NOF Fractures

Question 1

What typically causes NOF fractures?

Answer 1

Low energy injuries (most common)

High energy injuries (fall from a high, MVA)

Pathological fractures due to metastases

Question 2

What is the definition of a NOF fracture?

Answer 2

Can occur anywhere from the subcapital region of the femoral head to 5cm distal to the lesser trochanter

Question 3

What are the two distinct areas of the NOF?

Answer 3

1. Intra-capsular:
   - From the subcapital region of the femoral head to the basocervical region of the femoral neck (prox to the trochanters)
2. Extra-capsular: outside of the capsule
   - Intertrochanteric = between the greater trochanter and lesster trochanter
   - Sub-trochanteric = from the lesser trochanter to 5cm distal

Question 4

What is the blood supply to the NOF?

Answer 4

Retrograde: passes from distal to proximal along femoral neck

Via medial circumflex femoral artery = lies directly on the intra-capsular femoral neck (so displaced intra-capsular fractures disrupt the blood supply to the femoral head and it will undergo avascular necrosis)

Question 5

What classification system is used for NOF fractures?

Answer 5

Garden Classification

Question 6

What are the clinical features of a NOF fracture?

Answer 6

History:
- Acute onset hip pain (may radiate to pelvis or knee)
- Inability to weight bear
- Groin pain
- History of fall or trauma

Examination:
- Shortened and externally rotated leg (due to pull of external rotators)
- Do a full neuro examination

Question 7

What Ix do you do for a NOF fracture?

Answer 7

AP and lateral X-Ray of Hip and AP pelvis:
- Assess the fracture

Full length femoral radiographs if suspicion of a pathological fracture

Routine bloods: FBC, UEC, Coags, Group and Hold, CK if long lie time to assess rhabdo

Complete assessment of older patient: especially if they had a fall so you can work that up
- UA
- ECG
- CXR

Question 8

What is the surgical option for a displaced subcapital fracutre?

Answer 8

Hip hemi-arthoplasty or THR ( in patient who was systemically well, independent prior to injury)

Question 9

What is the general surgical option for undisplaced intracapsular fractures?

Answer 9

fixation with a screw

Can consider hemi or THR

Question 10

What might make you more likely to recommend a hemi or THR for someone with an undisplaced intracapsular fracture?

Answer 10

Systemically well: medically fit for anaesthesia and procedure
Independent prior to injury
Able to walk independently with no more than a walking stick
Are not cognitively impaired

Question 11

What is the surgery for extracapsular fractures?

Answer 11

Inter-trochanteric: dynamic hip screw

Sub-trochanteric: intramedullary nail

Question 12

What are the post-op complications from a NOF fracture surgery?

Answer 12

Pain
Bleeding
Leg-length discrepancy
Neurovascular damage
Avascular necrosis
Non-union

Question 13

What is the management of NOF fracture?

Answer 13

Surgery
Rehabilitation! best to be quick
DVT prophylaxis
Analgesia

Question 14

What are the long term complications of hip surgery?

Answer 14

Joint dislocation
Aseptic loosening
Peri-prosthetic fracture
Deep infection/prosthetic joint infection