Blood supply- 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
Classification - Intracapsular
- Extracapsular
- Intertrochanteric
- Subtrochanteric
History and examination
- Groin pain?
- Days before fracture => ? Pathological (Ca)
- No Hx of trauma?
- Sciatic nerve damage?
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
Garden classificationNotes- 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
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