Case 6 - Falls

Question 1

Who’s at the highest risk of falling?

Answer 1

The natural ageing process means that older people have an increased risk of having a fall.

Question 2

How common are falls?

Answer 2

Falls are a common, but often overlooked, cause of injury. Around 1 in 3 adults over 65 who live at home will have at least one fall a year, and about half of these will have more frequent falls.

Question 3

Why are falls dangerous?

Answer 3

Around 1 in 3 adults over 65 who live at home will have at least one fall a year, and about half of these will have more frequent falls. Most falls do not result in serious injury. But there’s always a risk that a fall could lead to broken bones, and it can cause the person to lose confidence, become withdrawn, and feel as if they have lost their independence.

Question 4

What are the causes of falls?

Answer 4

Older people are more likely to have a fall because they may have:

1) Balance problems and muscle weakness
2) Poor vision
3) A long-term health condition, such as heart disease, dementia or low blood pressure (hypotension), which can lead to dizziness and a brief loss of consciousness

Question 5

When are falls more likely to occur?

Answer 5

A fall is also more likely to happen if:

1) Floors are wet, such as in the bathroom, or recently polished
2) The lighting in the room is dim
3) Rugs or carpets are not properly secured
4) The person reaches for storage areas, such as a cupboard, or is going down stairs
5) The person is rushing to get to the toilet during the day or at night

Question 6

What are the neurological risk factors of falling?

Answer 6

1) Confusion
2) Cognitive impairment
3) Depression
4) Poor vision
5) Poor balance
6) a poor coordination

Question 7

What are the unmodifiable risk factors of falling?

Answer 7

1) Age
2) Female sex - osteoporosis is often associated with the hormonal changes that occur during the menopause.
3) History of falls

Question 8

What are the chemical risk factors of falling?

Answer 8

1) Polypharmacy
2) Particular drugs (e.g. steroid medication)
3) Alcohol

Question 9

What are the cardiovascular risk factors of falling?

Answer 9

1) Orthostatic hypotension - low blood pressure, which can lead to dizziness and a brief loss of consciousness
2) Arrhythmias
3) Syncope

Question 10

What are the neuromuscular risk factors of falling?

Answer 10

1) Muscle weakness
2) Gait disorders: Parkinson’s hemiplegia, cerebellar disease, antalgic, normal pressure hydrocephalus, proximal myopathy, etc
3) Peripheral neuropathy including sensory ataxia, foot drop
4) Arthritis and joint disorders
5) Osteoporosis

Question 11

What is a hip fracture?

Answer 11

A hip fracture is a bony injury of the proximal femur typically occurring in the elderly.

Question 12

How common are hip fractures?

Answer 12

Hip fractures are a common serious injury in older people (mean age of 80), with around 60,000 occurring each year in the UK. They are 4x more prevalent in women and cost the NHS and social care £1 billion per year.

Question 13

What are the regions of the proximal femur?

Answer 13

The proximal femur consists of a head, neck, trochanters (greater and lesser) & shaft. It is the largest bone in the human body.

Question 14

What is the inter-trochanteric line?

Answer 14

The inter-trochanteric line lies on the anterior surface of the femoral neck, running between the trochanters. It demarcates the inferior attachments of the hip capsule.

Question 15

Outline the anatomy of the hip capsule

Answer 15

The capsule of the hip is attached proximally to margins of acetabulum and transverse acetabular ligament. Distally, to the inter-trochanteric line, bases of greater & lesser trochanters and to the femoral neck posteriorly (approx. 1/2 inch from the trochanteric crest). It contains the retinacular vessels - a major component of the blood supply to the femoral head.

Question 16

The femoral head receives blood supply from which 3 sources?

Answer 16

1) Retinacular vessels - main blood supply. Originates from an extra-capsular arterial ring, supplied by medial and lateral circumflex vessels (profunda femoris A.). Reinforced by the superior and inferior gluteal arteries (internal iliac A.).
2) Foveal artery - not a major source. During skeletal development, supplies the epiphysis with a small amount of blood. Said to become obliterated in adult life (ligamentum teres).
3) Metaphyseal vessels - not a major source. After skeletal maturity, metaphysical arteries also contribute blood to the femoral head.

