Hip Fractures

Question 1

Defintion

Answer 1

Most commonly occurs in elderly individuals with underlying osteoporosis following low-energy trauma
- A hip fracture is considered to be any fracture of the femur that occurs distal to the femoral head and proximal to a line drawn a few centimetres below the lesser trochanter

Question 2

Epidemiology

Answer 2

Osteoporosis or osteopenia:
- Post-menopausal women
- Elderly
- Steroid use
- Low BMI
- Smoking and alcohol
Falls: includes risk factors for falls, such as visual impairment and dementia
High-energy impact
Metastatic cancer: may result in a pathological fracture

Question 3

Pathophysiology

Answer 3

Capsule of hip joint attaches to the rim of acetabulum of pelvis and the intertrochanteric line on the femur. It surrounds the head of the femur.
The head of the femur has a retrograde blood supply - The medial and lateral circumflex femoral arteries join the femoral neck just proximal to the intertrochanteric line.
Fracture of the intra-capsular neck of the femur can damage these blood vessels = avascular necrosis.

Question 4

Intra-capsular fractures classification

Answer 4

Fracture proximal to the intertrochanteric line.
The Garden classification is used for intra-capsular neck of femur fractures:
- Grade I – incomplete fracture and non-displaced
- Grade II – complete fracture and non-displaced
- Grade III – partial displacement (trabeculae are at an angle)
- Grade IV – full displacement (trabeculae are parallel)

Question 5

Extra-capsular fractures

Answer 5

Extra-capsular fractures leave the blood supply to the head of the femur intact. Therefore, the head of the femur does not need to be replaced.
- Intertrochanteric fractures occur between the greater and lesser trochanter. These are treated with a dynamic hip screw (AKA sliding hip screw)
- Subtrochanteric fractures occur distal to the lesser trochanter (although within 5cm). The fracture occurs to the proximal shaft of the femur. These may be treated with an intramedullary nail

Question 6

Signs

Answer 6

• Shortened and externally rotated leg
• Greaer trochanteric tenderness, pain on palpation of groin
• Limited straight leg raise
• Limited internal and external rotation
• Pain on axial loading

Question 7

Symptoms

Answer 7

Fall or trauma: MC fall from standing
Inability to weight bear
Pain in the affected hip, groin, or thigh

Question 8

Diagnosis

Answer 8

Plain radiograph: AP pelvis and lateral hip x-rays
Bloods:
- FBC
- U+E
- Blood glucose
- Coagulation screen
- Group and save and crossmatch
ECG

Question 9

Treatment

Answer 9

NICE: surgery should be performed on the day of, or the day after, admission. A posterior approach is commonly used:
- Intracapsular fracture: Total hip replacement involves replacing both the head of the femur and the socket.
-Extracapsular Intertrochanteric fractures: dynamic hip screw
- Extracapsular Subtrochanteric fractures: Intramedullary nail