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Yr 2 - Movement > Clinical: Neck of Femur Fractures > Flashcards

Clinical: Neck of Femur Fractures Flashcards

1
Q

Anatomy of hip

A
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2
Q

Describe the hip joint

A

Multi-axial ball & socket joint between femoral head & acetabulum

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3
Q

How is the femoral head connected to the proximal femoral shaft?

A

Via the femoral neck

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4
Q

What is the blood supply to the hip?

A

Medial and alteral circumflex femoral arteries (all around the neck of the femur)

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5
Q

What can disruption to the blood supply to the head and neck of the femur result in

A

Avascular necrosis

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6
Q

Why is hip disease a cause of pain referred to the knee?

A

Supplied by same nerves (femoral, obturator, sciatic)

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7
Q

What is the definition of a hip fracture?

A

Fracture of the femur distal to the femoral head and proximal to a level 5 cms below the lesser trochanter

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8
Q

What is an intracapsular fracture?

A
  • 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
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9
Q

What is an extracapsular fracture?

A
  • 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
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10
Q

What are the 2 classes of extracapsular fractures?

A
  1. Intertrochanteric
  2. Subtrochanteric
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11
Q

What type of falls can cause hip fractures?

A
  • Fall directly onto lateral hip
  • Twisting mechanism (foot planted and person rotates)
  • Sudden spontaneous fracture which causes a fall (underlying bone problem)
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12
Q

Why is it important to determine the reason for any fall?

A

Especially in elderly patients, falls often signal underlying ill health

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13
Q

Which history should be taken from a patient during a hip fracture?

A
  • Mechanism of injury
  • Collateral history
    • Carers, relatives
  • Past medical history
  • Social history
  • Medication history
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14
Q

What to do in beginning of hip fracture examination:

A
  • Introduce yourself
  • Confirm patients details: name & DOB
  • Explain examination
  • Check understanding & gain consent
  • Hand gel/ wash hands
  • Expose patient appropriately
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15
Q

What should be looked for in hip fracture examination?

A
  • Symmetry of hips
  • Length length discrepancy
  • Muscle wasting
  • Scars
  • Around the bedside
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16
Q

What should be felt for in hip fracture examination?

A
  • Ask patient if they have any pain first
  • Temperature
  • Palpate around hip joint
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17
Q

What movements should be examined in a hip fracture?

A

Supine position:

  • Hip Flexion (max.120°)
  • Hip Abduction (max. 45°)
  • Hip Adduction (max 30°)

Internal & external rotation (max 45°)

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18
Q

Typical case presentation of hip fracture:

A
  • 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.
19
Q

What routine investigations are requested after a hip fracture?

A
  • Blood tests
  • ECG
  • CXR
  • Pelvis xray, hip xray
20
Q

What 2 views are always taken during a hip xray?

A
  • AP
  • Lateral
21
Q

Intracapsular fracture xray

A
22
Q

Extracapsular fracture xray

A
23
Q

1-2% of hip fractures are not visible on normal xrays. What other imaging would you then need to consider?

A
  • MRI pelvis
  • CT pelvis
24
Q

What are differential diagnoses for something presenting as a hip fracture?

A
  • Acetabular fracture
  • Pubic ramus fracture
  • Femoral shaft fracture
  • Femoral head fracture
  • Septic hip
25
Q

What other fractures may occur at the same time as a hip fracture?

A
  • Wrist
  • Clavicle
  • Humeral
  • Ribs
  • Pelvis
26
Q

Management of hip fracture?

A
  • Pain management
  • Hydration
  • Treat medical problems
  • Surgery
27
Q

What type of fractures are less likely to disrupt blood supply of bone?

A

Extracapsular

28
Q

How soon should surgery be done after diagnosing a hip fracture?

A

Max 36 hours

29
Q

Why is early next day mobilisation after surgery key?

A
  • 3% loss of lean body mass
  • Helps to reduce post surgery complications
    • Thrombosis, pneumonia, respiratory failure, delirium, pressure sores
30
Q

When would a hip fracture only require non-operative management?

A
  • Late presentation but patient is pain free
  • Undisplaced stress fracture (younger patient)
  • Immobile and not in pain
  • Terminally ill (to die within a week)
31
Q

Describe pre-operative phase of hip surgery

A
  • Medical optimisation and identification of risks
  • Agreed protocols for example for reversal of anticoagulation
32
Q

Describe peri-operative phase for hip surgery

A
  • Discussion between surgeons, anaesthetists and orthogeriatricians
  • Appropriate listing for theatre
33
Q

Describe post-operative phase and rehabilitation of hip surgery

A
  • Early physiotherapy and occupational therapy input
  • Analgesia
  • MDT involvement
34
Q

What are the short-term complications of hip fractures?

A

Thromboembolic complications

35
Q

What are the long term complications of hip fractures?

A
  • Avascular necrosis
  • Non-union/failure of fixation
36
Q

Why are older people more likely to suffer from post-operative complications?

A

Less able to respond to perioperative stress & more likely to suffer from an adverse outcome –> age related physiological changes

37
Q

What is orthogeriatrics?

A

Subspecialty developed in response to clinical, social and financial needs in the management of patients with fragility fractures, and more specifically hip fractures.

38
Q

What is an orthogeriatrician’s role in hip fractures?

A
  • Perioperative medical assessment
  • Falls & bone health assessment
  • Oversee postoperative rehabilitation
39
Q

How common is a 2nd hip fracture?

A
  • 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)
40
Q

What is osteoporosis characterised by?

A

Low bone mass

41
Q

What is FRAX?

A

Fracture risk assessment tool –> 10 year probability of a major osteoporotic fracture

42
Q

What is the NICE guidance for hip fractures?

A
  1. Offer nerve block
  2. Physiotherapy assessment & mobilisation on the day after surgery.
  3. Mobilisation at least daily & ensure regular physiotherapy review
  4. Early supported discharge
43
Q

What are the standards for best practice for hip fractures?

A
  1. Surgery within 36 hours of diagnosis
  2. Geriatrician review within 72 hours
  3. Pre-op AMTS (assess cognition) & post-op 4AT (assess delirium)
  4. Post-operative geriatrician led MDT
  5. Nutritional assessment
  6. Falls & Bone Health Assessment
  7. Physiotherapist assessment post-op (day after surgery)
44
Q

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
A
  • 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

Yr 2 - Movement (39 decks)

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