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Introduction

A fracture is defined as a bone lesion characterized by disruption of continuity of bone tissue (5). Although any site may fracture the pelvic girdle, the term hip fracture is commonly associated with the breakdown of some of the bones forming the hip joint (11). As with other fractures or dislocations, can be caused by violent impacts (traffic accidents) where the leg is straight and produces a force that is transmitted to the hip (6).

fractures of the pelvis can be especially dangerous if you injure the soft tissues such as blood vessels, nerves or internal organs (6).

Femoral Neck Fracture
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impact

Hip fractures are particularly common in people over 60, especially women, whose bones tend to be weak and brittle due to osteoporosis (4,6,11) and the trend of falling. The incidence is increasing due to increased life expectancy (11).

In Costa Rica, femoral neck fractures with the wrist, are the most common in the elderly (4). In hip and thigh injuries, hip fracture occupies first place in incidence with 90% (5).

In the United States estimates that between 300 000 and 500 000 people suffer from this type of fractures per year (11) and although the surgery is performed in that country, medical tourism to Costa Rica currently suggests that the Therapists must be prepared to rehabilitate foreign patients who have suffered this problem. Causes



Falls (4) and osteoporosis (4.5) are the most common cause of hip fractures, and these events are generally etiology multifactorial (social, physical, medicine, etc) 4. Virtually all minor changes to the age (4) are related and therefore falls with hip fractures, among them we can mention (4):

• Osteporosis and osteoarthritis stiffness and / or reduced muscular control
Unsteady
• Alteration of postural reflexes
• cardiovascular disorders (myocardial infarction, pacemaker Dysfunction of the barroreceptores)
• auditory and visual disturbances
• neurological disorders (stroke, myelopathy, altered proprioception, acute confusional, alterations cognitive)
• hypoglycemia, anemia, syncope

Hip Osteoarthritis is characterized by pain, edema, loss of function and erosion of articular cartilage. It is common cause of disability (6).

is important to note that the sharp falls even on the buttocks, can cause injuries such as broken branches of the pubis, acetabulum, or cartilage injury or even perforation of the acetabulum and femoral head (6).

Hip Joint Arthritis http://www.edward.org/AEImages/adam04/graphics/images/es/19678.jpg

Although falls are the most common cause of hip fractures, one should not assume that all falls are always in this type of injury. Even it is estimated that only 3% to 5% of falls end in splits (4).

• exogenous factors or environmental factors include (5):
• slippery or uneven surfaces such as carpets
• Barriers wrinkled
• pet steps or lack of lighting and railings

Symptoms and signs
Generally
after a fall where a hip fracture occurs appear the following signs and symptoms:

• shooting pain in the groin and over the greater trochanter (5.8) and sometimes radiates to the knee (8)
• functional impotence to move the hip (5)
• deformity and shortening (5.8 )
• External rotation of the tip (5)
• Weakness in the muscles of the hip (8)

hip fracture patients
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Rating

Hip fractures are classified their anatomical location (4.5) and severity (5). The basic considerations are whether the fracture is in the areas intracapsular, extracapsular (5) or acetabular (3,4,5).

intracapsular fractures, also known as femoral neck fractures (5.11) are the most commonly seen in people over age 65 (11). Are located at the head and neck of the femur and when they are displaced affect the irrigation of the femoral head (3.5) so they can produce avascular necrosis (3.5).

Fracture Types
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This type of fracture to are subdivided using the classification of Garden5, where non-displaced fractures can be type I and II, associated with a better prognosis in terms of consolidation and incidence of necrosis (5). Displaced fractures can be type III and IV, with a more guarded prognosis (5).

X-ray hip fracture
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Extracapsular fractures are those that are located in the intertrochanteric and subtrochanteric regions (3,4,5). The first are between the greater trochanter and the child and are the result of low energy trauma in bones with osteoporosis (5). Are associated with higher mortality (5). From the practical point of view are classified into stable and unstable, according to the criteria of Evans / Jensen (5), which help determine treatment and prognosis (5).

subtrochanteric fractures are located between the lower edge of the lesser trochanter and the junction between the proximal and middle third of the femur (5). These injuries are more common in young and trauma resulting from high density (5).

acetabular fractures, as its name implies, occur in the hip bone level and may be particularly acetábulo4 dangerous when it affects internal organs to the pelvic region (6).

X-ray left acetabular fracture
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The
Treatments primary goal of treatment is to reduce pain and increase range of motion (11). In the majority of hip fractures should be surgical treatment, however, in some patients is contraindicated by their medical condition (4), so rather covers non-surgical treatment.

Non-Surgical Treatment

This treatment consists of rest in bed for several months and sometimes drive (4). In this case we observed complications of maintaining a patient in the same position for an extended period of time (eg pressure ulcers and respiratory dysfunction (4). There also exists the risk of inadequate consolidation, lowering expectations healing (4).

