Surgery (7) Flashcards
The main classification of Neck of femur fractures (2) + its meaning
Intracapsular fractures of femur
(2) types
Intracapsular Fractures
- Divided into undisplaced and displaced
- Undisplaced often would unite if left alone but 1/3 will go onto displace if not fixed ⇒ screw
- Displaced will not usually unite without reduction because of the disrupted blood supply to the femoral head
Classification of intracapsular fractures of NOF and its management
Surgical repair of NOF when and what (THR vs hemiarthroplasty)
Offer replacement arthroplasty (total hip replacement or hemiarthroplasty) to patients with a displaced intracapsular hip fracture
Offer total hip replacement rather than hemiarthroplasty to patients with a displaced intracapsular hip fracture who:
- were able to walk independently out of doors with no more than the use of a stick and
- are not cognitively impaired and
- are medically fit for anaesthesia and the procedure
Management of all types of NOF
What to do post-op after NOF surgery?
Post-op review
- Examination: no evidence of neurovascular deficit
- Evidence of a DVT
- Bloods rechecked
- X-ray
- Once x-rays satisfactory patient usually mobilised after a day or so by the physiotherapists
Complications of total hip replacement surgery
Triad of factors predisposing for DVT
- vascular injury
- stasis of blood flow
- hypercoagulability
Risk factors for DVT
Well’s score and its interpretation
Measures to avoid DVT
- Administer low molecular weight heparin/fondaparinux/UFH
- use of a flowtron- a compressive device which is worn around the calf during surgery ( squeeze/ relax/squeeze…mimics venous pump)
- compression stockings post-surgery
Diagnosis of DVT
If a DVT is ‘likely’ (2 points or more)
- a proximal leg vein ultrasound scan should be carried out within 4 hours and, if the result is negative, a D-dimer test
- if a proximal leg vein ultrasound scan cannot be carried out within 4 hours a D-dimer test should be performed and low-molecular weight heparin administered whilst waiting for the proximal leg vein ultrasound scan (which should be performed within 24 hours)
If a DVT is ‘unlikely’ (1 point or less)
- perform a D-dimer test and if it is positive arrange:
- a proximal leg vein ultrasound scan within 4 hours
- if a proximal leg vein ultrasound scan cannot be carried out within 4 hours low-molecular weight heparin should be administered whilst waiting for the proximal leg vein ultrasound scan (which should be performed within 24 hours)
Management of DVT
Low molecular weight heparin (LMWH) or fondaparinux should be given initially after a DVT is diagnosed
- a vitamin K antagonist (i.e. warfarin) should be given within 24 hours of the diagnosis
- LMWH or fondaparinux should be continued for at least 5 days or until the international normalised ratio (INR) is 2.0 or above for at least 24 hours, whichever is longer, i.e. LMWH or fondaparinux is given at the same time as warfarin until the INR is in the therapeutic range
- warfarin should be continued for at least 3 months. At 3 months, NICE advise that clinicians should ‘assess the risks and benefits of extending treatment’
- NICE add ‘consider extending warfarin beyond 3 months for patients with unprovoked proximal DVT if their risk of VTE recurrence is high and there is no additional risk of major bleeding’. In practice most clinicians give 6 months of warfarin for patients with an unprovoked DVT/PE
- for patients with active cancer NICE recommend using LMWH for 6 months
