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Hip Fractures Flashcards

1
Q

how are hip fractures classified

A

where they are in relation to the capsule

the level of displacement and therefore instability within the joint (often Garden’s classification)

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2
Q

which surgical options are available for fractured hip

A

DHS - extracapsular as lower risk AVN
cannulated screw - extracapsular/low risk AVN gives additional rotational stability
hemiarthroplasty - intracapsular hip fractures
THR
girdlestone - following infection/chronic dislocation

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3
Q

how is osteoporosis measured

A

T score < - 2.5 on DEXA for postmenopausal women and men > 50

T score is BMD compared to healthy young adult of same sex

-1 to -2.5 = osteopenia

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4
Q

which tool can be used to predict risk of future fracture in primary care

A

the FRAX tool gives 10 year probability of a hip fracture and also spine, shoulder or forearm
based on: age, sex, previous injuries

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5
Q

which pharmacological treatments are available for osteoporosis

A 
calcium/vit D3 supplements
bisphosphonates (1st/2nd line)
strontium ranelate (3rd line)
SERMs
PTH
HRT
Testosterone
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6
Q

what are the causes of osteoporosis

A 
post menopause
hyperparathyroidism
malabsorption
osteomalacia
multiple myloma
hypopituitarism
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7
Q

which drugs can predispose towards osteoporosis

A 
corticosteroids
anticonvulsants
heparin
thyroxine
extreme alcohol excess
lithium
chemo
methotrexate
SSRIs
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8
Q

what clinical features might osteoporosis present with

A

low impact fracture
reduced height (vertebral fracture)
kyphosis

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9
Q

how do steroids affect bone mineral density

A

decreased absorption of calcium from the gut
decrease muscle mass
increase osteoclast activity

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10
Q

which lifestyle changes can be made to avoid osteoporosis

A

sufficient daily calcium intake
smoking cessation
reduce alcohol intake
increased weight bearing exercise

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11
Q

which race appears to be less susceptible to osteoporosis

A

Afro-caribbean are less susceptible than white or asian women

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12
Q

which bisphosphonate is recommended for first line prevention of osteoporotic fractures

A

alendronic acid

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13
Q

how do bisphosphonates work?

A

become absorbed onto hydroyapatite crystals in bone.
This slows their rate of growth and dissolution and therefore bone turnover
also used in the treatment of Paget’s disease

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14
Q

why must patients on bisphosponates have regular dental check ups

A

they are at risk of osteonecrosis of the jaw especially if receiving IV bisphosphanates

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15
Q

what are 3 problems with bisphosphonates

A

difficult to take - must be taken on an empty stomach at least 30 mins before food and must be upright after taking

osteonecrosis of the jaw

can induce stress fractures - especially if used for more than 5 years

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16
Q

what is denosumab

A

RANKL inhibitor: human monoclonal antibody which inhibits osteoclast formation, function and survival therefore decreasing bone resorption
also boosts OB activity
subcutaneous injections every 6/12

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17
Q

what are the 2nd line treatments for osteoporosis

A

IV bisphosphonates

denosumab

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18
Q

how are IV bisphosphonates administered

A

fewer tolerance issues
given once yearly for 3 years

may be restarted 3 further years later

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19
Q

why must bisphosphonates be taken on an empty stomach

A

poorly absorbed from the gut as bind to calcium in food

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20
Q

what are the 4 stages of management for fractured neck of femur

A

1) why has the person fallen
2) is the person medically well/fit for surgery
3) why has the bone broken - bone health
4) rehab

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21
Q

what are the 4 groups of fallers

A

1) medical (heart problems etc)
2) dementia/cognitive impariments
3) Mechanical
4) postural drop

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22
Q

what is the most common cause of fall

A

mechanical (50-60%)

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23
Q

what is the 2nd most common cause of fall

A

postural drop

can be delayed by upto 5-10mins after standing

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24
Q

what are the stages of managment for postural drop

A

1) drugs review
2) hydrate adequately
3) FULL leg stockings
4) fludrocortisone to inc fluid retention
5) alpha agonist midorone - vasoconstrictor, can induce supine HTN

