Fractured Neck of Femur
Doctor Instruction:
You are a Foundation Year Doctor working in the Emergency Department. Your next patient is a 65-year-old woman, Mary, presenting following a fall. Please take a history and perform an appropriate examination.
Patient History:
Your name is Mary. You are 65 years old woman – retired.
While walking down the stairs 2 hours ago, you slipped accidentally and fell down the stairs, and suddenly, you heard a crack at your left hip. Since then, you have had this sudden, ongoing severe pain and your husband called the ambulance. You can't remember how long you have been lying on the ground. You are not sure if you have hit your head during the fall. No dizziness/vertigo. No palpitation. No loss of consciousness. No chest pain/ palpitation. No shortness of breath. No neurological symptoms. No fits/ incontinence/ tongue biting. No weakness/ slurred speech/ vision change. No warning signs. Waterworks/bowel normal.
You note you have pain in the groin and hip, which radiates to the knee. The pain is excruciating 10/10 – worsening by any movement, especially rotation. You have been given some morphine in the ambulance which helped. You are unable to stand or bear weight on the left side. You have some swelling in your left hip.
Ideas, Concerns, Expectations:
You think you have cracked a bone or something as your GP previously said you have brittle bones! You are concerned that you may need an operation! You want to avoid surgery as much as possible and get your pain under control.
Past Medical History:
Osteoporosis, Parkinson's disease. Diabetes type 2, paroxysmal atrial fibrillation, heart failure
Drug History:
Levodopa, alendronic acid weekly, metformin, furosemide, apixaban, omeprazole, vitamin D supplement
Family History:
Atrial fibrillation
Social History:
Drink 2-3 glasses of wine every other night
Ex-smoker – used to smoke around 5-10cigarettes a day for 10 years
Examination Findings:
Left leg shortened, abducted, and externally rotated. Pain palpating the greater trochanter.
Differentials:
Neck of femur fracture
Acetabular fracture
Pubic rami fracture
Femoral shaft or subtrochanteric femur fracture
Femoral head fracture
To rule out causes for falls e.g. Parkinson's, anaemia, electrolyte imbalance, arrhythmias, heart failure, MI, stroke, UTI, chest infection, dehydration, incorrect eyewear, poor footwear, obstacles at home…etc.
Investigations:
Bedside:
Primary Survey (ABCDE)
Observation including lying and standing BP
ECG / 24-48h Holter monitor (arrhythmias e.g. AF)
Consider Echo (aortic stenosis? fall)
Assess fluid status
Urine dip (rule out infection, +++blood in rhabdomyolysis)
Dix-Hallpike test if suspecting BPPV for cause of fall
Bloods:
Bloods (FBC, CRP, anticoagulation screen, electrolytes, bone profile, LFTs – rule out potential causes for fall/ fracture e.g. anaemia, electrolyte imbalance, underlying infection, plan for surgery…etc.) + group and save/ cross-match for surgery + CK (potential long lie/rhabdomyolysis) + glucose (hypoglycaemia is a cause of falls)
Imaging:
XR hip (AP + Lateral) – look for fractures, disruption of Shenton's line/ trabeculae, inferior/superior cortices…etc
MRI/ CT may be indicated if XR is negative, but fracture is suspected
Consider CT head for head injuries if indicated e.g. on anticoagulants
Consider XR Chest if suspecting pneumonia contributing to fall
Management:
Conservative :
Appropriate analgesia e.g. opioids, nerve block
VTE risk assessment + prophylaxis e.g. LMWH / stocking
Prophylactic antibiotics (those at risk of MRSA/ open wound)
Nutrition support if appropriate
Review medications
Review functional status
Measure cognitive impairment/signs of delirium
Prevention of pressure ulcers
Patient/family education
Falls assessment
PT / OT input
Medical:
Treat any underlying infection if appropriate
Management of co-morbidities
Surgery:
Refer to orthopaedics / orthogeriatric
Pre-operative assessment for surgery
Aim surgery within 48hours of admission for hip fractures
Post-surgical care: analgesia, VTE prophylaxis, rehabilitation/ PT/ OT, fall risk assessment, treat the underlying cause for falls/fracture
Intracapsular Hip Fracture:
Undisplaced Intracapsular fracture – internal fixation with screws, otherwise arthroplasty in those who are less fit
Displaced intracapsular fracture – arthroplasty (total / partial)
Consider extramedullary implants such as sliding hip screw in preference to intramedullary nail in patients with trochanteric fractures above and including the lesser trochanter.
