Hip and Thigh

Question 1

What are the classifications of NOF fractures?

What is the significance of a displaced intra-capsular fracture?

Answer 1

Intra-capsular (can be further classified by the Garden classification).

Extra-capsular - divided into inter-trochanteric and sub-trochanteric (which is down to 5cm distal to the lesser trochanter).

Displaced intra-capsular fractures can lead to avascular necrosis of the femoral head due to disruption of the retrograde blood supply (via the medial circumflex femoral artery). Therefore these patients tend to need joint replacement rather than fixation.

Question 2

If a patient has a #NOF how will the affected leg appear on examination?

Answer 2

The affected leg will be shortened and externally rotated due to the pull of the short external rotators.

The patient will have pain on pin-rolling and axial loading.

Question 3

What investigations would you do for a suspected fractures NOF?

Answer 3

Bedside - ECG (if the patient has fallen)

Bloods - FBC, U&Es, coagulation screen, group and save, creatinine kinase (if long lie).

Imaging - plain film AP hip and pelvis x ray, lateral hip X ray, full length femoral x ray.

Question 4

What is the management for a fractured NOF?

Answer 4

A to E assessment.

give adequate analgesia (IV opioids or regional block).

Surgical management:
Intracapsular: hip hemiarthroplasty (in an elderly patient, in a young patient we would do THR to prevent erosion of the acetabulum).
Extracapsular - intertrochanteric: fixation with dynamic hip screws
Extracapsular - subtrochanteric: intramedullary nail

cannulated screws or nails.

N.B. These patients are often elderly and need assessment by ortho-geriatricians, physiotherapists and OTs.

Question 5

What investigations would you do for suspected hip osteoarthritis?

Answer 5

Plain radiograph which would show:

Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts

Question 6

What are the three surgical approaches to hip replacement surgery?

Answer 6

Posterior approach - most common, fast rehabilitation, abductors are preserved.

Anterolateral approach - Abductor is detached + leg is fully adducted.

Anterior approach - rarely used. Used if the patient’s hip is infected and needs a washout.

Question 7

What classification is used to classify the degree of comminution to femoral shaft fractures?

Answer 7

The Winquist and Hansen classification.

(Type 0 - 4).

Question 8

What investigations would you do for a suspected femoral shaft fracture?

Answer 8

urgent bloods - group and save, FBC, U&Es, coagulation screen.

Imaging - plain film radiograph (AP and lateral view of the femur including hip and knee).

the patient may need further imaging via CT scanning if multiple fractures are suspected.

Question 9

What is the management for a femoral shaft fracture?

Answer 9

A to E assessment, stabilising the patient.

Adequate analgesia (opioids or regional block).

Immediate reduction and immobilisation (traction splinting).

Most require surgery within 48 hours - intramedullary nail / temporary external fixation followed by nail.

Question 10

What are some risk factors for quadriceps tendon rupture?

Answer 10

Increasing age
Male
Diabetes
CKD
Rheumatoid arthritis
Corticosteroid use

Question 11

What investigations would you do for a suspected quadriceps tendon rupture?

Answer 11

It can be diagnosed based on clinical suspicion alone. However we would likely do:

Plain radiographs of the knee to check for any fractures.

USS and sometimes MRI o look at the tendon rupture.

Question 12

What is the management for quadriceps tendon rupture?

Answer 12

Partial tears can be managed conservatively with immobilisation in a brace and rehabilitation.

Complete tears usually require surgical intervention - the tendon will be repaired by drill holes/ suture anchors or end-to-end sutures if the tear is intra-tendinous. The knee is then immobilised in a brace, then physiotherapy starts 6 weeks after repair.

Question 13

how are distal femur fractures classified?

Answer 13

A - extra-articular
B - partial articular
C - Complete articular

Question 14

What are the imaging investigations you would do for a suspected distal femur fracture?

Answer 14

Plain x ray - AP and lateral view of the whole femur and knee.

If there is intra-articular extension, we may also do CT imaging to assist in operative planning.

Question 15

What is the management for a distal femur fracture?

Answer 15

A to E assessment

Analgesia, sedation + reduction + immobilisation with skin traction.

Most then have surgery - retrograde nailing or Open reduction internal fixation (ORIF).

N.B. Sometimes external fixation may be used for severe comminuted or open fractures.

Question 16

What imaging would you request for a suspected pelvic fracture?

Answer 16

3 x ray views - AP, inlet and outlet view.

However in a trauma setting often a CT scan is performed as part of the patient assessment.

Question 17

What 2 classification systems are used to describe pelvic ring fractures?

Answer 17

Young and Burgess classification - groups fractures based on the vector of disrupting force + degree of displacement.

Tile classification - groups fractures based on stability of the pelvic ring.

Question 18

What is the management of a pelvic ring fracture?

Answer 18

A to E assessment.

A Pelvic binder should be applied to give skeletal stabilisation.

Conservative management / operative management if the patient is unstable etc. Surgical management tends to involve a combination of anterior and posterior stabilisation.

Question 19

What is a Morel-Lavallee lesion?

Answer 19

An internal devolving injury, where the skin and subcutaneous tissue is stripped away from the underlying fascia, and fluid collects in the space.

It occurs due to trauma.

Question 20

What imaging would you request for a suspected acetabular fracture?

Answer 20

Plain x ray - AP view and judet view.

However in a trauma setting a CT scan is often performed as part of the patient assessment. This is the gold standard for acetabular fracture diagnosis.

Question 21

What classification is used for acetabular fractures?

Answer 21

The Judet and Letournel classification. It divides the fractures into elementary (basic) and associated (multiple) fractures.

Question 22

What is the management for an acetabular fracture?

Answer 22

A to E assessment.

If there is hip dislocation it should be reduced immediately to stop further damage to the acetabulum.

If the fracture is undisplaced it can be managed conservatively with protected weight bearing for 6-8 weeks.

if it is displaced, surgery is indicated. Young patients tend to get surgery to restore the anatomy of the joint surface + pelvic stability. Older patients tend to get fixation and then total hip replacement.