12 - T&O Spine, Hip and Thigh Flashcards
What are the different types of fractured neck of femur and what are the causes?
NOF is a fracture anywhere from subcapital region of femoral head to 5cm below the lesser trochanter
High energy: RTA in the young
Low energy: Fall from standing height in elderly
Think pathological fractures if no trauma
Intra or Extracapsular
Why is the mortality with NOF fractures so high in the first year?
Those with poor mobility before fracture, high age and co-morbidities at higher risk
Patient tends to die from complications such as pnuemonia etc
What is the blood supply to the femoral head?
Retrograde from MCFA from deep femoral artery from external iliac
Some blood from ligamentum arteriosum but only enough blood to supply head in children
Displaced intracapsular fractures can disrupt blood supply causing avascular necrosis
Extracapsular fractures can be classified as intertrochanteric and subtrochanteric. What are the different classifications of intracapsular fractures?
Garden Classification
Garden stage I: undisplaced incomplete, including valgus impacted fractures
medial group of femoral neck trabeculae may demonstrate a greenstick fracture
Garden stage II: undisplaced complete
no disturbance of the medial trabeculae
Garden stage III: complete fracture, incompletely displaced
femoral head tilts into a varus position causing its medial trabeculae to be out of line with the pelvic trabeculae
Garden stage IV: complete fracture, completely displaced
femoral head aligned normally in the acetabulum and its medial trabeculae are in line with the pelvic trabeculae
How will a NOF present?
- Pain in groin, thigh or referred to knee
- Inability to weight bear
- Shortened and externally rotated
- Pain on pin rolling and axial loading
- Unable to do straight leg raise
What are some investigations that need to be done if you suspect a #NOF?
- AP and Lateral Hip and Pelvis X-Ray
- Full neurovascular exam of the limp
- FBC, U+Es, CK if long lie for rhabdo
- Group and Save
- Urine dip, CXR and ECG in elderly
How is a #NOF managed?
- A to E
- Opioid or regional anaesthesia (fascia-iliaca block)
- Surgical (see image) with urgent physio and mobilisation after
If displaced intracapsular needs arthroplasty (full not hemi if active but will dislocate more) due to risk of AVN. If non-displaced can try screws to see if will repair without AVN as metal work has a life span
What are some post op complications with #NOFs?
Immediate: pain, bleeding, leg length discrepancies, neurovascular damage
Long term: joint dislocation, aseptic loosening, peri-prostethic fracture, deep/prosthetic joint infection, mortality, AVN, malunion-nonunion
Make sure to get early physio, ortho-geriatricians and OTs involved
Why should you not use NSAIDs in fracture healing?
Need inflammatory process for bone healing so will prolong healing time
What is the Nottingham Hip Score?
Tool used by surgeons to work out the 30 day mortality risk of a patient following a #NOF
High lactate is also a marker of mortality in #NOF
What are some of the symptoms and risk factors of hip osteoarthritis?
Symptoms
- Dull pain in groin or buttock that is exacerbated by movement and relieved by rest
- Stiffness and crepitus worse after resting
- May have antalgic gait but if severe may have fixed flexion defority and Trendelenbery gait
- Passive movement painful and reduced range of motion
What are some differential diagnoses for hip OA?
- Trochanteric bursitis
- Gluteus medius tendinopathy
- Sciatica
- Femoral neck fracture
What investigations are done to diagnose and classify hip OA?
- X-ray Pelvis to show at least 2 typical OA features
- MRI gold standard if not sure from X-ray
- Can use WOMAC tool to monitor disease progression. Looks at pain, stiffness and function
How is hip OA managed?
Conservative:
- NSAIDs for pain
- Weight loss, exercise, smoking cessation
- Physiotherapy
Surgical (if above doesn’t work)
- Hip hemi/arthroplasty
What are some complications with a hip arthroplasty?
- Thromboembolic disease
- Bleeding
- Dislocation
- Infection
- Loosening of prosthesis
- Leg length discrepancy
- Need for revision hip arhtroplasty after 15-20 years
What is the pathophysiology of a femoral neck shaft fracture?
- Often due to high energy trauma
- Associated with neurovascular injury
- Large blood loss (up to 1.5L) as highly vascularised due to haemopoetic role. Supplied by penetrating branches of profunda femoris
- Often transverse fracture in proximal femur
How does a femoral shaft fracture present and how is it classified?
- Pain in thigh and/or hip/knee
- Inability to weight bear
- Assess skin as may be open or threatened (tethered, white, non-blanching)
- Proximal fragment in flexion and external rotation (iliopsoas and gluteus medius/minimus)
- Full neurovascular exam needed
- May have signs of hypovolemia
What investigations are done when a femoral shaft fracture is suspected?
- Routine urgent bloods including coagulation and G+S
- Plain Film Radiograph AP and Lateral of femur, hip, knee
- CT scan if polyfracture or concurrent #NOF suspected
How is a fractured femoral shaft managed before surgery?
