Orthopaedic: Hip and Thigh

Question 1

What are the types of NOF fractures you can have?

Answer 1

• Intra-capsular –
  
  • Subcapital (of femoral head)
  • Basocervical (of femoral neck)
• Extra-capsular: Inter-trochanteric, Sub-tronchanteric

Question 2

What are you worried about with intracapsular fractures?

Answer 2

AVN

Question 3

What is the main blood supply to the femoral head from?

Answer 3

• Retinacular arteries from Medial circumflex femoral artery
• Ligamentum teres: has a very small blood supply

Question 4

How does a NOF fracture present?

Answer 4

• Trauma, often low-energy
• Followed by pain and an inability to weight bear.
• Pain: groin, thigh or, commonly in the elderly, referred to the knee.
• Leg appears shortened and externally rotated
• Assess NVS: neurovascular deficits are rare in isolated neck of femur fractures

Question 5

How do you investigate a NOF fracture?

Answer 5

• C-ABCDE Management
• Bloods: FBC, U&Es, coagulation screen, Group and Save; CK (rhabdomyolysis)
• Plain-film radiographic: AP, lateral and full length
  
  • Full length if you suspect a pathological fracture
• Older patients: CXR, ECG

Question 6

How do you manage a NOF fracture?

Answer 6

• ABCDE
• Analgesia: opioid, regional analgesia (such as a fascia-iliaca block)
• Surgical:
  
  • Intracapsular: bin it: total hip replacement/ hip hemiarthroplasty
  • Extracapsular: pin it: dynamic hip screws, intramedullar femoral nail, cannulated hip screw
  • See table.
• Post surgical : early rehabilitation, through engagement with physiotherapists

Question 7

What classification is used for intracapsular fractures?

Answer 7

Garden Classification

Question 8

How does a femoral shaft fracture present?

Answer 8

• Pain in thigh
• Inability to bear weight
• Deformity - proximal fragment flexion (iliapsoas) and external rotation (gluteus medius & minimus)
• Assess skin and perform a full neurovascular examination

Question 9

How is a femoral shaft fracture managed?

Answer 9

• Management: ABCDE, opioid analgesia if open (AB prophylaxis and tetanus, photograph).
• Immediate reduction and immobilization - in-line traction
• Traction splinting
• Surgery: within 24-48 hours, antegrade intramedullary nail, external fixation - many require surgery
  
  • Complications: neurovascular injury, malunion, infection, fat embolism
• Long leg casts

Question 10

How is a distal femur fracture managed?

Answer 10

Mx: realignment (+ sedation + anaesthesia)

Majority require surgical mx

• Retrograde intramedullary nailing - proximal extra-articular fractures or simple intra-articular fractures,
• ORIF with a distal femoral plate - distal fractures or complex intra-articular fractures
• External fixation may be used in severe comminuted or open fractures.

Question 11

How is OA Mxd?

Answer 11

1. Conservative: weight loss, given advice about local muscle strengthening exercises and general aerobic fitness
2. Paracetamol and topical NSAIDs
3. Oral NSAIDs/COX-2 inhibitors, opioids, capsaicin cream and intra-articular corticosteroids + PPI
4. Consider: non-pharmacological treatment options include supports and braces, TENS and shock-absorbing insoles or shoes
5. Last resort: joint replacementx