1: Hip Fractures & Conditions Flashcards
what are NOF fractures commonly caused by
- low energy injuries i.e. falls in frail older patient
- high energy injuries e.g. road traffic collision or fall from height
what are major risk factors for hip fractures
- increasing age
- osteoporosis
- F>M
why are hip fractures prioritised on the trauma list and when should they aim to be performed
↑ morbidity and mortality
- aim to perform within 48 hours
how can hip fractures be categorised
- intracapsular: proximal to the intertrochanteric line
-
extracapsular
- intertrochanteric: between greater trochanter and lesser trochanter
- sub trochanteric: from lesser trochanter to 5cm distal to this point
basic anatomy of the femur
describe the blood flow to the NOF
retrograde: passes from distal to proximal along the femoral neck to the femoral head
- MCFA which lies directly on the intracapular femoral neck
- supply from ligamentum arteriosum in l.teres but this is insufficient to maintain supply in adults
what is there risk of in an intracapsular #NOF
avascular necrosis
what will patients with a displaced intracapsular #NOF require
hemiarthroplasty or THR
how can intracapsular fractures be further classified
Garden classification
what is the Garden classification for intracapsular hip fractures
what is the difference in approach to displaced vs non-displaced intracapsular fractures
- non displaced may still have an intact blood supply so no avascular necrosis = internal fixation with screws to hold femoral head in place while fracture heals
- displaced will disrupt blood supply = hemiarthroplast/THR
describe the difference between hemiarthroplasty and total hip replacement
- hemiarthroplasty: replace head of femur but acetabulum remains in place and cement used to hold the stem of prosthesis in shaft of femur (pt with limited mobility/significant co-morbidities)
- total hip replacement: replace both head of femur and socket (pt who can walk independently and fit for surgery)
how can extracapsular fractures be treated
intertrochanteric: dynamic hip screw (sliding hip screw) through the neck and into head of femur
- plate with a barrel which holds screw is screwed to the outside of the femoral shaft
- screw through head allows controlled compression at fracture site which improves healing
subtrochanteric: intramedullary nail with is inserted through the g.troch into central cavity of shaft
what is the typical presentation of a hip fracture
- pain in groin/hip which can commonly radiate to knee in elderly
- NWB
- shortened, abducted, externally rotated
what factors are important to identify in patients presenting with hip fractures
any underlying reversible causes for a ‘mechanical fall’ e.g. anaemia, arrhythmias or Parkinson’s
what is a key sign of a #NOF on AP X-ray
displaced Shenton’s line
- formed by medial edge of the femoral neck and the inferior edge of the superior pubic ramus
what are long term complications following #NOF repair
- joint dislocation
- aseptic loosening
- peri-prosthetic fracture
- deep infection/prosthetic joint infection
what is the most common mechanism of femoral shaft fractures (4)
- high energy trauma
- fragility fractures in elderly
- pathological fractures
- bisphosphonate related fractures
what is a potential consequence of a femoral shaft fracture and why
the femur is a highly vascularised bone due to its role in heamtopoeisis
- supplied by penetrating branches of the profunda femoris artery so large volumes of blood can extravasate if fractured
how will a patient with a femoral shaft fracture present
- pain/swelling in thigh, hip, and/or knee pain
- NWB
- obvious deformity in most cases
- skin may be open or threatened
what happens to the proximal fragment in a femoral shaft fracture
pulled into flexion and external rotation by iliopsoas and glut med/min
- can further tent the skin
what system is used to classify the degree of comminution to femoral shaft fractures
Winquist and Hansen Classification
* Type 0 – No comminution
* Type I – Insignificant amount of comminution
* Type II – Greater than 50% cortical contact
* Type III – Less than 50% cortical contact
* Type IV – Segmental fracture with no contact between proximal and distal fragment
what is the management of a femoral shaft fracture
- A-E assessment and stabilise patient
- adequate pain relief
- immediate reduction and immobilisation using in-line traction to ensure appropriate haemtoma formation and pain reduction
- surgery - but long leg casts may be indicated in undisplaced femoral shaft fractures
how does traction splinting work
e.g. Kendrick traction splint
- used in suspected or isolated fractures of the mid-shaft femur
- act to hold femur in correct position against the action of the large thigh muscle mass
when is traction splinting used
pre-hospital setting
- should not be in place any longer than necessary due to risk of skin necrosis at groin
what are contraindications for traction splinting
- hip/pelvic fractures
- supracondylar fractures
- ankle/foot fractures
- partial amputation
what is the surgical management of a femoral fracture
24-48 hours but sooner if open fracture
- antegrade IM nail (98% union rate and low rate of post-op complications)
what are common complications following femoral shaft fracture
- Nerve injury or vascular injury
- Pudendal nerve injury (around 10%) or femoral nerve injury (rare)
- Mal-union (or rotational mal-alignment), delayed union, or non-union
- occurs in around 30% and 10% of proximal and distal fractures respectively - Infection, especially with open fractures
- Fat embolism
- Venous thromboembolism
A 6 year old boy presents with progressive hip pain for last few weeks associated with a limp is a common presentation for which condition
Perthes disease
What are features of Perthe’s disease
Degenerative condition affecting the hip joints of children, typically between the ages of 4-8 years due to avascular necrosis of the femoral head
- presents with gradual hip pain and limp
- stiff and reduced ROM
- X-ray: early changes include widening of joint space, later changes include decreased femoral head size/flattening
what is development dysplasia of the hip
socket of the hip is too shallow and the femoral head is not held tightly in place, so the hip joint is loose
- more common in left hip
What signs will be positive in DDH
Barlow’s test, Ortolani’s test are positive
- picked up on newborn examination
Describe transient synovitis (irritable hip)
- typical age 2-10 years
- acute hip pain assoc with viral infection
- most common cause of hip pain in children
What is the most appropriate method of analgesia for a patient with #NOF
Iliofascial nerve block
Describe slipped upper femoral epiphysis
- age 10-15
- more common in obese males
- displacement of femoral head epiphysis postero-inferiorly
- bilateral slip in 20% of cases
- knee or distal thigh pain is common
how does avascular necrosis of the hip present
- buttock or groin pain
- reduced mobility
what are causes of avascular necrosis of the hip
- long term steroids
- chemo
- trauma
- alcohol excess
what are the x-ray findings of avascular necrosis of the hip
irregular borders of the articular surface with sclerosis of the femoral head
