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