Hip and Proximal Femoral Fractures Flashcards
who do hip and proximal femoral fractures occur in
generally related to osteoperosis in the elderly
females more common
often significant co-morbidities which contribute to risk of falling, and medical complications after surgery
treatment
high morbidity and mortality risk of operative and non-operative treatment
most pt’s undergo surgery in first 24 hours
what are the consequences of hip and proximal femoral fractures
non-operative management - muscle wasting, pressure sore, chest infection
20% fail to regain independence after surgery
30% fail to return to pre-injury function
clinical features
shortening
external rotation
trochanteric bruising
unable to SLR
groin pain on rotational movements
shenton line
imaginatory line drawn along inferior border of superior pubic ramus
interruption can indicate DDH and femoral neck fracture
what should patients who have a clinical suspicion/confirmation of hip fracture have before leaving ED
big 6 interventions - analgesia, NEWS, pressure area inspection, bloods, fluids, delirium screening
confusion assessment method
recognise delirium
frail patients
receive geriatric assessment within 3 days of admission
frailty symptoms: falls, immobility, delirium, incontinence, susceptibility to side effects of medication
falls assessment and prevention
- Risk identification – ask about falls, observe balance and gait deficits and ability to benefit from interventions to improve strength and balance
- Multifactorial risk assessment
- Osteoporosis risk
- Visual impairment
- Cognitive impairment and neurological examination
- Urinary incontinence
- Home hazards
- CV examination and medication review
post op analgesia ladder
oxycodone if confused on morphine
intracapsular hip fractures
risk of AVN and high non-union rate
treatment of intracapsular hip fracture
THR - higher risk of disclocation but better function. used for high functioning patient
Hemi-arthroplasty (replacing femoral head alone) - preferred for those with restricted mobility and cognitive impairment
what material is used for hemiarthroplasty
ceramic is standard unless clinically implicated otherwise
extracapsular hip fractures
should not cause AVN and have a high union rate
treatment of extracapsular hip fractures
compression or DHS - causes compression of fracture site which promotes healing
IM nail and sliding hip screw can also be used
fracture usually heals in a shortened position
the more parts the screw is made of the more instability and inc likelihood of failure
subtrochanteric fractures
usually occur in the elderly patient with osteoperosis and a fall to the side
poor blood supply - longer to heal and higher risk of non-union
what may subtrochanteric fractures be associated with
long term biphosphonate use (paradoxically for osteoperosis)
treatment of subtrochanteric fractures
IM nail - strong indirect fixation without further disruption to blood supply
femoral shaft fractures
usually high energy and so a risk of concomitant fracture elsewhere
stress fractures also occur in osteoperotic bone, metastatic disease, biphosphonate use, Paget’s disease
complications of femoral shaft fractures
substantial blood loss - up to 1.5l
fat from medullary canal - fat embolism with confusion, hypoxia and ARDS
management of femoral shaft fracture
initial - resuscitation, femoral nerve block and application of Thomas splint (stabilises fracture minimising further blood loss and fat embolism)
definitive - closed reduction and stabilisation with IM nail
minimally invasive plate fixation can also be used
management of femoral shaft fracture at different ages:
0-2
2-6
6-12
12+
In children less than 2 years old: more than half are due to NAI – look for other signs. Treat these with Gallows traction and early hip spica cast
Children aged between 2 and 6: Thomas splint
Children between 6 and 12: flexible IM nails
Children >12: adult IM nail.
