T&O: Hip Fractures

Question 1

Describe the radiographic features o NOF fractures.

Answer 1

1. Shenton’s line disruption
2. Increased prominence of lesser trochanter (due to external rotation of femur)
3. Femur often position in flexion and external rotation (due to unopposed iliopsoas)
4. Sclerosis in fracture plane, smudgy from impaction

Question 2

What are the 3 levels at which NOFs can occur?

Answer 2

1. Subcapital: femoral head/neck junction
2. Transcervical: midportion of femoral neck
3. Basicervical: base of femoral neck

Question 3

Describe the different treatment options for NOF fractures.

Answer 3

1. Conservative
2. Internal fixation
   - e.g. dynamic hip screw, crossed screw-nails, dynamic screw + plate
   - recommended for young, otherwise fit Pts with small risk of AVN
   - associated with higher risk of non-union, AVN and re-operation
3. Prosthetic replacement
   - e.g. hemiarthroplasty ot total hip arthroplasty
   - for fractures at high risk of AVN and the elderly

Question 4

Describe the system used to classify subcapital NOF fractures.

Answer 4

Garden classification predicts development of AVN:

Stage 1 - undisplaced incomplete. Stable, can be treated with internal fixation.

Stage 2 - unidisplaced complete. Stable, can be treated with internal fixation.

Stage 3 - complete fracture, incompletely displace. Unstable, treated with arthroplasty.

Stage 4 - complete fracture, completely displace. Unstable, treated with arthroplasty.

Question 5

Suggest possible complications of NOF fractures.

Answer 5

1. Non-union
2. AVN (50% risk in subcapital, 25% risk in transcerical/basicervical) - damage to medial femoral circumlex artery (lies directly on NOF)
3. Post-op infection
4. Dislocation

Question 6

What is the 1 yr survival rate for NOF fracture patients?

Answer 6

70-80%

Question 7

Is prognosis of trochanteric fractures better or worse than for NOF fractures?

Answer 7

Generally have good prognosis as are extracapsular fractures (intertrochanteric or subtrochanteric) with good blood supply and adequate collateral circulation - low incidence of AVN and non-union.

Question 8

How would you surgically manage a Pt with an intertrochanteric or sutrochanteric fracture?

Answer 8

Intertrochanteric: dynamic hip screw

Subtrochanteric: intramedullary femoral nail

Question 9

Which investigations would you perform on a Pt presenting with hip fracture?

Answer 9

1. Bloods:
   - FBC
   - UandE
   - glucose
   - coagulation screen
   - group and save
2. Bedside tests:
   - ECG
3. Imaging:
   - pelvis and femur X-ray
   - chest X-ray

Question 10

How would you clinically diffferentiate a hip fracture from a dislocation?

Answer 10

Fracture: leg is shortened and externally rotated

Posterior dislocation (85%): leg is shortened, flexed and internally rotated

Anterior dislocation (10%): leg is externally rotated

Question 11

Name 3 possible complications of hip dislocation.

Answer 11

1. Sciatic n. damage (10-20%)
2. Avascular necrosis (esp. if reduction delayed >24hrs)
3. Osteoarthritis (if cartilage damage)