welp, Dad broke his hip

woodstock

woodstock

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He was biking and he fell off. Apparently he planted his foot wrong and lost his balance and went down.

He's fighting the need to get surgery but he really doesn't have a choice. This is below the ball and socket.

Lovely. Just lovely. sigh.
 
Thanks Scott. What a huge bummer, it sounds really painful. My Dad already has various aches and pains from being a pretty active person. He's always getting into scrapes of some sort.

Anyone know what the time to recover is? He's going to get surgery when his coumadin levels come down (although he's currently fighting that...)

Hope he's ambulatory for Italy and Switzerland! Although I guess we could push him around in a wheelchair.
 
Been an interesting month for this. About 4 weeks about while I was providing glider instruction, my 14 year old son who was helping with a 3 wheel golf cart swerved to miss a pot hole and tipped it up on two wheels dumping him off. He landing in such a way to fracture his femur about 3 inches below the hip Socket. He had 3 screws put in and is on a no weight bearing limitation for 3 months.

A little over a week ago 3 of our local glider pilots were skiing. One was skiing down the hill when another skier ran into him knocking him over and fracturing his hip. He was released from the hospital today and so far is has not required surgery but is on a now weight bearing limitation for 3 months.

Brian
 
Dave Bahn would know. He did that stuff for a living.

woodstock said:
Thanks Scott. What a huge bummer, it sounds really painful. My Dad already has various aches and pains from being a pretty active person. He's always getting into scrapes of some sort.

Anyone know what the time to recover is? He's going to get surgery when his coumadin levels come down (although he's currently fighting that...)

Hope he's ambulatory for Italy and Switzerland! Although I guess we could push him around in a wheelchair.
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Ahem.. red flag here... why is he on coumadin? I'm hoping that whomever is holding it is also considering the use of an alternative (short acting) right up to the day of surgery.

Hope everything goes well, and he recovers fully...
 
Doggtyred said:
Ahem.. red flag here... why is he on coumadin? I'm hoping that whomever is holding it is also considering the use of an alternative (short acting) right up to the day of surgery.

Hope everything goes well, and he recovers fully...
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He had a valve replaced many years ago. he's been on coumadin ever since.

Docs are weaning him off coumadin the next few days. What alternatives might that be?

He had surgery (both knees replaced) over 10 yrs ago, I seem to remember he had to go off coumadin and I can't remember if they gave him something else short term.
 
If his fracture was in his femoral neck, then the treatment of choice would likely be a hemi arthroplasty (sort of like a total hip replacement, but not the socket). If lower, it might be a plate along with a big screw that goes up the neck, or more recently we have been using a long rod that goes down inside the femur, along with a screw that goes up the neck. If the fracture is impacted and non-displaced, the least invasive treatment would be through the use of three screws up the neck.

So, the kind of fixation used is determined by the location and extent of the fracture. None of these will likely heal on their own, except possibly in the case of a fracture that is impacted, where essentially the neck is driven into the head of the femur. Even then, most surgeons would still place three screws to help hold it in place.

Typically, the coumadin would be stopped and we would wait until the INR was less than around 1.5 or so, but in someone with a mechanical heart valve we would bridge with shots of heparin (or derivatives), and then stop everything to do the surgery. Immediately after surgery we would start up with the shots again along with the coumadin. The risks of bleeding from the blood thinners have to be balanced out against the risk of having clots and a stroke from the heart valve. A hip fracture is a big deal, especially in someone with other medical problems.

I'm no more an expert than anyone else who writes anything on the internet, but I have been doing hip and knee surgery and teaching at a university for 15 years as an orthopaedic surgeon, for what it's worth (also an AME and flight surgeon in the AF).

Good luck.
 
Thanks Jim. Do you mind if I send you an email/PM?

I spoke to Dad this morning. He apparently had an epiphany last night and is having surgery. His coumadin levels are coming down (below 3 right now he said - not sure how much below) and it's sched for this afternoon he said. I remember him saying "rod and screws" - maybe two screws? It's a diagonal break he said. He also mentioned heparin short term.
 
