Hip fractures + femoral shaft fractures

Question 1

What are the two categories of hip fractures?

Answer 1

• Intracapsular (subcapital and transcervical)
  
  • Above the intertrochanteric line
  • Especially if displaced, high risk of avascular necrosis
• Extracapsular (intertrochanteric and subtrochanteric)
  
  • Below the intertrochanteric line

Question 2

Why is there a high risk of avascular necrosis in those with an intracapsular fracture?

Answer 2

• There is disruption of the retrograde blood supply
• The ligamentum teres (remnant of the foveal artery) then becomes the only blood supply to the head of the femur

Question 3

How do most hip fractures occur?

Answer 3

• Elderly individuals with underlying osteoporosis following low energy trauma, such as a fall from standing
• Less often, hip fractures occur in younger individuals secondary to high energy trauma, such as a road traffic accident

Question 4

Risk factors for hip fracture

Answer 4

• Osteoporosis or osteopenia
  
  • Post menopausal women
  • Elderly
  • Steroid use
  • Low BMI
  • Smoking and alcohol
• Falls: includes risk factors for falls, such as visual impairment and dementia
• Metastatic cancer: may results in pathological fracture

Question 5

Clinical features of hip fracture

Answer 5

Symptoms

• Fall or trauma: most commonly a fall from standing
• Inability to weight bear
• Pain in the affected hip, groin or thigh

Signs

• Shortened and externally rotated leg

Question 6

Investigations for hip fracture

Answer 6

• Plain radiographs: AP pelvis and lateral hip x-rays
• Bloods
  
  • ​FBC (anaemia may be present)
  • U&Es (correct any abnormalities, may be rhabdomyloysis is long-lie after fall)
  • Blood glucose (screen for hypoglycaemia as cause of fall)
  • Coagulation screen (required peri-operatively)
  • Group & save and cross match
• ECG (to assess for cardiogenic cause of fall)

Question 7

What feature can you look at on an X-ray to see if there is a fracture?

Answer 7

Shenton’s line

Question 8

Answer 8

No fracture

Question 9

Answer 9

1) Yes
2) Left
3) Intracapsular
4) No

Question 10

Answer 10

1) Yes
2) Right
3) Intracapsular
4) Yes

Question 11

Answer 11

1) Yes
2) Right
3) Extracapsular
4) Displaced

Question 12

Which classification is used to categorise intracapsular hip fractures?

Answer 12

Question 13

What may be used as pain relief for a hip fracture?

Answer 13

Fascia iliaca block

Question 14

Surgical management of hip fracture

Answer 14

• Intracapsular
  
  • ​Displaced
    
    • Fit/young: total hip replacement
    • Frail/old: hemi arthroplasty
  • Non-displaced
    
    • Canulated hip screws
• Extracapsular
  
  • Inter-trochanteric
    
    • Dynamic hip screw
  • Sub-trochanteric
    
    • Intramedullary nail

Question 15

Prognosis of hip fracture

Answer 15

One year mortality is 30%

(Commonly due to complications such as thromboembolism and infections)

Question 16

Femoral shaft fractures are most commonly seen in:

Answer 16

• High-energy trauma
• Fragility fractures in the elderly (low trauma)
• Pathological fractures (eg metastatic deposits, osteomalacia)
• Bisphosphonate-related fractures

Question 17

Symptoms of femoral shaft fracture

Answer 17

• Pain in thigh and/or hip or knee pain
• Unable to bear weight
• In severe cases, obvious deformity

Question 18

Femoral shaft fracture examination

Answer 18

• Assess the skin, which may be open or threatened
• Proximal fragment is invariably pulled into flexion and external rotation
• Full neurovascular examination

Question 19

Investigations for femoral shaft fracture

Answer 19

• Bloods: including coagulation and group and save
• Plain film radiograph including an AP and lateral of the entire femur, including hip and knee

Question 20

Management of femoral shaft fracture

Answer 20

• Adequate pain relief +/- regional blockade (fascia iliaca block)
• Immediate reduction and immobilisation (using in line traction)
• Should be surgically fixed within 24-48 hours
  
  • antegrade intramedullary nail