I have picked this topic to discuss because as we are located in one of the prime retirement areas of the country, and despite the relative youthfulness of our senior citizens here and their high level of activity, increasing in years does increase the risk of osteoporosis and of fractures, particularly hip fractures. The greater the degree of osteoporosis, the more the risk of fracture, and fractures which limit activity increase the risk of osteoporosis.
First of all, what is osteoporosis? Osteoporosis is often considered a loss of calcium from the bone, but, in fact, it is a loss of bone so that the bones are thinner and the inside structure is more fragile. Risk factors are advancing age, a low level of activity, being too thin, poor diet, and smoking. After menopause, women lose calcium a bit faster than men and since their bones are smaller to start with, they are a bit more at risk, but men do face this risk as well. Heredity is important – if your parents had problems with softening of the bones, then you will also be at increased risk.
Bone loss can be seen on an x-ray if it is extreme, but an x-ray is a very inaccurate way to estimate it. Ultrasound technique has been developed to scan the heel, which is a quick test, good for screening, but does not give the detail of more sophisticated testing on bone such as the hip and spine. The most common technique and most accurate uses x-ray beams of different energy levels to differentiate between bone and soft tissue such as muscle. This is the technique we use in our office. The report is expressed as a “T” score which measures the number of standard deviations below ideal. 0-1 is normal, -1 to -2.5 is borderline, and a score greater than -2.5 is osteoporosis. A “Z” score compares you to members of your age and gender. Scores above 100% are much better than average. Scores below that indicate that you are less than your peer group.
What is the risk of fracture if you have osteoporosis? There is no one answer to this as many factors come into play. Bone loss of -2.5 is associated with increased risk of fracture, but no matter how hard your bone is, if you fall hard enough or without a chance to break the fall, a fracture is likely.
When hip fractures do occur, there are four general types. Fractures of the hip socket (acetabulum) or of the pelvis are painful, but generally heal by themselves without any surgery. Weightbearing might be immediate or it might be delayed for some time, depending on the fracture pattern.
Fractures just below the ball of the hip (through the femoral neck) might be “impacted.” You might think of this as like an ice cream cone and the ice cream has gotten jammed down in the cone. These fractures are often treated with some special screws that can even be inserted through the skin, keeping the fracture from shifting. If the fracture just below the ball is complete so that it comes apart, this is called a subcapital fracture or sometimes an intracapsular fracture. Because these fractures disrupt the blood supply, they heal poorly if the bones are just realigned and fixed in position. These fractures are more commonly treated with a “hemiarthroplasty.” This means that half of the hip is replaced with a metal or metal and plastic ball and stem. This differs from a total hip replacement as the acetabulum (socket) is not involved.
The other common hip fracture is an intertrochanteric fracture. The trochanter is the point of the hip. This is about two hands breadth below the crest of the pelvis. An intertrochanteric fracture starts at the trochanter and goes diagonally downward, toward the inside of the leg. This is the type of break that is fixed with a metal plate and screw. It is often called a “hip nailing” as the original technique of treating this actually involved hammering a special metal support into the bone. We should mention at this time that what most people call the “hip” is the crest of the pelvis. That is where your belt would rest. The actual hip joint is down in the groin area and you can feel this if you move your leg and see where the rotation takes place.
Do hips ever just break and then you call? If this happens, it is extremely rare. What more commonly happens is if you trip and start to fall, the leg starts to twist, your weight is placed on it, and it is the weight and twisting that will cause it to break. Of course, some bones only break when you hit the floor. Many breaks can be avoided by being extra careful as far as balance. Using a night light and sitting on the edge of the bed for a few minutes at night before you get up is a good practice. Also watching out for steps, watching out for parking lot bumpers, generally being aware of balance are all a big help.
If you do, however, have a fracture, this is one of the best areas in the country to be treated. We are used to dealing with people with hip fractures. The oldest one that I have treated was 110 years old! Within the surgeons of our group, the combined experience is over 100 years of fixing hip fractures. We are always available for any injury that you might have. If we are not on call at the hospital, you can always ask for us. often, it is a good idea to keep our name and phone number in a handy place to give to the emergency room should you have to go there. It is still better, however, to see us before anything is broken and we can test your bone density and prevent any fractures from occurring in the first place.