Fractures Flashcards
Proximal femur fracture - aetiology, morbidity and mortality
> Falls
- may be underlying cause
- Cerebrovascular disease
- cardiac arrhythmia
- postural hypotension
- Mechanical fall
- Usually no obvious organic causes falls
> Osteoporosis
– age related qualitative defect bone (more females than males)
– may be related to smoking, alcohol, steroids.
> High risk of complications
Usually poor cardioresp. reserves, CKD
Vast majority have surgery.
> Usually drop a level of mobility
– stick –> 2 ticks –> walker / frame –> needs assistance –> wheelchair –> hoist
> If living independently, 20% risk of requiring institutional care.
- – residential home
- nursing home
> Surgical complications
- failure of fixation
- AVN
- Non-union
- Infection
- Dislocation
Proximal Femur Fracture - clinical features
> Shortening > External rotation > Trochanteric bruising > Unable to straight leg raise > Severe groin pain on rotational movements
Proximal Femur fracture classification
Intracapsular
Extracapsular
- trochanteric
- Subtrochanteric (inferior to lesser trochanter)
Proximal femur fracture - investigations
Xray
MRI fro occult fractures
May need lateral Xray to see intracapsular fractures.
Intracapsular fractures
- diagnosis on Xray?: what’s the sign
Risk of AVN
Risk of non union
Diagnosis: break in Shenton’s line on Xray
Shentons line - an imaginary line along inferior border of the superior pubic rams (superior border of the obturator foramen) and along the inferomedial border of the neck of the femur. Line should be continuous and smooth
Week 6 lecture on Hip fractures.
Shentons line
an imaginary line along inferior border of the superior pubic rams (superior border of the obturator foramen) and along the inferomedial border of the neck of the femur. Line should be continuous and smooth
Intracapsular fracture - repair
Need to Get It Right First Time (GIRFT) - elderly patients may not survive a 2nd operation and functionally deteriorate
- replacement
- hemiarthroplasty in those with poorer function or cognitive deficit
- THR gives better function but higher dislocation rate
- May consider fixation in undisplaced fractures and IC fractrures if younger fitter patient (<60)
If MRI +ve and XR -ve for Intracapsular fractures…
Treatment is not fully elucidated.
Risk of displacement, with weight bearing.
Discuss with patient / family pros and cons of surgery
Unclear exact natural history - how many subsequently displace.
Surgery may provide better pain relief and easier rehab
Fix vs replace controversy for IC fracture.
Hemiarthroplasty
Just one half of the hip joint is replaced.
i..e just the head is replaced or the acetabulum is replaced.
Extracapsular fractures
- risk of AVN?
- What kind of screw is used?
No risk of AVN
Usually heal with sliding hip screw; dynamic hip screw
Can also fix with intramedullary nail and sliding hip screw (less lever arm)
Can be 2 part, 3 part to 4 part depending on whether the trochanters are fractured.
Increased number of parts –> increased instability and increase failure rates
Success of fixation dependent on quality of reduction and centrality of screws in head.
Subtrochanteric fracture
Inferior to lesser trochanter of femur.
Blood supply to fracture site less good –> higher risk of non-union.
Associated with long term bisphosphonate use
- increased incidence.
Thomas splint may help with analgesia
IM nail biomechamnically superior - may last longer before breakage if delayed union
Pubic Rami fractures
Different from high energy pelvic fractures
- no major displacement and bleeding
Tender groin, less pain rotation than hip fracture
Conservative Mx
Greater trochanter fracture - management
Usually conservative Mx
Can get MRI to see if fracture traverses femoral neck –> internal fixation.
