Scand J Prim Health Care 1990; 8: 139-44

Hip Fractures in Primary Health Care Evaluation of a rehabilitation programme LARS BORGQUIST', EVA NORDELL', GUN-BRITT JARNLO', BJORN STROMQVIST', HANS WINGSTRAND* and KARL-GORAN THORNGREN'

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'Department of Community Health Sciences, Lund University, Dalby, S-240 10 Dalby, Sweden, 'Department of Orthopaedics, Lund University, S-22185 Lund, Sweden

Borgquist L, Nordell E, Jarnlo G-B, Stromqvist B, Wingstrand H, Thorngren K-G. Hip fractures in primary health care. Scand J Prim Health Care 1990; 8: 13944 The routine follow-up of hip fracture patients was transferred from the Orthopaedic Department, Lund University Hospital, to the primary health care districts in 1985. The medical state and social functions of all 298 patients during the first 12 months of the follow-up rehabilitation programme were registered. Before fracture, 61% lived in their own homes, 22% in old people's homes, and 14% in geriatric hospitals or nursing homes. Four months after fracture, 13% were dead, 47% were living in their own homes, 14% were in old people's homes, 25% in geriatric hospitals or nursing homes, while the rest were in other types of institutional residence. Of patients coming from their own homes, 75% were back at home four months after fracture and their social and functional status were as good as before fracture. The study has shown that routine check-ups at the orthopaedic department can be omitted. Follow-up in primary health care without radiography and orthopaedic expertise gives equally good functional results as in previous studies, provided that patients with pain and walking problems from the hip are guaranteed rapid specialist treatment. Key words: hip fracture, elderly, rehabilitation, follow-up, primary health care. Lars Borgquist, MD, VHrdcentralen Sodertull, S-22185 Lund, Sweden.

Due to an increasing proportion of elderly and an increase in incidence in Scandinavia as well as in other Western countries, the number of hip fractures may continue to increase in the coming decades (1-7). Thus, the increasing number of hip fractures will make great demands on the rehabilitation resources, and new forms of treatment for these patients are necessary (8-11). Improvements in the overall treatment are thus required. During the past decades there has been an adaptation to the increasing number of patients. Different ways of reducing hospitalization time have been applied, such as new operative techniques and rehabilitation programmes. A t the beginning of the 1950s all rehabilitation activities were performed in hospital. The patient was confined to bed for approximately four months and the mean hospital stay was more than five months (12). Because of a fear of healing complications the non weight-bearing period was very long. The non-weight-bearing period was

reduced from four months to two months during the 50s and from two months to one day at the end of the 60s. Further strategy changes in the treatment of hip fractures, i.e. a programme with rehabilitation at home in collaboration with primary care and change in surgical techniques, decreased the mean hospitalization time from 44 to 16 days between 1966 and 1982 (13). In spite of this the return rate home at discharge from hospital increased from 44 to 75% for patients coming from their own home. Previous studies have shown how rehabilitation programmes can be applied in primary health care (10, 14). In order further to adapt to the increasing number of hip fracture patients, all routine followups of hip fractures were transferred from the orthopaedic department in Lund to primary health care in 1985. The aim of the present investigation was to present rehabilitation results achieved with this follow-up programme in primary health care, and to Scand f Prim Health Care 1990; 8

140

L. Borgquistetal.

Table I. Patients grouped according to type of fracture and sex. Patients coming from their own home are shown within brackets. Male

Female

Total

Basocervical Trochanteric

35(23) 3 (1) 35(19)

113(76) 11 (7) lOl(54)

148(99) 14 (8) 136(73)

Total

73(43)

225(137)

298(180)

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Cervical

compare the results with those presented in previous studies. PATIENTS AND METHODS All consecutive patients with hip fractures occurring since 1 November 1985 in the Lund University Hospital catchment area were followed prospectively concerning social and functional parameters. This presentation concerns the patients during the first registration year, from 1 November 1985 to 31 October 1986. All the patients were operated with hook-pin osteosynthesis for cervical fractures and sliding screw-plate for trochanteric fractures. Immediate weight-bearing was encouraged. Radiographs were obtained directly on the operating table postoperatively and then after some days of weight-bearing. Further radiography and follow-up at the orthopaedic department were omitted unless hip pain occurred. A follow-up scheme for each patient was sent from the orthopaedic department to the primary health centres (19 different centres) in the catchment area. The follow-up scheme comprised questions about habitat, hip function, and the functional, soPer cent

