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)

Lines

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