Neck of Femur Fracture Flashcards
What cases a neck of femur fracture?
Low energy injuries= fall in frail elderly pts
High energy injuries - road traffic collisions affecting ipsilateral side
Describe the anatomy of the hip joint
Hip joint is a ball and socket joint
Femoral head articulates with the acetabulum
Neck fo femur is around 130 degrees to the shaft and anteverted 10 degrees.
What is the blood supply to the hip joint?
The femoal head’s blood supply is primarily uni-directional, mostly from the medial femoral circumflex artery from the profound femoris.
Also from the lateral femoral circumflex artery, which must penetrate the iliofemoral ligament and the artery to the head to the femur (from the obturator after) in young people, which reduces in size to form ligament arteriosum in ligament teres.
What artery is particularly prone to damage and what can this cause?
The medial femoral circumflex artery lies directly on the femoral neck so is vulnerable to damage in a fracture.
This can cause avascular necrosis of the femoral head.
How are neck of femur fractures classified?
Intracapsular
- Subcapital (through the junction of the head and neck)
- Basocervical (through the base of the femoral neck)
Extracapsular
- Intertrochanteric (between the two trochanters)
- Subtrochanteric (<5cm distal to the lesser trochanter)
What is the capsule of the hip?
Strong yet loos capsule formed from external fibrous layer and internal synovial membrane
Fibrous layer attaches to the acetabulum proximally peripheral to the rim
Distally the fibrous layer attaches to the femoral neck, anteriorly to the intertrochanteric line and posteriorly, the lateral part of the neck is extra capsular.
How can intracapsular fractures be classified?
Garden classification: I - non displaced, incomplete II - non-displaced, complete fracture III - partially displaced - usually rotated, angulated, complete fracture IV - fully displaced complete fracture
What is the typical presentation for hip fracture?
History fo recent fall or trauma
Significan pain (in groin, over the hip, in thigh and knee)
Inability to weight bear.
± chronic metabolic problems such as osteoporosis, renal failure (vitamin D)
What does a fractured hip look like on examination?
Shortened and externally rotated leg Due to pull of the short external rotators: • Gluteus maximus Piriformis • Superior gemellus • Obturator internus • Inferior gemellus • Quadratus femoris Internal rotators attach at the lesser trochanter so lose their effect Pain on pin-rollowin the leg and axial loading Pt unable to straight leg raise Full NV exam is essential
DDx
Consider fractures of pelvis (pubic rams),a acetabulum, femoral head, femoral diaphysis
Pathological fracture if no hx of trauma
What investigations would you require for hip fracture?
AP and lateral XR of the affected hip as well as AP pelvis to assess contralateral normal hip
Bloods - FBC, U&E, coagulation, group and race, creatine kinase for rhabdomyolysis
Bedisde: Urine dip, ECG
MRI if clinical equipoise remains
How would you manage patient initially with neck of femur fracture?
Stabilise Airway, breathing, circulation, disability, exposure
Ensure adequate analgesia
Assessment of underlying cause
What is definitive management for sub capital fracture?
Hip hemiarthroplasty
Replacement fo the femoral head and neck via a femoral component fixed in the proximal femur
What is the definitive management for intertrochanteric (extra capsular) and basocerivcal fracture?
Dynamic hip screw - lag screw into the neck, a side plate, and cortical screws.
The lag screw is able to slide through the side plate allowing for compression and primary healing of the bone.
What is the definitive management for non-displaced intracapsular fractures? What if there is significant cormorbidity?
Internal fixation - Cannulated hip screws
Three non-parallel screws in an inverted triagle formation
If there is major disease, hemiarthroplasty
What is the definitive management for a subtrochanteric fracture?
Intramedullary femoral nail
Metal rod is placed through the medullary cavity of the femur for stabilisation
How are displaced intra-capsular fractures in normally well and active elderly patients with high performance treated?
Total hip arthroplasty - replacing both the femoral head and neck (via a femoral component) and the acetabulum (via an acetabular cup)
If <70 internal fixation if possible, hip arthroplasty if not.
If >70 total hip arthroplasty
How is intracapsular undisplaced fracture treated?
Internal fixation or hemiarthroplasty if unfit
How is an intracapuslar displaced fracture treated?
young and fit (<70) - reduction and internal fixation
older and reduced mobility (hemiarthroplasty or total hip replacement)
How is extra capsular fracture treated?
Dynamic hip screw, if reverse oblique, transverse or subtrochateric: inter medullary device
Risk factors
Ostoporotic
Elderly
Female
What are immediate post-operative complication
Pain, bleeding, leg-length discrepancies, potential NV damage
Long term complications?
Joint dislocation (flexed, internally rooted and adducted leg in posterior dislocation, external roation, mild flexion and abduction in anterior dislocation)
Peri-prosthetic fracture
Infection
What line can help make a diagnosis of neck of femur fracture on a plain radiograph?
Shenton’s line - line across the inferior border of the superior pubic rami and along the inferomedial border of the neck of femur
Why would you replace a intracapsular fracture hip?
High risk fo avascular necrosis of the femoral head and non-union associated with fracture fixation. Fracture fixation is associated with a higher re-op rate than hemiarthroplasty
What is the mortality for hip fracture?
30%
5 investigations essential on admitting patient in prep for surgery?
FBC U&E Glucose ECG CXR Group and save
