Classify the types of proximal femoral fracture
- subcapital: below the femoral head
- transcervical: across the mid-femoral neck
- basicervical: across the base of the femoral neck
What are the common clinical signs of a proximal femoral fracture? When may these be absent?
Shortened and externally rotated leg May be absent if fracture is not displaced
Explain the aetiology of proximal femoral fractures
Falls in elderly: varies from falls directly onto the hip, to a twisting mechanism with the foot planted and body rotated. Significant trauma in younger: axial loading, with abducted hip (NOF) or adducted hip (fracture-dislocation).
Describe the plain radiograph features of a proximal femoral fracture
*Always view AP pelvis and lateral hip radiographs* Shenton's line disruption Lesser trochanter more prominent: external rotation Femur flexion and external rotation: unopposed iliopsoas Asymmetry of lateral femoral neck/head Sclerosis in fracture plane Smudge sclerosis from impaction Bone trabecular angulation
Which artery suppled most of the blood to the femoral head?
Medial femoral circumflex artery
What imaging should be offered in suspected occult hip fracture?
MRI within 24hr Otherwise consider CT
Name 5 correctable comorbidites that can delay surgical management of the proximal femoral fractures
Anaemia Anticoagulation Volume depletion Electrolyte imbalance Uncontrolled diabetes Uncontrolled heart failure Correctable cardiac arrhythmia or ischaemia Acute chest infection Exacerbation of chronic chest conditions
Describe the preoperative pain management for hip fractures
Pain should be assessed: 1. immediately upon presentation at hospital 2. within 30 minutes of administering initial analgesia 3. hourly until settled on the ward 4. regularly as part of routine nursing observations Analgesia should be sufficient to allow passive external rotation of leg, nursing care and rehabilitation. Paracetamol every 6 hours preoperatively Additional opioids if insufficient preoperatively Consider nerve blocks NSAIDs not recommended*
Describe the postoperative pain management for hip fractures
Paracetamol every 6 hours postoperatively Additional opioids if insufficient postoperative pain relief NSAIDs not recommended*
What is the aim behind operating on hip fractures?
Operate on patients with the aim to allow them to fully weight bear (without restriction) in the immediate postoperative period.
What surgical procedures are offered for the different types of hip fracture?
- Screw fixation or conservative if undisplaced intracapsular hip fracture.
- Replacement arthroplasty (total or hemi) for displaced intracapsular hip fractures.
- Extramedullary implants (DHS) in patients with trochanteric fractures above and including the lesser trochanter.
- Intramedullary nail for subtrochanteric fracture.
What tests should be ordered prior to theatre for hip fracture surgery?
FBC U&E CXR ECG Crossmatch 2 units Consent
Describe the clinical features of hip dislocation
Hip dislocation usually occurs posteriorly, with subsequent leg shortening, flexion, and internal rotation. May be accompanied by fracture of acetabulum or significant soft tissue injury.
Which nerve may be damaged with hip dislocation? State an associated complication of this
Sciatic nerve Equinus foot deformity: plantar flexed foot, contracture of tendoachilis, structural and bony deformity
Which patients are more likely to suffer an hip dislocation?
Patients with total hip replacement (THR)
How is hip dislocation treated?
Reduction under GA Traction for 3 weeks: promotes joint capsule healing
Describe the typical cause of a femoral shaft fracture
High force trauma e.g. RTA Otherwise, pathological fractures should be considered
Describe the common radiographic findings of a femoral shaft fracture
Proximal bone fragment is flexed (iliopsoas), abducted (gluteus medius), externally rotated (gluteus maximus). Distal fragment is shorted (hamstrings) and adducted plus externally rotated (adductors).
What is the treatment of a femoral shaft fracture?
Stabilise with resuscitation and traction Locked intramedullary nail
What is the typical cause of a tibial fracture?
High force trauma Stress injury may occur with chronic low force trauma
Define a toddler's fracture
Spiral distal tibial fracture seen in young children. Associated with a twisting injury, may present with refusal to weight-bear. Should never occur in children not yet walking ➔ consider non-accidental injury and alert paediatric team
Name 3 reasons to revise a total hip replacement
Aseptic loosening (most common reason)
Describe the 3 types of patella fractures
- Undisplaced fracture across the patella
- Comminuted fracture: fall or direct blow
- Transverse fracture with a gap: forced passive flexion whilst quadriceps contracted
Describe the clinical features of a patella fracture
- Painful swollen knee
- If separated, gap may be palpable
- Usually blood in joint
Helpful to establish if patient can extend knee, as this will influence treatment
Outline the treatment of a undisplaced patellar fracture
As extensors are intact, treatment is protective
- Aspirate if haemarthrosis threatens skin
- Plaster cast for 4-6 weeks
- Daily quadricep exercises
Outline the treatment of a comminuted patellar fracture
Extensors are intact, but patella is irregular
Attempts should be made to preserve the patella
- Partial patellectomy + circlage wire
- Hinge brace to mould fragments
- Resurfacing if still symptomatic
Outline the treatment of a displaced transverse patella fracture
Disrupted extensor mechanism
- Internal fixation of fragments: tension band
- Brace worn until active extension regained
- Daily flexion and extension exercises
What is the commonest cause of patella dislocation?
Traumatic disloaction due to sudden contraction of quadriceps muscles while the knee is stretched in valgus and external rotation
Describe the clinical features of dislocation of the patella
- Displaced patella sits laterally
- Uncovered prominent medial femoral condyle
- Loss of active and passive knee movement
What x-ray changes are seen with dislocation of the patella?
- Patella displaced laterally
- Tilted or rotated
- 5%: associated osteochondral fracture
How is discloation of the patella treated?