Hip fracture (neck of femur, pelvic, pubic ramus)

Question 1

What are the risk factors for hip fracture?

Answer 1

• Osteoporosis/osteopenia
• Older age - average age is 83yo
• Falls
• Low BMI
• Female sex - lifetime risk is double for women (Swedish study) 11.1% vs 22.7%
• High-energy trauma - if under 40yo

Question 2

What is the most common mechanism of injury in hip fractures?

Answer 2

Fall from standing height

In younger people usually motor vehicle accidents

Question 3

How are hip fractures classified?

Answer 3

• Intracapsular - retinacular vessels can be damaged –> avascular necrosis
• Extracapsular - trochanteric or subtrochanteric

The Garden classification is then used for intracapsular fractures.

Question 4

Summarise the Garden classification.

Answer 4

Type 1 - undisplaced, incomplete in valgus

Type 2 - undisplaced, complete

Type 3 - displaced <50%, complete in varus

Type 4 - displaced, complete

Question 5

What is the management of hip fractures?

Answer 5

• A to E approach
• Thorough examination and history including cause of fall and other comorbidities
• Analgesia
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Question 6

What position indicates a displaced hip fracture?

Answer 6

A shortened and externally rotated leg may indicate a displaced fracture

There will be inability to weight bear or move the hip

Pain in hip, groin or thigh

Question 7

What investigations should be done in hip fractures?

Answer 7

• FBC
• U&Es
• Glucose
• Clotting screen
• Group and save
• ECG
• CXR
• AP and lateral views of the pelvis
• +/- MRI - if no fracture on XR but high suspicion
• 4AT assessment for cognitive impairment

Question 8

What cognitive assessment score is used to assess mental state in hip fractures?

Answer 8

4AT - 4 or more is possible delirium or cognitive impairment

Question 9

What is Shenton’s line and its significance in hip fractures?

Answer 9

Shenton’s line = from the inferomedial border of the femoral neck to the inferior border of the superior pubic ramus

Interrupted on AP XR in hip fractures

Question 10

What is the management of hip fractures?

Answer 10

• Intracapsular, undisplaced = DHS
• Intracapsular, displaced = THR or Hemi
• Extracapsular = DHS for stable intertrochanteric OR intramedullary nail for subtrochanteric

Frail, non-mobile patients may be managed conservatively but this has poor outcomes.

Surgery must be carried out on the day of, or the day after, admission to avoid increased risk of mortality

Question 11

How soon after hip fracture surgery should the patient mobilise?

Answer 11

On the day of or the day after surgery

Question 12

When should discharged patients be followed up after hip fracture?

Answer 12

Within 4 months

Question 13

What is the mortality after hip fractures?

Answer 13

30% at 1 year

Question 14

What are the complications of hip fracture?

Answer 14

• VTE
• Avascular necrosis
• Non-union

Question 15

What is a pathological fracture of NOF?

Answer 15

Due to osteoporosis