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25
what is the 1 yr mortality from falling and being on the floor for more than 1 hour
50%
26
what is the Hayflick limit
the finite number of times a cell can divide - dictated by telomeres
27
define frailty
Frailty is a global accumulation of physical, cognitive, medical and functional deficits leading to a reduction in the individual’s ability to respond to an insult
28
which areas of the body are commonly affected by fragility fractures
``` hip spine wrist ribs humerus pelvis ```
29
what is the mortality of hip fracture
20%
30
what are the risk factors for osteoporosis
``` age female genetics oestrogen deficiency hypogonadism smoking low/very high BMI inactivity ethnicity (caucasians) eating disorders ```
31
what is a Z score
standard deviations of BMD from age AND gender matched mean
32
which osteoporosis drugs increase bone formations
teriparatide (PTH) | strontium ranelate
33
which osteoporosis drugs decrease resoprtion
``` bisphosphonates RANKL inhibitors (denosumab) ```
34
how does rPTH work
normally PTH causes bone loss, but given in pulses increases bone production and BMD given as a daily sc injections for 2 years
35
what are the causes of vitamin D deficiency
``` inadequate sunlight inadequate diet malabsorption medication low levels in breastmilk multiparosity abnormal vit D metab ```
36
what is the presentation of osteomalacia
bone pain/tenderness proximal muscle weakness back pain stress fractures
37
what would you see on bloods to confirm vitamin D deficiency
``` LOW 25(OH)vitD HIGH serum PTH LOW/NORMAL serum Ca LOW serum phosphate HIGH alkaline phosphatase (osteoclast activity) ```
38
what is Paget's disease
disordered bone metabolism --> osteoclast overactivity followed by compensatory osteoblast activity leads to the formation of WOVEN bone --> weaker
39
what are the signs and symptoms of Pagets disease
bone pain, path fracture, (sarcomatous change) --> direct indirect: - high CO - compression: - --> skull (cranial nerve palsies, deafness, basilar invaginations) - --> spine (sciatica, cauda equina)
40
how is pagets diagnosed
X ray bloods (high alk phos w/ normal Ca vD PTH and phosphate) urinary hydroxyproline increased isotope bonescan
41
when would you treat pagets
if symptomatic in danger of nerve compression around a weight bearing joint
42
how would you treat pagets
bisphosphonates
43
define a fracture
a loss of continuity of the substance of a bone due to physical force
44
what type of fractures happen in long bones
``` transverse - banding force spiral - torsion oblique comminuted - high energy segmental ```
45
what type of fractures happen in cancellous bones
impacted | crush/compression
46
what type of fractures happen in periarticular bone
avulsion
47
what two features promote fracture healing
intact fracture haematoma | controlled microenvironment
48
what are the 4 stages of fracture healing
1) inflammation 2) soft callus 3) hard callus 4) remodelling
49
what happens in the first stage of fracture healing
inflammation and development of haematoma: - fibrin clot - polymorphs - platelets - monocytes later: - fibroblasts - osteoprogenitor cells - vascular ingrowth
50
what happens in the second stage of fracure healing
after pain and swelling subside bone fragments united by fibrous or cartilaginous tissue bony ends no longer freely moveable but angulation still possible
51
what happens in the third stage of fracture healing
mineralisation of cartilage OBs convert cartilaginous tissue to woven bone ENDOCHONDRAL and membranous bone formation this increases fracture stiffness and produces an external callus
52
what happens in the final stage of fracture healing
woven bone converted to lamellar bone excess callus is removed medullary canal is reconstituted
53
which implants for fractures provide absolute stability
internal fixation
54
what is the aim of reduction
to reduce deformity
55
what is important about the rate of bone healing and implants
fracture must heal before implant fails
56
what is the rule of 2's
``` x ray of fractured joint: 2 views - at right angles 2 joints 2 occasions 2 limbs ```
57
what are the three R's of fracture treatment
reduction retention rehabilitation
58
what non-operative methods of stabilisation/retention are there
strapping plaster traction
59
which operative methods of fracture retention are there
plates and screws IM nail ex fix percutaneous pins
60
what are the indications for internal fixation
- displaced intra-articular fractures - factures with tenuous blood supply - multiple injuries - more than one fracture in single limb - pathological of long bones
61
what are the general complications with fractures and fracture healing
soft tissue damage recumbency anaesthesia/surgery
62
what are the specific complications associated with fractures
``` fat embolism ( fat globules may be visible in urine) nerve/vessel/visceral damage infection problems with union joint stiffness AVN myositis ossificans ```
63
what is the mechanism of injury for nerve damage in fractures
nerve stretched over bone/fracture ends axonotmesis repaired by neurotmesis
64
what are the characteristics of arterial vascular trauma
``` painful pale/plum coloured paraesthetic pulseless perishing cold ```
65
what is the classic triad of symptoms associated with fat embolism
respiratory neurological petechial rash
66
what is a prominent symptom of compartment syndrome
pain: - out of proportion to injury - on passive stretch of muscle late signs: - pins and needles - pulselessness
67
what is malunion
where fracture has united in poor position - cosmetic deformity - functional problem
68
what is delayed union
union fails to occur within the expected time
69
which factors can contribute to delayed union
``` smoking steroid use old age severe anaemia diabetes vit D def/hypothyroid/osteoporosis infection inadequate blood supply ```
70
what is the definition of non-union
fracture has failed to unite and healing process is no longer active two main types: 1) hypertrophic non-union 2) atrophic non-union
71
what causes hypertrophic non-union
inadequate stability but viable bone ends results in sclerotic and flared bone ends which make excessive callus visible fracture line filled with fibrous tissue/cartilage
72
what causes atrophic non union
no evidence of cellular activity bone ends become narrow and porotic fibrous tisse needs removing and may need graft
73
what are the causes of joint stiffness
w/in joint - articular damage, capsular contractures near joint - ligament contracture; muscle adhesions/shortening remote- other joints
74
what happens in avascular necrosis
bone death due to blood supply disruption slow revascularisation bone is soft and distorted causes secondary OA
75
where are common sites of AVN following fracture
femoral head scaphoid talus lunate
76
what is myositis ossificans
calcified soft tissues near the joint this restricts movements
77
what can cause pathological fractures
``` tumours infection osteoporosis osteomalacia paget's disease osteopetrosis (sclerotic bone) skeletal dysplasias ```
78
which secondary tumours can cause pathological fractures
``` breast bronchus prostate kidney thyroid ```
79
why do children's fractures occur differently
childrens bone high col:mineral and more porous therefore special types of fracture: 1) greenstick - angulating, not rotation or displacement 2)buckle 3)plastic deformity - bent but no obvious fracture
80
what is the most common type of growth plate injury
Salter Harris type 2
81
what is a Salter Harris type 1 fracture
slipped epiphyseal plate | fracture passes all the way through the growth plate not involvign the bone
82
what is a Salter Harris type 2 fracture
fracture in the gorwth plate and above the growth plate in the metaphysis
83
what is a Salter Harris type 3 fracture
fracture through growth plate down to epiphysis
84
what is a Salter Harris type 4 fracture
fracture goes through metaphysis, growth plat and epiphysis poor prognosis
85
what is a salter harris type 5 fracture
a rammed growth plate damaged by crushing inury worst prognosis

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