Hip Fractures Flashcards
A hip fracture is a bony injury of the proximal femur typically occurring in the elderly.
A hip fracture is a bony injury of the proximal femur typically occurring in the elderly.
The proximal femur consists of a head, neck, … (greater and lesser) & …. It is the largest bone in the human body.
The proximal femur consists of a head, neck, trochanters (greater and lesser) & shaft. It is the largest bone in the human body.
The … of the hip is attached proximally to margins of acetabulum and transverse acetabular ligament. Distally, to the inter-trochanteric line, bases of greater & lesser trochanters and to the femoral neck posteriorly (approx. 1/2 inch from the trochanteric crest). It contains the … vessels - a major component of the blood supply to the femoral head.
The capsule of the hip is attached proximally to margins of acetabulum and transverse acetabular ligament. Distally, to the inter-trochanteric line, bases of greater & lesser trochanters and to the femoral neck posteriorly (approx. 1/2 inch from the trochanteric crest). It contains the retinacular vessels - a major component of the blood supply to the femoral head.
Blood supply to the femoral head
The femoral head receives blood from three sources:
Retinacular vessels - main blood supply. Originates from an extra-capsular arterial ring, supplied by medial and lateral circumflex vessels (profunda femoris A.). Reinforced by the superior and inferior gluteal arteries (internal iliac A.).
Foveal artery - not a major source. During skeletal development, supplies the epiphysis with a small amount of blood. Said to become obliterated in adult life (ligamentum teres).
Metaphyseal vessels - not a major source. After skeletal maturity, metaphysical arteries also contribute blood to the femoral head.
Hip fractures may be categorised as either intra- or extra-capsular, depending on their location in relation to the …-…. …
Hip fractures may be categorised as either intra- or extra-capsular, depending on their location in relation to the inter-trochanteric line.
Hip fractures may be categorised as either intra- or extra-capsular, depending on their location in relation to the inter-trochanteric line
Above = … Below = …
Above = intra-capsular Below = extra-capsular
The type of hip fracture determines the likelihood of disruption to the blood supply of the femoral head. Broadly speaking, …-capsular fractures are associated with a higher-risk of disruption, owing to the close proximity of the retinacular vessels.
The type of fracture determines the likelihood of disruption to the blood supply of the femoral head. Broadly speaking, intra-capsular fractures are associated with a higher-risk of disruption, owing to the close proximity of the retinacular vessels.
Garden’s classification (intra-capsular fractures)
Intra-capsular fractures are further sub-classified according to Garden’s classification.
There are four types
Type I - …, impacted in valgus
Type II - Complete, …
Type III - Complete, partially …
Type IV - Complete, completely …
Type I - Incomplete, impacted in valgus
Type II - Complete, undisplaced
Type III - Complete, partially displaced
Type IV - Complete, completely displaced
With type … + … intra-capsular factors there is minimal displacement, and therefore a lessened risk of disruption to the femoral head blood supply. Conversely, with type … + … , where there is much greater displacement, there is substantially higher risk.
With type 1 & 2 intra-capsular factors there is minimal displacement, and therefore a lessened risk of disruption to the femoral head blood supply. Conversely, with type 3 & 4, where there is much greater displacement, there is substantially higher risk.
A number of risk factors pre-dispose patients to hip fractures - these are … (7)
Increasing age Osteoporosis Low muscle mass Steroids Smoking Excess alcohol intake Metastatic spread of cancer to bone
In the elderly, hip fractures are normally caused by …
In the elderly, hip fractures are normally caused by falls.
The mechanism of hip fracture varies from direct falls onto the affected hip, to twisting, in which the patient’s foot is planted and the body rotates. Bones are typically … (reduced bone density) and also deficient in … reserve (i.e. they are very brittle) in the elderly
The mechanism varies from direct falls onto the affected hip, to twisting, in which the patient’s foot is planted and the body rotates. Bones are typically osteopaenic (reduced bone density) and also deficient in elastic reserve (i.e. they are very brittle).
In younger patients, hip fractures are more commonly the result of …
In younger patients, hip fractures are more commonly the result of major trauma (e.g. motor vehicle accidents), or in patients with gait disturbance (e.g. in multiple sclerosis) in which they are at increased risk of falls. Certain medications, such a prolonged corticosteroid use, can also predispose to osteopaenia.
Certain medications, such a prolonged … use, can also predispose to osteopaenia.
Certain medications, such a prolonged corticosteroid use, can also predispose to osteopaenia.
Patients usually describe a fall or recent trauma; it is unusual for fractures to occur with no precipitating trauma. …-energy trauma is more common in younger patients, although accounts for only a small percentage (2-3%) of all hip fractures.
Patients usually describe a fall or recent trauma; it is unusual for fractures to occur with no precipitating trauma. High-energy trauma (e.g. motor vehicle accident) is more common in younger patients, although accounts for only a small percentage (2-3%) of all hip fractures.
It is important to elucidate why an individual may have fallen; whether the fall was … in nature (e.g. slipped on a wet floor) or if the event was … (e.g. MI, stroke, chest infection, UTI etc.)
It is important to elucidate why an individual may have fallen; whether the fall was mechanical in nature (e.g. slipped on a wet floor) or if the event was precipitated (e.g. MI, stroke, chest infection, UTI etc.)
Signs and symptoms of hip fracture
Symptoms
Hip / knee pain
Inability to bear weight
Limited range of motion
Signs
Bony tenderness over affected hip
Shortened / externally rotated leg (only present if significant displacement)
Imaging for hip fracture
CXR: required pre-operatively.
Plain films: XR pelvis, AP and lateral of affected hip. Full length views of the femur may be obtained, particularly if metastatic disease in the bone is suspected.
MRI/CT: if plain films are inconclusive, to rule out occult fracture. MRI is gold-standard, CTs are generally more readily availible.
Cardiac echo: if new murmur is auscultated, abnormal ECG, or significant cardiac history. Often requested by the anaesthetist pre-operatively.
Bloods in hip fractures
FBC U&E CRP Clotting Group & Save x 2 Bone profile Vitamin D
X-rays are the first-line imaging investigation - fractures may be obvious, s… or o…
X-rays are the first-line imaging investigation - fractures may be obvious, subtle or occult.
… line - an imaginary curved line drawn along the inferior border of the superior ramus, along the inferomedial border of the neck of femur. It should be continuous and smooth.
Shenton’s line - an imaginary curved line drawn along the inferior border of the superior ramus, along the inferomedial border of the neck of femur. It should be continuous and smooth.
Routine investigations and catheter in hip fractures
Routine blood tests and two group and saves should be sent. All patient should have a CXR. Urine dipsticks and MSUs should be sent when relevant.
In the majority of cases a urinary catheter should be placed as urinary retention is common. Cognitive status should be assessed and recorded.
What analgesia is usually indicated for hip fractures?
Appropriate analgesia should be administered - the use of NSAIDs is discouraged. Paracetamol and opiod analgesia should be prescribed with reference to the patients weight, renal function and age. In the absence of contraindications a fascia iliaca block should be offered.
Medication review in hip fractures
Patients may have an acute kidney injury requiring adjustments to regular medication. In general anticoagulants and antiplatelets are held - however context is key! If a patient has had a recent CABG or PCI for example discussion with cardiology / cardiothoracic surgery is warranted. Where reversal of anticoagulation or coagulopathy is needed discuss with haematology.
