T&O: NOF fractures, hip + femoral shaft Flashcards
What is the classifcation for Intracapsular NOF fractures?
Garden classification:
Garden I: incomplete and undisplaced fracture
Garden II: Complete but undisplaced fracture
Garden III: Complete fracture with partial displacement
Garden IV: Complete fracture with 100% displacement
What are the 2 most common injuries for NOF fracture?
Low energy trauma - osteoperiotic frail older pt -falls
High energy trauma - road traffic accident, fall from height
Which 2 areas can be affected in an extracapsualr NOF fracture?
Extracapsular
Inter-trochanteric - between greater and lesser trochanter
Sub-trochanteric - from lesser trochanter to 5 cm distal to this point
The Garden classification for NOF fracutres describes both Intra-capsualr and Extra-capsular fractures
TRUE or FALSE?
FALSE
Only for Intracapsular fractures !
Blood supply to the the NOF is ____________ and is supplied by the ___________ which lies directly on the __________. Fracture to the NOF can lead to___________
Blood supply to the the NOF is __retrograde__ and is supplied by the _**Medial Circumflex Artery** which lies directly on the _femoral neck_. Fracture to the NOF can lead to__avascular necrosis_.
What are the symptoms / presentation of NOF fracture?
- Severe pain in the hip or groin- may also be in anterior thigh, and elderly may refer to knee
- Inability to bear weight on the affected leg
- Shortening and external rotation of the affected leg
- Swelling or bruising over the hip area
What would you find on examination ?
Shortened, externally rotated leg (external rotators: obturator internus, gemelli, piriformis, quadratus femoris)
Test: Pain on pin rolling and axial loading
Neurovascualr : rare to have defecits- but do full exam
investigate injury cause: especially if Hx of injury not clear
What are some differencial diagnosis for NOF fracture?
Other fractures :
- Pelvis - esp. pubic ramus
- Femoral head / diaphysis
- acetabulum
Pathological Fractures:
Esp. if no significant trauma
What type of emboli is at risk of forming with a femoral shaft fracture?
Fat emboli
Fat emboli gives a classic triad of signs. What are they?
Hypoxaemia, neurological abnormalities, petechial rash
What findings would you see on an XR of a child with Perthes’ disease?
Femoral head collapse and fragmentation which suggests osteonecrosis.
What is a recognised complication of a total hip replacement?
Posterior hip dislocation
What are risk factors following an ORIF surgery?
Surgical site infection, DVT or PE, NV injury, non-union, metalwork prominence.
What would be the management for an intertrochanteric NOF fracture?
This is an extracapsular break off the femur between the greater and lesser trochanters. Needs DHS.
How do you treat NOF?
Garden 1/2- ORIF and cancellous screws
Garden 3/4- depends on age–> <55–> ORIF and screws
>75–> hemiarthroplasty
55-75- total hip replacement
EXTRACAPSULAR- ORIF and DHS
What do we mean by an inter-trochanteric fracture?
Between lesser and greater trochanter
What is a sub-trochanteric fracture?
Fracture from lesser trochanter to 5cm distal to this point
How does an extra capsular NOF fracture present?
Hx of trauma - high energy or low energy if more elderly. Pain. can not weight bear.
What would you see on examination of an extra capsular NOF fracture/intracapsular NOF?
Shortened and externally rotated leg. Pain on pin rolling the leg or axial loading.
What investigations would you do a suspected extracapsular NOF fracture?
XR AP and lateral. FBC< U+E, Coag screen, group and save, CK is suspect rhabdomyolysis . In elderly pt, do urine dip, egg, cxr.
What are RF for extra capsular NOF fracture?
Being elderly (osteoporotic), stress fractures, trauma. Pathological fractures (have underlying disease meaning bone is brittle) - Paget’s disease, osteomalacia, osteoporosis, osteogenesis imperfecta, bone cancer
What is initial management for NOF fracture?
A-E assessment + stabilise. Analgesia - opiod or regional fascia - iliac block. if elderly - need to have assessment by ortho-geriatricians. Need to be seen by physio and occupy therapists.
What is surgical management for intertrochanteric NOF extracap fracture?
DHS - dynamic hip sore. Here - screw into the NOF and side plate fixed screw - compress to cause bone healing.
What is surgical management for subtrochanteric NOF extracap fracture?
Intramedullary femoral nail - titanium rod is placed through medullary cavity of the demur to help stabilise it.
Name 2 immediate post op NOF fracture surgery complications
Pain, bleeding, leg length discrepancy, NVS damage
What are long term complications of NOF fracture surgery?
Joint dislocation, aspect loosening, peri-prosthetic fracture, deep infection, prosthetic joint infection
What is level of mortality increased by, at one year post NOF fracture?
Up to 30%
Define intracapsular NOF fracture
Fracture in sub capital region of the femoral head to the basocervical region
What surgical management would you consider with a displaced sub capital inter capsular NOF fracture?
Hip hemiarthorplasty or total hip arthroplasty if independence and systemically well
Pt has non displaced intracapsular NOF fracture that needs to be treated surgically. What surgery would be considered?
Cannulated hip screws or a total hip arthroplasty
What type of surgery would be done for a basocervical intracap NOF fracture?
DHS or total hip arthroplasty if systemically well and independent.
What is the most common type of of hip dislocation?
Posterior (90%)
What is the mechanism of action of a posterior hip dislocation?
Dashboard injury
How does a posterior hip dislocation present?
Internally rotated and slightly flexed and abducted
How does an anterior hip dislocation present?
Externally rotated, slightly flexed and abducted
What is trochanteric bursitis?
Inflammation of the bursa overlying the greater trochanter
How does trochanteric bursitis present?
Lateral hip pain (worse with activity and at night)
Swelling
Positive trendelenburg test