Extracapsular Hip Fracture:
Intramedullary nail used to treat subtrochanteric fracture
Extracapsular fractures by internal fixation using intramedullary nails but hip arthroplasty is used if internal fixation fails in unstable fractures.
Those not suitable for surgery but not receiving end-of-life care:
Bed rest/non-weight bearing + regularly reassess suitability for surgery
Not currently suitable for surgery + receiving end of life:
Palliative care / symptomatic relief, ensure bed rest and non-weight bearing.
Prevention of falls:
Eye test/suitable eyewear, ensure good fitting footwear, remove environmental hazards e.g. rugs/ turn on lights, ensure good hydration, review medication, hearing assessment and correction,
Viva Questions:
Explain the pathophysiology of a fracture.
A fracture occurs when a bone breaks due to trauma or excessive force. The body responds with an inflammatory phase, forming a blood clot (hematoma) at the site. A callus made of collagen and cartilage stabilizes the bone and eventually remodels into new bone tissue, healing the fracture.
Tell me the different types of fractures.
Fractures can manifest in various forms, each classified based on the pattern and characteristics of the break. The main types of fractures include:
Simple or Closed Fracture: The bone breaks without puncturing the skin.
Compound or Open Fracture: The broken bone protrudes through the skin, increasing the risk of infection.
Transverse Fracture: The break occurs horizontally across the bone.
Oblique Fracture: The break is at an angle across the bone.
Comminuted Fracture: The bone shatters into multiple pieces.
Greenstick Fracture: Common in children, where the bone bends and cracks but doesn't fully break.
Compression Fracture: Common in the spine, involving a loss of height in the vertebral body.
Stress Fracture: Tiny cracks in the bone due to repetitive stress or overuse, often seen in athletes.
Describe the anatomy of a hip joint.
Acetabulum: The socket-shaped cavity in the pelvis, formed by the fusion of three bones: ilium, ischium, and pubis. It accommodates the rounded head of the femur.
Femoral Head: The ball-shaped top of the femur that fits into the acetabulum, creating the ball-and-socket joint.
Articular Cartilage: Covers the surfaces of the acetabulum and the femoral head, providing a smooth, low-friction surface for movement.
Ligaments: Several strong ligaments provide stability and support to the hip joint, including the iliofemoral, pubofemoral, ischiofemoral, and ligamentum teres.
Labrum: A ring of cartilage that surrounds the acetabulum, deepening the socket and providing stability to the joint.
Synovial Membrane: The inner lining of the joint capsule that produces synovial fluid, reducing friction and providing nourishment to the joint.
What are the differences between an intracapsular and extra-capsular hip fracture? How does this affect management?
Intracapsular Fracture:
Location: Occurs at or within the hip joint capsule, specifically involving the femoral neck or the head of the femur.
Effect on Blood Supply: Intracapsular fractures may disrupt the blood supply to the femoral head, potentially leading to avascular necrosis (loss of blood flow and subsequent death of bone tissue).
Management Challenges: These fractures might necessitate surgical intervention, such as pinning, screw fixation, or replacement. However, the blood supply concerns can make healing more complex.
Extracapsular Fracture:
Location: Occurs outside the joint capsule, typically along the trochanteric or subtrochanteric region of the femur.
Effect on Blood Supply: As these fractures are outside the capsule, the blood supply to the femoral head remains unaffected.
Management: Extracapsular fractures are often more stable and tend to heal better than intracapsular fractures. Surgical treatment usually involves fixation using devices like screws, plates, or nails.
When are total hip replacements preferred more than partial hip replacements? Vice-versa.
Total Hip Replacement (THA):
Preferred when the entire hip joint is damaged due to conditions like severe osteoarthritis, rheumatoid arthritis, avascular necrosis, or fractures that involve both the femoral head and acetabulum.
Generally suitable for cases where both the femoral head and the acetabulum are significantly affected, requiring complete joint replacement.
THA replaces both the femoral head and the hip socket (acetabulum) with artificial components.
Partial Hip Replacement (Hemiarthroplasty):
Preferable when only the femoral head is damaged or fractured, such as femoral neck fractures, and the acetabulum or hip socket is healthy.
Appropriate for older, less active patients, especially with femoral neck fractures, where replacing only the femoral head may be sufficient.
Hemiarthroplasty involves replacing the femoral head with a prosthesis, leaving the natural socket intact.
How does a bone heal?
Bone healing involves stages:
Inflammation and blood clot formation.
Soft callus formation with collagen.
Hard callus formation with new bone.
