CL 3: Hip Fracture

Question 1

What is the definition of a hip fracture?

Answer 1

Hip fracture definition: Used to describe a number of fracture types involving the proximal femur. This is a fracture distal to the femoral head and the proximal to a level of 5cm below the lesser trochanter.

Question 2

What are the different types of hip fractures?

Answer 2

Classification of hip fractures via location:

Intracapsular: occur within the joint at the level of the femoral neck and so may result in the loss of blood supply to the bone. Surgery may result in a full or partial hip replacement.

Extracapsular: Outside the hip capsule - occur from the extracapsular femoral neck to the area 5cm below the lesser trochanter. These can be further divided into intertrochanteric and sub trochanteric hip fractures. Since they have a better blood supply, surgical treatments include internal fixation with a pin or a screw.

Question 3

What is the usual mechanism of injury for hip fractures?

Answer 3

When to suspect a hip fracture:

- In older patients who complain of hip pain 
- Falls or pain whilst walking
- In patients with reduced bone loss (osteoporosis or bone metastases)
- High mechanism trauma in younger patients especially 

Mechanism of injury for the majority of hip fractures are: 

- Falling directly onto lateral hip 
- Twisting mechanisms 
- Sudden fracture due to underling bone metastases or osteoporosis which cause the patient to fall

Question 4

What are the diagnostic factors for a hip fracture?

Answer 4

Diagnostic factors - look for the presence of risk factors

- Osteoporosis/osteopenia 
- Age over 65 
- Falls 
- Low BMI 
- Female 
- High energy trauma 

- Inability to weight bear 
- Pain in affected leg/hip
- Pain with hip movement 
- Shortened and externally rotated leg

Question 5

What should you examine for in a hip fracture?

Answer 5

• Look - look around the bed side for walking ages etc., asymmetry of the hip (fracture can result in a shortened and externally rotated leg), muscle wasting (quadriceps can make them more likely to fall when standing as there is no muscle bulk to maintain balance) and scars.
  
  • Feel - check first if they have any pain. Also look at temperature and palpate the joint.
  • Move They will be in considerable pain so any movement will be limited. Check in the supine position, hip flexion, abduction, adduction and internal and external rotation.
  • A complete examination is necessary to sort any underlying cause. Get information about general health and identify if there are any medical problems that need treating urgently or anything that would delay surgery. It is important to get a full CV exam to see if they have a narrowed heart valve, respiratory, peripheral pulses and cognition.

Question 6

What tests are used in a hip fracture?

Answer 6

• Blood tests
  
  • ECG
  • Chest X-rays
  • Pelvis X-ray and Hip X-ray.

These check if there is any abnormalities that need to be corrected urgently so that the patient is not delayed to going into theatre

Question 7

What are differentials for a hip fracture?

Answer 7

Differential diagnoses: (history and imaging help with this)
- Acetabular fracture
- Pubic ramus fracture
- Femoral shaft fracture
- Femoral head fracture
- Septic hip
It is also important to look for any other fractures sustained at the time of injury and not to just focus on the hip e.g. clavicular, wrist etc.

Question 8

What are the different types of management in a hip fracture?

Answer 8

Management is then once the hip fracture is confirmed:

- Pain relief via the administration of a fascia-iliaca  nerve block which reduces the need for opiates and the delirium associated with this. Pain management protocols.
- Hydration for surgery 
- Treat medical problems 
- Surgery - this needs to be done at a timely fashion. This is the best form of pain relief and prevents chest infections and pressure sores occurring due to the patient being bed bound. 

Hip fracture operations are broadly divided into:
- Arthroplasty - a replacement surgery for joints done be realigning the joints or replacing it with a prosthetic one
- External fixation
The decision is based on patient factors and the type of fracture. Due to the anatomy fractures occurring within the joint capsule may lead to disruption of the bone supply and may lead to replacement of the bone of the joint by an arthroplasty. Extracapsular fractures are less likely to do so and so are fixed using external fixation using nails, plates and screws. Some patients do not undergo surgery as it may be too high risk due to underlying co-morbidities.

Question 9

What are a possible complications of a hip fracture?

Answer 9

Hip fracture complications
- Short term - thromboembolic complications (PEs and DVTs) - patients are given anti-thromboembolic drugs to prevent this
- Long term avascular necrosis and non-union/failure of fixation
The rate of medical complications post-operatively for older patients is much higher, accounting for the increased mortality in hip replacements. Older patients will often have impaired function and reserve. They are less able to respond to perioperative stress and more likely to suffer an adverse outcome. By identifying this and optimising perioperative care we can identify and treat medical problems sooner.

Question 10

What do you look for in a fall assessment?

Answer 10

Falls assessment by an orthogeriatrician:
- History
- Cognition
- Examination
- MDT assessment Possible interventions - medication review, vision, hearing, continence, nutrition footwear etc.
Over 50% of hip fracture patients will have a further fall within a year and a third will sustain a fall related injury. It is therefore important to identify such factors to prevent another fall.