Orthopaedics Flashcards
Blood supply to femoral head
Blood supply is mainly via the retrograde supply along the neck of the femur
- Lateral femoral circumflex artery (most important)
- Medial femoral circumflex artery
- Give rise to cervical arteries
Some proximal supply from intraosseus nutrient vessels and the ligamentum teres but mainly important in youth
Obvious implication: intracapsular fractures lead to disruption of blood supply and increase likelihood of subsequent avascular necrosis of the femoral head
Complications of fractured neck of femur
Mortality at 90 days is 20%
-confounded by poor health present in someone that breaks their femur by falling from standing
Avascular necrosis
Dislocation of prosthesis
Loss of fixation
Non-union
VTE
Immediate management of fractured neck of femur
ATLS A–>E principles
In particular:
B: elderly people falling from height can fracture rib s causing flail chest and haemothroax
C: Precipitating cause of the fall may be MI or arrhythmia which represent immediate threat to life. Additionally, likely to have pacemaker and ischaemic heart disease and may be on b-blockers and DOAC
D: Cause of fall could be subdural haemorrhage, now may have extensive subdural or extradural haemorrhage. Think about anticoagulation and anti-platelets.
E: Look for breaks in skin and pressure sores. Sepsis, delirum etc could have caused the fall.
NEUROVASCULAR STATUS OF LIMB: before and after each intervention
- IV access and IV fluids - 250ml bolus for elderly with heart failure
- Analgesia, caution of opiates in the elderly. Additionally, clearly record opioid administration as this will be important after block has been placed.
- NBM and maintenance fluids
- Plain radiographs if not already done, AP and lateral (long-leg if PMHx of malignancy)
- Foam gutter splint for comfort and to reduce pressure sores (won’t be moving that leg)
- Fascia iliaca block. IF OPIOIDS administered MUST repeat observations immediately after block and every 15 minutes for first hour. There has been cases of respiratory depression (pain is the natural antagonist to opioids).
- TEDs and LMWH
- Pacemaker check: for tachyarrhythmia causing fall. Also will likely need setting changed for operation.
Bedside stabilisation for subtrochanteric fractures
Thomas or Kennedy split
-provides pain relief and reduces bleeding
Reverse oblique fractures
Gamma-nail
-short intra-medullary fixation
Unstable with DHS
Treatment of extracapsular fractures
DHS unless >/4 parts
Treatment of subtrochanteric fractures
Intramedullary femoral nail
Proximal: antegrade
Distal: retrograde (more complex)
Immediate treatment of mid-shaft femoral fractures
- ATLS (ABCDE).
- Establish two large calibre IV access and give up to 1000mL of crystalloid; initial haemodynamic compensation is common in the young and may hide a large blood loss. Can lose up to 4U (1500mL) of blood into tissues around a femoral fracture.
-Give blood
- Send blood for FBC, U&E, group and save.
- Realign and splint the leg with skin traction and a Thomas splint. This will help to control pain and haemorrhage.
- An X-ray of a femoral fracture not in a splint should never be seen! Diagnose clinically; splint, then get the X-ray.
- If an ‘OPEN’ fracture, photograph the wound, socially clean it, and place a betadine dressing over it, stabilize it. Commence IV antibiotics and tetanus toxoid if required.
- Full secondary survey, looking for associated injuries
Treatment of femoral mid-shaft fractures in children
- Nearly always heal and remodel.
- Age 0–2y. Treat in gallows (suspension) traction until callus seen (2–4 weeks) or Pavlik harness/hip spica.
- Age 2–6y. Treat with closed manipulation and hip plaster spica (allows discharge) or continuation of the Thomas splint.
- Age 6–14y. Options are a flexible intramedullary nail (‘elastic’ nail), ORIF with a plate and screws, or external fixation.
- Age >14y. Can consider locked intramedullary fixation.
Complications of femoral mid-shaft fractures
- Compartment syndrome.
- Fat embolus (1%) and possible ARDS.
- Infection (5% after open, 1% after closed nailing).
- Non-union.
- Thromboembolic disease.
- Neurological injury.
- Mal-union, rotation being the most symptomatic.
- Pressure sores, bronchopneumonia, UTI on conservatively treated patients.
Definition of a slipped upper femoral epiphysis
Displacement of the femoral epiphysis (growth plate) in relation to the neck of the femur
Clinical findings of a slipper upper femoral epiphysis
Pain in the knee or hip
Limping child
Affected leg slightly shorter and held in external rotation
Limited abduction and internal rotation on examination
When hip is flexed –> causes external rotation (almost pathognomonic)
Obese child
Usually male
Pathognomonic examination finding of a slipped upper femoral epiphysis
Abduction is limited; when the hip is flexed, it will rotate externally—this sign is almost diagnostic of the condition.
Risk factors for slipped upper femoral epiphysis
Obesity (50%)
Male (3:1 ratio)
Rapid growth
Hormonal: hypothyroidism, growth hormone deficiency, renal ricketts,
Left > Right
Bilateral slipped upper femoral epiphysis
Bilateral in 20%
Get AP, lateral/ frog view of both hips
There is an argument for prophylactic fixation of unaffected hip - more likely in metabolic causes
