Hip Fractures

Question 1

Which are the groups of patients that may suffer hip fractures?

Answer 1

High energy injuries: anyone

Low energy injuries: elderly

Question 2

What is the classical presentation of a hip #?

Answer 2

Hip pain on passive movements.

If it is displaced may appear: shortened and externally rotated.

Pain in the groin.

Note many people can still weight bear particularly if the fracture is impacted.

Question 3

What are some differentials of hip #?

Answer 3

OA flare up
Malignancy
Dislocated hip
Acetabular #
Avascular necrosis
Septic arthritis (not common in the hip)

Question 4

How are hip # classified?

Answer 4

Intracapsular (above the trochanters) or Extracapsular (intertrochanteric or subtrochanteric)

Garden classification for intracapsular #

Question 5

What is the garden classification?

Answer 5

Classification for intracapsular neck of femur #

Garden I: Valgus impacted (head has tilted) undisplaced
Garden II: Complete fracture across however undisplaced
Garden III: Displaced with some continuity
Garden IV: Dispalced with no fracture line continuity

Question 6

What type of fractures do bisphosphonates predispose you to?

Answer 6

Subtrochanteric #

Question 7

What is the significance with regards to whether the fracture is intra or extra capsular?

Answer 7

Intracapsular # which are displaced will invariably damage the blood supply from the lateral and medial circumflex aa which supply the femoral head.

Question 8

What are the blood vessels which supply the femoral head?

Answer 8

Lateral and medial circumflex (from profunda femoris, runs through joint capscule)

Intermedullary vessels in the bone (run inside intermedullary canal)

The aa of the ligementum teres (<10%)

Question 9

What are the major complications of hip fractures?

Answer 9

AVN

Carries a high mortality and morbidity (loss of independence for many)

Question 10

How are intracapsular fractures managed?

Answer 10

Undisplaced = Garden 1 and 2 fixed usually with a cannulated hip screw

Displaced = 3 and 4 replaced with a hemiartroplasty.

Question 11

What are the exceptions to the rule with regards to intracapsular fracture management?

Answer 11

Young fit patients with a displaced fracture should aim to have there fractures fixed within 6 hours; as there hemiarthoplasty will not last and will need multiple revisions.

Patients in there 40-60’s with a garden 3 or 4 should have a total hip replacement as these will deal with the high functional demand better

Question 12

What are the different types of hemiarthroplasty?

Answer 12

Unipolar: stem and head one continuous piece that moves together.

Bipolar: stem and head are made from two pieces forming a small ball and socket joint, the idea being that it is easier to replace in revisions.

Cemented and uncemented for both. (Cemented is more common)

Question 13

How do you manage intertrochanteric fractures?

Answer 13

Dynamic hip screw

Question 14

How do you manage subtrochanteric fractures?

Answer 14

Intermediary nail + a hip screw

Question 15

Describe the acute management of a elderly patient presenting with a potential hip fracture?

Answer 15

1. History, examination
2. Bloods (Gr+Save, INR), ECG, CK, AP Pelvis and lateral hip
3. Pain relief - fascia iliac block + opiods
4. Med review and geriatric review. medical optimisation e.g. fluids
5. Surgery within 36h
6. post surgery > rehab, mobilise 24h, OT, physio, falls, OP risk, safe discharge plan