2.09 - Falls and Frailty Flashcards
What is the main consequence of delayed fixation of a hip fracture
Avascular necrosis of the femoral head
Which kind of hip fracture uses the Garden’s Classification
Intracapsular fractures - neck of femur fractures
What are the two types of extracapsular hip fractures
Intertrochanteric line fracture
Subtrochanteric line fracture (must be within 5cm of the line)
What is Shenton’s line
Continuous curved line seen on X-ray which goes up femur and around the inside of the hip joint
A discontinuous Shenton’s line may be indicative of a hip fracture, but is not diagnostic
Define each level of the Garden’s scale
I -> Incomplete fracture, minimally displaced
II -> Complete fracture, non-displaced
III -> Complete fracture, partially displaced
IV -> Complete fracture, completely displaced
Which garden ratings are low risk and which are high risk
I and II = low
III and IV = high
Which classifications of hip fracture are normally fixed with internal fixation (nails)
I and II
Which classifications of hip fracture are normally fixed with hemiarthroplasty or total hip replacement
III and IV
When is a total hip replacement performed to treat a hip fracture
Generally healthier patients
Able to walking using a maximum of one walking stick
No ongoing conditions that pose a risk to surgery
Expected to live more than two years post-op
When is a hemiarthroplasty performed to treat a hip fracture
More unwell patients
Not very mobile pre injury
What is the difference between total hip replacement and hemiarthroplasty
Total hip replacement - Replace femoral head and acetabulum
Hemiarthroplasty - Replace only the femoral head
How long after diagnosis of hip fracture must surgery occur
Within 48 hours
What are the short term post-op aims of hip fracture fixation
- Mobilise patient 6-8 hours after surgery
- Patient can fully weight bear
- Discharge 1 or 2 days post op
What is the routine analgesia for hip fracture patients
Paracetamol 1g PO/IV 6D
Codeine 3mg PO 6D PRN
Oramorph 5-10mg PO BD PRN
What are the 3 steps of the WHO pain ladder
- Non-opioids (paracetamol, NSAIDs)
- Weak opioids (codeine, tramadol)
- Strong opioid (morphine, oxycodone) and non-opioid
When would an iliofascial block be used
If a patient was still in pain after paracetamol and was nil by mouth
Where is an iliofascial block injected
1-2cm below the point 1/3 of the distance from the ASIS to the pubic tubercle
What is the state of a patient given a spinal block
Awake
Numb from L1 and below
Why is spinal anaesthetic preferred to general
Lower risk of post-operative pneumonia
Mechanical prophylaxis for VTE
TED (thrombo-embolus deterrent) stockings during surgery
Pneumatic pressure devices
Medical VTE prophylaxis
DOAC
LMWH
Warfarin (rare)
When is medical VTE prophylaxis used
Start 4 hours after surgery
Usually given LMWH in hospital and DOACs after discharge
What is the most important factor in preventing VTE in post-op patients
Mobilisation
Pain management alongside - can’t move if you’re in pain
Why is warfarin rarely used
Must take blood to measure INR regularly
2 is too low, 5 is too high - narrow window
Taken orally so bioavailability is variable
Lots of drug interactions
How can the effects of warfarin be reversed
IV Vitamin K
Why are LMWHs most commonly used in Pre- and Post- op VTE prophylaxis
Rare side effects
Smaller risk of bleeding
Why are DOACs primarily used after a patient has been discharged from hospital
Taken orally, so convenient at home but cannot be taken pre-op
What are the main risk factors for post-op pneumonia
Reduced mobility pre/post surgery
Immunosuppression (caused by anaesthetics)
Previous antibiotic use
Aspiration pneumonia
Surgery
How do we reduce risk of aspiration pneumonia
Keep patients nil by mouth at least 6 hours for food and 2 hours for liquids after being under general anaesthesia
How is post-op pneumonia managed
Broad -> Specific post culture abx
O2 if required
CXR
Alert anaesthetic and surgical team
