Hip Fractures; Tibial plateau fractures

Question 1

Describe how you classify hip fractures [1]

Answer 1

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

Question 2

Describe Garden’s classification (intra-capsular fractures) [4]

Answer 2

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

Question 3

What the classical feature of a NOF? [1]

Answer 3

the classic signs are a shortened and externally rotated leg

Question 4

TOM TIP: It is worth understanding and remembering the concept of the retrograde blood supply to the head of the femur and how this determines the choice of operation

Describe the blood flow in the hip joint x [+]

Answer 4

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
- Branches of this artery run along the surface of the femoral neck, within the capsule, towards the femoral head.
- They provide the only blood supply to the femoral head.
- A fracture of the intra-capsular neck of the femur can damage these blood vessels, removing the blood supply to the femoral head, leading to avascular necrosis.

Question 5

Basic overview:

What is important about the managament of intra and extra-capsular fractures due to the blood supply being affected? [2]

Answer 5

Non-displaced fractures (Grade I-II Gardeners):
internal fixation e.g. with screws to hold femoral head in place

Displaced fractures (Grade III-IV Gardeners):
- Head of femur needs to be removed and replaced either via hemiarthroplasty (replacing the head of the femur but leaving the acetabulum (socket) in place) or total hip replacement (involves replacing both the head of the femur and the socket)

Question 6

Which anatomical landmark should be used in x-rays of hips to help determine if a fracture has occured? [1]

Answer 6

Shenton’s line - an imaginary curved line drawn along the inferior border of the superior ramus, along the inferomedial border of the neck of femu

Question 7

Describe the different types of extra-capsular fractures [2]

Answer 7

Intertrochanteric fractures:
- occur between the greater and lesser trochanter.

Subtrochanteric fractures:
- occur distal to the lesser trochanter (although within 5cm).
- The fracture occurs to the proximal shaft of the femur.

Question 8

Where is the fracture in this patient? [1]

Answer 8

Figure 3. A hip X-ray showing a right-sided intertrochanteric (extracapsular) hip fracture

Question 9

Describe the fracture in this x-ray [1]

Answer 9

Figure 2. A hip X-ray showing a left-sided intracapsular hip fracture with partial displacement.

Question 10

Describe the different managment options for a hip fracture? [4]

Answer 10

Internal fixation:
- using screws, plates, or intramedullary nails to stabilize the fracture, allowing for bone healing.

Hemiarthroplasty:
- This surgical procedure involves replacing the femoral head and neck with a prosthesis, typically used for displaced femoral neck fractures in elderly patients.

Total hip arthroplasty:
- This involves replacing both the femoral head and the acetabulum with prosthetic components, usually indicated for patients with pre-existing hip joint arthritis or those who may not be suitable candidates for hemiarthroplasty.

Conservative management:
- Non-operative treatment, including pain control, traction, and early mobilization, may be considered for stable, non-displaced fractures or in patients with significant medical comorbidities.

Question 11

Describe how you would manage an:

• Intracapsular, undisplaced fracture [1]
• Intracapsular, displaced fracture [2]

Answer 11

Intracapsular, undisplaced fracture:
- internal fixation, or hemiarthroplasty if unfit.

Intracapsular, displaced fracture:
- replacement arthroplasty (total hip replacement or hemiarthroplasty) to all patients

Question 12

NICE recommend replacement arthroplasty (total hip replacement or hemiarthroplasty) to all patients with a displaced intracapsular hip fracture

How do you decided if a THR or hemiarthroplasty is most appropriate? [3]

Answer 12

total hip replacement is favoured to hemiarthroplasty if patients:
* were 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.

Question 13

Describe how you treat an intertrochanteric fracture [1]

Answer 13

Intertrochanteric fractures:
- These are treated with a dynamic hip screw (AKA sliding hip screw).
- A screw goes through the neck and into the head of the femur
- A plate with a barrel that holds the screw is screwed to the outside of the femoral shaft.
- The screw that goes through the femur to the head allows some controlled compression at the fracture site, whilst still holding it in the correct alignment. Adding some controlled compression across the fracture improves healing.

Question 14

Describe how you manage a subtrochanteric fracture [1]

Answer 14

These may be treated with an intramedullary nail (a metal pole inserted through the greater trochanter into the central cavity of the shaft of the femur).

Question 15

The NICE guidelines (updated 2017) say that surgery should be carried out after how long from admission? [2]

Answer 15

The NICE guidelines (updated 2017) say that surgery should be carried out either the same day or the day after the patient is admitted (within 48 hours).