RESULTS Hospitalization. The mean duration of stay in hospital, all patients, was 17 days (16 days for cervical and 18 days for trochanteric fractures). Patients coming from their own home stayed longer (18 days). The mean duration was 15 days for men and 18 days for women of those coming from their own home. Residence (Figure 1). Before fracture, 61% lived in their own homes, 22% in old people’s homes, and Per cent

All ptlentr

90-

cial, and psychological states. Most of the questions were divided into two categories (yedno) and some into three categories (yes, partly, no). A primary health care personnel (mainly a district-physiotherapist) contacted all patients at one, two, and four months postoperatively. On all the occasions the follow-up scheme was applied. This rehabilitation programme has been tested previously (10, 14). The treatment, which was camed out in the patients’ own homes or other places where they lived, consisted mainly of walking instructions and a successive decrease of walking aids. All patients over 50 years of age were included in the study (98% of the hip fractures during the period). The total number included was 298 patients. The ratio womedmen was 3:l (22.973) and the fractures were evenly distributed between cervical and trochanteric, irrespective of prefracture habitat (Table I). The mean age for all patients was 78 years for cervical, 80 years for basocervical, and 81 years for trochanteric fractures. The mean age was 78 and 80 years for men and women, respectively. Student’s t-test and the chi-square test were used in the statistical analysis.

All patients

100

100

a0

80

70

-

0

Acute hosp Nuninghonm Oldpeopleshon Convakscant Ownhorns

W-

M40

30 20 10

-

-

0-

Admltted

Dlrch8rged

Fig. 1A. Residence at admittance and discharge for all patients (n = 298). Scand J Prim Health Care 1990: 8

1

2

4 months

Fig. IS.Residence at different periods after fracture for all patients (n = 298).

Hip Fractures in Primary Health Care Table 11. Residence in per cent at different periods (n = 298). Patients coming f r o m their own home are shown within brackets (n = 180).

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Time

Own home Convalescent home Old people's home Nursing home or geriatric hospital Acute hospital Deceased

Prefracture

One month

Four

("/.I

("/.I

("/.I

61( 100) 1 22 14 2 0

47(75) 0.5 (0.5) 14 (6) 25 (9.5)

6 (4) 5 (4)

0.5 (0) 13 (9)

100

100

Total

Table IV. Functional parameters at different periods. Per cent of surviving patients coming f r o m own home. PreOne fracture month

Parameter

months

39(65) 3 (3) 12 (3) 35(21)

100

14% in geriatric hospitals or nursing homes. Four months after fracture, 47% lived in their own homes, 14% in old people's homes, and 25% in geriatric hospitals or nursing homes. 13% were dead at four months after fracture. Of patients coming from their own home, 75% were living in their own homes four months after the fracture, 6% in old people's homes, 10% in geriatric hospitals or nursning homes, and 9% were dead (Table 11).

Medical and functional status. The hip functions such as flexion (ability to sit in a chair) and extension (ability to lie supine with straight legs), the walking capacity indoors (long distance. means walking between rooms and short distance means walking within a room) and outdoor walking (long distance is walking more than 500 meters and short distance is walking less than 500 meters), the ability to manage activities of daily living (ADL) such as dressing and personal hygiene, and the ability to do cleaning cooking as well as shopping are shown in Tables I11 and IV for patients originally coming from their own home. All functions improved between one and

141

Four months

83 12 5

92 5 3

Ambulation with a walking91 stick or no support

23

54

91

75

86

>500 m 62 short 30 not at all 8

16 44

38

40

44 18

manage 94 partly 5 no 1

72 25 3

81 18 1

CleaninglCooking

yes 75 partly 10 no 15

36 21 43

56 17 27

Shopping

yes 66 partly 8 no 26

10 9 81

28 11 61

long 89 short 9 not at all 2

Indoor walking

Climbing stairs Outdoor walking

ADL

four months postoperatively but did not entirely reach the pre-fracture level. Before fracture 94% of the patients could manage their ADL and at four months after the fracture 81% had regained this ability totally and 18% partially. Similar results, but with a slight decrease at four months after fracture compared with the prefracture status, were seen for indoor walking (increase) and climbing stairs (five steps o r more), while outdoor walking and shopping decreased more (Figures 2, 3, 4).

