Pelvic, Hip + Femoral Fractures Flashcards
Which types of injury cause pelvic fractures?
High energy injuries in young patients
Low energy pubic rami fractures in older, osteoporotic bones
What is the pelvic ring made up of and what implication does it have for fractures?
Sacrum, ilium, ischium, pubic bones, ligaments
–> if pelvis is disrupted in one place then there will be another corresponding break in the pelvic ring
Which vessels may cause bleeding in a pelvic injury?
Internal iliac arteries
Pre-sacral venous plexus
Which nerves may be damages in a pelvic injury?
Lumbo-sacral plexus (roots + branches)
Which type of pelvic fracture is most at risk of high blood loss and why?
Open book pelvic fracture
- increased pelvic volume, can hold several litres of blood before tamponade + clotting occur
What is the initial management of a pelvic fracture?
ABCDE
If open book –> promptly reduce
Pelvic binder or external fixator
What can be done if bleeding continues despite binder/fixation?
Angiogram + embolization or
Open packing of pelvic (if doing a laparotomy for abdominal injuries)
Which examination is mandatory following a pelvic fracture and why?
PR exam
- assess sacral nerves
- blood may indicate rectal tear (involve general surgery)
When in the pelvic to osteoporotic low energy fractures tend to occur?
Pubic rami
How are low enemy pubic rami fractures managed?
Tend to be minimally displaced so settle with conservative management
Describe the arterial supply of the femoral head
Circumflex femoral arteries (branches of profunda femoral artery)
- travel up femoral neck to femoral head
What is the general approach to management of hip fractures?
Usually surgical repair within 24 hours unless time required for medical optimisation
- although most patients are high risk for surgical complications (elderly, co-morbidities), the risks of conservative management are just as high
What is the biggest risk of an intracapsular hip fracture?
AVN if the blood supply is disrupted
–> non-union
What is the principle of management of an intracapsular hip fracture and what are the two options?
Replacement of the femoral head –>
- hemiarthroplasty (femoral head alone)
- total hip replacement
Which group of patients would usually get a hemiarthroplasty for an intracapsular hip fracture?
Patients with restricted mobility and/or cognitive impairment
(THR has a higher risk of dislocation, especially in cognitively impaired patients)
Which group of patients would usually get a THR for an intracapsular hip fracture?
Higher functioning patients
Which two fractures are classed as intracapsular hip fractures?
Subcapital
Transcervical
Which fractures are classed as extra capsular hip fractures?
Intertrochanteric
Subtrochanteric
What is the management of an extra capsular hip fracture?
Dynamic hip screw
How does a dynamic hip screw work?
Large screw inserted into femoral head, across the fracture line + plate fixed to femoral shaft
As patient weight bares, screw slides into the barrel of the plate –> compression at the fracture site which promotes healing
Why does an extra capsular hip fracture not require replacement of the femoral head?
Low risk of AVN and therefore low risk of non-union
What type of injury causes a subtrochanteric proximal femoral fractures?
Fall onto side in a patient with osteoporosis
Why do subtrochanteric proximal femoral fractures take a long time to heal?
Subtrochanteric bone has relatively poor blood supply + under considerable bending stress
–> long time to heal + non-union common
How is a subtrochanteric proximal femoral fracture managed?
IM nail required for stabilisation
Thomas splint may help post-op
What are some complications of femoral shaft fractures?
If displace, blood loss up to 1.5 litres can occur
Fat from damaged medullary canal can enter the damaged venous system –> fat embolism
What is the initial management of a femoral shaft fracture?
Analgesia –> e.g. femoral nerve block + opioids
Thomas splint –> stabilise, reduced further blood loss and fab embolism
What is the definitive management of a femoral shaft fracture?
Usually closed reduction + IM nail
How does the leg usually appear in a fractured neck of femur?
Shortened + externally rotated