Woodstock, is the heart valve metal or animal? Aortic or Mitral? There is some serious ju-ju about removing coumadin from METAL aortic valves.

If below the femoral neck, they put a rod down the femur. This usually goes well but one in a bazillion will shatter.

Lastly, ACFP knows that if you are immobilized and 75, 2 years later 50% of your are not there. So promptness is an important thing.
 
Send PM- will be around. An INR of three is pretty high for a hip surgery, lots of potential for bleeding, unless they plan to acutely reverse his INR using fresh frozen plasma just prior to surgery. Usually it's three screws, a single large screw with a plate and multiple screws ( generally three or four), a hemiarthroplasty (half a hip replacement), or a rod that goes inside the femoral shaft with again a large screw or blade that goes up the neck of the femur. Can't think of any combinations that use just two screws.
 
From what you described, it sounds like a mechanical heart valve, which generally tend to last longer but require chronic coumadin. If he had a pig valve, they wouldn't require coumadin, but tend to not last as long. Does he complain of hearing clicking as the valve works? If so, it was probably a mechanical valve. Of course, he could be on coumadin for other things like atrial fibrillation, history of blood clots, increased clotting tendencies, etc as well. Only trying to surmise the situation based upon your description, and of course the information gets lost in translation.
 
Dr B - it's a pig valve. He is 69 and the surgery is today which hopefully is a good thing. Now I'm worried about his coumadin levels based on Dr. N's post. If it was around 3 this morning, will it keep dropping by mid-afternoon?

I know they already started taking blood from him for the surgery.
 
bbchien said:
Femoral nail with two at the distal end.
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I suppose if they used a TFN, but most orthopaedists would count the screw up the neck as well, adding up to three. Can't think of any femoral neck constructs that use just two. A femoral nail for a femur fracture would typically use two distal and one proximal, either antegrade or retrograde.
 
Generally, a pig valve does not require chronic anticoagulation, so he might be on coumadin for some of the other reasons I mentioned. Typical INR's would be in the 2-3 range. Most institutions no longer take blood from a patient prior to surgery (sounds like they're planning to do hemodilution). All this has shown to do is lower his existing blood levels, without much added benefit- basically just starting people off low to begin with. Most surgeons would not want to consider operating until the INR was down around 1.5 or lower, and this can be done acutely with fresh frozen plasma.
 
woodstock said:
I spoke to Dad this morning. He apparently had an epiphany last night and is having surgery. His coumadin levels are coming down (below 3 right now he said - not sure how much below) and it's sched for this afternoon he said. I remember him saying "rod and screws" - maybe two screws? It's a diagonal break he said. He also mentioned heparin short term.
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Good luck, hope he has a speedy recovery.
 
Sorry to hear about your dad. I guess one plus is since he's active, he should have better luck with PT and getting back to normal than a lot of people.


Trapper John
 
Dr Jim, I just sent you a PM. I think Dad sounds the calmest of all of us. Mom is flipping out and I've been on the internet all morning trying to learn about this.
 
If it's a pig valve there is a larger window in which the valve can tolerate lack of anticoagulation. They can reverse this with a pair of injections of Vitamin K 10 mgms about 16-20 hours prior to O.R. Restarting coumadin the day of surgery usually results in thin blood by postoperative day #3.

With a metal aortic valve, people have stroked in the 3 day window of relatively "thick blood" which is necessary for nice, dry outcomes with this sort of procedure. So in that case they get get reversed with vitamin K, get put on heparin IV, which needs tight monitoring, the heparin discontinued 60 minutes prior to OR, and then gets put back on when the orthopedist can handle the thought of his work oozing.....12-12-24 hours, usually depending on how it looked inside. Then, while the IV heparin is running, coumadin is re-initiated to thing the blood starting 3 days later.

PS Hold you mom's hand. Moms spend their entire lives managing the family and "flip out" is sooo very normal.
 
Geez Louise Dr. B. If he gets through the next week, are his odds better then?

They are doing surgery tomorrow, his INR wasn't quite low enough yet.

