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