Neck of femur fractures

Question 1

define hip fracture/ Neck of femur fracture

Answer 1

fracture that happens is at the area between the edge of the femoral head and 5cm below the lesser T
(NICE 2017)

Question 2

what is the epidemiology of hip fractures

Answer 2

admission for an operation in the UK is hip fracture-related
Approximately 72,000 hip fractures occur annually in the UK
Over 7000 occurred Dec 2022, compared to average ofapprox. 5500

Question 3

Aetiology of hip fractures

Answer 3

Average age: Males 84, Females 83.
Predominantly in older population but can occur at any age
2.9 x more likelyin Women- due to nature/degree of bone loss and increased falls
Commonly occursas a frailty fracture associated with a fall- consider this demographic

Question 4

clinical presentation that would call for a hip diagnosis

Answer 4

History of a fall/trauma
Hip/groin or thigh pain
Inability to weight bear
Pain on hip movement
Tenderness over the femoral neck
Presenting deformity - shorted and externally rotated leg.
X-ray/MRI/CT scan

Question 5

what diagnostic tool would be used to diagnose hip fractures

Answer 5

X-ray, MRI or CT

Question 6

when would you use an MRI or CT over an X-ray

Answer 6

when the MRI does not detect anything because sometimes it’s not clear, so if you still suspect a hip fracture, you can do an MRI
and if no MRI detection and still suspect it CT scan but may be difficult to get a hold of

Question 7

classifications for a neck of femur fracture

Answer 7

**intracapsular fractures (femoral neck) **
= subcapital fracture
= transversical fracture

extracapsular fractures
= intertrochanteric fractures
= fracture of the greater T
= fracture of the lesser TA
= subtrochanteric fracture

Question 8

What are the grades of intracapsular fractures and the garden classifications

Answer 8

Grade 1 = incomplete fracture
Grade 2 = complete un-displaced fracture
Grade 3 = complete fracture with some displacement
Grade 4 = full displaced fractures

Garden 1&2 = cannulated screws
Garden 3&4 = hemiarthroplasty or total hip replacement

Question 9

why are garden 3/4 or graded 3/4 intracapsular fractures dangerous

Answer 9

because they disturb the blood flow to the femoral head (there is a lot of blood flow there)
= This could lead to AVN

Question 10

what are some treatments for hip related fractures

Answer 10

• surgery, which should be done the day of or the day after injury
• fixation
• any comorbidities need to be managed and stabilised before surgery can go on
  conservative management = rare

Question 11

what are cannulated screws and which garden classification or intracapsular/ extra classification would you use for this procedure

Answer 11

internal fixation that consists of 3 large screws placed through the neck of the femur into the head.

classification: is Garden 1 and 2
because there is no displacement of the fracture = the femoral head is viable

Question 12

what are the disadvantages and advantages of cannulated screws

Answer 12

short operation, less blood loss and fewer risks

• disadvantage = they can carry the risk of AVN or the screws can fail
• can risk malunion and non-union

Question 13

define malunion

Answer 13

Refers to a problem in healing, where when the bone heals, it heals in an abnormal way that leads to the shortening or rotation of the limb

Question 14

Define non-union

Answer 14

failure of a fractured bone to heal and mend after an extended period

Question 15

what type of weight bearing is associated with cannulated screws

Answer 15

protected weight bearing, so walking sticks or zimmer frames

Question 16

what is a dynamic hip frame fixation and what garden classification would this be used for

Answer 16

large screw is placed inside the hip and then you have a screw that is placed on the lateral femoral cortex with screws

movement is only allowed in one direction, so the fracture can stay in place, and still allow enough movement for the bone to heal.

and normally is weight-bearing

This is normally for garden 1&2 type of fractures and intertrochanteric fractures

Question 17

what is intramedullary nail fixation and what garden type is it used for

Answer 17

it’s a nail that that is inserted to the medullary cavity of the femur and then another screw is placed across the fracture to provide support and then a lock is used at the distal aspect of the femur (across)

Type 1 and 2

Question 18

what is a hemiarthroplasty and what garden types would this surgery be done on

Answer 18

surgery to replace the head of the femur with an artificial implant, a ceramic or metal ball used.

Question 19

what is the difference between hemiarthroplasty and a full hip replacement

Answer 19

the socket of the joint is not replaced in a hemiarthroplasty

Question 20

what are the guidelines following a hemiarthroplasty surgery

Answer 20

follow up after 6 weeks, no hip flexion past 90 degrees, no adduction past midline (e.g. crossing your legs) and no excessive movement in any direction.

Question 21

what type of weight bearing is permitted after hemiarthroplasty

Answer 21

Full weight bearing.

Question 22

what is a total hip replacement surgery and what garden classification would this be used for

Answer 22

This is where both the head and the acetabulum are replaced by artificial implants.
This for garden type 3 and 4

Question 23

What are the guidelines according to NICE on whether a patient is eligible for THR

Answer 23

• if they do not have any previous conditions or comorbidities, that puts them at risk
• if they were able to independently walk around outside on their own before the injury, only needing a walking stick for support
• can carry out activities of daily living independently beyond 2 years

Question 24

what are the guidelines following a THR

Answer 24

no hip flexion above 90 degrees combined with internal and external rotation for 12 weeks post-op

Question 25

what type of weight bearing is permitted after THR

Answer 25

FWB

Question 26

what can go wrong post operation

Answer 26

infection/sepsis the body can reject the surgery leg length discrepancy nerve damage malunion/ nonunion death pneumonia stroke or heart attack AVN intraoperative fracture periprosthetic fracture - fracture around the artificial joint. pulmonary embolism = blood clot in the vessel of the body Deep vein thrombosis (DVT) = blood clot forming in one of the deep veins = lead to swelling. loosening of the implant Abductor problems

Question 27

What are NICE guidelines for hip Fracture Management

Answer 27

not essential but for it to be taken into account. created in 2011, and updated in 2023 - Timing of surgery for best PT outcome - guidelines for pain control before and after surgery - multidisciplinary management - patient and carer info, providing info to cares and family etc.

Question 28

what is the the pre-op therapy involvement

Answer 28

consideration of cognitive issues with MDT consideration of discharge plans with the MDT initial interview with pt/carer/family by OT or therapy Chest physio to optimise patient for surgery = airway clearance technique (ACT) to drain the lungs

Question 29

what would be done for Day 1 post-op? The prep and assessment.

Answer 29

prep: - get handover from nurse/MDT - check protocol - check medical notes/ post-op instructions - know the patient's baseline - introduce yourself/role and the session aim. - gain consent if able Assessment: - teach bed based exercises - give advice/ precautions if needed - transfer the patient to the edge of the bed - take into account dizziness/ nausea/ lower limb strength - attempt to sit to stand to the Zimmer frame/walking aid - from stand to bed, with their walking frame or Zimmer frame. - try mobility if appropriate.

Question 30

What are some extra considerations for day 1 post-op

Answer 30

pain relief confusion - delirium hypotension - Low blood pressure is where the force of the blood pushing against the artery walls is too low location of the wound, if it's bleeding and knowing the incision type. - mobilising early post-op = prevents complications e.g. blood clots, strengthens muscles, improves circulation and joint health Hb = Hemoglobin count, if it is low there are low oxygen levels.