Hip Fractures

Question 1

A hip fracture is a bony injury of the proximal femur typically occurring in the elderly.

Answer 1

A hip fracture is a bony injury of the proximal femur typically occurring in the elderly.

Question 2

The proximal femur consists of a head, neck, … (greater and lesser) & …. It is the largest bone in the human body.

Answer 2

The proximal femur consists of a head, neck, trochanters (greater and lesser) & shaft. It is the largest bone in the human body.

Question 3

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.

Answer 3

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.

Question 4

Blood supply to the femoral head

The femoral head receives blood from three sources:

Answer 4

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.

Question 5

Hip fractures may be categorised as either intra- or extra-capsular, depending on their location in relation to the …-…. …

Answer 5

Hip fractures may be categorised as either intra- or extra-capsular, depending on their location in relation to the inter-trochanteric line.

Question 6

Hip fractures may be categorised as either intra- or extra-capsular, depending on their location in relation to the inter-trochanteric line

Above = …
Below = …

Answer 6

Above = intra-capsular
Below = extra-capsular

Question 7

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.

Answer 7

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.

Question 8

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 …

Answer 8

Type I - Incomplete, impacted in valgus
Type II - Complete, undisplaced
Type III - Complete, partially displaced
Type IV - Complete, completely displaced

Question 9

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.

Answer 9

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.

Question 10

A number of risk factors pre-dispose patients to hip fractures - these are … (7)

Answer 10

Increasing age
Osteoporosis
Low muscle mass
Steroids 
Smoking 
Excess alcohol intake
Metastatic spread of cancer to bone

Question 11

In the elderly, hip fractures are normally caused by …

Answer 11

In the elderly, hip fractures are normally caused by falls.

Question 12

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

Answer 12

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).

Question 13

In younger patients, hip fractures are more commonly the result of …

Answer 13

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.

Question 14

Certain medications, such a prolonged … use, can also predispose to osteopaenia.

Answer 14

Certain medications, such a prolonged corticosteroid use, can also predispose to osteopaenia.

Question 15

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.

Answer 15

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.

Question 16

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.)

Answer 16

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.)

Question 17

Signs and symptoms of hip fracture

Answer 17

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)

Question 18

Imaging for hip fracture

Answer 18

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.

Question 19

Bloods in hip fractures

Answer 19

FBC
U&E
CRP
Clotting
Group & Save x 2
Bone profile
Vitamin D

Question 20

X-rays are the first-line imaging investigation - fractures may be obvious, s… or o…

Answer 20

X-rays are the first-line imaging investigation - fractures may be obvious, subtle or occult.

Question 21

… 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.

Answer 21

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.

Question 22

Routine investigations and catheter in hip fractures

Answer 22

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.

Question 23

What analgesia is usually indicated for hip fractures?

Answer 23

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.

Question 24

Medication review in hip fractures

Answer 24

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.

Question 25

Pre-operative assessment - hip fractures

Answer 25

The orthopaedic team should review, mark, book and consent the patient. In most trusts medical teams or orthogeriatrics will also review the patient.

Where the patient lacks capacity, any lasting powers of attornery for health should be identified or a consent form 4 completed in the patients best interest.

Anaesthetic assessment should be obtained. The options of spinal anaesthesia or general anaesthetic should be discussed. The patient should be made NBM depending on when surgery is planned.

Question 26

How are hip fractures managed?

Answer 26

Most hip fractures are treated surgically, unless there are significant co-morbidities restricting surgical intervention. Surgical management differs between intra- and extra- capsular fractures.

Question 27

What are the risks associated with conservative management of hip fractures? (No surgery)

Answer 27

The evidence shows without surgery, patients remain bedbound with high risk of blood clots, chest infections and other complications. Surgical fixation on the other hand allows early mobilisation (same-day or next day) and rehabilitation.

As such it is only in rare cases that conservative treatment is used. This can involve traction, bed rest or restricted mobilisation. Outcomes are often very poor in these patients.

Question 28

When is surgery for hip fracture recommended? (Timeframe)

Answer 28

NICE guidelines recommend surgery to be performed on the day of, or the day after, admission. The aim is to allow patients to fully weight bear (without restriction) in the immediate postoperative period.

Question 29

Minimally or non-displaced intracapsular fractures (e.g. Gardens I/II) - how are these managed?

Answer 29

These are frequently treated with cannulated hip screws (often 2 or 3).

Question 30

Displaced intra-capsular fractures (e.g. Gardens III/IV) - how are these managed?

Answer 30

These tend to be managed either with a total hip replacement (THR) or a hemi-arthoplasty.

