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YEAR 3 - SEMESTER 1 > CASE 8 - FNOF > Flashcards

CASE 8 - FNOF Flashcards

1
Q

Neck of femur fractures typically occur in the…

But can also occur in young patients as a result of…

A

Neck of femur fractures typically occur in the ELDERLY

But can also occur in young patients as a result of high-energy trauma (e.g. car crash)

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2
Q

Name 3 factors which contribute to the stability of the hip joint

A
  1. 12 muscles surrounding the coxafemoral joint
  2. CAPSULE: composed of 3 ligaments (iliofemoral, ischiofemoral, pubofemoral)
  3. Depth of the coxafemoral joint (compared to the glenohumoral joint, another ball and socket joint which has much less stability due to its shallowness)
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3
Q

State the following information for INTRACAPSULAR NOF fractures:

  • Location
  • Prognosis
  • Risk of avascular necrosis
  • Damage to joint capsule
A

INTRACAPSULAR

Location: proximal to the intertrochanteric line

Prognosis: worse

Risk of avascular necrosis: high

Damage to joint capsule: YES (consequently, blood supply from the femoral circumflex arteries and nutrient arteries inside the bone are disrupted. The ligamentum teres remains, but this is insufficient).

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4
Q

State the following information for EXTRACAPSULAR NOF fractures:

  • Location
  • Prognosis
  • Risk of avascular necrosis
  • Damage to joint capsule
A

EXTRACAPSULAR:

Location: below the intertrochanteric line

Prognosis: better

Risk of avascular necrosis: low (but there is a risk of massive bleeding lol)

Damage to joint capsule: NO (therefore better fracture healing)

(LOOK @ GEEKYMEDICS)

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5
Q

Describe the 4 stages of the Garden classification for FNOF.

A

Stage 1: incomplete fracture line or impacted fracture

Stage 2: complete fracture line, not displaced

Stage 3: complete fracture line, partially displaced

Stage 4: complete fracture line, completely displaced

STAGES 1 & 2: NON-DISPLACED
STAGES 3 & 4: DISPLACED

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6
Q

What does Pauwel’s classification of femoral neck fracture involve?

What are the 3 stages?

A

Defines FNOF based on the orientation and direction of the fracture line across the femoral neck.

3 STAGES:

  1. STABLE, obliquity between 0-30 degrees
  2. LESS STABLE, obliquity between 30-50 degrees
  3. UNSTABLE, obliquity between 50-70 degrees (or more)
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7
Q

As the fracture becomes more vertical, the instability…

A

As the fracture becomes more vertical, the instability INCREASES

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8
Q

List 4 risk factors for a FNOF

A

Age (≥65 years in women and ≥75 years in men)

History and risk factors of osteoporosis including menopause, amenorrhoea, smoking, excessive alcohol or caffeine intake, physical inactivity, long term or high dose corticosteroid use

Previous fragility fracture

History of falls

Poor nutrition (e.g. low calcium)

Low body mass index (<18.5kg/m2)

Dementia

Visual impairment: due to the increased risk of falls

History of tumours (primary or secondary bone tumours, breast, bowel, prostate, kidney, lung, thyroid tumours)

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9
Q

Name 3 symptoms of a FNOF

A
  1. Pain: in the groin, hip, or knee
  2. Inability to weight-bear
  3. Decreased or painful mobility of the affected hip
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10
Q

List 5 clinical findings of a FNOF

A
  1. Leg is abducted, shortened, and externally rotated
  2. Palpation of the hip causes pain
  3. Cannot perform straight-leg raise (useful for discerning occult hip fractures)
  4. Soft tissue symptoms: bruising, swelling
  5. Log roll test: pain on gentle internal and external rotation of the affected leg
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11
Q

Name the bedside investigation, laboratory investigations, and imaging that should be ordered for a FNOF.