Social status. The percentage of surviving patients Per cent

ADL

(personal hyglenaldmsslng)

No

Table 111. Hip function at different periods. Per cent of surviving patients corning f r o m own home. Flexion denotes ability to sit in a chair, extension denotes ability to lie supine with straight legs. Parameter Pain (at rest) Pain (walking) Flexion Extension

Prefracture

One month

Pamy

Four months

5

22

18

13 97 96

55 98 94

38 97 93

Manages

Prefracture

1 Month

4 Months

Fig. 2. Proportion managing ADL (dressinglpersonal hygiene) - patients coming from own home at different periods after fracture (n = 180). Scand I Prim Health Care 1990: 8

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L. Borgquist et al.

Per cant

Indoor walking

im

NO: a all

80

Shorl dlbtilm

80

70

Table V. Social and psychological parameters at different periods. Per cent of surviving patients coming from own home. Parameter

80

PreOne fracture month

50

Four months

40

Lmg dinanm

34 20 10 0

Prefracture

1 Month

4 Monlhs

Fig. 3. Proportion managing indoor walking - patients coming from own home at different periods after fracture Scand J Prim Health Care Downloaded from informahealthcare.com by 36.250.89.14 on 05/20/14 For personal use only.

(n = 180).

who were living on the ground floor, living with someone, had visited someone last week or month and were receiving a visit by someone last month were almost the same at four months after fracture compared with the prefracture status. Before fracture, 27% of the patients coming from their own home had communal home help, and at four months 25% had communal home help (Table V). The patients’ satisfaction with the hip showed a slight decrease with time but was still at a high level four months after the fracture (Figure 5 ) . DISCUSSION The results presented for patients coming from their own home show that on the whole the prefracture status is regained within four months after the hip fracture for the majority of the patients. Hip function, ADL, and most of the other functions were regained within four months after fracture. The basic social conditions as shown in Table V were pre-

Living on ground floor

42

49

47

Stairs at home

77

68

73

Elevator at home

29

32

29

Living with someone

43

43

42

Disease in spouse

19

17

15

Communal home help

27

22

25

Visited someone last week

58

31

51

Visited someone last month

67

38

68

Received a visit last month

87

93

88

yes 90 Satisfied with hip: do not know 7 no 3

81 15 4

78 11 11

no 93 Partly 7 entirely 0

89 9 2

89 11 0

Disoriented

dominantly unchanged after the hip fracture. The reason for pain on walking at four months after the fracture (Table 111) may be that the healing process is not finished yet, combined with an increasing level of ambulation (Figure 3). Four months after the fracture, 78% of the patients were satisfied with their hips and a further 11% had no opinion, which seems to imply a rather satisfied situation for them too (Table V). If a gradual improvement continues Satlsfld wlth hlp

Per cent

Pn cent

CImnlnglCooklng

100

M

100

90 90

N3

80

Panly

60

Panly

80 70

70 60

50

50 40

40

30

30

Yes

20

Yes

20

10

10

0

0

Prefracture

1 Month

4 Months

Fig. 4. Proportion managing cleaningkooking - patients coming from own home at different periods after fracture (n = 180). Scand I Prim Health Care 1990: 8

Prefracture

1 Monlh

4 Months

Fig. 5. Proportion satisfied with the hip - patients coming from own home at different periods after fracture (n = 180).

