The Hip Flashcards
Aetiology of NOF fractures & blood supply
Causes:
- low energy injuries e.g. elderly fall
- high energy injuries e.g. road traffic collision
Femoral head sits in acetabulum
Blood supply:
(Deep femoral->) most from Medial femoral circumflex artery (also LCFA) -> retinacular arteries
(Minor supply artery of ligamentum teres)
Intertrochanteric line A
INTERTROCHANTERIC CREST P
Classification NOF fractures
Intracapsular - subcapital (through head & neck junction) or basocervical fracture (base femoral neck)
Extracapsular - intertrochanteric or sUbtrochanteric (<5cm distal lesser trochanter)
Garden classification (intracapsular fractures): Non-displaced 1 (incomplete) 2 (complete) Displaced 3 (complete, partial displacement) 4 (complete, fully displaced)
Clinical features NOF fractures
Recent fall/ trauma (if not pathological fractures)
Significant pain
Inability weight bear
May associated chronic metabolic problems e.g. oesteoporosis, renal F
Shorten red leg
ER
Unable straight leg raise
Full neurovascular examination
Investigations for NOF fractures
Initial radiographic imaging - AP, lateral hip. AP pelvis. Full length femoral views if suspicion pathological fracture.
Routine bloods (FBC, U&Es, coag, G&s, long time - creatinine kinase rhabdomyloysis)
Urine dip
CXR
ECG
What sign can you look for on an X-ray to assess for fractured NOF?
Shenton’s line - medial edge femoral neck, inferior edge superior pubic ramus
Loss contour = sign
Not always present
Management of NOF fractures
A-E
Analgesia
Underlying causes
V rare conservative
✅surgical depending type fracture
Subcapital (IC) - hemiarthroplasty (THR if high performance status)
Intertrochanteric (EC) & basocervical (IC) - dynamic hip screw (with sideplate, allows compression bone heal quicker)
Non-displaced intra-capsular - cannulated hip screws (3 non-parallel screws)
Subtrochanteric (EC) - intramedullary femoral nail
What are some causes of femoral shaft fractures?
High energy trauma
Fragility fractures (elderly)
Pathological fractures
Bisphosphonate-related fractures (classically transverse in proximal femur)
Clinical features of femoral shaft fractures
Pain thigh, hip, knee
Unable weight bear
May deformity
Proximal - flexed, ER
Assess skin
Neurovascular exam
Secondary survey - associated injuries
Winquist & Hansen Classification of femoral shaft fractures
Degree of comminution Type 0 - none Type 1 - insignificant amount Type 2 - >50% cortical contact Type 3 - <50% cortical contact Type 4 - segmental fracture no contact between proximal & distal fragment
Investigations for femoral shaft fractures
ATLS protocol
Routine urgent bloods (coag, G&S) (serum Ca - pathological)
Imaging:
Plain film radiograph - AP, lateral femur + hip + knee
Further imaging CT - polytrauma suspected
Management of femoral shaft fractures
A-E Stabilise Fluid resus Pain relief (opioid, regional blockade) Open - antibiotics, tetanus, photo
Immediate reduction & immobilisation - in line traction
Traction splinting - mid-shaft fractures
Long leg casts indicated undisplaced, comorbidities
Rest: surgery
✅surgically fixed 24-48hrs
- isolated antegrade intramedullary nail
- external fixation polytrauma/ open -> later intramedullary nail
Common femoral shaft fracture complications
Pudendal N injury 10%
Femoral N injury rare
Malunion, delayed union, non-union
Infection
Fat embolism
Hip flexor/ knee extensor weakness
Limb stiffness
Re-fracture
Clinical features of OA of hip
Dull aching pain
Aggravated activity
Relieved rest
Joint May stiff after immobility
Muscle wasting
Reduced power
Leg length discrepancy
Fixed flexion deformity - antalgic/ trendelenberg gaits
Crepitus
Reduced range movement
Differentials for OA of hip
Trochanteric bursitis Gluteus medius tendinopathy Sciatica AVascular necrosis femoral head NOF fracture
Investigations for OA of hip
Clinical Supported radiographic evidence: Narrowing joint space Osteophytes Subchondral Sclerosis Bony cysts