Surgical

In nondisplaced fractures using nails or screws (4), whereas displaced fractures or where there is severe arthritis (4), use one of the following methods.

• Hemiarthroplasty: replacement of the femoral head or acetabulum, but not both (8,11).
• Total Hip Arthroplasty: Replacement of the femoral head and acetabulum (8,11,12).

These procedures exist from the 60's8 and although the general principle is the same, the materials, techniques of anesthesia, surgery and nursing care have improved considerably (8). They are especially recommended for patients with cartilage wear (osteoarthritis) of the joint (8).

The prosthesis is usually polyethylene acetabulum while the femoral cobalt-chromium, titanium or stainless steel (8,11). Both are designed to withstand high levels of stress (11). The prosthesis is attached to healthy portions of the bone using acrylic cement and screws (11).

During the procedure, the damaged bone ends are removed and put into place the prosthesis metal, ceramic or plastic (11). The general steps listed below (11):

1. The femoral head is removed and is cut to fit the prosthesis
2. The socket is shaped to accept the new cavity
3. Place the metal bracket on the acetabulum acetabular8 drink called
4. the prosthesis is inserted in the place where femoral head was

Removing the head of the femur (left) and molding of the acetabulum (right)
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Placement acetabular prosthesis (left) and head of the femur (right)
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Complications and prognosis

Potential complications of arthroplasties are associated with post-operative conditions and associated risk factors (4,8,11). The main complications are:

• infections (4.5)
• loss of functional capacity (5)
• venosa4 Thrombosis, 5, or pulmonary embolism (5)
• retention or urinary or fecal incontinence (5)
• dislocation of the prosthesis components (4)
• nerve injury (4)
• Pain Depression
• Offset Anemia of chronic disease (5)

The prognosis is similar to the decision of the therapeutic method depends on the location of the fracture (4). It is estimated a mortality of 12% to 41% in six months (3.4), according to associated risk factors. The causes of death related to pneumonia, electrolyte imbalance, strokes, heart failure and pulmonary embolism (4).

Risk Factors

risk factors are related to the causes of falls. The main risk factors identified in the study of Lopez et all, 2007 is summarized below (5):

• age: post-menopausal women and men over age 75 (5)
• Females: More common in women because of the anatomical arrangement and pattern hormonal3, 5 separate are more likely to osteoporosis (5)
• White Race: Less common in people of color (5)
• Osteoporosis: A decrease in bone density (3.5) falls
• Syndrome: Caused by slippery or uneven surfaces, obstacles, lack lighting, etc. (5)
• Sedentary: Typical of older people with limited mobility (5)
• Loss of muscle mass, causes abnormal gait and posture problems (5)
• visual deficit: Considered also risk factor for falls (5)
• Unsteady gait: The loss of muscle mass or neurological disorders (5)
• Eating Disorders: Obesity *, malnutrition, alcohol abuse (5)
• lower limb orthopedic conditions: Osteoarthritis of the Hip (Coxoartrosis), osteoarthritis of the knee (gonarthrosis), deformities of the first toe (hallux valgus)

(*) Some authors do not consider obesity as a risk factor for soft tissue usually act as damping mechanism in a fall (3).



Prevention Prevention of hip fractures involves a deal as far as possible riesgo5 factors. Some of the key recommendations are (3.5):

• Early diagnosis and treatment of osteoporosis
• Treatment of visual problems
• security measures to prevent falls (correct lighting, security bars, etc)
• Exercise for improving balance and walking
• Proper diet

Care Patient

pre-and postoperative care of a patient with hip arthroplasty vary from one institution to another. By way of illustration, are some recommendations used by the Hospital General Universitario de Valencia (10). Although many of these care are performed by nurses, it is always important that any health professional related to the patient to know the basic protocol.

recommended care during hospitalization and surgical preparation are:

• Environmental Management and Maintenance
• comfort venous access devices
• Administration of medicines.
• Advice / education about the surgery

care recommended in the postoperative period are divided into immediate, first day, second day and third day. The most important are listed below:

Help
• self care (bathing, hygiene, food, etc)
Repositioning Education
• exercises / activities prescribed
Post Anesthesia Care Pain Management
monitoring vital signs of peripheral embolism
• Care Maintenance
• venous access devices
• analgesics
• Care of the incision site urinary catheter care
Control of bleeding
• primary caregiver support

Home Care

postoperative care at home are important as they can speed recovery patient's complete rehabilitation. Some of the recommendations suggested by the University Medical Center Mississippi are as follows (12):

• Sitting in a chair with armrests to help get up and do it always with the affected leg in front of the unaffected leg.
• Sit with your feet at least 6 inches.
• The affected leg should always look ahead
• Do physical therapy exercises but should be discontinued if you experience severe pain
• If your legs swell when walking, lying down with feet elevated
• Use handrails on stairs and upload until the doctor tells
• Use low-heeled shoes
• Place a pillow between your legs when sleeping on one side and the unoperated side
• Use support stockings and take them off at least twice a day for 30 minutes.
• If traveling by car, making stops every hour to get out and walk around to increase blood flow to the legs.