Hip Fractures in Primary Health Care Table VI. Comparison of patients 1985-86 coming from their own home with results from a previous study 1976-77 ( I 6) at the Orthopaedic Department in

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Lund. 1976-77

1985-86 180

Number of patients

103

Percentage of total

66

60 ns

Mean age

75

78 *

Mean hospitalization time (days)

26

18 * *

Women (Yo)

73

76 ns

Cervical fractures (YO)

63

55 ns

Discharge to own home (YO)

74

56 * *

In own home at 4 months (%)

79

75 ns

2

2 ns

Hospital mortality ('Yo)

4

9 ns

A D L prefracture (YO) A D L at 4 months (YO)

Mortality at 4 months (%)

89 83

94 ns 81 ns

Climbing stairs prefracture (YO) Climbing stairs at 4 months ('Yo)

89 78

91 ns 86 ns

Outdoor walking prefracture (%) 89 Outdoor walking at 4 months (YO) 73

92 ns 82 ns

Cleaningkooking prefracture (Yo) Cleaningkooking at 4 months (%)

74 63

85 ns 73 ns

Shopping prefracture (Yo) Shopping at 4 months (%)

67 39

74 ns 39 ns

22

27 ns

36

25 ns

Communal homehelp prefracture ('Yo)

Communal homehelp at 4 months ('Yo)

ns not significant * p < 0.05 * * p < 0.01

there is usually no reason to suspect malunion. Pain disturbing the walking capacity with need for more walking aids than before fracture always resulted in contact with the orthopaedic department. Almost all fractures had a good range of motion (flexion, extension) of the hip (Table 111). Previous studies have shown that only small changes occur when four months have passed after the fracture, if a n active rehabilitation scheme is used for the patient (15, 16). From those studies it is known that up to 80% of the patients coming from independent living have returned home within four months. In the present investigation the percentage was 75%, but the mean age of our patients coming from their own homes was three years higher. In the

143

total material trochanteric fractures constituted 50% of the total number of hip fractures (45% for patients coming from their own home), which is a higher fraction than in a previous study in which 37% of patients coming from their own home had a trochanteric fracture (Table VI). It is well known that trochanteric fracture patients are older and more often afflicted with other diseases, thus influencing the rehabilitation possibilities (17). There were only small differences between our study and the previous study as far as functional and social status are concerned (Table VI). Some functions in the present study (outdoor walking, cleaningkooking) were divided into three categories (yes, partly, no) compared with two categories in the 1976-77 study (yes, no) which might explain the better score in the present study. In the 1976-77 study (16) patients coming from their own home were discharged directly to their own home at a higher rate (74%) than in the present study (56%). T h e results achieved then could be considered as a n optimal discharge rate. However, mean hospitalization time has now further decreased to I8 days (compared with 26 days in the 1976-77 study) for patients coming from their own home (cervical fractures, 15 days; and trochanteric fractures, 20 days). This has an influence on the possibilities of direct discharge home, as has the mean age of the patients, which has increased from 75 to 78 years. Furthermore, a decentralized referral system is now in use which might have the advantage that the patient is better known by the district nurses. They are often the persons who decide about the institutional care. O n the other hand the use of convalescence homes and geriatric rehabilitation hospitals might increase when each primary health care district can decide where to place the patients. Each primary district has only between 10 and 30 patients per year. A study of the following registration years will make this clearer. To operate again for a hip fracture complication is indicated in not more than 5&'75% of the cases (lS), and, apart from pain and reduced function, factors of social, mental and environmental character have to be considered. These factors are better analysed by primary health care personnel than by specialists in the hospital. The often disturbingly long delay between the onset of symptoms of healing complications after cervical fractures and reoperation, when indicated (19), may also decrease with the new follow-up system. Scand I Prim Health Care 1990; 8

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L. Borgquist et al.

Due to the mortality (16 patients died within four months), not all of the total of 180 patients coming from their own home would have needed follow-up resources. Of the 164 surviving patients coming from their own home 26 were seen at the orthopaedic outpatient unit within four months. This means that with this decentralized follow-up system about 135 out-patient visits to the orthopaedic department and 135 radiographic investigations have been saved for patients coming from their own home. At the same time, visits to the patients’ homes by district-physiotherapists might have increased, but this is of benefit for the walking instructions to the patients. The district physicians were mainly contacted for general medical care of the patients for other diseases. The present study indicated that routine follow-up of hip fractures at the orthopaedic department after discharge can be omitted. Follow-up in primary health care without radiography and orthopaedic expertise gives good functional results provided that patients with pain and walking problems from the hip are guaranteed rapid specialist treatment. A rapid specialist involvement should then be possible due to the released out-patient resources at the hospital.

