History
A 78-year-old female presents to the emergency department via ambulance after a fall from standing whilst shopping with her grandson.
She has received paracetamol, dihydrocodeine and morphine with the paramedics. She is slightly more comfortable now, but still in pain. She suffers from hypertension and is independent at home.
Observations
HR 105, BP 110/80 mmHg, RR 23, SpO2 94%, Temp 37.2
2
Case-based discussion: 1
History
A 78-year-old female presents to the emergency department via ambulance after a fall from standing whilst shopping with her grandson. She has received paracetamol, dihydrocodeine and morphine with the paramedics. She is slightly more comfortable now, but still in pain. She suffers from hypertension and is independent at home.
Observations: HR 105, BP 110/80 mmHg, RR 23, SpO2 94%, Temp 37.2
What is the most likely examination finding?
Case history
Shortened and internally rotated leg Ability to weight bear
Shortened and externally rotated leg Loss of sensation and peripheral pulses Positive Rovsing’s sign
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Explanations
What is the most likely examination finding?
Shortened and internally rotated leg
Most likely to be shortened and externally rotated Ability to weight bear
Inability to weight bear would be expected Shortened and externally rotated leg
Characteristically shortened and externally rotated due to the pull of the short external rotators Loss of sensation and peripheral pulses
Distal neurovascular deficits are rare in isolated NOF fractures Positive Rovsing’s sign
This is a sign of appendicitis
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6
History
A 78-year-old female presents to the emergency department via ambulance after a fall from standing whilst shopping with her grandson.
She has received paracetamol, dihydrocodeine and morphine with the paramedics. She is slightly more comfortable now, but still in pain. She suffers from hypertension and is independent at home.
Observations
HR 105, BP 110/80 mmHg, RR 23, SpO2 94%, Temp 37.2
Case-based discussion: 1
8
Insane facts (NICE and CDC)
10% of people with a hip fracture
die within 1 month 1/3 of people with a hip fracture die
within one year
Insane facts (NICE and CDC)
10% of people with a hip fracture
die within 1 month 1/3 of people with a hip fracture die within one year
Hip fractures cost the NHS £1 billion per year
Women experience 75-80% of all
hip fractures
Definition
• Hip fracture: any fracture of the femur distal to the femoral head and 5cm below the lesser trochanter (NICE)
Epidemiology
• 15% of females suffer from a hip fracture at some point
• Fall from standing: most common mechanism
• Risk factors
• Osteoporosis or osteopaenia
• Propensity to fall: e.g. visual impairment/dementia
• Metastatic cancer à pathological fracture
• High-energy impact
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Introduction
Anatomy
• Medial and lateral circumflex femoral arteries à retinacular vessels à supply femoral neck
• Retrograde blood supply
• Small contribution from ligamentum teres
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Anatomy
• Medial and lateral circumflex femoral arteries à retinacular vessels à supply femoral neck
• Retrograde blood supply
• Small contribution from ligamentum teres
Anatomy: intra vs. extracapsular
• Depends on relation to intertrochanteric line
• Intracapsular: above the insertion of the hip joint capsule
• Subcapital
• Transcervical
• Basicervical
• Extracapsular: below the insertion of the hip joint capsule
Intracapsular
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Anatomy: intra vs. extracapsular
• Depends on relation to intertrochanteric line
• Intracapsular: above the insertion of the hip joint capsule
• Subcapital
• Transcervical
• Basicervical
• Extracapsular: below the insertion of the hip joint capsule
• Trochanteric (inter-, peri-, reverse oblique)
• Subtrochanteric (5cm below the lesser trochanter)
Extracapsular
History
A 78-year-old female presents to the emergency department via ambulance after a fall from standing whilst shopping with her grandson. She has received paracetamol, dihydrocodeine and morphine with the paramedics. She is slightly more comfortable now, but still in pain. She suffers from hypertension and is independent at home.
Observations: HR 105, BP 110/80 mmHg, RR 23, SpO2 94%, Temp 37.2
Which of the following is an example of an intracapsular fracture?
Case history
Intertrochanteric Subtrochanteric Subcapital
Subcondylar Supracondylar
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Explanations
Which of the following is an example of an intracapsular fracture?
Intertrochanteric
This is a type of extracapsular fracture Subtrochanteric
This is a type of extracapsular fracture Subcapital
Correct. This is a type of intracapsular fracture Subcondylar
This is not a type of hip fracture Supracondylar
This is not a type of hip fracture
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Clinical features
Symptoms Signs
Fall or trauma: most commonly a fall from standing
Shortened and externally rotated leg
Inability to weight bear Pain on palpation
Pain in the affected hip, groin or thigh Limited ROM: internal and external rotation Pain on axial loading
Shock: tachycardic and hypotensive
Why does leg shortening and external rotation occur in a neck of femur fracture?