A

BEDSIDE INVESTIGATION: ECG

LABORATORY INVESTIGATIONS: basic bloods (CBE, EUC, coags), creatinine kinase, urinalysis, group and save

IMAGING: X-ray of AP pelvis and lateral hip (first-line), MRI (gold standard. Also useful if plain radiographs are unrevealing)

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12
Q

Explain why you would want to order an ECG for a FNOF

A

To determine the underlying cause: may identify an arrhythmia or cardiac event that precipitated the fall

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13
Q

Explain why you would want to order:

  • Baseline bloods (CBE, EUC, coags)
  • Creatinine kinase
  • Urinalysis
  • Group & save

for a FNOF

A
  • Baseline bloods: good to know
  • Creatinine kinase: potential rhabdomyolysis if they’ve been on the floor for a while
  • Urinalysis: UTI or hyperglycaemia may have precipitated a fall
  • Group & save: blood loss from FNOF can be severe, and the patient may need a transfusion
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14
Q

Which analgesics are used for FNOF?

A
  1. Paracetamol (decreases the number of opioids needed)
  2. Opioids
  3. Local nerve block (iliofascial/femoral nerve blocks)
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15
Q

What are the principles of surgical management for FNOF?

A

URGENT reduction and internal fixation

EARLY mobilisation

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16
Q

When should surgery for FNOF ideally be performed?

A

In stable patients without significant comorbidities, within 24 hours

AVOID DELAYING SURGERY FOR MORE THAN 72 HOURS FOR ANY PATIENT

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17
Q

What are the benefits of early mobilisation after surgery?

A

Prevention of post-operative complications, e.g.

  • Venous thromboembolism
  • Pressure ulcers
  • Muscle loss
  • Bronchopneumonia
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18
Q

Falls in geriatric patients are often multi-factorial. List 5 INTRINSIC and 5 EXTRINSIC causes of falls.

A

INTRINSIC:

  • Postural hypotension
  • Polypharmacy
  • Specific drugs (e.g. beta-blockers, antihypertensives, benzodiazepines, diuretics)
  • Stroke
  • Seizure
  • Dizziness
  • Peripheral myopathy
  • Poor vision

EXTRINSIC:

  • Poor lighting
  • Hazards (e.g. rugs)
  • No assistive equipment
  • Low toilet seats
  • Hard-to-reach items
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19
Q

Identify different grades of FNOFs based on X-RAY imaging

A

Shenton’s line disruption: loss of contour between normally continuous line from medial edge of femoral neck and inferior edge of the superior pubic ramus.

Lesser trochanter is more prominent due to external rotation of femur

Femur often positioned in flexion and external rotation (due to unopposed iliopsoas)

Asymmetry of lateral femoral neck/head sclerosis in fracture plane

Smudgy sclerosis from impaction

Bone trabeculae angulated

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20
Q

Name the artery that is commonly implicated in avascular necrosis

A

Medial circumflex femoral artery (look up a photo)

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21
Q

Why do FNOFs cause external rotation of the leg?

A

There is an imbalance between the external and internal rotators: the external rotators are stronger.

(all external rotators attach to the greater trochanter)

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22
Q

Why is the risk of avascular necrosis higher for INTRACAPSULAR fractures?

A

There is damage to the joint capsule, disrupting majority of the blood supply to the femoral head

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23
Q

What is a normal INR value?

A

0.9-1.2

24
Q

High INR values indicate…

Low INR values indicate…

A

High INR values indicate THIN BLOOD (increased risk of haemorrhage)

Low INR values indicate increased CLOTTING propensity (e.g. thromboembolism)

25
Q

The target INR range for patients receiving warfarin differs depending on the indication for warfarin therapy.

For which patient groups is the target INR 2-3?

A

AFib

Venous thromboembolism

Mechanical heart valve (not mitral)

26
Q

The target INR range for patients receiving warfarin differs depending on the indication for warfarin therapy.

For which patient group is the target INR 2.5-3.5?

