Fragility Fractures Flashcards
What is osteoporosis?
A skeletal disease characterised by low bone mass and deterioration of bone tissue with a consequent increase in bone fragility and susceptibility to low trauma fractures.’
Trabeculae thinned & sparse: bones become structurally weaker.
Osteoporosis - >2.5 standard deviations below the mean for a young adult. (Normal – bone mineral density above 1 standard deviation below the mean for a young adult)
Where is fragility fractures commonly seen?
Osteoporotic fractures of the hip, wrist and spine
common
What is the usual history/aetiology of hip fractures?
- Usually low energy fall
- Incidence increases with:
- Age.
- more common in females (osteoporosis).
What is normally observed in examination of a hip fracture?
• Inability to bear weight in an elderly patient following
a fall.
• Signs:
• External rotation of the limb.
• Shortened limb.
• Pain on rotation of the hip.
• Bruising (extracapsular fractures).
• Examine N/V state (especially sciatic nerve motor
function of ankle & great toe dorsiflexion
What imaging is appropriate in hip fractures?
• “AP pelvis & hips” (some units just call this an AP
pelvis)
• & Lateral hip xray (usually “horizontal beam lateral)
• If diagnosis in doubt:
• MRI is most sensitive, & thus recommended.
• CT if MRI not readily available.
• Repeat AP (internal and external rotation) if neither
CT or MRI readily available.
Outline the initial management of a hip fracture?
- Admit, Bed rest, Analgesia.
- Routine bloods inc. Group and Hold.
- ECG.
- Chest X-Ray.
- Careful fluid replacement.
- Anti-coagulation (e.g. Clexane).
- Optimise existing medical conditions.
- Good nursing to avoid pressure sores.
- Reason for fall e.g. CVA, MI, Arrythmia, Hypothermia, Parkinsons, dementia, drugs including alcohol, Electrolyte imbalance, visual impairment, malnutrition, malignancy, abuse.
How are hip fractures treated?
• Almost all require surgery
• Aim of surgery:
• Reduce pain
• Regain mobility (aim for weight-bearing day 1 post-
op in elderly)
• Reduce risk of complications of being bed-bound
e.g. chest infection, DVT/PE, pressure sores
Describe the blood supply to the head of the femur.
- Intra-medullary vessels
- Retinacular vessels entering neck via capsular
attachment at the base of the femoral neck. These come from medial and lateral circumflex femoral arteries. Retinacular blood supply to femoral head cut off during intracapsular fracture but intact & supplying
the head in extracapsular fracture - Ligamentum teres blood supply neglible by adulthood.
How are hip fractures classified/divided?
- Extracapsular (blood supply intact): includes sub-capital and transcervical fracture.
- Intracapsular (blood supply compromised): includes basal; intertrochaneteric; and sub-trochanteric fracture.
What are the consequences of disturbed blood supply in intracapsular fractures?
Risk of non-union and avascular necrosis.
What is important about the blood supply in extracapsular fractures?
The blood supply is maintained.
What does the method of fixation rely upon on in extracapsular fractures?
The STABILITY of the fracture.
What is the Cochrane review advice on extracapsular fractures?
- DYNAMIC HIP SCREW (AKA SLIDING HIP SCREW) FOR MOST
- CEPHALOMEDULLARY NAIL (I.E. IM NAIL WITH FIXATION EXTENDING INTO FEMORAL HEAD E.G. GAMMA NAIL) ONLY REQUIRED FOR UNSTABLE PATTERNS E.G. SUBTROCHANTERIC OR REVERSE OBLIQUE EXTRACAPSULAR ♯FRACTURES
NOTE TO SELF: Look up the classification of intertrochanteric hip fractures based on the number and displacement of major fragments.
- Undisplaced (two parts)
- Displaced (two parts)
- Displaced - three parts - including greater trochanter
- Displaced - four parts - including lesser trochanter
- Reversed obliquity fracture
Outline the dynamic hip screw.
“Lag screw” inserted into centre of head.
Lag screw slides into the 4 hole plate to allow compression of the fracture.
“Dynamic” as the correct amount of micromotion helps to stimulate bone healing
Outline the management of fragility hip fractures.