Question 17

How are hip fractures categorised?

Answer 17

Hip fractures may be categorised as either intra- or extra-capsular, depending on their location in relation to the inter-trochanteric line:

1) Intracellular-capsular = above the inter-trochanteric line
2) Extra-capsular = below the inter-trochanteric line

Question 18

What does the type of hip fracture determine?

Answer 18

The type of fracture determines the likelihood of disruption to the blood supply of the femoral head. Broadly speaking, intra-capsular fractures are associated with a higher-risk of disruption, owing to the close proximity of the retinacular vessels.

Question 19

What is Garden’s classification?

Answer 19

Intra-capsular fractures are further sub-classified according to Garden’s classification. Classification is based on the integrity of the trabecular lines in an AP projection. It is used to guide management. There are four types:
Type I - Incomplete, impacted in valgus
Type II - Complete, undisplaced
Type III - Complete, partially displaced
Type IV - Complete, completely displaced

With type 1 & 2 there is minimal displacement, and therefore a lessened risk of disruption to the femoral head blood supply. Conversely, with type 3 & 4, where there is much greater displacement, there is substantially higher risk.

Question 20

What are the risk factors for hip fractures?

Answer 20

A number of risk factors pre-dispose patients to hip fractures:

1) Increasing age
2) Osteoporosis
3) Low muscle mass
4) Steroids
5) Smoking
6) Excess alcohol intake
7) Metastatic spread of cancer to bone

Question 21

What causes hip fractures in the elderly?

Answer 21

In the elderly, hip fractures are normally caused by falls. The mechanism varies from direct falls onto the affected hip, to twisting, in which the patient’s foot is planted and the body rotates. Bones are typically osteopaenic (reduced bone density) and also deficient in elastic reserve (i.e. they are very brittle).

Question 22

What causes hip fractures in younger people?

Answer 22

In younger patients, hip fractures are more commonly the result of major trauma (e.g. motor vehicle accidents), or in patients with gait disturbance (e.g. in multiple sclerosis) in which they are at increased risk of falls. Certain medications, such a prolonged corticosteroid use, can also predispose to osteopaenia.

Question 23

What are the clinical signs and symptoms of hip fractures

Answer 23

1) Bony tenderness over affected hip
2) Shortened / externally rotated leg (only present if significant displacement)
3) Hip / knee pain
4) Inability to bear weight
5) Limited range of motion

Question 24

What are the bedside investigations of a hip fracture?

Answer 24

1) Observations
2) Urine dip
3) ECG

Question 25

What are the blood related investigations of a hip fracture?

Answer 25

1) Full blood count (FBC)
2) Urea and electrolytes test (U&E)
3) C-reactive protein test (CRP)
4) Clotting
5) Group & Save blood test x 2
6) Bone profile
7) Vitamin D test

Question 26

What are the imaging related investigations of a hip fracture?

Answer 26

1) Chest radiograph (CXR): required pre-operatively.
2) Plain films: X-ray pelvis, AP and lateral of affected hip. Full length views of the femur may be obtained, particularly if metastatic disease in the bone is suspected.
3) MRI/CT: if plain films are inconclusive, to rule out occult fracture. MRI is gold-standard, CTs are generally more readily availible.
4) Cardiac echo: if new murmur is auscultated, abnormal ECG, or significant cardiac history. Often requested by the anaesthetist pre-operatively.

Question 27

What is Shenton’s line?

Answer 27

This is an imaginary curved line drawn along the inferior border of the superior ramus, along the inferomedial border of the neck of femur. It should be continuous and smooth.

Question 28

Outline the initial management of a hip fracture

Answer 28

The initial management involves analgesia, routine investigations and pre-operative work-up.

Question 29

Which analgesia are used for hip fractures?

Answer 29

Appropriate analgesia should be administered - the use of NSAIDs is discouraged. Paracetamol and opiod analgesia should be prescribed with reference to the patients weight, renal function and age. In the absence of contraindications a fascia iliaca block should be offered.

Question 30

What routine investigations are used for a hip fracture?

Answer 30

Routine blood tests and two group and saves should be sent. All patient should have a chest radiograph (CXR). Urine dipsticks and MSUs should be sent when relevant. In the majority of cases a urinary catheter should be placed as urinary retention is common. Cognitive status should be assessed and recorded.

