Intro to T&O and #NOF

Question 1

How to describe x-ray of trauma

Answer 1

• Patient demographics
• Type of x-ray
• Outline bones with finger - check for # inc Shenton line (line across superior pubic rami to medial femur)
• Check superior and inferior rami - outline all foramens

Question 2

Typical #NOF presentation

Answer 2

• Elderly and minimal trauma
• Or younger and high impact
• Inability to weight bear
• Shortened and externally rotated leg
• Pain on palpation and when rolling legs on bed
• Unable to SLR
• Remember to check pulses and sensation

Patients with non-displaced or incomplete neck of femur fractures may be able to weight bear

Question 3

What to do if patient in pain and x-ray is not showing #NOF

Answer 3

• Do CT
• Then do MRI to assess soft tissues, bone malignancy, bursitis etc

Question 4

Two types of #NOF

Answer 4

• Extracapsular - intertrochanteric and subtrochanteric
• Intracapsular

Use line between greater and lesser trochanter to tell - intertrochanteric line

Question 5

Fixing vs replacment of hip for #

Answer 5

• Total or hemiarthroplasty for all displaced intracapsular #
• Fixing with screws is used for extracapsular or if intracapsular is non-displaced and blood supply is intact

Question 6

When to use total vs hemiarthroplasty?

Answer 6

• Total hip replacement used when patients are younger, less co-morbids, can walk unaided and are active. This is because they last longer and so head of femur replacement does not damage acetabulum from grinding as this is replaced too
• Hemi - used in older patients, less mobile, more comorbids. Generally last 10 years

Question 7

Problem with total hip replacements

Answer 7

• Increased risk of dislocation
• Due to it being two pieces of metal rubbing against eachother
• Acetabulum and head of femur are replaced

Question 8

Management if #NOF is subtrochanteric

Answer 8

• Intramedullary nails

Question 9

Management of intertrochanteric #NOF

Answer 9

• Dynamic hip screw - plate outside of femur

Question 10

RF for #NOF

Answer 10

• Increasing age
• Osteoporosis

Question 11

Aim of timing of management for #NOF

Answer 11

Surgery within 48 hours

Question 12

Where do #NOF occur?

Answer 12

Subcapital of femoral head to 5cm distally from lesser trochanter

Question 13

What is the capsule?

Answer 13

Surrounds hip joint, attaches to rim of acetabulum on pelvis and intertrochanteric line on femur

Question 14

Why is femoral head at risk of AVN?

Answer 14

• Retrograde blood supply
• Medial and lateral circumflex arteries join femoral neck proximal to the intertrochanteric line
• Intracapsular displaced # can disrupt this blood supply and cause AVN of femorla head
• Predominantly is medial circumflex

Question 15

Classification system for intracapsular #NOF

Answer 15

• Garden classification
• Grade I - incomplete # and non displaced
• II - complete # and non displaced
• III - partial displacement - trabeculae at an angle
• IV - full displacement (trabeculae parallel)

Question 16

How does hemiarthroplasty work?

Answer 16

• Femoral head replaced
• Cement used within shaft to hold the stem of this in place

Question 17

How do dynamic hip screws work?

Answer 17

• Screw through neck and into head of femur
• Plate with a barrel that holds screw is screwed into outside of femur shaft

Question 18

What to remember to explore in patients who have fell and #hip?

Answer 18

REASON for fall
* Don’t settle for mechanical fall
* Find reason, explore history of fall
* Exclude anaemia, electrolyte imbalances, arrhythmias, HF, MI stroke and infection

Question 19

X-ray views used in #NOF

Answer 19

• Two views essential
• AP and lateral often used

Question 20

Management of #NOF

Answer 20

• Analgesia
• Investigations
• VTE risk assessment
• Pre op assessment
• Orthogeriatrics input?

Question 21

Routine bloods/inv for surgery of #NOF

Answer 21

• FBC
• U&E
• Coagulation screen
• Group and save
• Creatine kinase if long lie
• CXR
• ECG
• Urine dip

Question 22

Summary of surgical options for each type of #NOF

Answer 22

• Displaced intracapsular - Hemiarthroplasty or total
• Intracapsular non displaced - Cannulated hip screws
• Intertrochanteric - dynamic hip screw
• Subtrochanteric - intramedullary femoral nail

Question 23

Post op complications after hip op

Answer 23

Immediate:
* Pain
* Bleeding
* Leg length discrepency
* NV damage

Long term:
* Joint dislocation
* Aseptic loosening
* Peri-prosthetic #
* Deep infection/prosthetic joint infection