Clinical: Neck of Femur Fractures Flashcards
Anatomy of hip
Describe the hip joint
Multi-axial ball & socket joint between femoral head & acetabulum
How is the femoral head connected to the proximal femoral shaft?
Via the femoral neck
What is the blood supply to the hip?
Medial and alteral circumflex femoral arteries (all around the neck of the femur)
What can disruption to the blood supply to the head and neck of the femur result in
Avascular necrosis
Why is hip disease a cause of pain referred to the knee?
Supplied by same nerves (femoral, obturator, sciatic)
What is the definition of a hip fracture?
Fracture of the femur distal to the femoral head and proximal to a level 5 cms below the lesser trochanter
What is an intracapsular fracture?
- Within the capsule at the level of the femoral neck
- May result in loss of blood supply to bone
- May involve full or partial hip replacement
What is an extracapsular fracture?
- Outside the hip capsule
- Occur from the extracapsular femoral neck to the area 5cm distal to the lesser trochanter
- Can be further divided into: intertrochanteric & subtrochanteric fractures
- Treatment usually involves internal fixation with a pin or screw
What are the 2 classes of extracapsular fractures?
- Intertrochanteric
- Subtrochanteric
What type of falls can cause hip fractures?
- Fall directly onto lateral hip
- Twisting mechanism (foot planted and person rotates)
- Sudden spontaneous fracture which causes a fall (underlying bone problem)
Why is it important to determine the reason for any fall?
Especially in elderly patients, falls often signal underlying ill health
Which history should be taken from a patient during a hip fracture?
- Mechanism of injury
- Collateral history
- Carers, relatives
- Past medical history
- Social history
- Medication history
What to do in beginning of hip fracture examination:
- Introduce yourself
- Confirm patients details: name & DOB
- Explain examination
- Check understanding & gain consent
- Hand gel/ wash hands
- Expose patient appropriately
What should be looked for in hip fracture examination?
- Symmetry of hips
- Length length discrepancy
- Muscle wasting
- Scars
- Around the bedside
What should be felt for in hip fracture examination?
- Ask patient if they have any pain first
- Temperature
- Palpate around hip joint
What movements should be examined in a hip fracture?
Supine position:
- Hip Flexion (max.120°)
- Hip Abduction (max. 45°)
- Hip Adduction (max 30°)
Internal & external rotation (max 45°)
Typical case presentation of hip fracture:
- 82 year old lady presents with history of a fall from standing height & an inability to bear weight afterwards
- She complains of pain in her left hip. No preceding syncopal episodes & no LOC or chest pain
- O/E: In pain, left hip painful & sore to palpation with some bruising over left greater trochanter. No skin breaks & left leg is shortened & externally rotated. Distal neurovascular status intact.
What routine investigations are requested after a hip fracture?
- Blood tests
- ECG
- CXR
- Pelvis xray, hip xray
What 2 views are always taken during a hip xray?
- AP
- Lateral
Intracapsular fracture xray
Extracapsular fracture xray
1-2% of hip fractures are not visible on normal xrays. What other imaging would you then need to consider?
- MRI pelvis
- CT pelvis
What are differential diagnoses for something presenting as a hip fracture?
- Acetabular fracture
- Pubic ramus fracture
- Femoral shaft fracture
- Femoral head fracture
- Septic hip
What other fractures may occur at the same time as a hip fracture?
- Wrist
- Clavicle
- Humeral
- Ribs
- Pelvis
Management of hip fracture?
- Pain management
- Hydration
- Treat medical problems
- Surgery
What type of fractures are less likely to disrupt blood supply of bone?
Extracapsular
How soon should surgery be done after diagnosing a hip fracture?
Max 36 hours
Why is early next day mobilisation after surgery key?
- 3% loss of lean body mass
- Helps to reduce post surgery complications
- Thrombosis, pneumonia, respiratory failure, delirium, pressure sores
When would a hip fracture only require non-operative management?
- Late presentation but patient is pain free
- Undisplaced stress fracture (younger patient)
- Immobile and not in pain
- Terminally ill (to die within a week)
Describe pre-operative phase of hip surgery
- Medical optimisation and identification of risks
- Agreed protocols for example for reversal of anticoagulation
Describe peri-operative phase for hip surgery
- Discussion between surgeons, anaesthetists and orthogeriatricians
- Appropriate listing for theatre
Describe post-operative phase and rehabilitation of hip surgery
- Early physiotherapy and occupational therapy input
- Analgesia
- MDT involvement
What are the short-term complications of hip fractures?
Thromboembolic complications
What are the long term complications of hip fractures?
- Avascular necrosis
- Non-union/failure of fixation
Why are older people more likely to suffer from post-operative complications?
Less able to respond to perioperative stress & more likely to suffer from an adverse outcome –> age related physiological changes
What is orthogeriatrics?
Subspecialty developed in response to clinical, social and financial needs in the management of patients with fragility fractures, and more specifically hip fractures.
What is an orthogeriatrician’s role in hip fractures?
- Perioperative medical assessment
- Falls & bone health assessment
- Oversee postoperative rehabilitation
How common is a 2nd hip fracture?
- First 2 years following first fracture is high risk for patients getting a second major fracture
- More than 50% of hip fracture patients will have a new fall within a year (1/3rd of whom sustain fall related injury)
What is osteoporosis characterised by?
Low bone mass
What is FRAX?
Fracture risk assessment tool –> 10 year probability of a major osteoporotic fracture
What is the NICE guidance for hip fractures?
- Offer nerve block
- Physiotherapy assessment & mobilisation on the day after surgery.
- Mobilisation at least daily & ensure regular physiotherapy review
- Early supported discharge
What are the standards for best practice for hip fractures?
- Surgery within 36 hours of diagnosis
- Geriatrician review within 72 hours
- Pre-op AMTS (assess cognition) & post-op 4AT (assess delirium)
- Post-operative geriatrician led MDT
- Nutritional assessment
- Falls & Bone Health Assessment
- Physiotherapist assessment post-op (day after surgery)
Another case history example:
- 82 year old lady presents with history of a fall from standing height & an inability to bear weight afterwards. She complains of pain in her left hip. No preceding syncopal episodes & no LOC
- PMHx: Atrial fibrillation, hypertension, macular degeneration
- SHx: Alone, stairs, walking stick outside, family support
- Meds: Apixaban, ramipril, bisoprolol, amlodipine, furosemide
- O/E: In pain, left hip painful & sore to palpation with some bruising over left greater trochanter. No skin breaks & left leg is shortened & externally rotated. Distal neurovascular status intact
- Tender left lower ribs, AMT 7/10, BP 110/70, HR 55bpm irreg irreg, Sats 91% RA
- Hb 100 MCV 75, U&Es normal, ECG: AF 50bpm, CXR: fracture 7th & 8th lateral left ribs
- How to get her home?
- Bed downstairs?
- Medications? Is she over-medicated?
- Macular degeneration
- Low blood pressure?
- Low stats?
- Low AMT (7/10)
Need pain relief and oxygen
