• Aorta => Common iliac => External iliac => Common femoral => Deep femoral/Profunda femoris => Medial and lateral circumflex
• Medial is the bigger of the two
• Anastomose round the back
• Ligementum teres artery supplies 5-10% of the femoral head
• Can't supply the whole shebang
• => ALL intracapsular fractures need a new femoral head

Risk factors

• Low body weight
• Less peripheral oestrogen production
• Less remodelling due to mechanical stress
• Less cushioning during fall
• Marker of poor general health
• Alcohol and smoking
• Diuretics (except thiazides)
• Steroids
• Anticonvulsants

• Intracapsular
• Extracapsular
• Intertrochanteric
• Subtrochanteric

History and examination

• Groin pain?
• Days before fracture => ? Pathological (Ca)
• No Hx of trauma?
• Severe osteoporosis
• Sciatic nerve damage?
• Foot drop/weakness

Prevention

• Lighting, environment etc
• Smoking, alcohol, diet
• Exercise
• Calcium supplementation
• Change or avoid diuretics/anticonvulsants
• Bisphosphonates
• HRT
• cf Risk of PE, Endometrial cancer

Management

• Don't immobilise unless there's significant delay
• Then use traction with max. 10% of body weight
• Location:
• Intracapsular
• THR (or hemiarthroplasty but it'll need revision in 2-3 years)
• Consent: 1% sciatic nerve injury, leg length discrepancy, disclocation
  
• Extracapsular
• Dynamic hip screw (historical)
  
• Intramedullary nailing (stronger)
• Generally better not to operate immediately in sub-optimal conditions (nighttime etc) => Wait until morning
  
• But young (<50) intracapsular fracture => Emergency ORIF (chance of saving femoral head)
  

Lines

• 1 year all-cause mortality following hip fracture = 15-20%
• Hip fracture = Anything in the upper quarter of the femur
• "Neck of femur" extends to 2.5 cm below the lesser trochanter