Week 6 - F - Regional Adult Trauma (5) - Hip and proximal,distal & femoral shaft fractures

Question 1

Who do hip fractures usually affect? What gender is more commonly affected?

Answer 1

Commonly affect the osteoporotic elderly population

Majority of those affected by a hip fracture are female - majority are over 80 with whom 75% are female

Question 2

Many patients have significant co‐morbidites (cerebrovascular insufficiency, cardiac arrhythmias, postural hypotension etc.) which contribute to their risk of falling. What are mortality rates from hip fractures at one, four and 12 months?

Answer 2

At one months - around 10%

At four months - around 20%

At twelve months - around 30%

Question 3

Despite the risk of medical complications with surgery, nearly all patients with a hip fracture undergo surgery as the risks of non‐operative management are just as high What are cons of non operative management of hip fractures?

Answer 3

Prolonged bed rest may lead to wasting of the muscles and

pressure ulcer formation and

the fracture may not heal

Question 4

To maximize the chance of restoration of function and to promote early mobilization almost all hip fractures undergo surgery within the first 24 hours what are the type of patinets who do not undergo surgery for hip fractures?

Answer 4

Patients who are expected to die soon after the injury

Question 5

Hip fractures are broadly classified as being intracapsular or extracapsular. What are the intracapsular and extracaspular in reference to?

Answer 5

In reference to the capsule of ligaments that form a spiral to strengthen the hip joint

Question 6

What is the artery that branches of the femoral artery soon after its origin? What is the femoral artery a continuation of and what does it travel beneath?

Answer 6

The profunda femoris (deep femoral artery) is the branch of the femoral artery

Femoral artery is a continutation of the external iliac artery and passes benath the inguinal ligament

Question 7

What are the branches of the deep femoral artery that anastamose to supply the head and neck of the femur?

Answer 7

These are the medial and lateral circumflex arteries

Anastamose to form the retinacular arteries

Question 8

What is the foveolar artery (artery of ligamentum teres a branch of)?

Answer 8

It is a branch of the obturator artery

Question 9

Hip fractures can be split into intra and extra capsular fractures What is disrupted in intracapsular fractures?

Answer 9

The arterial supply to the head of the femur and therefore avascular necrosis of the femoral head can occur

Question 10

What can avascular necrosis of the femoral head cause in terms of fracture healing?

Answer 10

This can cause non-union of the fracture (specifically atrophic non-union)

Question 11

How are intracapsular fractures of the hip treated?

Answer 11

Usually with total hip replacement or hemi-arthroplasty (or internal fixation with a cannulated hip screw if undisplaced young and mobile )

Hemi arthroplasty involves only replacing the femoral head

Total hip replacement involves replacing the acetabulum and femoral head

Question 12

Which type is preferred as it gives better function however is only reserved for higher functioning patients? What is the main side effect

Answer 12

Totl hip replacement basically preferred for younger more active patients

However THR has increased dislocation rate as it is a smaller head

Question 13

What type of patient is hemi-arthroplasty preferred for?

Answer 13

Hemi-arthroplasty is preferred for patinets with restricted mobility and the cognitively impaired patient

Question 14

Do extracapsular hip fractures cause avascular necrosis of the femoral head and therefore affect union?

Answer 14

Extracapsular hip fractures should not cause avascular necrosis and have a high union rate.

Question 15

How should extracapsular hip fractures therefore be treated as they do not cause avascular necrosis?

Answer 15

Should be treated with internal fixation using compression or a dynamic hip screw

Question 16

How does a treated extracapsular hip fracture usually heal?

Answer 16

The fracture usually heals in a shortened position

Question 17

Subtrochanteric fractures also usually occur in the elderly patient with osteoporosis and a fall onto the side. What is bad for prognosis regarding subtrochanteric proximal femur fractures?

Answer 17

They have a less good blood supply and therefore an increased risk of non-union

Question 18

What may be used for preoperative stabilisation and pain relief and what is the definitve treatment in a subtrochanteric hip fracture?

Answer 18

Use thomas splint for pain relief

Intramedullary nail for fixation is recommended

Question 19

Femoral shaft fractures usually occur as high energy injuries and as such there a substantial risk of concomitant fracture elsewhere. What can a displaced femoral shaft fracture bring about the risk of?

Answer 19

Can bring about the risk of substantial blood loss and also fat from the medullary canal can enter the damaged venous system resulting in fat embolism

Question 20

Femoral shaft fractures require the same treatment as subtrochanteric fractures What is this treatment?

Answer 20

Thomas splint for pain relief and stabilisation

Closed reduction and stabilisation with an intramedullary nailing as fixation for definitve treatment

Question 21

Pubic rami fractures are usually low energy and occur in the elderly How are they treated?

Answer 21

Usually treated conservatively

Question 22

Distal femur fractures usually occur in osteoporotic bone with a fall onto the flexed knee. How can distal femur fractures be classified?

Answer 22

Fractures can be extra-articular (supracondylar) or intra-articular (intercondylar)

Question 23

What position does the distal femoral fracture usually attach and why? How are distal femoral fractures usually treated?

Answer 23

Usually adopts a flexed position due to the pull of the gastrocnemius

Treated with a plate and screws as it is difficult to maintain in a cast

Question 24

What is the origin of the gastrocnemius muscle?

Answer 24

It arises superior to articular surfaces of the medial and lateral condyles

Question 25

Distal femur fractures are treated with plates and screw How are femoral shaft fractures treated? Clue femoral shaft is basically a continuation of subtrochanteric so treatment is the same

Answer 25

Femoral shaft fractures are treated with intramedullary nailing