What came first, the chicken or the egg? I asked one of my children this once and their reply was “The duck!” Have you ever cared for a patient who fell and broke their hip? Yes? I bet you haven’t. First of all let me explain that I have no clinical

evidence for what I am about to tell you, but I think that it is well worth the effort for a research project. If anyone takes up this challenge, please let me know.

The chicken and egg question is one that we should often ask ourselves. Replace the chicken with “fall” and the egg with “hip fracture” and we have a very topical question. That is, what came first the fall or the hip fracture?

If I were to ask those of you who work in a paediatric

setting, how many kids fall over and break their hips I suspect the answer would be, “Not many”. When a kid falls over what does he break? His wrist or his clavicle is probably the most common answer depending upon how he breaks his fall. This being the case, why do elderly people break their hips? I have asked this question on numerous occasions, here are the most common replies and my responses;

They don’t realise that they are falling and so don’t put their arms out.

If this was true they would probably break their nose (which of course sometimes they do). If they fell backwards, the coccyx or the occipital bone would take the impact. To allow the hip to take the impact actually involves a good bit of athleticism in order to throw one leg to the side while hurling yourself in a downward direction. If the person falls from a bed, then the impact could be directly transmitted to the hip. There are lateral and rotational forces to consider of course which may explain a small percentage of injuries. Another consideration is this; how old are we when we first learn to put out  our arms in response to a fall? When a baby is first born a doctor / midwife will do the APGAR test. One part of this test is to simulate a drop. The doctor / midwife will of course keep securely hold of the baby during this part of the test. Immediately the baby responds with the morrow reflex (throwing its arms out). That baby has been cradled inside the womb all of its existence and has never had the experience of falling over. Even if the mother fell, the baby is so tightly cradled that it couldn’t extend its arms even if it wanted to. So how did it know that this is the right thing to do in response to a fall? It was born with this ability. We don’t loose that ability just because we have grown old. Maybe ear infections or some other condition may prevent us from realising that we are falling, but that is true of a child as well as an older person.

Their bones are more brittle than a childs.

So are their wrists and clavicles not just their neck of femur.

Could it be more to do with our eyes than the actual fall?

Does this sound familiar;

You are walking up a flight of stairs and don’t realise that you are at the top. You take another step (that isn’t there). What happens? You slam your foot onto the floor and then take a casual look over your shoulder to see if anyone noticed. You probably feel a bit silly but think nothing else of it and carry on with the rest of your day. What though if you had osteoporosis? Where would the shock be transmitted? Yes, straight up your leg to the trochanteric area (thats the bit that generally breaks in a hip fracture). Due to the fact that it is difficult to stand on a broken leg, you do the next best thing and collapse in a heap on the floor. You don’t feel the pain immediately, you are trying to gather you thoughts when someone comes along to help.

“What happened?” they say. “I don’t know, I just lost my footing and went down, now my hip hurts and I cannot get up again.” Recorded in your notes is that you fell and broke your hip. No more questions asked. The reality though is that the egg came before the chicken.

Does it make any difference which way round it was? After-all the outcome is the same. Someone on the floor with a broken hip. It isn’t going to make any difference as to how that person will be handled from now on.

Yes it does make a difference, because understanding this factor could prevent some falls from happening in the first place. Let me explain through a true to life example.

I was walking down a long well lit (natural light) corridor in a hospital a number of years ago. At one end was the x-ray dept. At the other end was the mental health unit. A friend of mine was escorting an elderly lady from the mental health unit. I noticed them stop....

Outside was a digger with the back acter (bucket) stuck up in the air. This cast a big shadow across the floor in front of my friend....

Now, we are not going to discuss the ethics behind what is about to happen. Suffice to say, this is the way the story unfolds.

As I approached I heard him say, “Come on Ethel, I have half a dozen of you to bring down here today.” Ethel was gently resisting. “Hello Gavin” he said, “this is Ethel, she is one of our awkward ones...” He hardly go the words out of his mouth when she planted one right on the end of his nose, causing it to bleed somewhat. “She is also one of our violent ones.” he said cradling his new wound.

I explained to him that Ethel was neither awkward nor violent but that he was both. He simply stared at me. ... There was a pause. ... He eventually grunted and quickly glanced down to his nose with a nod as though to say have you not noticed that I am the one clenching my nose tightly between my fingers.

He needed more information from me. Put yourself in Ethels shoes. She is quite happily sitting in her seat when a total stranger comes along and asks to take her to the x-ray dept. I say total stranger because Ethel has Alzheimer’s and so cannot remember him from Adam. Because she cannot assimilate everything he is saying she assumes he must be foreign. Never mind, at least he is trying, she can pick out the occasional English word. I’ll go with him and see what it is that he wants. As you are walking down a corridor you notice a big hole on the ground in front of you. “Be careful!” you say, “we are walking towards a hole in the ground”. But what comes out of your mouth? “My sons coming to see me tonight”. As far as you are concerned you have warned him about the ensuing danger.

He keeps on walking though and has took no note of what you have told him. He is awkward isn’t he? “Oh! Wait a minute, he is foreign. He probably didn’t understand what I said”, I’ll just pull back and stop him from falling in the hole.What happens? He grips you that bit tighter and jibbers away in his broken English. Now you get the picture... He is going to kill himself and take me with him. HE is the violent one. Are you going to defend yourself?

Ethel did.

What could my friend have done about this? If someone holds back while you are walking with them for no apparent reason. Look to see if there is a visual clue as to why. A shadow, a change in floor surface or a patterned carpet. Wether it be a visual or a mental perceptive problem, any of these things could create a visual cliff effect. We might fail to find the reason so what should he have done? He could have took an alternative route. He could have took someone else and come back for Ethel when the sun had moved. He could have closed the blinds. He could have jumped into the digger and moved it (providing all licenses and insurances were in order). He could have tried explaining, which is what he did do. He stood in the shadow and said “Come on Ethel, it is a shadow not a hole.” She looked at me and said, “Look at him...! He can fly”

Helen Bee in her book “The developing child” looks quite a lot into this concept, but it is something that any trust or organisation wishing to take into account a multifactorial falls prevention (mffp) prgramme should take into consideration.

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Gavin Wright

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