A

Mechanical heart valve (combined mitral and aortic)

27
Q

How can the anticoagulant effects of warfarin be reversed? (4 methods)

A
  • Reducing or witholding warfarin
  • Vitamin K1
  • Prothrombinex-VF
  • Fresh frozen plasma
    https: //tgldcdp-tg-org-au.proxy.library.adelaide.edu.au/viewTopic?topicfile=anticoagulant-therapy&guidelineName=Cardiovascular#toc_d1e933
28
Q

How can osteoporosis be diagnosed? (2 methods)

A
  1. Fragility fracture (pathological fracture resulting from a minimal-trauma fall)
  2. DEXA scan (dual-energy x-ray absorptiometry): T-score < -2.5 SD (between the patient’s BMD and the BMD of a healthy young adult)
29
Q

List 4 RFs for osteoporosis

A 
Smoking
Alcohol 
Malabsorption, malnutrition
Low body weight 
FHx of osteoporosis
30
Q

What is the pathophysiology of primary osteoporosis? (Types I and II)

A

Type I: postmenopausal –> decreased oestrogen –> less stimulation of osteoblasts and less inhibition of osteoclasts

Type II: senile osteoporosis due to gradual loss of bone mass as patients age

31
Q

What is the pathophysiology of secondary osteoporosis?

A

Drug-induced / iatrogenic causes, most commonly from long-term CORTICOSTEROID use (but can also result from anticonvulsants, PPIs, etc.)

Endocrine causes, e.g. hyperthyroidism, hypogonadism

32
Q

What is the MOA of bisphosphonates?

What are common side effects?

A

Inhibition of osteoclasts, decreasing bone resorption

Hypocalcemia
GORD –> oesophagitis
NV
Osteonecrosis of the jaw

33
Q

What is the MOA of denusomab?

What are common side effects?

A

A MAB against RANKL.

Targets RANKL, which normally binds to RANK to stimulate OSTEOCLAST activity.

Binding to RANKL = less osteoclast stimulation

Common side effects: hypercholesterolaemia, eczema, MSK pain (in men)

34
Q

Apixaban and Rivaroxiban are Factor ___ inhibitors

A

Apixaban and Rivaroxiban are Factor Xa inhibitors

35
Q

Discuss 3 suitability issues related to DOACs

A
  • No reversibility agents (there is for dabigatran, but it’s expensive and not commonly used)
  • No monitoring option, making compliance essential
  • No monitoring & dosing info for the following demographics: extremes of age, frail, underweight
  • Renal impairment
36
Q

Discuss 3 suitability issues related to Warfarin

A
  1. Bleeding risk
  2. Requires regular INR monitoring: becomes an issue if people are needle-phobic,
  3. Need to be able to adjust warfarin dose based on INR results (e.g. mental capacity)
  4. Hepatic impairment (though some are mixed)
37
Q

What is the MOA of warfarin?

What are common side effects?

A

Vitamin K antagonist; inhibits synthesis of vitamin K-dependent clotting factors (II, VII, IX, X) and the antithrombotic factors protein C and S.

Common side effects: bleeding

38
Q

What are the possible outcomes one year after a FNOF?

A

1/3 recover completely
1/3 have permanent disability
1/3 die

39
Q

Outline the surgical management of displaced and nondisplaced hip fractures

A

DISPLACED: poorer prognosis. Hemiarthroplasty where the head of the femur is replaced with a prosthesis.

NON-DISPLACED & INTERTROCHANTERIC: internal fixation with screws

40
Q

Name 3 types of hip fracture and the implications of each one

A
  1. Femoral neck/subcapital fracture: high risk of AVN and nonunion. High mortality in the elderly.
  2. Intertrochanteric fracture: less AVN risk because it’s EXTRACAPSULAR, but there is risk of ecchymosis
  3. Subtrochanteric fracture: typically due to high-stress load. Risk of nonunion and ecchymosis.
    https: //www.youtube.com/watch?v=y5my4uXomls
41
Q

Name the hip fractures that fall under the INTRACAPSULAR and EXTRACAPSULAR categories

A

INTRACAPSULAR: femoral head and neck

EXTRACAPSULAR: intertrochanteric, trochanteric, subtrochanteric

42
Q

What are the benefits of prothrombinex in patients with CHF?