Bone remodeling to restore original form.
What are the risk factors for fractures?
Osteoporosis: Weakening of bones, especially in older individuals, which makes them more susceptible to fractures.
Age: Advanced age increases the risk due to bone density reduction and the potential for reduced balance and coordination.
Gender: Women are at a higher risk, particularly after menopause due to decreased estrogen levels that can lead to bone loss.
Trauma or Falls: Accidents, falls, or high-impact injuries can lead to fractures, especially in vulnerable populations like the elderly.
Medical Conditions: Certain medical conditions, such as osteogenesis imperfecta, cancer, or conditions affecting bone strength, can increase fracture risk.
Medications: Prolonged use of certain medications like corticosteroids can weaken bones, elevating the risk of fractures.
Lifestyle Factors: Lack of physical activity, poor nutrition, smoking, excessive alcohol consumption, and inadequate calcium and vitamin D intake can also contribute to increased fracture risk.
What is the garden classification, e.g. for an intra-capsular neck of femur fracture?
Garden I: This stage represents an incomplete fracture with minimal displacement or an incomplete fracture without any displacement.
Garden II: It refers to a complete fracture with minimal displacement. The bone is completely fractured but remains relatively aligned.
Garden III: In this stage, a complete fracture shows moderate displacement. The bone alignment is partially shifted.
Garden IV: This stage indicates a complete fracture with severe displacement. The bone fragments are significantly displaced or completely separated.
What are the complications of hip fractures?
DVT (Deep Vein Thrombosis) and Pulmonary Embolism: Blood clots in the deep veins of the legs may form and travel to the lungs, causing a potentially life-threatening pulmonary embolism.
Infection: Surgery and hospitalization increase the risk of infections, such as urinary tract infections or surgical site infections.
Bedsores (Pressure Ulcers): Immobile patients are at risk of developing pressure ulcers due to prolonged bed rest.
Pneumonia: Reduced mobility, particularly in elderly patients, can lead to an increased risk of developing pneumonia.
Heterotopic Ossification: Abnormal bone formation in the soft tissues around the hip joint, leading to restricted movement.
Muscle Weakness and Atrophy: Lack of mobility after a hip fracture can cause muscle weakness and wasting in the affected limb.
Dislocation or Mal-union of Fracture: Improper healing or displacement of the fracture fragments can lead to mal-union or dislocation, affecting function.
Chronic Pain or Disability: Inadequate healing, complications, or delayed rehabilitation may lead to chronic pain or permanent disability.
What medications can increase the chances of falls/fractures?
Benzodiazepines and Sleep Medications: These drugs used for anxiety, insomnia, or sedation can cause drowsiness, impaired coordination, and balance issues.
Opioids: Medications like morphine, oxycodone, or hydrocodone used for pain relief can cause dizziness, sedation, and a higher risk of falls.
Antidepressants: Some antidepressants, especially tricyclic antidepressants, can cause dizziness and orthostatic hypotension, increasing the risk of falls.
Antipsychotics: Certain antipsychotic medications can affect balance and increase the risk of falls, particularly in the elderly.
Antihypertensive Medications: Blood pressure medications might lead to orthostatic hypotension, causing dizziness upon standing and increasing the risk of falls.
Antiepileptic Drugs: Medications used to manage seizures can cause dizziness or drowsiness, increasing the risk of falls.
Corticosteroids: Long-term use of corticosteroids may decrease bone density, leading to an increased risk of fractures.
What does fall assessment involve?
Medical History: Reviewing medical conditions, medications, previous falls, and any specific concerns related to balance or mobility.
Physical Examination: Assessing gait, balance, muscle strength, joint mobility, vision, and neurological functions.
Home Safety Evaluation: Examining the home environment for potential hazards that might contribute to falls, such as loose rugs, poor lighting, or slippery surfaces.
Medication Review: Evaluating the medications an individual is taking, as certain drugs can increase the risk of falls.
Cognitive Assessment: Checking cognitive functions, especially in older adults, to assess mental alertness and decision-making abilities that might impact fall risk.
Footwear Evaluation: Assessing the suitability of footwear, ensuring proper support and comfort.
Functional Assessment: Evaluating an individual's ability to perform activities of daily living, such as standing from a seated position or walking up and down stairs.
Balance and Mobility Testing: Conducting specific tests to evaluate balance, mobility, and risk of falls.
Nutritional Assessment: Assessing nutritional status, particularly deficiencies that might affect muscle strength and bone health.
Drugs e.g. tetracycline, furosemide, azathioprine, thiazide.