Pelvic, Hip + Femoral Fractures

Question 1

Which types of injury cause pelvic fractures?

Answer 1

High energy injuries in young patients

Low energy pubic rami fractures in older, osteoporotic bones

Question 2

What is the pelvic ring made up of and what implication does it have for fractures?

Answer 2

Sacrum, ilium, ischium, pubic bones, ligaments

–> if pelvis is disrupted in one place then there will be another corresponding break in the pelvic ring

Question 3

Which vessels may cause bleeding in a pelvic injury?

Answer 3

Internal iliac arteries

Pre-sacral venous plexus

Question 4

Which nerves may be damages in a pelvic injury?

Answer 4

Lumbo-sacral plexus (roots + branches)

Question 5

Which type of pelvic fracture is most at risk of high blood loss and why?

Answer 5

Open book pelvic fracture

- increased pelvic volume, can hold several litres of blood before tamponade + clotting occur

Question 6

What is the initial management of a pelvic fracture?

Answer 6

ABCDE
If open book –> promptly reduce
Pelvic binder or external fixator

Question 7

What can be done if bleeding continues despite binder/fixation?

Answer 7

Angiogram + embolization or

Open packing of pelvic (if doing a laparotomy for abdominal injuries)

Question 8

Which examination is mandatory following a pelvic fracture and why?

Answer 8

PR exam

• assess sacral nerves
• blood may indicate rectal tear (involve general surgery)

Question 9

When in the pelvic to osteoporotic low energy fractures tend to occur?

Answer 9

Pubic rami

Question 10

How are low enemy pubic rami fractures managed?

Answer 10

Tend to be minimally displaced so settle with conservative management

Question 11

Describe the arterial supply of the femoral head

Answer 11

Circumflex femoral arteries (branches of profunda femoral artery)
- travel up femoral neck to femoral head

Question 12

What is the general approach to management of hip fractures?

Answer 12

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

Question 13

What is the biggest risk of an intracapsular hip fracture?

Answer 13

AVN if the blood supply is disrupted

–> non-union

Question 14

What is the principle of management of an intracapsular hip fracture and what are the two options?

Answer 14

Replacement of the femoral head –>

• hemiarthroplasty (femoral head alone)
• total hip replacement

Question 15

Which group of patients would usually get a hemiarthroplasty for an intracapsular hip fracture?

Answer 15

Patients with restricted mobility and/or cognitive impairment
(THR has a higher risk of dislocation, especially in cognitively impaired patients)

Question 16

Which group of patients would usually get a THR for an intracapsular hip fracture?

Answer 16

Higher functioning patients

Question 17

Which two fractures are classed as intracapsular hip fractures?

Answer 17

Subcapital

Transcervical

Question 18

Which fractures are classed as extra capsular hip fractures?

Answer 18

Intertrochanteric

Subtrochanteric

Question 19

What is the management of an extra capsular hip fracture?

Answer 19

Dynamic hip screw

Question 20

How does a dynamic hip screw work?

Answer 20

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

Question 21

Why does an extra capsular hip fracture not require replacement of the femoral head?

Answer 21

Low risk of AVN and therefore low risk of non-union

Question 22

What type of injury causes a subtrochanteric proximal femoral fractures?

Answer 22

Fall onto side in a patient with osteoporosis

Question 23

Why do subtrochanteric proximal femoral fractures take a long time to heal?

Answer 23

Subtrochanteric bone has relatively poor blood supply + under considerable bending stress
–> long time to heal + non-union common

Question 24

How is a subtrochanteric proximal femoral fracture managed?

Answer 24

IM nail required for stabilisation

Thomas splint may help post-op

Question 25

What are some complications of femoral shaft fractures?

Answer 25

If displace, blood loss up to 1.5 litres can occur

Fat from damaged medullary canal can enter the damaged venous system –> fat embolism

Question 26

What is the initial management of a femoral shaft fracture?

Answer 26

Analgesia –> e.g. femoral nerve block + opioids

Thomas splint –> stabilise, reduced further blood loss and fab embolism

Question 27

What is the definitive management of a femoral shaft fracture?

Answer 27

Usually closed reduction + IM nail

Question 28

How does the leg usually appear in a fractured neck of femur?

Answer 28

Shortened + externally rotated