Question
Unopposed action of sartorius Unopposed action of gracilis
Unopposed action of tensor fasciae latae Unopposed action of adductor magnus Unopposed action of psoas
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Explanations
Why does leg shortening and external rotation occur in a neck of femur fracture?
Unopposed action of sartorius Incorrect
Unopposed action of gracilis
Flexes, medially rotates and adducts the hip Unopposed action of tensor fasciae latae
Inserts into the iliotibial tract and has numerous actions Unopposed action of adductor magnus
Large triangular muscle on medial side of the thigh primarily responsible for hip adduction Unopposed action of psoas
Psoas pulls the leg upwards and externally rotates it; unopposed iliopsoas action causes shortening and external rotation
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22
Shortened and externally rotated leg
Investigations
Primary investigations
• Plain radiographs: AP pelvis and lateral hip x-rays should be taken; sensitivity up to 98%
• Bloods: vital pre-operatively
• FBC: anaemia may necessitate preoperative transfusion
• U&Es: elderly patients often have a long-lie after a fall
• Blood glucose: screen for hypoglycaemia as an underlying cause of the fall
• Coagulation screen
• Group & save and crossmatch
• ECG: obtain a baseline ECG before surgery, and to assess for any cardiogenic causes of the fall
24
Investigations
Investigations to consider
• CT or MRI pelvis: can occasionally be difficult to visualise subtle fractures on an X-ray
• NICE: conducting MRI as second line (100% sensitive), or CT if MRI is not available within 24
hours
28 History
A 78-year-old female presents to the emergency department via ambulance after a fall from standing whilst shopping with her grandson. She has received paracetamol, dihydrocodeine and morphine with the paramedics. She is slightly more comfortable now, but still in pain. She suffers from hypertension and is independent at home.
Observations: HR 105, BP 110/80 mmHg, RR 23, SpO2 94%, Temp 37.2 Plain radiographs:Complete, displaced right-sided subcapital fracture
What is this patient’s Garden Classification?
Case history
Garden stage I Garden stage II Garden stage III Garden stage IV Garden stage V app.bitemedicine.com
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Explanations
app.bitemedicine.com
What is this patient’s Garden Classification?
Garden stage I
This would be an undisplaced, incomplete fracture, including valgus impacted fractures Garden stage II
This would be an undisplaced, complete fracture Garden stage III
This would be an incompletely displaced, complete fracture Garden stage IV
This describes a completely displaced, complete fracture Garden stage V
This is fictitious
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Management: general principles
Analgesia
• Offer immediate analgesia and reassess regularly (WHO pain ladder); NOT NSAIDs (NICE)
• Consider nerve blocks
Other
• IV fluids
• Look for and manage other injuries
Optimise the patient
• Identify and manage co-morbidities, such as anaemia, anticoagulation, electrolyte imbalance,
diabetes and heart failure
Multidisciplinary management
All patients require a formal, acute, orthogeriatric or orthopaedic ward-based Hip Fracture Programme:
• Orthogeriatric assessment
• Optimisation of fitness for surgery
• Identification of goals for rehab and recovering mobility
• Continued MDT review and orthogeriatric assessment
• Integration with other services: mental health, falls prevention, bone health, primary care etc.
• Minimise delirium
34 History
A 78-year-old female presents to the emergency department via ambulance after a fall from standing whilst shopping with her grandson. She has received paracetamol, dihydrocodeine and morphine with the paramedics. She is slightly more comfortable now, but still in pain. She suffers from hypertension and is independent at home.
Observations: HR 105, BP 110/80 mmHg, RR 23, SpO2 94%, Temp 37.2 Plain radiographs: Complete, displaced right-sided subcapital fracture
What is the most appropriate management option?
Case history
Total arthroplasty Dynamic hip screw Hemi-arthroplasty Intramedullary nail
Conservative management only app.bitemedicine.com
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Explanations
app.bitemedicine.com
What is the most appropriate management option?
Total arthroplasty
A displaced intracapsular fracture in a patient with minimal co-morbidities and independent at home Dynamic hip screw
Consider for undisplaced intracapsular fracture with minimal co-morbidities or intertrochanteric Hemi-arthroplasty
May be considered the best option if significant co-morbidities, immobility or cognitive impairment Intramedullary nail
Usually performed for subtrochanteric fractures Conservative management only
Not appropriate, this patient requires surgical intervention
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© BiteMedicine (2020)
Management
38
Management
© BiteMedicine (2020)
Management
40
Management: total arthroplasty
Management: hemiarthroplasty
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Management: DHS
History
A 78-year-old female presents to the emergency department via ambulance after a fall from standing whilst shopping with her grandson. She has received paracetamol, dihydrocodeine and morphine with the paramedics. She is slightly more comfortable now, but still in pain. She suffers from hypertension and is independent at home.