Question 16

Answer 16

intracapsular hip fracture, displaced, previously able to walk independently

Question 17

Answer 17

Internal fixation

Question 18

Answer 18

Dynamic hip screw

Question 19

Answer 19

Intramedullary device

Question 20

What imaging modality is best for avascular necrosis of the hip? [1]

Answer 20

plain x-ray findings may be normal initially.
- Osteopenia and microfractures may be seen early on. Collapse of the articular surface may result in the crescent sign

MRI is the investigation of choice. - It is more sensitive than radionuclide bone scanning

Question 21

Management of avascular necrosis of the hip is a stepwise approach.
What are the different steps? (overview) [3]

Answer 21

Conservative Management:
- Pharmacological therapy
- Physiotherapy

Surgical Management:
* Core decompression surgery:
* Osteotomy
* Bone grafting
* Arthroplasty

Question 22

Describe the managment plans for the following options for AVN of the hip

Conservative Management:
- Pharmacological therapy [3]
- Physiotherapy

Surgical Management:
* Core decompression surgery:
* Osteotomy
* Bone grafting
* Arthroplasty

Answer 22

Conservative Management:
- Pharmacological therapy: NSAIDS; Bisphosphonates (may slow the progression of bone necrosis and disease-related osteoporosis); Vasodilators such as iloprost can be used to improve blood flow to the affected area.
- Physiotherapy

Surgical Management:
Core decompression surgery:
- reduces intraosseous pressure, relieves pain, promotes vascular infiltration

Osteotomy:
- repositioning the necrotic segment away from the weight-bearing zone
- typically reserved for younger patients with good remaining articular cartilage

Bone grafting
- Autograft or allograft options can be used to support the subchondral bone and reduce collapse risk.

Arthroplasty
- Total hip replacement or hemiarthroplasty is usually reserved for patients with advanced disease.

Question 23

Describe where the tibial plateau is [1]

Answer 23

The tibial plateau refers to the proximal articular surface of the tibia, which forms the knee joint with the femur.

Question 24

Describe the mechanisms that causes a tibial plateau fracture [2]

Answer 24

Fractures arise from a:
- valgus force, which describes an outside force pushing the knee inwards along a coronal plane.
- varus force: an inside force pushing the knee outwards along a coronal plane.

Question 25

Tibial plateau fractures are often associated with which other types of injuries? [1]

Answer 25

Tibial plateau fractures: Often associated with soft tissue injuries.

Question 26

Which part of the tibial plateau bears 60% of the load through the knee? [1]

Why is this clioically significant? [1]

Answer 26

The medial tibial plateau bears 60% of the load through the knee.

Therefore the medial condyle is generally larger, stronger and transmits more weight compared to the lateral condyle. The lateral tibial condyle is convex in shape, compared to the concave medial side.

As a result the the lateral condyle is more frequently affected

Question 27

The [] classification is commonly used to describe tibial plateau fractures.

Answer 27

The Schatzker classification is commonly used to describe tibial plateau fractures.

Question 28

Describe how you manage closed tibial plateau fractures [2]

Answer 28

Nonoperative management:
- generally involves a hinged knee brace.
- Can partial weight bear for 8-12 weeks

Operative management:
- open reduction and internal fixation (ORIF).

Question 29

Describe how you manage open tibial plateau fractures [1]

Answer 29

External fixators are often used as a temporising measure in severe open fractures with contamination. Staged procedures to wash, debride and later fix the fracture can be arranged.

Question 30

Describe the clinical features of a rib fracture [+]

Answer 30

• severe, sharp chest wall pain is the most common symptom; the pain is often more severe with deep breaths or coughing
• there is usually significant chest wall tenderness over the site of the fractures and there may be visible bruising of the skin
• auscultation of the chest may reveal crackles or reduced breath sounds if there is an underlying lung injury
• pain and underlying lung injury can also result in a reduction in ventilation causing a drop in oxygen saturation
• pneumothorax: this can be a serious complication of a rib fracture and presents with reduced chest expansion, reduced breath sounds and hyper-resonant percussion on the affected side

Question 31

Describe what is meant by a flail chest [1]
Describe how a flail chest moves [1]

Answer 31

A consequence of multiple rib fractures that can occur following trauma:
- two or more rib fractures along three or more consecutive ribs, usually anteriorly
- moves paradoxically during respiration and impairs ventilation of the lung on the side of injury

Question 32

What is a potential complication of not treating a flail chest? [1]

Answer 32

the segment can cause serious contusional injury to the underlying lung if left untreated

Question 33

What is the best imaging modality to view a flail chest? [1]

Answer 33

the best diagnostic test is a CT scan of the chest as this will show the fractures in 3D as well as the associated soft tissue injuries.

Question 34

Describe management of a flail chest [2]

Answer 34

Most are managed conservatively with good analgesia to ensure breathing is not affected by pain

Surgical fixation can be considered to manage pain if this is still an issue and the fractures have failed to heal following 12 weeks of conservative management