NOF Fractures, OA Of Hip And Knee Flashcards
What is the 1 year mortality rate for neck of femur fractures?
30%
What type of injury commonly cause neck of femur fractures?
Low energy fragility fractures
High energy trauma
What are the 2 categories of neck of femur fractures?
Intracapsular
Extracapsular
What is classified as an intracapsular neck of femur fracture?
Any fracture from the intertrochanteric line proximally
What is the name of the classification system for neck of femur fractures?
Garden classification
What is the Garden classification?
I = non displaced incomplete fracture
II = non displaced complete fracture
III = partially displaced complete fracture
IV = fully displaced complete fracture
What is a I on the Garden classification for NOF fractures?
Non displaced incomplete fracture
What is a II on the Garden classification for NOF fractures?
Non displaced complete fracture
What is a III on the Garden classification for NOF fractures?
Partially displaced complete fracture
What is a IV on the Garden classification for NOF fractures?
Fully displaced complete fracture
When a patient presents with suspected NOF fracture what questions do you want to know?
Falls history
Blood thinners? Antihypertensives? Long term corticosteroids (weaken bone)
Social support at home
What is the acute initial managemtn of a patient with a NOF fracture?
A-E assessment
Resuscitate
What is the acute initial managemtn of a patient with a NOF fracture?
A-E assessment
Resuscitate
What is the acute initial managemtn of a patient with a NOF fracture?
A-E assessment
Resuscitate
How does a patient with a NOF fracture typically present?
Trauma
Unable to weight bare
Thigh, groin or referred knee pain
Leg in alternate position at res
On examination of the hip how does the lower limb typically present?
Why?
Shortened
Externally rotated
Psoas pulls up shortening
Gluteus max and deep gluteals externally rotate
What is important to assess with ha NOF fracture on examination?
Neurovascular status
Test sensation and pulses distally
What Ix should you do if you suspect a NOF fracture?
FBC
U+Es
G+S and cross match
Obs
Blood glucose
ECG
Urine dip
Creatine kinase (rhabdo?)
VBG
What is the gold standard imaging for a NOF fracture?
Plain radiograph AP + lateral of the pelvis
Sometimes full length femur too if think pathological fracture
Can do CXR for full patient work up if they are older patient
Why are intracapsular neck of femur fractures worse than extracapsular?
Retrograde blood supply to the femoral head via the medial femoral circumflex artery
If intracapsular fracture and is displaced can disrupt this blood supply leading to Avascular necrosis of the femoral head
What is the name of the line that can be used to help identify NOF fractures on X-ray?
Shentons line
What is shentons line?
Runs from medial edge of femoral neck along the inferior border of the superior pubic ramus
Look on page 2 of notes.
What is the initial management for a patient with a NOF fracture?
Analgesia (opioids or regional anaesthesia)
Cease DOAC
Keep NBM (prep for surgery)
IV fluids
What is an example of a regional anaesthetic technique used for analgesia with a NOF fracture?
Fascia iliaca block
What is a fascia iliaca block?
Local injected under tensor fascia lata to try and block the femoral nerve
What are the 2 consent forms used for adults?
Forms 1 and forms 4
Who is consent form 1 used for?
Adults with capacity
Who is consent form 4 used for?
Adults without capacity (need 2 doctors signatures)
What is the method of management for a patient with a NOF fracture?
Surgical
What is the goal of operating on someone with a NOF fracture?
Mobility
Pain relief
Pre event status
Ideally weight bearing straight after operation
What is the surgical management for a patient with a non displaced (Garden class I or II) NOF fracture?
Fix it in place
DHS (Dynamic Hip Screw)
Cannulated Hip Screws
What is the surgical management for patients that have displaced intracapsular NOF fractures (Gardens III or IV)?
Replace the joint
Hemiarthorplasy
Total Hip Replacement
When do you do a hemiarthroplasty or a Total Hip replacement for a patient with a Gardens III or IV intracapsular NOF fracture?
If is gonna get good use out of it do a Total Hip (they walk independently alone outside with no more than 1 stick)
What is the surgical management of an extracapuslar NOF fracture?
Internal fixation:
DHS or IM nail
What are the short term complications of repair of NOF fractures?
DEATH
Bleeding
Pain
Infection
DVT/PE
Stiffness
Limb length discrepancy
Nerve/vessel/bone damage
Dislocation
What are the long term complications of a hemiarthroplasty or total hip replacement?
