NOFF Flashcards
An 82 year old woman is brought to the ED by ambulance with a history of falling down in the bathroom. She is unable to stand and is lying in bed with external rotation of the left lower limb. How would you assess and manage her?
Impression
Given history of falls in elderly woman and presentation of non-weight bearing, and ER, this is most likely a neck of femur fracture,
Other Ddx to consider
- MSK: intracapsular fracture, acetabular fracture, dislocation, trochanteric bursitis
- other soft tissue injury
Consider non-mechanical causes of the fall
- DAME
o syncope
Goals
- Targeted Hx/Ex/Ix with X-Rays to confirm provisional, assess other factors behind fall
- appropriate pain management and referral to ortho for definitive surgical management
NOFF - History
History
- MIST AMPLE
- Any other trauma sustained? esp head trauma etc
- RISKS: female, elderly, known osteoporosis, fam history, history of falls, known fragility fractures
- DAME risk factors for fall: meds review (anticoagulants), etc
- PSHx (hip replacement?), PMHx, allergies
- SNAP
NOFF - Examination
Examination
- General appearance + vitals
- Hip examination: as tolerated by pain, assess distal neurovascular status
NOFF - Investigations
Investigations
- Bedside: ECG, UA
- Bloods: (pre-op) G+H, FBC, Coags, UEC; CK
- Imaging: X-ray - AP and lateral views: looking at shenton’s line for deformity
- otherwise, further investigation for underlying cause of fall if clinically suspicious.
NOFF - Management
Management
- contact ortho and anaesthetics for pre-op review
Supportive
- IV access and appropriate pain relief IV morphine + Paracetamol PO
- U/S guided facia-iliaca block to reduce opioid requirement and effective management of pain pre-operatively
- General surgical: NBM, VTE prophylaxis
- IDC
Definitive
- ORIF vs arthroplasty: depends on patient and fracture status.
o intra vs extracapsulr fractures
o hemi vs total hip replacement
Ongoing
- physio for rehab
- GP/fracture clinic follow-up
