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13.03.14 Hip fracture

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?
    • 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)


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Garden classification




Notes
  • 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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