M: Hip fractures Flashcards

1
Q

What is a hip fracture by definition?

A

Fracture of the femur above a point 5cm below the most distal part of the lesser trochanter

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2
Q

In what 5 ways can a hip fracture be classified by location?

A

1) Subcapital
2) Transcervical
3) Basicervical
4) Intertrochanteric
5) Subtrochanteric

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3
Q

Other than location in what 3 ways are hip fractures normally classified?

A

1) Femoral neck fractures (between the base of the femoral neck and intertrochanteric line)
2) Intertrochanteric (between the greater and lesser trochanters)
3) Subtrochanteric

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4
Q

Which 2 types of hip fractures account for over 90% of hip fractures of hip fractures, what proportions do they occur in?

A

Femoral neck and intertrochanteric fractures - occur in roughly equal proportions

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5
Q

What factor commonly leads to complications in fractures of the hip?

A

Disruption of the blood to the femoral head - non-union and avascular necrosis necrosis

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6
Q

What provides the main blood supply to the head of the femur?

A

Trochanteric anastomosis:

inferior and superior femoral circumflex arteries and medial and lateral femoral circumflex arteries

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7
Q

A branch of what artery makes a small contribution to the blood supply of the femoral head, what does it run along?

A

Branch of obturator artery, running along the ligamentum teres

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8
Q

Disruption of the main blood supply to the femoral head leads to what?

A

Avascular necrosis of the femoral head

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9
Q

What does necrosis of the femoral head lead to?

A

Pain and limitation of movement due to deformity

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10
Q

For what 6 reasons are hip fractures so important?

A

1) Affects lots of patients
2) High cost to the NHS
3) High care cost following immediate management
4) Important cause of mortality
5) Important cause of morbidity
6) Associated with loss of independence

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11
Q

In which group are hip fractures more common?

A

Elderly - over the age of 65

More common in females than males (3:1)

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12
Q

What are the 2 main risk factors for a hip fracture, both associated with ageing?

A

1) Osteoporosis

2) Falls

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13
Q

With a fracture due to low impact trauma, there is often an underlying bone condition, give 5 common examples?

A

1) Osteoporosis (commonest cause)
2) Osteomalacia (Vit D deficiency)
3) Bone metastases
4) Haematological malignancy
5) Paget’s disease

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14
Q

What is Paget’s disease?

A

Weakened and deformed bones due to disruption of the bones normal cycle of renewal and repair, commonly affects the pelvis and spine with pain being one of the main symptoms

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15
Q

What 4 kinds of cancer commonly lead to bone mets?

A

1) Bronchus
2) Breast
3) Kidney
4) Prostate

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16
Q

What are the 6 main features on presentation with a hip fracture?

A

1) Fall
2) Pain - in groin, thigh or knee
3) Difficulty in weight bearing
4) Deformity if fracture displaced - shortened limb, externally rotated
5) Features relating to co-morbidity
6) Complications of fall and immobility

17
Q

Why is pain in a hip fracture sometimes referred to the knee?

A

Nerve supply to the hip is from the anterior division of the obturator nerve, the posterior division supplies the knee leading to referred pain

18
Q

When assessing a hip fracture patient what 6 factors should be considered in the history?

A

1) Circumstances and causes of the fall
2) Co-morbidities and PMH
3) Previous fractures and falls
4) Cognitive impairment
5) Social history
6) Mobility and level of independence prior to fracture

19
Q

Give 3 possible causes of a fall in an elderly patient?

A

1) Acute medical illness
2) Cardiac related
3) Medication and alcohol related

20
Q

What 3 conditions are mainly considered when assessing an elderly patient’s cognitive impairment following a hip fracture?

A

1) Delerium
2) Depression
3) dementia

21
Q

In the examination of a patient with a hip fracture wat 7 things should be assessed as part of a general examination?

A

1) BP
2) Pulse
3) Temp
4) SaO2
5) Hydration
6) Abbreviated Mental Test Score

22
Q

Why should and abdominal and neurological examination be carried out in a patient present with a hip fracture?

A

Abdo - ensure patient not in urinary retention

Neurological - look for any associated head injury or evidence of a CVA

23
Q

Other than a neuro, resp, cardio and abdo examination what else should be looked for in a patient with a hip fracture?

A

Pressure areas or any skin conditions

24
Q

What 6 investigations should be carried out in an elderly patient presenting with a hip fracture?

A

1) FBC, U&Es, Blood glucose
2) Creatine kinase (if long lie - rhabdomyolysis)
3) Calcium profile
4) XR of hip and CXR
5) ECG
6) Other dictated by clinical picture eg. ABGs

25
Q

What are the 7 features of pre-operative management following a hip fracture?

A

1) Pain relief
2) Hydration and optimum nutrition
3) Pressure area care
4) Optimise medical condition - eg. treat infection
5) Thromboprophlaxis
6) MRSA decolonisation
7) Surgery within 36 hours of injury if medically stable

26
Q

Garden classification of hip fractures includes grades 1-4, what is each grade?

A

Grade 1) Incomplete impacted fracture in valgus malalignment which is generally stable
Grade 2) Incomplete but not displaced fracture
Grade 3) Incompletely displaced fracture in varus malignment
Grade 4) Completely displaced fracture with no engagement of the 2 fragments

27
Q

How are intracapsular fractures managed surgically?

A

Replacement hemiarthroplasty

28
Q

How are extracapsular hip fractures managed surgically?

A

Dynamic hip screws or cannulated screws

29
Q

When is no surgical management of a hip fracture indicated?

A

When the fracture is a pain free, undisplaced and impacted

30
Q

What are the main 2 aspects of pre-operative management?

A

1) Peri-operative Abx - reduction in incidence of nosocomial (hospital derived) infection
2) MRSA prophylaxis

31
Q

What are the 8 commonly complications of hip fracture and surgery?

A

1) Wound infections (superficial, deep)
2) Thromboembolism (DVT, PE)
3) Bronchopneumonia
4) Cardiac
5) UTI and urinary retention
6) Pseudo-obstruction
7) Pressure sores
8) Malnutrition

32
Q

Prevention of further fractures (as well as falls) is part of post-operative management, in which 3 ways can this be done?

A

1) Treatment of osteoporosis
2) Calcium and Vit D supplements
3) Biphosphonates/ strontium ranelate/ denosumab

33
Q

What are the 3 aspects of best practise of hip fractures in the elderly?

A

1) Surgery within 36 hours of presentation
2) Cognitive assessment pre and post op
3) Orthogeriatrician involvement - seen by geriatrician within 72 hours and have a geriatrician led rehab