Dislocations
Peri-prosthetic fracture
Prosthetic joint infection
Aseptic loosening
Mal union/non union
What is the post op management for a patient who just had a hemi-arthroplasty or THR?
Mobilise + rehab
Assessed by orthogeriatricians
Prevent future falls + fragility fractures
What is the screening tool we used to assess a patients 10yr probability of having a fracture?
WHO FRAX Score
Why is the WHO FRAX score important in post op NOF fracture management?
Determines who we should be giving bone protecting medicine
Who do we use the WHO FRAX score on and who do we give immediate bone protection to?
Age < 75s use WHO FRAX tool
Age > 75 start BONE PROTECTIOON
What medication class do we use for bone protection?
Bisphosphonates
Replace vitamin D/calcium
What bisphosphonates are used as bone protection?
Alendronic acid orally
Or
IV Zolendronic acid
Why is IV zolendronic acid typically favoured as bone protection over oral alendronic acid?
Alendronic acid is uncomfortable to take, have to sit upright and still for 30mins and can cause oesophagitis. Has to be taken once a week
IV zolendronic acid lasts 12month
What is a potential complication of IV zolendronic acid?
Osteonecrosis of the jaw
What is osteoarthritis?
Degenerative joint changes where the cartilage of the joint wears away which can lead to bony erosion
What are the risk factors for osteoarthritis of the hip?
Old
Female
Obese
Genetics
Low bone density
Trauma
Joint abnormalities
Vit D deficiency
Joint laxity
How does a patient with OA of the hip present?
Pain:
-groin/hip/buttock
-worse on exercise relieved by rest
Antalgic gait
Fixed Flexion deformity?
Pain on passive movements
What Ix do you do when suspecting Hip OA?
Height + Weight (BMI)
Might do CRP and other bloods but its typically a clinical diagnosis
What imaging is done for Hip OA?
Plain radiograph Hip
Sometimes MRI hip
What oestoarthritic changes can be seen on x-ray?
Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis
What are the 3 categories of management for OA of hip?
Conservative
Mediiical
Surgical
What is the conservative management of hip OA?
Exercise
Weight loss (if BMI is high))
Education
What are the medical managements of hip OA?
Analgesia (use WHO pain ladder)
Hip joint steroid injection
What is the surgical management for hip OA and when do you do it?
Total hip replacement
When the symptoms significantly affect QOL and non surgical management has failed or isn’t suitable
What is the post op management of hip OA following a THR?
Mobilise
VTE prophylaxis
Weight loss
Exercise
Smoking cessation
What are the risk factors for knee OA?
Old
Female
Obese
Genetics
Trauma
Joint abnormalities
Muscle weakness
Bone density
How does knee OA present?
Pain:
-around knee can radiate to thigh or hip
-exacerbated by exercise relieved by rest
Often bilateral
Crepitus
Joint stiffness
What imaging for knee OA?
Plain radiograph (AP and lateral like the hip)
Often skyline view taken to see patella femoral involvement
LOSS seen
What is the conservative management of knee OA?
Exercise (physiotherapist)
Weight loss
Education
Activity modification
Smoking cessation
What is the medical management of knee OA?
TOPICAL NSAIDs
PO analgesia
Knee joint steroid injection
What is the surgical management of knee OA?
Total joint replacement or partial unicondylar knee replacement if only 1 condyle is affected
When do you surgically manage knee OA?
If symptoms massively impact QOL and non surgical managemtn has failed or isn’t suitable
What is patellofemoral arthritis?
How does it present?
OA affecting the articular cartilage in the trochlear groove under the patella
Pain on anterior aspect of knee
How is patello-femoral arthritis managed surgically?
Patello-femoral replacement but if other parts of joint involved to TKR
What plain radiograph view is very importnat in patello-femoral arthritis?
Skyline view
What is important following TKR?
Prompt mobilisation
VTE prophylaxis
What is the main function of the ACL?
Main stabiliser of the knee
Prevents anterior translation of the tibia relative to the femur
What sort of history does an ACL tear present with?
Knee twisted while weight bearing
So sudden change in direction
RAPID JOINT SWELLING AND PAIN
Unusable to weight bare
If patient presents late, knee may give way
Mainly non contact injury
What imaging is done for ACL injury?
