Neck of Femur Fracture Flashcards
Mortality of NOF
Up to 30% at one year
These fractures require specialist care and a lot of orthopaedic units now have dedicated orthogeriatricians
Mechanism of injury
Low energy injuries in frail older patients (most common)
High energy like RTC or fall from heigh (associated with other significant injuries)
Where can NOF fractures occur?
Anywhere from subcapital region of the femoral head to 5 cm distal to the lesser trochanter
What can NOFs be described as?
Intracapsular
Extracapsular divided into inter-trochanteric or subtrochanteric
Explain intra-capsular fractures
From the subcapital region of the femoral head to the basocervical region of the femoral neck immediately proximal to the trochanters
Explain inter-trochanteric fractures
Between greater trochanter and the lesser trochanter
Explain subtrochanteric fractures
From lesser trochanter to 5cm distal to this point
Explain blood supply to neck of femur
Retrograde passing from distal to proximal along the femoral neck to the femoral head.
This is mainly through medial circumflex femoral artery lying directly on the intra-capsular femoral neck.
Displaced intra-capsular fractures and blood supply.
Disrupt the blood supply to the femoral head and will cause avascular necrosis.
This means that intra-capsular fractures that are displaced will require joint replacement arthroplasty instead of fixation
Classification of intracapsular fractures
Garden classification
Explain Garden classification of intracapsular fracture
Supply to head of femur in early life.
Ligamentum arteriosum inside ligamentum teres.
Negligible in adults
Clinical features
Trauma often low-energy
Pain and inability to weight bear
Pain is felt in groin, thigh or even referred to knee.
Examination findings
Shortened and externally rotated leg due to pull of the short external rotators
Pain on pin-rolling the leg and axial loading
Other examinations
Full neurovascular examination even if neurovascular deficits are rare.
If they are present they need to be acted upon urgently
Also investigate the nature of the fall, especially if it is not completely clear
D
Other fractures like pelvis, acetabulum, femoral head and femoral diaphysis
Pathological fractures
Ix
Plain film radiograph with AP and lateral views.
Also AP pelvistoassess the contralateral normal hip for pre-operative planning and templating.
Also full length femoral radiograph if there is suspicion of a pathological fracture.
Bloods - FBC, U&Es, coagulation screen and Group and save.
If they were on the floor a long time CK to see if there is rhabdomyolysis.
Urine dip, CXR and ECG can also be done in older patient group for a full assessment.
Initial management
A to E approach to stabilise the patient
Treat any immediately life- or limb-threatening problems.
Opioid analgesia and/or regional like a fascia-iliaca block
Definitive management is surgical
When should non-operative conservative management be done?
Rarely recommended as benefits of surgical intervention nearly always outweigh the potential conservative management
What surgical procedures might be done?
Hip hemiarthroplasty
Dynamic hip screw
Cannulated hip screws
Intramedullary femoral nail
Explain hip hemiarthroplasty and when it might be done
Replacement of the femoral head and neck via a femoral component fixed in the proximal femur.
Done in displaced subcapital fracture
Explain dynamic hip screw and when it’s used.
Lag screw into the neck, a sideplate and bicortical screws.
The lag screw is able to slide through the sideplate, allowing for compression and primary healing of the bone.
Done in intertrochanteric and Basocervical fractures
Explain cannulated hip screws and when they are done.
Three parallel screws in an inverted triangle formation.
Done in non-displaced intracapsular fracture
Explain intramedullary femoral nail and when it is done.
Titanium rod is placed through the medullary cavity of the femur for stabilisation.
Done in sub-trochanteric fractures
Immediate post-op complications
Pain
Bleeding
Leg-length discrepancies
Potential neurovascular damage
Who should NOF patients be managed under post-op?
Ortho-geriatricians to ensure early rehab, physio and get involved with the occupational therapist
Long term complications following repair
Joint dislocation
Aseptic loosening
Peri-prosthetic fracture
Deep infection/prosthetic joint infection
Mortality is 30% at one year
