Hip Fracture

Question 1

Why is hip fracture such a significant injury?

Answer 1

it is the most common injury in elderly people and the commonest reason they will need to undergo emergency surgery

Question 2

What are the mortality risks associated with hip fracture?

Answer 2

10% within 1 month

30% within 1 year

most deaths are not due to the fracture itself, but due to underlying comorbidities

Question 3

What is the definition of a hip fracture?

Answer 3

fracture of the femur distal to the femoral head and proximal to a level 5cm below the lesser trochanter

Question 4

Label the components of the pelvis and femur

Answer 4

Question 5

What is the definition of the hip joint?

Answer 5

a multi-axial ball and socket joint between the femoral head and the acetabulum

Question 6

What helps to stabilise the hip joint?

Answer 6

muscles and ligaments

Question 7

Label the muscles and the ligaments around the hip joint

Answer 7

Question 8

What is the role of the femoral neck?

Answer 8

it connects the femoral head to the proximal femoral shaft and attaches to the intertrochanteric region

Question 9

What is the main function of the greater and lesser trochanters?

Answer 9

they are sites for muscle attachment

Question 10

what is the blood supply to the hip joint?

What can happen if it is disrupted?

Answer 10

medial and lateral circumflex femoral arteries

disruption of the blood supply to the head and neck of the femur can impair fracture healing

this can lead to avascular necrosis

Question 11

What nerves are present in the hip region?

Answer 11

1. femoral nerve
2. obturator nerve
3. superior gluteal nerve
4. nerve to quadratus femoris

Question 12

How can hip fractures be classified?

Answer 12

Intracapsular:

this is within the joint at the level of the neck of the femur

Extracapsular:

this is below the neck of the femur (outside the hip capsule)

this can be intertrochanteric or subtrochanteric

Question 13

In which 4 situations is a hip fracture suspected?

Answer 13

1. in the elderly
2. falls
3. high mechanism trauma - tends to be in younger patients
4. osteoporosis

Question 14

What is the mechanism of injury of hip fracture during a fall?

Answer 14

1. falling directly onto the lateral hip
2. a twisting action when falling
3. a sudden spontaneous fracture which causes a fall (insufficiency fracture)

Question 15

What is an insufficiency fracture?

Answer 15

severe osteoporosis causes the bone to spontaneously break

this then causes a fall

underlying bone metastases in bone cancer can also cause spontaenous fractures

Question 16

Why is it important to determine the cause of why someone might have fell?

Answer 16

the occurrence of falls and fractures often signal underlying ill health

the underlying cause needs to be identified and treated

Question 17

What are the 5 areas that must be covered when taking a history of a fall/hip fracture?

Answer 17

1. mechanism of injury - before, during and after the fall
2. collateral history - this is a history from another person if the elderly person cannot recount it themselves
3. past medical and surgical history
4. medication history
5. social history

Question 18

Why is a medication history important in elderly patients who have fallen?

Answer 18

polypharmacy (being on more than 4 tablets) increases risk of falls

if patients are on anticoagulants, the effect needs to be reversed before the patient has surgery

Question 20

What are the 6 risk factors when diagnosing hip fractures?

Answer 20

1. reduced bone density in osteopenia or osteoporosis
2. age over 65 years
3. falls
4. low BMI
5. female gender
6. high energy trauma in patients 40 years or younger

Question 21

What are the 4 diagnostic factors in hip fracture?

Answer 21

1. inability to weight bear due to pain
2. pain in affected leg/hip
3. pain with hip movement
4. shortened and externally rotated leg

Question 22

Where is pain generally felt in a hip fracture?

Answer 22

around the region of the greater trochanter

it can radiate distally into the knee

Question 23

What are the 3 stages in examination of the hip?

Answer 23

1. look
2. feel
3. move

Question 24

Before examining a patient, what 6 stages should be carried out?

Answer 24

1. introduce yourself
2. confirm patients details
3. explain examination
4. check understanding and gain consent
5. hand gel/wash hands
6. expose patient appropriately

Question 25

Upon examination, which features should be looked for?

Answer 25

1. symmetry of the hips 2. leg length discrepancy 3. muscle wasting 4. scars

Question 26

Upon examination, what features should be felt for?

Answer 26

1. ask the patient if they are in any pain 2. check temperature 3. palpate around the hip joint

Question 27

What movements should be carried out when examining a hip fracture?

Answer 27

from the supine position, the following movements should be carried out: 1. hip flexion (max 120o) 2. hip abduction (max 45o) 3. hip adduction (max 30o) 4. internal and external rotation (max 45o)

Question 29

Why should a complete examination be conducted in suspected hip fracture patients? What does this consist of?

Answer 29

fracture often signifies underlying ill health this consists of: 1. cardiovascular 2. respiratory 3. peripheral pulses 4. cognition

Question 30

What tests are involved in management of hip fractures?

Answer 30

1. blood tests 2. ECG (it may have been MI or arrhythmia causing the fall) 3. CXR (in case of non-presenting pneumonia) 4. pelvis X-ray and hip X-ray

Question 31

Which patients are suggested to have plain X-rays? What types of X-rays are conducted?

Answer 31

all patients with a history of fall/trauma who present with a pain in the hip Anteroposterior (AP) pelvic X-ray and AP & lateral views of affected hip

Question 32

What type of hip fracture is shown?

Answer 32

intracapsular

Question 33

What type of hip fracture is shown?

Answer 33

extracapsular

Question 34

When may an MRI be performed in a hip fracture patient?

Answer 34

if a fracture can't be seen on the X-ray but there is a suspicion that a fracture is present

Question 35

What % of hip fractures are missed? When do they tend to present?

Answer 35

10% of all hip fractures are missed Only when someone starts mobilising they will get pain, leading to a late presentation

Question 36

What may a hip fracture be misdiagnosed as? What else might be causing the pain?

Answer 36

1. acetabular fracture 2. pubic ramus fracture 3. femoral shaft fracture 4. femoral head fracture 5. septic arthritis of the hip

Question 37

What are the 4 stages involved in management of a hip fracture?

Answer 37

1. pain management 2. hydration with adequate IV fluids 3. treating underlying medical problems 4. surgery

Question 38

What are the benefits of early surgery in hip fracture patients?

Answer 38

this allows the patient to become mobile sooner if they are bedbound, there is increased risk of pressure sores, infections, pneumonia and death

Question 39

What is meant by athroplasty?

Answer 39

the surgical reconstruction or replacement of a joint

Question 40

What is the difference in how extracapsular and intracapsular fractures are fixed surgically?

Answer 40

**Intracapsular:** fractures within the hip joint have an athroplasty this involves replacement of the entire joint with a prosthetic joint **Extracapsular:** internal fixation is offered as there is no risk to the blood supply

Question 41

What are the main short term complications after a hip fracture? How is this avoided?

Answer 41

**thromboembolic complications** e.g. pulmonary embolism, DVT all patients are given prophylactic low molecular weight heparin for 20 days after surgery

Question 42

What are the 2 main long term complications of hip fractures?

Answer 42

1. avascular necrosis of the femoral head 2. non-union/failure of fixation

Question 43

What is involved in a falls assessment?

Answer 43

1. history 2. cognition 3. examination 4. MDT assessment 5. possible interventions - medication review, vision, hearing, continence, nutrition, etc.