Question 31

NICE advise that THR is offered to patients with displaced intra-capsular fractures (e.g. Gardens III/IV) who …

Answer 31

Are able to walk independently out of doors with no more than the use of a stick and
Are not cognitively impaired and
Are medically fit for anaesthesia and the procedure

(In young fit patients urgent reduction and internal fixation is often attempted first)

Question 32

How are Intertrochanteric fractures managed?

Answer 32

These may be managed with a dynamic hip screw (DHS) or intra-medullary (IM) nail. DHS are unique in the fact that they allow the fracture ends to ‘slide’; this is thought to promote bone healing.

Question 33

How are Subtrochanteric fractures managed?

Answer 33

These tend to be managed with an intra-medullary (IM) nail.

Question 34

Daily review - hip fracture management

Answer 34

Delirium is common post-operatively (and pre-op) and should be screened for. Chest infection and urinary infection are also relatively common. Less often op site haematomas or op site infections may be seen.

Significant complications like peri-operative cardiac events and DVT/PE may occur. Patients should be reviewed by both the orthopaedic surgeons and the orthogeriatricians. Prophylaxis for fragility fractures should be considered.

Question 35

Patients are at increased risk of … and … following a hip fracture and surgical fixation.

Answer 35

Patients are at increased risk of DVT and PE following a hip fracture and surgical fixation.

Question 36

Normally prophylactic dose … is started 6-12 hours post-op for hip fractures. This will normally be continued for a minimum of one month, though it may be longer depending on circumstance (e.g. prolonged hospital stay). TED stockings and intermittent pneumatic compression may also be used

Answer 36

Normally prophylactic dose LMWH is started 6-12 hours post-op. This will normally be continued for a minimum of one month, though it may be longer depending on circumstance (e.g. prolonged hospital stay). TED stockings and intermittent pneumatic compression may also be used.

Question 37

Normally prophylactic dose LMWH is started 6-12 hours post-op for hip fractures. This will normally be continued for a minimum of … …, though it may be longer depending on circumstance (e.g. prolonged hospital stay). … stockings and intermittent pneumatic compression may also be used.

Answer 37

Normally prophylactic dose LMWH is started 6-12 hours post-op. This will normally be continued for a minimum of one month, though it may be longer depending on circumstance (e.g. prolonged hospital stay). TED stockings and intermittent pneumatic compression may also be used.

Question 38

Many patients with hip fractures will already be on anticoagulants - what should be done regarding prophylaxis following surgery?

Answer 38

Of course many patients in this cohort will already be formally anticoagulated for other conditions such as AF. In these patients anticoagulation should be resumed under the instruction of the operating team +/- haematology/cardiology advice.

Question 39

Physiotherapy and Occupational therapy - hip fractures

Answer 39

Patients should be encouraged to mobilise the day after surgery. Early mobilisation helps reduce the risk of blood clots, chest infections and deconditioning. Patients should have daily physiotherapy as an inpatient and a plan for community support at discharge.

Patients home situation should be reviewed and a re-ablement package instituted as needed to (ideally) return the patient to their home or care home.

Question 40

Neck of femur fractures (typically with significant displacement) will classically present with a … and … limb.

Answer 40

Neck of femur fractures (typically with significant displacement) will classically present with a shortened and externally rotated limb.

Question 41

An 81-year-old lady is brought in by ambulance after tripping on a step at home. Her medical history includes hypertension, T2DM and osteoporosis. She complains of severe pain in her left hip and is unable to weight bear following the fall. Following a clinical review and appropriate analgesia an X-ray is ordered. The X-ray is inconclusive, however, clinical suspicion remains.

Which of the following describes the appropriate next step?

Discharge home with analgesia
Analgesia and intensive physiotherapy
USS hip
CT hip
Surgical exploration

Answer 41

Hip fractures may be challenging to diagnose from X-ray, additional cross-sectional imaging may be required.

In cases where clinical suspicion remains a CT or MRI should be considered. Though MRI is gold-standard, modern multi-slice CT tends to be more easily accessible and offers good sensitivity. NICE recommend CT scan if MRI is contraindicated or unavailable within 24 hours.

Question 42

Bisphosphonates are commonly used to treat osteoporosis and prevent fragility fractures. Which of the following is a rare but recognised adverse effect of bisphosphonates?

Stroke
Deep vein thrombosis
Hot flushes
Osteonecrosis of the jaw 
Pulmonary embolism

Answer 42

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a rare, but severe adverse effect seen in bisphosphonate use.

Question 43

NICE recommends offering total hip replacement over hemiarthroplasty in patients whom are:

Answer 43

• Able to walk independently outdoors with no more that one stick
• Not cognitively impaired
• Medically fit for the operation

Question 44

Extra-capsular inter-trochanteric fractues are typically managed with a ….

Answer 44

Extra-capsular inter-trochanteric fractues are typically managed with a DHS.