Question 31

Outline the pre-operative assessments for a hip fracture

Answer 31

1) The orthopaedic team should review, mark, book and consent the patient. In most trusts medical teams or orthogeriatrics will also review the patient.
2) Where the patient lacks capacity, any lasting powers of attornery for health should be identified or a consent form 4 completed in the patients best interest.
3) Anaesthetic assessment should be obtained. The options of spinal anaesthesia or general anaesthetic should be discussed. The patient should be made NBM depending on when surgery is planned.

Question 32

How does a hip fracture affect a patient’s regular medication?

Answer 32

Patients may have an acute kidney injury requiring adjustments to regular medication. In general anticoagulants and antiplatelets are held - however context is key! If a patient has had a recent CABG or PCI for example discussion with cardiology / cardiothoracic surgery is warranted. Where reversal of anticoagulation or coagulopathy is needed discuss with haematology.

Question 33

How are most hip fractures treated?

Answer 33

Most hip fractures are treated surgically, unless there are significant co-morbidities restricting surgical intervention. Surgical management differs between intra- and extra- capsular fractures.

Question 34

What may occur if a patient with a hip fracture does not have surgery?

Answer 34

The evidence shows without surgery, patients remain bedbound with high risk of blood clots, chest infections and other complications. Surgical fixation on the other hand allows early mobilisation (same-day or next day) and rehabilitation.

Question 35

What is conservative treatment?

Answer 35

This is a treatment only used in rare cases. It can involve traction, bed rest or restricted mobilisation. Outcomes are often very poor in these patients.

Question 36

What should patients have surgery for a hip fracture?

Answer 36

NICE guidelines recommend surgery to be performed on the day of, or the day after, admission. The aim is to allow patients to fully weight bear (without restriction) in the immediate postoperative period.

Question 37

How are minimally or non-displaced intracapsular fractures (e.g. Gardens I/II) treated?

Answer 37

These are frequently treated with cannulated hip screws (often 2 or 3).

Question 38

How are displaced intra-capsular fractures (e.g. Gardens III/IV) treated?

Answer 38

These tend to be managed either with a total hip replacement (THR) or a hemi-arthoplasty. NICE advise that THR is offered to patients who:

1) Are able to walk independently out of doors with no more than the use of a stick and
2) Are not cognitively impaired
3) Are medically fit for anaesthesia and the procedure

Question 39

How are intertrochanteric fractures managed?

Answer 39

These may be managed with a dynamic hip screw (DHS) or intra-medullary (IM) nail. DHS are unique in the fact that they allow the fracture ends to ‘slide’; this is thought to promote bone healing.

Question 40

How are subtrochanteric fractures managed?

Answer 40

These tend to be managed with an intra-medullary (IM) nail.

Question 41

How are hip fractures complications managed in the daily review?

Answer 41

Delirium is common post-operatively (and pre-op) and should be screened for. Chest infection and urinary infection are also relatively common. Less often op site haematomas or op site infections may be seen.
Significant complications like peri-operative cardiac events and DVT/PE may occur. Patients should be reviewed by both the orthopaedic surgeons and the orthogeriatricians. Prophylaxis for fragility fractures should be considered.

Question 42

What is post-op VTE prophalaxyis?

Answer 42

Patients are at increased risk of DVT and PE following a hip fracture and surgical fixation. Normally prophylactic dose LMWH is started 6-12 hours post-op. This will normally be continued for a minimum of one month, though it may be longer depending on circumstance (e.g. prolonged hospital stay). TED stockings and intermittent pneumatic compression may also be used. Of course many patients in this cohort will already be formally anticoagulated for other conditions such as AF. In these patients anticoagulation should be resumed under the instruction of the operating team +/- haematology/cardiology advice.

Question 43

What are the roles of post-op physiotherapy and occupational therapy?

Answer 43

Patients should be encouraged to mobilise the day after surgery. Early mobilisation helps reduce the risk of blood clots, chest infections and deconditioning. Patients should have daily physiotherapy as an inpatient and a plan for community support at discharge. Patients home situation should be reviewed and a re-ablement package instituted as needed to (ideally) return the patient to their home or care home.