Proximal femoral and #NOF

Question 1

ΔΔ hip pain?

Answer 1

• trochanteric bursitis
• OA
• NOF#
• avascular necrosis
• pain syndromes (athletes)
• referred pain
• infection
• malignancy

Question 2

Hx: 56 yr old woman with pain over greater trochanter, radiating down lateral leg, worse at night?

Ex: tender, pain on rotation, +ve Trendelenburg test

Answer 2

trochanteric bursitis

Question 3

where is a “proximal femoral fracture”?

Answer 3

<5 cm below lesser trochanter

>5 cm below = femoral shaft fracture

Question 4

Hx: elderly lady comes in with groin pain and unable to weight bear on right leg, O/E shortened and externally rotated?

Answer 4

prox femur/NOF#

Question 5

Qs to ask in Hx of prox femur #?

Answer 5

• mechanism of injury (low energy?= fragility)

* baseline function (walking, ADLs)

Question 6

how to Ex prox femur/NOF#?

Answer 6

• check for tenderness by pressing in groin around joint area (NOT if obvs diagnosis and pt in pain)
• only move leg so far as tolerated
• palpate pubic rami to check for fracture
• check + document NV status
- sensation (1st and 2nd toe web space) is supplied by the deep peroneal nerve and may rarely be affected in compartment syndrome of the thigh

Question 7

Ix prox femur/NOF#?

Answer 7

BEDSIDE:
• *ECG

BLOODS:
• *FBC, U+E, coag, group and save

IMAGING:
- X-ray pelvis (AP)
AND
- X-ray lateral hip
• *CXR
• +/- CT/MRI

(**specifically pre-surgery Ix)

Question 8

X-ray findings in prox femur/NOF#?

Answer 8

• disrupted Shenton’s line
• leg shortened and externally rotated
• intracapsular? if yes, displaced (Garden 3-4) or non-displaced (Garden 1-2)

Question 9

if trochanteric #… what to be suspicious of + how to Ix?

Answer 9

cancer
• BLOODS: bone profile, LFTs, PSA, myeloma screen
• IMAGING: full-length femoral imaging

Question 10

Tx prox femur#/NOF#?

Answer 10

conservative:
• NBM
• early mobilisation + physio, OT

medical:
• analgesia (+/- nerve block)
• DVT + Abx prophylaxis
• stop warfarin (aim <1.5)

surgical: (w/n 24 hrs***)
• displaced intracapsular = hemiarthroplasty (or THR if functional/OA)
• non-displaced intracapsular or extracapsular or pt <50 = DHS
• subtrochanteric or femoral shaft = intramedullary hip screw

Question 11

complication of intracapsular displaced #? Tx?

Answer 11

• hemiarthroplasty - replaced femoral head
(50/50 chance of avascular necrosis as circumflex arteries sit on femoral neck)
• THR preferred if functional/OA

Question 12

when is there a low risk of avascular necrosis? what surgery is preferred then?

Answer 12

if extracapsular or non-displaced intracapsular #

DHS preferred

Question 13

if low energy injury or extracapsular #, what to be suspicious about? Ix?

Answer 13

pathological #

BLOODS: FBC, U+E, LFT, bone profile, TFT, PTH, vit D, b12 and folate

Question 14

Ex findings for intracapsular NOF#?

Answer 14

externally rotated
adducted
shortened

Question 15

Ex and iTx for femoral shaft #?

Answer 15

HIGH IMPACT injury
Ex:
• < 2L blood loss
• check distal pulses (fem artery injury?)
• check sensation (sciatic nerve injury?)

Tx:
• stabilise pt
• Thomas splint traction
• intramedullary nail
• early mobilisation

Question 16

Hx: pt comes in from RTA with flexed leg, INTERNALLY rotated, adducted, and shortened, femoral head felt in buttock?

Answer 16

posterior hip dislocation

reduction under GA w/n 4 hours to reduce AVN risk