A

Dry powder mix: won’t affect fluid status

43
Q

What is an ACAT assessment?

A

The Aged Care Assessment Team (ACAT) assesses the needs of older people. It makes recommendations for government-funded care and support.

Must be >65 years old (or >50 for Aboriginal and Torres Strait Islanders)

44
Q

Which neurovascular obs should be checked for compartment syndrome?

A

5 P’s:

Pain
Pallor
Pulselessness
Paresthesia
Paralysis
45
Q

Why is the leg shortened and externally rotated in FNOFs?

A

Shortening and external rotation of the leg occurs because the muscles acting on the hip joint rely on the CONTINUITY of the femur.

When there is displacement of the femur, the actions of the iliotibial tract and gluteus maximus are unopposed. The iliotibial tract pulls the leg UP (causing shortening) and the gluteus maximus causes external rotation.

46
Q

Name the 3 types of INTRACAPSULAR fractures

A
  • Subcapital
  • Transcervical
  • Basicervical

https://www.radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_trauma_lower_limb/hip_fracture_x-ray

47
Q

Name the 2 types of EXTRACAPSULAR fractures

A
  • Intertrochanteric
  • Subtrochanteric
    https: //www.radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_trauma_lower_limb/hip_fracture_x-ray
48
Q

List 3 adverse effects of bisphosphonates and denosumab

A

BISPHOSPHONATES:

  • GORD
  • NV
  • Diarrhoea
  • Hypocalcemia
  • MSK pain
  • Osteonecrosis of the jaw

DENOSUMAB:

  • Eczema
  • Hypercholesterolaemia
  • Musculoskeletal pain (in men)
49
Q

DEXA scan costs & benefits?

A

.

50
Q

Name 2 triggers for instituting a resuscitation plan

A
  • Surprise question
  • SPICT tool
    etc.
    https://www.sahealth.sa.gov.au/wps/wcm/connect/11f77a004dc97fde967dfeb05b75bb55/Tool+1-+Resuscitation+Plan+7+step+diagram+WebS.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-11f77a004dc97fde967dfeb05b75bb55-nwLZqqr
51
Q

Why is Enoxaparin initiated alongside warfarin for post-operative DVT prophylaxis?

A

There is a delayed effect when using warfarin (can take a few days for it to work).

The anticoagulation effect of enoxaparin is more immediate; it stimulates antithrombin III, which inhibits factor X and thrombin. As a result, fibrin is not produced (clots required fibrin and platelets).

Fibrin has a half-life of around 60 hours; warfarin does not affect fibrin, so the existing fibrin in the bloodstream can still contribute to clotting risk.

Proteins C and S (which warfarin act on, and which inhibit coagulation) also have shorter half-lives than most of the vitamin k-dependent clotting factors that are inhibited by warfarin, resulting in a pro-coagulable state for the first few days.

52
Q

To which drug class does Enoxaparin belong?

A

LMWHs / low-molecular weight heparins

53
Q

What is the mechanism of action of LMWHs?

A

Binds to antithrombin III, subsequently inactivating clotting factors IIa and Xa.

Fibrin cannot be formed.

https://www.youtube.com/watch?v=gM5q-7JHnqw

54
Q

Name the contents of the femoral triangle, from lateral to medial

A

NAVEL:

  • Femoral nerve
  • Femoral artery
  • Femoral vein
  • Empty space (to accommodate different levels of flow/distension of the vessels)
  • Lymph nodes (within the femoral canal)
55
Q

Benzodiazepines act by potentiating the effect of which neurotransmitter?

A

GABA

Benzodiazepines potentiate the inhibitory effects of GABA throughout the CNS, resulting in anxiolytic, sedative, hypnotic, muscle relaxant and antiepileptic effects.

YEAR 3 - SEMESTER 1 (15 decks)

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