Risk factors for hip fractures among pilgrims, Hajj 1998G (1418H)

Hip fractures are a major acute orthopedic condition among the elderly population worldwide [1]. Studies have shown that subsequent disability, dependency, and high case-fatality rates [2, 3] frequently complicate hip fractures. During Hajj (the Islamic pilgrimage to Makkah), hip fractures are a leading cause among pilgrims (Hajjees) for admissions and prolonged hospital stay. There are a few descriptive studies on trauma during Hajj; however, none of these studies address the risk factors for hip fractures. The objective of this study is to identify the modifiable risk factors for hip fractures during the Hajj season.

During the Hajj period of 1998 (1418 H), we conducted a case-control study in 3 of 4 major hospitals in Makkah. A hip-fracture case was defined as any patient with a fracture involving the neck of the femur or femoral trochanter (greater, lesser, or subtrochanteric). A control was defined as any patient with fractures other than the hip, admitted to any of the 3 hospitals during the study period.

Included were 61 case-patients and 118 control-patients from 17 different nationalities. The male to female sex ratio was 2:1. Fifty-five case-patients (90.2%) were Hajjees compared with 65 (55.1%) control-patients; Odds Ratio (OR) 7.5, 95% Confidence Interval (CI) 2.8-21.1. The mean age (in years) of case-patients and control-patients was 65 and 42 respectively (p<0.005). Fifty-five case-patients (90.2%) were aged 50 years or older compared to 53 (44.9%) of the control-patients (OR 11.2, 95% CI 4.2-31.6). The older the age the higher the likelihood for hip fracture (p<0.001).

Injuries that resulted in fractures (precipitous injuries) included: falls caused by a variety of reasons, mechanisms and sites; road traffic accidents (RTA), including knocks associated with motor cycles; and other casualties. The leading precipitous injury among case-patients was falling, either while walking on a level surface (44 cases, 72.1%), or taking stairs (9 cases, 14.8%). Only 6 injuries (9.8%) were caused by RTA. Of all precipitous injuries, 53 (86.9%) cases of hip fractures and 41 (34.7%) other fractures resulted from falls (OR 12.9, 95% CI 5.2-33.0). Half of the case-patients (29, 49.2%) fell inside or around the Holy Mosque (Haram) compared with 10 (8.5%) control-patients (OR 10.5, 95% CI 4.3-25.9). Of the 53 case-patients who fell, 25 (47.2%) slipped on smooth ground as compared to 9 (22.0%) of the 41 control-patients (p< 0.05). Among those who slipped, 20 case-patients (80.0%) and 6 control-patients (66.7%) reported slipping on wet surfaces (p>0.05). Seven case-patients (13.2%) and one control-patient (2.4%) fell inside bathrooms (OR 15.2, 95% CI 1.8-336).

Compared with control-patients, hip-fracture case-patients were more likely to have a chronic illness such as diabetes mellitus, hypertension or ischemic heart disease (OR 4.3, 95% CI 1.8-10.0) and hearing difficulty (OR 3.8, 95% CI 1.4-11.0). However, there was no difference between case-and control-patients with regard to the use of walking aids (OR 3.7, 95% CI 0.9-16.0), having visual difficulty (OR 1.4, 95% CI 0.6-3.4), or having a smoking habit (OR 1.1, 95% CI 0.4-3.2). Only 4 patients, 2 cases and 2 controls, had a past history of any fracture during the preceding 5 years (p>0.05).

Risk factors for hip fractures work as a complex unit and the personal and environmental factors intermingle [3]. Regarding Hajj season, the risk factors for hip fractures can be divided into two categories: non-modifiable and modifiable risk factors. Non-modifiable risk factors include: age and gender of the Hajjee and whether or not he or she suffers from symptoms of an acute or an underlying chronic disease; from sensory and perceptual declines; from functional disabilities; or has symptoms from drugs that enhance risks for falls and fracture of bones [4]. Conversely, modifiable factors are mainly environmental-such as slippery floors, curling rugs, stairways, and poor lighting.

Falls, especially around Haram, were the main cause for hip fractures among Hajjees. Falls were facilitated by the hard, smooth, slippery, and occasionally wet, marbled surfaces of Haram, the surrounding grounds, and stairways. Slippery surfaces increase the risk for falls [5] and hard surfaces increase the risk for fractures [4,6].

Although the janitors of Haram are conscientious in drying the floors, immediately after each mop-up operation, it is not uncommon to find areas wet with lines of water formed by cleaning machines, or wet from spilled Zamzam (sacred well) water or soft drinks. Also, the residual soap makes the floors more slippery. Moreover, it was noted that most Hajjees wore the most slippery type of slippers in the marbled courtyards surrounding Haram. The floors of bathrooms annexed to Haram, ablution areas, and the Zamzam area are almost always wet because of the nature of Hajjee activities at these sites.

Besides the direct consequences to a Hajjee's health, hip fractures disrupt Hajj activities and have a very high cost of hospitalization [1]. In a few developed countries, the minimum direct cost of a hip-fracture case was shown to exceed 3,000 US dollars [7]. During Hajj season, the actual burden of injuries in general, and hip fractures in particular, is not known. Similar to the carefully monitored infectious disease surveillance system, a Hajj injury surveillance is recommended to allow for better understanding of injury patterns and determinants, and to help health authorities plan for future seasons. Interventions to improve environmental conditions have greatly reduced the incidence of falls, the prime cause of hip fractures.