Observations: HR 105, BP 110/80 mmHg, RR 23, SpO2 94%, Temp 37.2 The procedure goes smoothly and the patient is now 3-days post-op.
The patient asks you what proportion of patients return to their baseline mobility post-op. What do you answer?
Case history
10%
30%
50%
70%
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Explanations
The patient asks you what proportion of patients return to their baseline mobility post-op. What do you answer?
10% Incorrect
30%
Incorrect 50%
40-60% of patients recover their pre-fracture level of mobility (Dyer et al. 2016) 70% Incorrect
90%
Incorrect
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46
Top-Decile Explanations
app.bitemedicine.com
A patient has a total arthroplasty using a lateral approach. He develops weak abduction of the affected hip.
What nerve is affected?
Femoral nerve
Rare but catastrophic complication of anterior approach à pain and quadriceps muscle weakness Sciatic nerve
Affected via the posterior approach à foot drop, buttock pain down posterior thigh, paraesthesia Superior gluteal nerve
May be damaged using the direct lateral approach when the gluteus medius is split and retracted anteriorly à weak abduction and Trendelenburg gait
Inferior gluteal nerve
Rarely entrapped as a complication of the posterior approach à gluteus maximus lurch Obturator nerve
Extremely rare à medial thigh paraesthesia, groin pain, and/or adductor weakness
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Complications
System Complication
Musculoskeletal • Avascular necrosis
Surgical complications • General: VTE, bleeding, infection
• Non-union and fixation failure
• Sciatic nerve injury
• Lateral femoral cutaneous nerve injury
• Superior gluteal nerve injury
50
Insane facts (NICE and CDC)
10% of people with a hip fracture
die within 1 month 1/3 of people with a hip fracture die
within one year
54
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References
Slide 5: DocP at German Wikipedia / CC BY-SA 3.0 DE (https://creativecommons.org/licenses/by-sa/3.0/de/deed.en).
https://commons.wikimedia.org/wiki/File:Heupfractuur.jpg
Slide 9: BruceBlaus / CC BY (https://creativecommons.org/licenses/by/3.0). https://commons.wikimedia.org/wiki/File:Blausen_0488_HipAnatomy.png Slide 10: Henry Vandyke Carter / Public domain. https://commons.wikimedia.org/wiki/File:Gray548.png
Slide 11: Henry Vandyke Carter / Public domain. https://commons.wikimedia.org/wiki/File:Gray342.png
Slide 12 and 13: Modified. Mikael Häggström, M.D. https://commons.wikimedia.org/wiki/File:X-ray_of_a_normal_hip.jpg Slide 19: https://commons.wikimedia.org/wiki/File:Iliopsoas.png%20Thieme%20-
%20General%20Anatomy%20and%20Musculoskeletal%20System%20/%20CC%20BY-SA%20(https://creativecommons.org/licenses/by-sa/4.0) Slide 22:https://commons.wikimedia.org/wiki/File:Shf_ohne_dislokation_medial_ap.jpg
Slide 23: The original uploader was Eucla at French Wikipedia. / CC BY-SA (http://creativecommons.org/licenses/by-sa/3.0/).
https://commons.wikimedia.org/wiki/File:Fracture_du_col_du_f%C3%A9mur.jpg Slide 24: Booyabazooka / CC BY-SA (http://creativecommons.org/licenses/by-sa/3.0/).
https://commons.wikimedia.org/wiki/File:Cdm_hip_fracture_343.jpg
Slide 27: http://emdidactic.blogspot.com/2019/04/proximal-femur-fractures.html
Slide 35: Mikael Häggström, M.D.https://commons.wikimedia.org/wiki/File:X-ray_of_hip_with_total_arthroplasty_-_Anteroposterior.jpg Slide 36: Carl Jones, Nikolai Briffa, Joshua Jacob2 and Richard Hargrove / CC BY (https://creativecommons.org/licenses/by/4.0).
https://commons.wikimedia.org/wiki/File:X-ray_of_hips_with_a_hemiarthroplasty.jpg
All other diagrams and flowcharts are copyrighted and owned by © BiteMedicine (2020). These images/figures may not be reproduced, distributed, or
56
References
Slide 37: Booyabazooka / CC BY-SA (http://creativecommons.org/licenses/by-sa/3.0/).
https://upload.wikimedia.org/wikipedia/commons/5/5c/Cdm_hip_implant_348.jpg
All other diagrams and flowcharts are copyrighted and owned by © BiteMedicine (2020). These images/figures may not be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without prior written permission of BiteMedicine, except in the case of brief quotations embodied in critical reviews and certain other noncommercial uses permitted by copyright law. For permission requests, please email us at [email protected]
