NOF

Question 1

What are the two mechanisms of injury in NOF?

Answer 1

Low energy

High energy

Question 2

Where do NOF happen?

Answer 2

Anywhere from supcapital region of the femoral head to 5cm distal to lesser trochanter

Question 3

What are the two main classifications of NOF?

Answer 3

Intracapsular

Extracapsular

Question 4

What are the two types of extra-capsular fractures?

Answer 4

Inter-trohanteric

Sub-trochanteric

Question 5

What is important to ask about in the history of NOF?

Answer 5

• Preceding event - identify cardio/neurological causes
• Mechanism of fall
• level of function prior to fracture

Question 6

What is an obvious finding of examination of NOF?

Answer 6

Shortened and externally rotated leg

Question 7

What is the main blood supply that may be disrupted in a displaced intracapsular NOF?

Answer 7

Medial circumflex artery - avascular necrosis

Requires arthropalsty

Question 8

What is the classification system used of NOF?

Answer 8

Garden classification

Question 9

What is the garden classification?

Answer 9

I - incomplete and undisplaced
II - complete fracture but undisplaced

III - complete and partial displacement
IV - complete and fully displaced

Question 10

What examinations would you perform on someone presenting with suspected NOF?

Answer 10

Signs of neurovascular compromise 
Tenderness 
Movement 
Other injuries 
Head injuries

Question 11

What investigations would you do for suspected NOF?

Answer 11

Bedside: BP, ECG, urine dip, A to E, blood glucose

Bloods: FBC, U&Es, group and save, coagulation, bone profile/vit D, CK levels

Imaging: X-ray (AP+Lateral), CXR, whole femur X-ray for pathological fractures, CT and MRI(gold standard) if fracture can’t be seen on x-ray.

Question 12

What are signs of rhabdomyolysis?

Answer 12

Renal failure and coke coloured urine

Question 13

What type of analgesia can be given in NOF?

Answer 13

Opioid

Regional block - fascia-iliaca block

Question 14

What are the side effects of opioids?

Answer 14

Delirium

Constipation - prescribe laxatives as well

Question 15

When is fascia-iliac block contraindicated?

Answer 15

Hypercoagulable states

Pt on anti-coagulants

Question 16

What other medication/things can be prescribed other the analgesia for NOF?

Answer 16

LMWH - DVT prophylaxis
Fluids - blood loss of up to 500ml in NOF
Prophylactic antibiotic’s

Question 17

What are the surgical options for NOF?

Answer 17

• Displaced sub capital - Hip arthroplasty (total/hemi)
• Inter-trochanteric and basocervical - dynamic hip screw/ short IM nail
• non-displaced intra-capsular - cannulated hip screws
• sun-trochanteric - anterograde intramedullary femoral nail

Question 18

What is the Nottingham hip fracture score?

Answer 18

Predicts 30 day mortality after hip fracture surgery

7 independent factors

NHFS>=6 cut-point for high mortality

Question 19

Why is serum lactate relevant in NOF?

Answer 19

Increase in venous lactate is predictor of early death

Question 20

What are the complications of surgery in NOF?

Answer 20

Pre-op - delirium, reduced mobility, bleeding, death

Intra-op - bleeding, nerve damage, muscle damage

Post -op - delirium, pressure sores, reduced mobility, PONV, bleeding, osteonecroisis, dislocation, DVT/PE, wound infection, chest infection - pneumonia, leg length discrepancies, neurovascular damage

Question 21

What should be done post-op to achieve best outcome for pts with NOF?

Answer 21

Early rehab - physio and OT

Question 22

What should pts with fragility fracture be on?

Answer 22

Bisphosphonates

Question 23

Which types of fractures are commonly associated with fragility fractures?

Answer 23

NOF

Spine

Wrist

Question 24

What is consent form 1 and 4?

Answer 24

Consent 1 - all adult pts consenting to treatment and have capacity

Consent 4 - Adult pts without capacity, best interest intervention done and next of kin informed. Signed by 2 consultants.