This sort of thing is EXACTLY why I started taking my parents on trips with me in the past few years - to get as much quality time as possible while they were still hale and hearty. I knew that someday things would happen that would slow them down permanently but I didn't think it would be while he was still just late-60s. I hope his stubborn-ness and activity levels help him bounce back from this quickly.

Thanks for the kind thoughts everyone.
 
Yes, the drill/reamers look like the one in the photo. They are very expensive since they need to be autoclaved, and the batteries don't last that long either.
 
Hey! Could you knock off the talk about age 69 being old folks? Some of us are doing a pretty good job of denial, and such heresy doesn't help our rationalization.

woodstock said:
Geez Louise Dr. B. If he gets through the next week, are his odds better then?

They are doing surgery tomorrow, his INR wasn't quite low enough yet.

This sort of thing is EXACTLY why I started taking my parents on trips with me in the past few years - to get as much quality time as possible while they were still hale and hearty. I knew that someday things would happen that would slow them down permanently but I didn't think it would be while he was still just late-60s. I hope his stubborn-ness and activity levels help him bounce back from this quickly.

Thanks for the kind thoughts everyone.
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Best of luck all around. Such injuries are often life-ending events in the elderly, but I certainly hope this will not be the case for your father. No, 69 is not that elderly, at least not these days. Just to put things in perspective, I just found out a friend has been having serious heart problems. I have few details beyond his symptoms and ejection fraction, which was 15%. My suegro had an ejection fraction in that range when he died from CHF at age 90. My friend is in his mid-forties, a few years younger than me. He has a wife and two kids.
 
Just talked to Dad again. INR is 2.9. I think they hoped this would come down a little faster. Surgery is supposed to be at noon/1 PM tomorrow. He also has diabetes, but his blood sugar is holding at 120 so far despite the fact that he has been in bed for the past day. That's also another thing to worry about, because he keeps his blood sugar under control due to all his normal activity, no doubt. He takes glucophage for that.

I'm getting rather freaked out about all of this. Saturday morning I wouldn't have thought 69 was in the "senior citizen" category and I thought my Dad was hale and hearty. Medical issues, true, but holding all the pieces together and doing just fine and getting around very well. It sounds like there could well be a domino effect from just about any of these elements. His doctor has been practicing for 23 years so that is good.

He has lower back pain due to a disc issue (he doesn't usually sleep flat, he needs his legs elevated) but as long as he is moving around he says he feels just fine during the day time. Stiff in the morning but then he gets up and moves around and is OK. He's got the pig valve, and diabetes. His knee on the broken hip side was bothering him - it was replaced 10-15 years ago.

Are there any specific questions we should be asking right now? Right now he says he's not in pain even though he hasn't had any painkillers since the morning so that is good.
 
Everskyward said:
I'm not a doctor and I don't play one on TV but I would be asking why they are in such a hurry.
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The risk of complications increases significantly by waiting longer than 24 hours. Prolonged immobilization can result in bed sores, urinary infections, pneumonias, blood clots, etc. The fracture will not heal on its own-the only way to treat this and get him going again is through surgery.

However, he sounds to be a high risk patient, with diabetes, on coumadin, valve replacement, etc. So, he needs to be medically optimal before going to the OR. If he's not getting fresh frozen plasma or vitamin K, it's going to be longer than just one day for the INR to normalize from a level of three.

So, the operation is urgent, but not an emergency.
 
woodstock said:
Just talked to Dad again. INR is 2.9. I think they hoped this would come down a little faster. Surgery is supposed to be at noon/1 PM tomorrow. He also has diabetes, but his blood sugar is holding at 120 so far despite the fact that he has been in bed for the past day. That's also another thing to worry about, because he keeps his blood sugar under control due to all his normal activity, no doubt. He takes glucophage for that.

I'm getting rather freaked out about all of this. Saturday morning I wouldn't have thought 69 was in the "senior citizen" category and I thought my Dad was hale and hearty. Medical issues, true, but holding all the pieces together and doing just fine and getting around very well. It sounds like there could well be a domino effect from just about any of these elements. His doctor has been practicing for 23 years so that is good.

