218 - Hip Fracture Flashcards by Lucy Knox

What possible causes of an elderly person falling are there?

Medical issues
Dementia
Mechanical
Postrual hypotension

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How do you asses postural hypotension?

Lying and standing Bp (must have been lying at rest for a while)

Tilt-test

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What common drug may cause postural hypotension?

Bisoprolol

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what is the mortality of hip fractures?

20%

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What 4 steps can be taken to try prevent hip fractures?

Prevent osteoporosis
Treat osteoporosis
Prevent falls
Prevent injuries from falls

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What is the definition of a fracture?

Loss of continuity of the substance of bone due to a physical force

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What are the different configurations of fracture?

Long bone:

Transverse
Oblique
Spiral
Comminuted
Segmental

Cancellous bone:

impacted
crush/compression

Periarticular:
- avulsion

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How do you describe a fracture?

Level - where it is - proximal 3rd? ephiphysial/metaphysial/diaphysial

Deformity:

Displacement
angulation
rotation
shortening

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In a hip fracture what signs may you see?

Internal rotation
Shortening of leg
Pain

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What do you need for normal bone healing?

Intact fracture haematoma

controlled micromovement

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What are the 4 stages of normal bone healing?

Inflammation
Soft Callous
Hard Callous
Remodelling

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What does a fracture haematoma contain?

Inflammatory mediators
Fibrin clots
Polymorphs
Platelets
Monocytes
Fibroblasts - osteoprogenitor cells develop
- vascular ingrowth begins

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What happens in the soft callus stage of bone healing?

Pain and swelling subside
boney fragments unite with fibrous/cartilaginous tissue
Ends fixed in place, but can still angulate

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What happens in the hard callus stage of bone healing?

Mineralisation of cartilage
Osteoblast activity - woven bone
Stiffness increases
An external callus forms - can feel this

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What happens in the remodelling stage of bone healing?

Bone remodels to form lamellar bone
Medullary canal is made
Occurs best in children
takes 1-2 years

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What interventions are done in a fracture?

Reduction if needed
Retention - non-op (cast, strapping, traction), opperative (screws..)
Rehab - exercise limb. weight bearing good.

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What operative retention methods of a fracture are there?

Plates + screws - eg. dynamic hip screw, cannulated screws
intramedullary screws
External fixtures
Percutaneous pins

Why would you need to do operative retention of a fracture?

If there is a:

displaced intra-articular fracture
tenuous blood supply
Multiple injuries
in a pathological long bone

What are possible complications of a fracture?

General soft tissue damage
Fat embolism
Nerve damage
Vascular trauma
Compartment syndrome

Union problems - non-union, malunion, delayed union
AVN - Avascular necrosis

What triad of effects do you see in a fat embolism?

Respiratory issues
Neurological issues
Petechial rash

What are the 2 types of non-union? How do you approach them?

Hypertrophic - viable bone ends but not adequate stability -> achieve stability and let heal
Atrophic - no cellular activity in bone - > need bone grafting and removal of fibrous tissue

What is AVN?

Avascular necrosis

Bone death due to blood supply disruption
Very slow revascularisation
Bone soft and easy to destroy
Pain + stiffness

What are pathological fractures? Why do you get them?

Fracture are minimal stress

Primary tumours
Secondary tumours
Infection
Congenital (osteogenesis imperfecta)
Metabolic bone disorders

Why are childrens fractures different from adults?

Periosteum is thicker
More metabolically active
Higher collagen: mineral content - more elastic and porous
Ligaments stronger than bone - physis is weak spot

What type of fracture is common in children but not adukts?

Greenstick - concave cortex is intact, convex side breaks Plastic deformity

Name 3 metabolic bone disorders

Osteoporosis Osteomalacia/rickets Paget's disease

What is osteoporosis?

Loss of bone mass | more osteoclast resorption than osteoblast formation

What risk factors are there for osteoporosis?

``` Age female genetics oestrogen deficiency - early menopause, late menarche, tamoxifen hypogonadism smoking alcohol medications - steroids, anticonvulsants, SSRIs, PPIs ```

What are protective against osteoporosis?

Weight bearing physical activity HRT while you take it

How do you diagnose osteoporosis?

FRAX tool to asses risk DEXA bone mineral density scan - get T score, normal = 0 to -1, osteoporosis if <-2.5 - Z score is age + sex matched

What are the treatment options for osteoporosis?

``` Calcium + vit D Exercise Falls prevention measures Increase bone formation: - Teriparatide - PTH pulses - Strontium renelate ``` Decreases bone resorption - Bisphosphonates: alendronate (inhibits osteoclasts) - Denosumab - RANK ligand inhibitor (prevents osteoclast differentiation)

What is osteomalacia and rickets?

Vit D deficiency, in adults, in children

Describe the steps that occur in vit D deficiency

Low vit D - > reduced Ca uptake from gut - > low serum Ca - > increase PTH - > Ca resporption form bone - > reduced mineralisation of bone

What can cause a vit D deficiency?

``` Inadequate sunlight/vit D in diet malabsorption Medication (phenytoin, rifampicin) Multiparosity Abnormal vit D metabolism ```

What blood results would you see in osteomalacia.rickets?

Low serum 25(OH) vit D Low serum Ca Low serum phosphate High serum PTH High alkaline phospatase

What signs do you see in rickets?

Curved long bones

What signs do you see in osteomalacia?

Bone pain Proximal muscle weakness Stress fractures

How do you treat osteomalacia/rickets?

Vit D supplements - calcichew - Oral D2/D3 - Active Vit D - Alphacaleidol

What is Pagets disease?

Disordered bone metabolism | Osteoclast overactivity and compensatory osteoblast activity - disordered woven bone - weaker

What Symptoms do you get in pagets?

Bone pain Pathological fractures Compression effects - CN palises, deafness, siatica, cauda equina

How do you diagnose Pagets?

X-Ray (often incidental) Isotope bone scan - increased uptake Urinary hydrocyproline increased Bloods show: High alkaline phosphatase, but normal Ca, Vit D, PTH, phosphate.

How do you treat pagets?

Not always necessary if not symptoms Bisphosphinates eg. risedronate, zolendronate