longer receiving acute medical and surgical care, people are able to return home, following a period of therapeutic interventions, this can be undertaken away from the hospital setting.

The community providers of care facilities and community beds can provide respite and further rehabilitation with nursing input if this is required. This provision enables an early supported discharge of patients following treatment for fractured neck of femurs, shaft and distal femur fractures.

When the surgical and ortho-geriatric Consultants are happy that you have made a good recovery from your operation you will be deemed ‘medically ready for discharge’.

If you are ‘medically ready for discharge’ but still need rehabilitation and physiotherapy before you are able to go back to your own home you may be transferred to a community rehabilitation facility. The facility will obtain information about you to ensure that they are aware of your medical history and continuing care needs and importantly your therapy needs. They will work with you and your family/carers to assess your needs, building on the information gathered from your previous ward teams to ensure the safest and most appropriate discharge. This move is a transfer and continuation of your care needs. We will involve you and your relatives/carers in all decisions about your care.

If rehabilitation is not a suitable option for your needs you may be offered support on discharge at home with carers or respite in a care home. For some patients it is appropriate to consider longer term care in a care home or even care in a hospice.

If you would like to speak to the nurse in charge about any concerns you may have, ask to speak to the nurse in charge or Ward Sister.

General Advice and Consent

Most of your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion with the healthcare team.

Consent to treatment

Before any doctor, nurse or therapist examines or treats you, they must seek your consent or permission. In order to make a decision, you need to have information from health professionals about the treatment or investigation which is being offered to you. You should always ask them more questions if you do not understand or if you want more information.

The information you receive should be about your condition, the alternatives available to you, and whether it carries risks as well as the benefits. What is important is that your consent is genuine or valid. That means:

• you must be able to give your consent
• you must be given enough information to enable you to make a decision
• you must be acting under your own free will and not under the strong influence of another person

Information about you

We collect and use your information to provide you with care and treatment. As part of your care, information about you will be shared between members of a healthcare team, some of whom you may not meet. Your information may also be used to help train staff, to check the quality of our care, to manage and plan the health service, and to help with research. Wherever possible we use anonymous data.

We may pass on relevant information to other health organisations that provide you with care. All information is treated as strictly confidential and is not given to anyone who does not need it. If you have any concerns please ask your doctor, or the person caring for you.

Under the General Data Protection Regulation and the Data Protection Act 2018 we are responsible for maintaining the confidentiality of any information we hold about you. For further information visit the following page: Confidential Information about You.

If you or your carer needs information about your health and wellbeing and about your care and treatment in a different format, such as large print, braille or audio, due to disability, impairment or sensory loss, please advise a member of staff and this can be arranged.