Some activities are not recommended are as follows (12):

• not sit with crossed legs
• not walk on wet or polished floors
• not lean forward or sideways to pick up objects
• not sit on low chairs or sofas
• not take baths in the bathtub
• surgical wound not rub
• not lift anything heavier than 5 pounds
• not drive, have sex or play sports until the doctor tells
• Before any extraction or surgery of the teeth, tell the dentist about hip surgery

Some of the symptoms and warning signs after surgery (12):

• pain, swelling or redness in the calf of either leg
• Redness, warmth or drainage surgical wound fever or chills
• severe hip pain that does not improve with medication
• sharp and sudden pain in the hip that is accompanied by a sound "popping"
• shortening of the leg and foot outward deflection
• productive cough and phlegm out of yellow or green
• Shortness of breath or pain burning on urination, back pain accompanied by

Conclusions

In any medical treatment, patient education is paramount. Any health professional should have general knowledge of diseases and common treatments. Hip fractures are problems whose incidence is increasing worldwide and is therefore essential to obtain all information as possible, including, obviously, minimal nursing care.

The nursing staff has the knowledge and professional training to treat patients pre-and post-operative. Although the physical therapist is not directly involved in some processes (eg, surgery), it is part of a multidisciplinary team that aims to care for and rehabilitate the patient. All knowledge gained support in communication with other team members and will always benefit the patient.

Medical Tourism in Costa Rica is increasing and with it the need for physical therapists with knowledge of general care patients. Since hip replacement also is increasing, students in this career should be prepared to serve patients coming from other countries.

Importantly, at all times the health personnel should be able to anticipate, predict and adjust the risk (3), and understand that health education is one of the key elements for the management of patients with this type of surgery (3). Original Paper



This research was part of the Rehabilitation Nursing Course, American University.

Disposible online:
http://www.bluejaygallery.com/download/FracturasCadera.pdf


References

(1) Baptist Hospital. 2009. Care for Total Hip Replacement in the Orthopedic Unit. Baptist Health South Florida. United States.
(2) Beita Ruiz, Anais. 2009. Recommendations for Patients with Hip Replacement Surgery for Osteoarthritis. Shop eFisioterapia.net. Spain.
(3) Campos, F. Girbes, I. Canto, M. Gonzalez, E. 2005. Hip fracture: a problem that is expected to increase in coming years. Integral Nursing. Spain.
(4) Carvajal Montoya, Alvaro. 2007. Falls and Hip Fractures in the Elderly. Medical Journal of Costa Rica and Central. LXIV 199-202. Costa Rica
(5) Lopez, Giorjanela. Chacón, Kennedy. Rivera, Alvaro. 2007. Hip fracture incidence in Costa Rica. Medical Journal of Costa Rica and Central America. LXIV 125-132. Costa Rica
(6) Moore, Keith. Dalley, Arthur. 2003. Clinical Oriented Anatomy. Edition 4. Editorial Médica Panamericana. Argentina.
(7) Riquelme, Raul. Candia, Rodrigo. Riquelme, Roberto. Santana, Pablo. Montoya, Victor. 2008. Total Hip Arthroplasty in Severe Osteoarthritis. Hernan Henriquez Aravena Hospital. Chile.
(8) Sanchez, Alfredo. 2002. Total Hip Replacement. Health Charter. Fundación Clínica Valle del Lili. Number 70. Colombia.
(9) Silva, Carlos. Alvarado, Constanza. Llinás, Adolfo. Navas, Jose. Rodriguez, Hugo. Cadena, Eusebio. Carrillo, Germain. Zayed, Gamal. 2006. Conventional Total Hip Replacement Mini-incision face. Fundación Santa Fe de Bogotá. Colombia.
(10) Ten Gil, A. Adrian Campos, E. Casan Benito, A. Gonzalez Sanchez, E. 2007. Nursing care in patients undergoing hip arthroplasty in CHGUV. Digital Nursing. Hospital General Universitario de Valencia. Spain.
(11) Tortora, Gerald. Derrickson, Bryan. 2006. Principles of Anatomy and Physiology. 11 th. Edition. Editorial Médica Panamericana.
Mexico (12) University of Mississippi. 2005. Home Care for Patients with Hip Replacement. Medical Center of the University of Mississippi. U.S.