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EDITORIALS: Sophia E de Rooij Hip protectors to prevent femoral fracture BMJ 2006; 332: 559-560 [Full text]

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Preventing hip fractures from an ophthalmological perspective

Peter Cackett, James Cameron   (12 March 2006)

Hip Protector design may influence compliance problems

Julian R Minns, Alexis Chuck   (6 April 2006)

Preventing hip fractures from an ophthalmological perspective 12 March 2006
Peter Cackett, Ophthalmology SpR Princess Alexandra Eye Pavilion, Chalmers Street, Edinburgh, EH3 9HA, James Cameron Send response to journal: Re: Preventing hip fractures from an ophthalmological perspective	Sophia de Rooij summarises the main pathways to preventing hip fracture.1 She cites the trial by Close et al. where an interdisciplinary approach to elderly people with recurrent falls significantly reduced the risk of further falls.2 In this study 59% of patients with recurrent falls were found to have visual impairment (defined as Snellen visual acuity less than 6/12 in either eye). In a recent study of 537 elderly patients who had fallen and sustained a hip fracture, 46% were found to be visually impaired (defined as best binocular visual acuity of 6/18 or less).3 This study also found that a significant proportion of those patients with visual impairment who had sustained a hip fracture had not seen an optometrist in the preceding 3 years. Therefore from an ophthalmological perspective there are two main pathways to preventing hip fractures in the elderly. Firstly it is essential to identify those patients with hip fractures who have visual impairment in order to prevent further falls in these patients. Secondly and more importantly the group of elderly patients with visual impairment and at risk of falling need to be targeted by public health providers in order to improve their access to optometry and ophthalmological care. 1. de Rooij SE. Hip protectors to prevent femoral fracture. BMJ. 2006 Mar 11;332(7541):559-60. 2. Close J, Ellis M, Hooper R, Glucksman E, Jackson S, Swift C. Prevention of falls in the elderly trial (PROFET): a randomised controlled trial. Lancet. 1999 Jan 9;353(9147):93-7. 3. Cox A, Blaikie A, Macewen CJ, Jones D, Thompson K, Holding D, Sharma T, Miller S, Dobson S, Sanders R. Optometric and ophthalmic contact in elderly hip fracture patients with visual impairment. Ophthalmic Physiol Opt. 2005 Jul;25(4):357-62. Competing interests: None declared
Hip Protector design may influence compliance problems 6 April 2006
Julian R Minns, Consultant Clinical Scientist RMPD, Newcastle General Hospital, Westgate Rd, Newcastle Upon Tyne, NE4 6BE, Alexis Chuck Send response to journal: Re: Hip Protector design may influence compliance problems	There are many issues relating to the compliance of hip protectors which have not been debated in the trials that Sophie de Rooij outlined in her Editorial. What has never been made clear in these trials are the designs of the hip protector pads, some are a complete hard shell, some have a shock absorbing material under the hard shell and some are foam- based soft pads. Hard shell devices rely on a "Force-shunting" principle in which the force at impact is directed away from the greater trochanter to the surrounding soft tissues. This will only be effective if the hard shell component of the hip protector is correctly positioned centrally over the greater trochanter. The consequences of the hard shell designs being misplaced could lead to the force-shunting effect being negated; and the hard edge of the hip protector, when lying over the greater trochanter, could produce high interface pressures and be the reason why many patients find them uncomfortable to wear and lie on at night consequently discarding them which would lead to the low compliance seen with these devices in the trials. Pads that are soft usually are more bulky and larger than the hard shell designs and rely on the foam material directly over the greater trochanter to disseminate the force and energy to the immediate soft tissues around the greater trochanter. We have studied these effects and found that positioning is a very relevant factor in the design and effectiveness of these devices and badly positioned pads of any design could give rise to loss of protection from hip fracture and give rise to tissue viability problems on areas of the skin which are at risk of damage in the frail elderly patients that hip protectors are being advocated for. We suggest that information on the type of hip protector studies should be made clear in any further trials conducted and information on the position and usage at the time of fracture should be noted to get a better understanding of the true effectiveness of these devices in preventing a fracture of the hip from a fall. 1. de Rooij SE. Hip protectors to rpevent femoral fracture. These may not be effective, after all.(Editorial) BMJ,2006 Mar 11;332:559-60. 2. Parker JP, Gillespie WJ and Gillespie LD. Effectiveness of hip protectors for preventing hip fractures in elderly people: systemic review. BMJ, 2006 Mar 11;332:571-574. 3. Minns RJ et al. Assessing the safety and effectiveness of hip protectors. Nursing Standard, Une 2004; 18:39:33-38. Competing interests: None declared