Fractured NOF Flashcards
:)
See other #NOF deck for cards from intro and Teach me surgery
Questions to ask in history for #NOF
- Fall history - nature of fall, landing, long lie?
- PMH - co-morbids, previous falls, chemo, OP etc
- DH - anticoags, warfarin
- SH - normal mobility, how to mobilise, support at home, ADL independence?
Clinical examination finding of #NOF
- Externally rotated
- Shortened
Physical exam of #NOF
- Roll legs on bed - exhibits pain usually
- Determine location of pain
- Full NV exam
Investigations on admission for #NOF and WHY
- FBC - cause of fall - anaemia? infection?
- Clotting screen and INR if warfarin - assess bleed risk for surgery and current bleeding from # risk?
- U&E, LFT - baseline
- CRP - infection?
- Creatine kinase - long lie, rhabdo
- X-ray pelvis - AP and lateral for hip
- Group and save - if needs blood in surgery
- ECG - arrhythmia for fall?
- Urine culture if suspect UTI
- PTH, Vitamin D, Calcium and PO4
Treatments that can be given in ED before hip # surgery
- Fluids
- Analgesia - opioid +/- regional block eg fascia iliaca block
What medications should be written on patients drug chart for #hip?
- Analgesia + LAXATIVE if opioid
- Any fluids given
- VTE prophylaxis
- Abx prophylaxis - given within 1 hr of skin incision though
What fluids should be given to patients with hip #?
- Isotonic crystalloids eg 0.9% saline
- Often dehydrated, restore IV volume
- Blood if lost a lot and Hb is very low
- Then maintenance fluid and correct electrolyte abnormalities - add K+ if low
Treatment for intracapsular displaced #NOF
- Total hip replacement or hemiarthroplasty
Consider total hip replacement rather than hemiarthroplasty for people with a displaced intracapsular hip fracture who:
* were able to walk independently out of doors with no more than the use of a stick and
* do not have a condition or comorbidity that makes the procedure unsuitable for them and
* are expected to be able to carry out activities of daily living independently beyond 2 years
Discussion during process of consenting for hemiarthroplasty
- Procedure in general
- Risks - VTE, bleeding, pain, dislocation, leg length differences, long term failure, infection, rare = nerve damage, bone damage, woumd healing problems, death
- Benefits - realign bone, promote healing, try to improve mobility
What is RESPECT form, what issues can occur from it?
- Involves discussions aboit ceiling of care, plans for resuscitation and end of life
- Includes DNAR
- Need to discuss if attempting CPR would benefit the patient or if it would cause harm, discomfort and loss of dignity
- Take into account patients opinion and views
- But sometimes there can be a disagreement with medical professional
What is Nottingham Hip Fracture score?
- Predictor of 30 day mortality post hip #
- Takes into account age, sex, AMTS, Hb on admission, if living in institution, co-morbidities and malignancy within last 20 years (not inc BCC and SCC)
- HOWEVER, there are significant differences across different trusts in how it predicts mortality
- Score of 6 or more seems to be high risk
Serum lactate and hip #
- Marker of mortality
- Increase in 1mmol/L = 1.9 fold increase in odds of 30 day mortality
- 3 mmol/L or more = high risk
What do team look for on x-ray post hemiarthroplasty?
- Leg length
- Position and rotation of femoral head
- Femoral stem positioning
- Distribution of cement
- Any post op #
- Osteolysis or luscency around prosthesis
- Joint space
- Soft tissue
Instructions from theatre team post op
- Abx prophylaxis continuation?
- Pain management directions
- Wound care
- Monitoring
- Restrictions - movement, showering etc
- Products given in surgery - blood, fluids etc
Role of junior doctor post hip replacement
- Pain management
- Monitor patient for complications
- Wound care
- Fluids
- Rehabilitation monitoring
- Education on current situation for patient and family
- Emotional support
Post op complications of hip replacement
- Delirium
- Wound infection
- DVT/PE
- Chest infection
Treatment of post op complications
- Delirium - find cause, treat, 4AT scoring, maintain sleep/wake cycle, orientate daily
- Wound ifnection - debride, abx, implant retention (unless prosthesis is involved massively), negative pressure wound therapy?
- DVT/PE - wells score, CTPA/whatever score states, apixaban
- Chest infection - CXR, sputum culture, abx guidelines
Recommendations for bone protection post #NOF
- If under 75 - use FRAX tool
- Over 75 - offer bone protection
What bone protection is usually given?
- Bisphosphonates 1st line - Alendronate or Risedronate
- If Ca2+ intake adequate - just give Vitamin D alongside
- If inadequate - give calcium and vitamin D
What is involved in surgery discharge summary?
- Admission and discharge date
- Operating surgeon
- Diagnosis
- Procedure done
- Post op
- Rehab
- Medications given
- Discharge medications
- Follow up arranged
- Any wound care advice/fu
- Mobility equiptment changes
- Discharge recommendations
NICE guidance on hip #
- Have surgery day of or day after admission
- Correct comorbids pre surgery
- Pain - assess immediately, then within 30 mins of 1st fose, then hourly and when doing regular obs
- Paracetamol every 6 hrs, opioids if not covering, consider nerve block
- Spinal or general anaesthesia for op
- Anterolateral approach for hemiarthroplasty (NOT posterior)
- Early mobilisation - offer at least once daily with regular physio input
- Hip fracture programme for discharge
Advice post hip op for patient - basic
- avoiding flexing the hip > 90 degrees
- avoid low chairs
- do not cross your legs
- sleep on your back for the first 6 weeks