ACKNOWLEDGEMENTS This investigation was supported by Malmohus lins County Council, the Swedish Medical Research Council (Project 2031), and Lunds Sjukvirdsdistrikt.

REFERENCES 1. Alffram PA. An epidemiologic study of cervical and trochanteric fractures of the femur in an urban population. Acta Orthop Scand 1964; (Suppl65). 2. Jarnlo G-B, Jakobsson B, Ceder L, Thorngren K-G. Hip fracture incidence in Lund, Sweden 1966-1986. Acta Orthop Scand 1989; 60:278-82. 3. Sernbo I, Johnell 0, Andersson T. Differences in the incidence of hip fracture - Comparison of an urban and a rural population in southern Sweden. Acta Orthop Scand 1988; 59: 382-5. 4. Johnell 0, Nilsson B, Obrant K, Sernbo I. Age and sex patterns of hip fracture changes in 30 years. Acta Orthop Scand 1984; 55: 290-2. 5. Zain Elabdien BS, Olerud S, Karlstrom G, Smedby B.

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Rising incidence of hip fracture in Uppsala, 1965-1980. Acta Orthop Scand 1984; 55: 284-9. 6. Zetterberg C, Elmerson S, Andersson GB. Epidemiology of hip fractures in Giiteborg, Sweden, 1940-1983. Clin Orthop 1984; (191): 43-52. i. Hansson LI, Ceder L, Svensson K, Thorngren K-G. Incidence of fractures of the distal radius and proximal femur. Comparison of patients in a mental hospital and the general population. Acta Orthop Scand 1982; 53: 721-6. 8. Ceder L, Thorngren K-G. Rehabilitation after hip repair. Lancet 1982; ii: 1097-8. 9. Holmberg S, Thorngren K-G. Rehabilitation after femoral neck fracture. Acta Orthop Scand 1985; 56: 305-8. 10. Jarnlo G-B, Ceder L, Thorngren K-G. Early rehabilitation at home of elderly patients with hip fractures and consumption of resources in primary care. Scand J Prim Health Care 1984; 2: 105-12. 11. Jensen JS, Tmdevold E, Scirensen PH. Social rehabilitation following hip fractures. Acta Orthop Scand 1979; 50: 777-85. 12. Borgquist L. Organisationsnivier inom sjukvirden. En studie av hoftfrakturer hos ildringar. (Organization levels in Public Health Service. A study of fractures of the proximal end of the femur in the elderly, “English summary”). Thesis, University of Lund, Lund, Sweden 1974. 13. Ceder L, Stromqvist B, Hansson LI. Effects of strategy changes in the treatment of femoral neck fractures during a 17-year period. Clin Orthop 1987; 218: 53-7. 14. Ceder L. Hip fracture in the elderly. Prognosis and rehabilitation. Thesis: Dept of Orthopaedics, University of Lund, Lund, 1980. 15. Borgquist L, Ceder L, Thorngren K-G. Social status 10 years after hip fracture - Prospective follow-up of 103 patients (Accepted, Acta Orthop Scand, 1990). 16. Ceder L, Thorngren K-G, Walldtn B. Prognostic indicators and early home rehabilitation in elderly patients with hip fractures. Clin Orthop 1980; 152: 17S84. 17. Thorngren M, Nilsson LT, Thorngren K-G. Prognosisdetermined rehabilitation of hip fractures. Compr Gerontol. S. 1988; 2: 12-7. 18. Stromqvist B, Hansson LI, Nilsson LT, Thorngren K-G. Hook-pin fixation in femoral neck fractures - A two-year follow-up study of 300 cases. Clin Orthop 1987; 218: 58-62. 19. Nilsson LT, Stromqvist B, Thorngren K-G. Secondary arthroplasty for complications of femoral neck fracture. J Bone Joint Surg (Br) 1989; 71-B: 777-81. Received December 1989 Accepted April 1990