He has lower back pain due to a disc issue (he doesn't usually sleep flat, he needs his legs elevated) but as long as he is moving around he says he feels just fine during the day time. Stiff in the morning but then he gets up and moves around and is OK. He's got the pig valve, and diabetes. His knee on the broken hip side was bothering him - it was replaced 10-15 years ago.

Are there any specific questions we should be asking right now? Right now he says he's not in pain even though he hasn't had any painkillers since the morning so that is good.
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I would want to be there.
 
AcroBoy said:
The risk of complications increases significantly by waiting longer than 24 hours. Prolonged immobilization can result in bed sores, urinary infections, pneumonias, blood clots, etc. The fracture will not heal on its own-the only way to treat this and get him going again is through surgery.

However, he sounds to be a high risk patient, with diabetes, on coumadin, valve replacement, etc. So, he needs to be medically optimal before going to the OR. If he's not getting fresh frozen plasma or vitamin K, it's going to be longer than just one day for the INR to normalize from a level of three.

So, the operation is urgent, but not an emergency.
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How much longer do you think it might take for his INR to come down enough? This happened last night just about 7 PM. Will tomorrow afternoon be OK?
 
AcroBoy said:
The risk of complications increases significantly by waiting longer than 24 hours. Prolonged immobilization can result in bed sores, urinary infections, pneumonias, blood clots, etc. The fracture will not heal on its own-the only way to treat this and get him going again is through surgery.

However, he sounds to be a high risk patient, with diabetes, on coumadin, valve replacement, etc. So, he needs to be medically optimal before going to the OR. If he's not getting fresh frozen plasma or vitamin K, it's going to be longer than just one day for the INR to normalize from a level of three.

So, the operation is urgent, but not an emergency.
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His doctor said he was in good shape/good health despite the meds he is on. I didn't get the sense that they thought he was super-high-risk even though he undoubtedly isn't low-risk, with the medical issues he has. That said I want him to get the surgery as soon as he can, and get moving again.
 
EppyGA said:
I would want to be there.
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I just talked to both of my parents. They didn't think tomorrow was a good idea. I'd have to leave at 645 AM to get there before 1130 regardless. I'm going to ask my boss if I have carte blanche to leave when I need to, though. I would probably be a lot more use to come down after he's out of the hospital and back home. The big thing will be getting his truck home to PA in the next month or two. They drove separately so that he could drive his pickup with all of his tools. My Dad pretty much lives for "making/building things" and you can find him in the woodshop more often than not.

I just remembered some details re: how a minor fall could cause a break like this. Over the years my Dad has taken MANY falls - he's always scaling roofs for instance, or scaffolding, or what have you - one time he fell backwards off of steps carrying a toilet out of the house when he was remodeling one of their bathrooms - that was about 3 yrs ago I think. Yes, landed on his rump. Last fall he slipped coming down a ladder. He's had a number of falls over the years that so far never broke anything. I wonder if it caused anything hairline to occur, or stress fractures.

My Dad isn't a "sit around the house" kind of person, this is for sure. I just hope he bounces back from this as quickly as everything else he's gotten himself into. He's a tough guy, I'll tell you that.

Anyway, I'm prattling at this point. I'm pretty freaked now and hope this turns out well. I didn't know how many domino effects can happen from a hip fracture. I don't understand how on the one hand I hear this is less problematic than knee replacement (and he's had two of them) yet this can be life threatening.
 
I went through this (different problem) with my dad a couple years ago. Be there for your mom while he is in surgery. Dad was in for 12 1/2 hours (Whipple procedure, cancer had attached to a blood vessel) and Mom would not have gotten through it if my wife and I hadn't been there. Best of luck to you all.
 
Elizabeth, take a deep breath. If I'm faced with an urgency and I need to get a patient's INR down pronto, 2 units of Fresh Frozen Plasma and we're there. Then we add heparin afterward. These boys know what to do.

It sounds like he's got good caretakers. Try to keep yourself together so you can make sure you mom makes it. The docs take care of your Dad. The daughter takes care of the Mom......
 
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