M: Hip fractures

Question 1

What is a hip fracture by definition?

Answer 1

Fracture of the femur above a point 5cm below the most distal part of the lesser trochanter

Question 2

In what 5 ways can a hip fracture be classified by location?

Answer 2

1) Subcapital
2) Transcervical
3) Basicervical
4) Intertrochanteric
5) Subtrochanteric

Question 3

Other than location in what 3 ways are hip fractures normally classified?

Answer 3

1) Femoral neck fractures (between the base of the femoral neck and intertrochanteric line)
2) Intertrochanteric (between the greater and lesser trochanters)
3) Subtrochanteric

Question 4

Which 2 types of hip fractures account for over 90% of hip fractures of hip fractures, what proportions do they occur in?

Answer 4

Femoral neck and intertrochanteric fractures - occur in roughly equal proportions

Question 5

What factor commonly leads to complications in fractures of the hip?

Answer 5

Disruption of the blood to the femoral head - non-union and avascular necrosis necrosis

Question 6

What provides the main blood supply to the head of the femur?

Answer 6

Trochanteric anastomosis:

inferior and superior femoral circumflex arteries and medial and lateral femoral circumflex arteries

Question 7

A branch of what artery makes a small contribution to the blood supply of the femoral head, what does it run along?

Answer 7

Branch of obturator artery, running along the ligamentum teres

Question 8

Disruption of the main blood supply to the femoral head leads to what?

Answer 8

Avascular necrosis of the femoral head

Question 9

What does necrosis of the femoral head lead to?

Answer 9

Pain and limitation of movement due to deformity

Question 10

For what 6 reasons are hip fractures so important?

Answer 10

1) Affects lots of patients
2) High cost to the NHS
3) High care cost following immediate management
4) Important cause of mortality
5) Important cause of morbidity
6) Associated with loss of independence

Question 11

In which group are hip fractures more common?

Answer 11

Elderly - over the age of 65

More common in females than males (3:1)

Question 12

What are the 2 main risk factors for a hip fracture, both associated with ageing?

Answer 12

1) Osteoporosis

2) Falls

Question 13

With a fracture due to low impact trauma, there is often an underlying bone condition, give 5 common examples?

Answer 13

1) Osteoporosis (commonest cause)
2) Osteomalacia (Vit D deficiency)
3) Bone metastases
4) Haematological malignancy
5) Paget’s disease

Question 14

What is Paget’s disease?

Answer 14

Weakened and deformed bones due to disruption of the bones normal cycle of renewal and repair, commonly affects the pelvis and spine with pain being one of the main symptoms

Question 15

What 4 kinds of cancer commonly lead to bone mets?

Answer 15

1) Bronchus
2) Breast
3) Kidney
4) Prostate

Question 16

What are the 6 main features on presentation with a hip fracture?

Answer 16

1) Fall
2) Pain - in groin, thigh or knee
3) Difficulty in weight bearing
4) Deformity if fracture displaced - shortened limb, externally rotated
5) Features relating to co-morbidity
6) Complications of fall and immobility

Question 17

Why is pain in a hip fracture sometimes referred to the knee?

Answer 17

Nerve supply to the hip is from the anterior division of the obturator nerve, the posterior division supplies the knee leading to referred pain

Question 18

When assessing a hip fracture patient what 6 factors should be considered in the history?

Answer 18

1) Circumstances and causes of the fall
2) Co-morbidities and PMH
3) Previous fractures and falls
4) Cognitive impairment
5) Social history
6) Mobility and level of independence prior to fracture

Question 19

Give 3 possible causes of a fall in an elderly patient?

Answer 19

1) Acute medical illness
2) Cardiac related
3) Medication and alcohol related

Question 20

What 3 conditions are mainly considered when assessing an elderly patient’s cognitive impairment following a hip fracture?

Answer 20

1) Delerium
2) Depression
3) dementia

Question 21

In the examination of a patient with a hip fracture wat 7 things should be assessed as part of a general examination?

Answer 21

1) BP
2) Pulse
3) Temp
4) SaO2
5) Hydration
6) Abbreviated Mental Test Score

Question 22

Why should and abdominal and neurological examination be carried out in a patient present with a hip fracture?

Answer 22

Abdo - ensure patient not in urinary retention

Neurological - look for any associated head injury or evidence of a CVA

Question 23

Other than a neuro, resp, cardio and abdo examination what else should be looked for in a patient with a hip fracture?

Answer 23

Pressure areas or any skin conditions

Question 24

What 6 investigations should be carried out in an elderly patient presenting with a hip fracture?

Answer 24

1) FBC, U&Es, Blood glucose
2) Creatine kinase (if long lie - rhabdomyolysis)
3) Calcium profile
4) XR of hip and CXR
5) ECG
6) Other dictated by clinical picture eg. ABGs

Question 25

What are the 7 features of pre-operative management following a hip fracture?

Answer 25

1) Pain relief
2) Hydration and optimum nutrition
3) Pressure area care
4) Optimise medical condition - eg. treat infection
5) Thromboprophlaxis
6) MRSA decolonisation
7) Surgery within 36 hours of injury if medically stable

Question 26

Garden classification of hip fractures includes grades 1-4, what is each grade?

Answer 26

Grade 1) Incomplete impacted fracture in valgus malalignment which is generally stable
Grade 2) Incomplete but not displaced fracture
Grade 3) Incompletely displaced fracture in varus malignment
Grade 4) Completely displaced fracture with no engagement of the 2 fragments

Question 27

How are intracapsular fractures managed surgically?

Answer 27

Replacement hemiarthroplasty

Question 28

How are extracapsular hip fractures managed surgically?

Answer 28

Dynamic hip screws or cannulated screws

Question 29

When is no surgical management of a hip fracture indicated?

Answer 29

When the fracture is a pain free, undisplaced and impacted

Question 30

What are the main 2 aspects of pre-operative management?

Answer 30

1) Peri-operative Abx - reduction in incidence of nosocomial (hospital derived) infection
2) MRSA prophylaxis

Question 31

What are the 8 commonly complications of hip fracture and surgery?

Answer 31

1) Wound infections (superficial, deep)
2) Thromboembolism (DVT, PE)
3) Bronchopneumonia
4) Cardiac
5) UTI and urinary retention
6) Pseudo-obstruction
7) Pressure sores
8) Malnutrition

Question 32

Prevention of further fractures (as well as falls) is part of post-operative management, in which 3 ways can this be done?

Answer 32

1) Treatment of osteoporosis
2) Calcium and Vit D supplements
3) Biphosphonates/ strontium ranelate/ denosumab

Question 33

What are the 3 aspects of best practise of hip fractures in the elderly?

Answer 33

1) Surgery within 36 hours of presentation
2) Cognitive assessment pre and post op
3) Orthogeriatrician involvement - seen by geriatrician within 72 hours and have a geriatrician led rehab