Initial
- ATLS protocol with A to E and appropriate fluid resus
- Adequate pain relief (opioid or regional block)
- If open fracture abx prophylaxis and photography
- Immediate reduction and immobilisation using in-line traction so haematoma forms in right place
- If too many co-morbidities or undisplaced femoral shaft fracture then long-leg cast and no surgery
How is a femoral shaft fracture managed surgically after traction splinting?
Within 24-48 hours needs antegrade intramedullary nail (retrograde if hip replacement)
If unstable polytrauma or open fracture then external fixation until intramedullary nail can be done
Early mobilisation after nailing decreases complications. If bilateral fractures more pulmonary complications
When should you not use traction splinting for a fracture?
- Hip or pelvic fracture
- Supracondylar fracture
- Fractures of ankle or foot
- Partial amputation
What are some complications of a femoral shaft fracture?
- Neurovascular injury (pudendal or femoral nerve)
- Mal-union, delayed union non-union (higher risk if smoker or post op NSAID use)
- Infection (especially open)
- Fat embolism
- Hip flexor or knee extensor weakness
What is the pathophysiology and risk factors for a quadriceps tendon rupture? Name 3 differentials?
Rupture usually occurs at site of insertion on superior patella. Mechanism is following sudden excessive loading of quadriceps e.g landing from a jump
Risk factors: increasing age (>40), CKD, Diabetes, RA, medication like corticosteroids and fluoroquinolones
Differentials: patella tendon rupture, patella fracture, femoral shaft fracture
How will a quadriceps tendon rupture present?
Symptoms
- May hear a pop or feel a tearing sensation then…
- Pain in anterior knee or thigh
- Difficult to weight bear
Examination
- Localised swelling
- Tender palpable defect at top of patella
- If complete tear inability to straight leg raise or extend knee
How is a suspected quadriceps tendon rupture investigated and diagnosed?
Diagnosis can be made clinically but definitive diagnosis with US imaging
Plain film radiograph will show caudally displaced patella (patella baja) and can rule out patella fractures
MRI if not sure from US
How is a quadriceps tendon rupture managed?
Partial tear: nonoperatively if extensor mechanism in tact. Immobilisation of knee in brace then intensive rehab
Complete tear: If at insertion then longitudinal drill holles or suture anchors, if intra-tendinous tear then end-to-end sutures. Post op immobilise in brace then rehab at 6 weeks
What is a distal femur fracture and how are they classified?
Fracture extending from distal metaphyseal-diaphyseal junction to articular surface of femoral condyles
Either high energy trauma in young, low energy in elderly due to malignancy/osteoporisis or peri-kneeprosthetic fracture
How does a distal femur fracture present and what are some differentials you should consider?
- Severe pain in distal thigh following fall or traumatic injury
- Inability to weight bear
- Swelling and ecchymosis of distal thigh
- May be haemarthrosis knee effusion if fracture extends into joint
- Full neurovascular exam
DD: tibial plateau fracture, haemarthrosis, tibial shaft fracture
How is a suspected distal femur fracture investigated?
- ATLS protocol so urgent bloods with G+S
- Serum Ca/Myeloma screen if suspect pathological fracture
- AP and Lateral plain radiograph of knee and femur
- CT if intraarticular involvement
How is a distal femur fracture managed?
- If minimal displacement or very co-morbid then non-operative long period of immobilisation and non weight bearing in brace
- If significant mal-alignment in A+E then initial realignment and immobilisation with skin traction before surgery
- Surgical: retrograde intramedullary nail (if proximal extra-articular or simple intra-articular) or open reduction internal fixation (ORIF)
External fixation if severe comminuted or open fracture
What are the complications of a distal femoral fracture?
- Malunion
- Non union (often in metaphyseal area)
- Secondary OA if intrarticular extension of fracture
- Knee pain/Stiffness
What is the pelvic ring and the true pelvis?
Pelvic ring: two inominate bones (ilium, ischium, pubis), the sacrum and their supporting ligaments
True pelvis: rectum, bladder, uterus, iliac vessels, lumbosacral nerve roots
Pelvic fracture can cause life threatening haemorraghe, neurological deficit, urological trauma, bowel injury
How do pelvic ring fractures present and what should you check on examination?
Usually high energy from blunt trauma like RTA or falls from height so concurrent injuries
Pelvic deformity with significant pain and swelling around pelvis. External rotation and shortened limbs
Do full neurovascular assessment of lower limbs including checking anal tone as sacral nerve roots and iliac vessels can be injury
Need to check for urethral injury, open fractures (in rectum and vagina), abdominal injury, ecchymosis or haematomas around perineum/scrotum/labia
Also check chest, head spine, acetabulum and long bones
How do low energy pelvic fractures present and how are they managed?
Often affects ASIS due to sartorius, AIIS due to rectus femoris and ischial tuberosity due to hamstrings
How are pelvic fractures investigated and classified?
- ATLS guidelines
- 3 plain film radiographs to see whole ring (AP, inlet view, outlet view) OR
- CT
Young and Burgess or Tile Classification