Knee X-ray AP and lateral to exclude bony involvement
GOLD STANDARD = MRI
What fracture is common with an ACL injury?
Tibial spine fracture (avulsion fracture where the ACL inserts on tibia)
What tests on examination test the functionality of the ACL?
Anterior drawer test
Lachmanns test
What is that management for an ACL rupture?
RACE (Rest Actively Compression and Elevation)
Conservatively splinting (physiotherapist and rehab/prehab for surgery)
Surgical = ACL reconstruction after. Physio and swelling has gone down
What is the main complication oof ACL rupture?
Post traumatic knee. OA
What is the function of the PCL?
Prevents hyper Flexion
Prevents posterior translation of the tibia relative to the femur
What usually is the presentation of a PCL tear?
High energy trauma to the back of the knee
Immediate posterior knee pain
What is often seen on examination with a PCL tear?
Posterior sag
When knee flexed to around 30 degrees can see tibia sags
What imaging is done for PCL tear?
Plain radiograph knee AP and lateral
MRI knee
What this the management for PCL tear?
Rest Actively Compression and Elevation
Brace + physio
Analgesia
After swelling gone down and sufficient physio consider PCL reconstruction
What is the function of the MCL?
Valgus stabiliser of knee
What usually leads to injury to the MCL?
External rotational force on the lateral side of the knee.
How does an MCL injury present?
Trauma to lateral side of knee
Immediate medial joint pain
What is the imaging for MCL injury?
Plain radiograph knee AP and lateral
MRI knee
What is the management for MCL injury?
Conservatively (RACE rest actively compression adn elevation)
Analgesia
Knee brace
Physio
MCL reconstruction if. There is avulsion
What is the unhappy/terrible triad?
MCL tear
Medial meniscus tear
ACL rupture
How is the unhappy triad managed?
Send home in a brace
Rest actively, compression elevation
Allow swelling to settle
Then. Surgical management
How does a meniscal tear present?
Twisted knee while flexed and weight bearing
Intense sudden onset pain
SLOW delayed swelling
Joint effusion
Limited knee Flexion
What is a key characteristic of meniscal tears?
Knee locking
Why do meniscal tears swell slowly compared to ACL, PCL and MCL tears?
Menisci are fibrocartilaginous shock absorbers so have very poor blood supply whereas the other ligaments have a great blood supply
What 2 tests are used to test for meniscal tears?
McMurrays test
Apleys grind test
What is McMurrays test?
Patient supine
Flex knee at 90 degrees
Laterally rotate tibia and extend to test medial meniscus
Externally roate and extend to test lateral meniscus
What is Apleys test?
Patient prone
Knee flexed at 90
Internally rotate and externally rotate tibia
Then do it with compressive force
What is the imaging for meniscal tear?
Plain film radiograph
MRI knee
What is the management from meniscal tear?
RACE
Brace
Analgesia
Physio+rehab
If tear <1cm conservatively
>1cm arthroscopic repair
What are the risk factors of patella tendon rupture?
Male
CKD
Diabetes Mellitus
Rheumatoid arthritis
Medications
What medications increase the risk of patella tendon rupture?
Corticosteroids
Fluroquinolones
What is the method of injury that causes a patella tendon rupture?
Direct injury
Eccentric loading
Recent history of tendinopathy
What is the typical presentation of a patellla tendon rupture?
Tearing sensation
Sudden pain across anterior thigh/knee
Landing from a jump
What can be found on examination of a patella tendon rupture?
Bruising + swelling above /below patella
Cant straight leg raise
Can feel palpable gap
What imaging is done for patella tendon rupture?
X-ray AP + lateral
US knee
MRI can be done if late presentation
What is the management for patella tendon rupture?
Stabilise and brace
Analgesia
Surgery = direct repair if bad
Post op physio
What usually causes a patella fracture?
Direct trauma to patella (fall or RTC)
Or
Strong quadriceps contraction
How does a patella fracture present?
Anterior knee pain
Cant straight leg raise due to pain
Anterior BOGGY swelling
What imaging done for patella fracture?
Plain radiograph AP, lateral and skyline
What is the management for patella fractures?
If not displaced and minimal impact on extensor mechanism brace cast and physio
If displaced or significant impact to extensor mechanism do surgical intervention like ORIF
What are the complications of patella fractures?
Loss of ROM
Secondary osteoarthritis
