Hip Fracture 1/3 of People with a Hip Fracture Die Die Within 1 Month Within One Year

Case-based discussion: 1

History A 78-year-old female presents to the emergency department via ambulance after a fall from standing whilst shopping with her grandson.

She has received paracetamol, dihydrocodeine and morphine with the paramedics. She is slightly more comfortable now, but still in pain. She suffers from hypertension and is independent at home.

Observations HR 105, BP 110/80 mmHg, RR 23, SpO2 94%, Temp 37.2

2 Case history History A 78-year-old female presents to the emergency department via ambulance after a fall from standing whilst shopping with her grandson. She has received paracetamol, dihydrocodeine and morphine with the paramedics. She is slightly more comfortable now, but still in pain. She suffers from hypertension and is independent at home.

Observations: HR 105, BP 110/80 mmHg, RR 23, SpO2 94%, Temp 37.2

Q1 Q2 Q3 Q4 Q5 Q6

What is the most likely examination finding?

Shortened and internally rotated leg

Ability to weight bear

Shortened and externally rotated leg

Loss of sensation and peripheral pulses

Positive Rovsing’s sign

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Explanations Q1 Q2 Q3 Q4 Q5 Q6

What is the most likely examination finding?

Shortened and internally rotated leg Most likely to be shortened and externally rotated

Ability to weight bear Inability to weight bear would be expected

Shortened and externally rotated leg Characteristically shortened and externally rotated due to the pull of the short external rotators

Loss of sensation and peripheral pulses Distal neurovascular deficits are rare in isolated NOF fractures

Positive Rovsing’s sign This is a sign of appendicitis

app.bitemedicine.com 5 6 Case-based discussion: 1

History A 78-year-old female presents to the emergency department via ambulance after a fall from standing whilst shopping with her grandson.

She has received paracetamol, dihydrocodeine and morphine with the paramedics. She is slightly more comfortable now, but still in pain. She suffers from hypertension and is independent at home.

Observations HR 105, BP 110/80 mmHg, RR 23, SpO2 94%, Temp 37.2

7 Insane facts (NICE and CDC)

10% of people with a hip fracture 1/3 of people with a hip fracture die die within 1 month within one year

8 Insane facts (NICE and CDC)

10% of people with a hip fracture 1/3 of people with a hip fracture die die within 1 month within one year

Women experience 75-80% of all Hip fractures cost the NHS £1 billion hip fractures per year

9 Introduction

Definition • Hip fracture: any fracture of the femur distal to the femoral head and 5cm below the lesser trochanter (NICE)

Epidemiology • 15% of females suffer from a hip fracture at some point • Fall from standing: most common mechanism • Risk factors • Osteoporosis or osteopaenia • Propensity to fall: e.g. visual impairment/dementia • Metastatic cancer à pathological fracture • High-energy impact

10 Anatomy

• Medial and lateral circumflex femoral arteries à retinacular vessels à supply femoral neck

• Retrograde blood supply

• Small contribution from ligamentum teres

11 Anatomy

• Medial and lateral circumflex femoral arteries à retinacular vessels à supply femoral neck

• Retrograde blood supply

• Small contribution from ligamentum teres

12 Anatomy: intra vs. extracapsular

Intracapsular • Depends on relation to intertrochanteric line • Intracapsular: above the insertion of the hip joint capsule • Subcapital • Transcervical • Basicervical

• Extracapsular: below the insertion of the hip joint capsule

13 Anatomy: intra vs. extracapsular

Extracapsular • Depends on relation to intertrochanteric line • Intracapsular: above the insertion of the hip joint capsule • Subcapital • Transcervical • Basicervical

• Extracapsular: below the insertion of the hip joint capsule • Trochanteric (inter-, peri-, reverse oblique) • Subtrochanteric (5cm below the lesser trochanter)

14 Case history History A 78-year-old female presents to the emergency department via ambulance after a fall from standing whilst shopping with her grandson. She has received paracetamol, dihydrocodeine and morphine with the paramedics. She is slightly more comfortable now, but still in pain. She suffers from hypertension and is independent at home.

Observations: HR 105, BP 110/80 mmHg, RR 23, SpO2 94%, Temp 37.2

Q1 Q2 Q3 Q4 Q5 Q6

Which of the following is an example of an intracapsular fracture?

Intertrochanteric

Subtrochanteric

Subcapital

Subcondylar

Supracondylar

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Explanations Q1 Q2 Q3 Q4 Q5 Q6

Which of the following is an example of an intracapsular fracture?

Intertrochanteric This is a type of extracapsular fracture

Subtrochanteric This is a type of extracapsular fracture

Subcapital Correct. This is a type of intracapsular fracture

Subcondylar This is not a type of hip fracture

Supracondylar This is not a type of hip fracture

app.bitemedicine.com 17 Clinical features

Symptoms Signs

Fall or trauma: most commonly a fall from Shortened and externally rotated leg standing

Inability to weight bear Pain on palpation

Pain in the affected hip, groin or thigh Limited ROM: internal and external rotation

Pain on axial loading

Shock: tachycardic and hypotensive

18 Question Q1 Q2 Q3 Q4 Q5 Q6

Why does leg shortening and external rotation occur in a neck of femur fracture?

Unopposed action of sartorius

Unopposed action of gracilis

Unopposed action of tensor fasciae latae

Unopposed action of adductor magnus

Unopposed action of psoas

app.bitemedicine.com 19

Explanations Q1 Q2 Q3 Q4 Q5 Q6

Why does leg shortening and external rotation occur in a neck of femur fracture?

Unopposed action of sartorius Incorrect

Unopposed action of gracilis Flexes, medially rotates and adducts the hip

Unopposed action of tensor fasciae latae Inserts into the iliotibial tract and has numerous actions

Unopposed action of adductor magnus Large triangular muscle on medial side of the thigh primarily responsible for hip adduction

Unopposed action of psoas Psoas pulls the leg upwards and externally rotates it; unopposed iliopsoas action causes shortening and external rotation

app.bitemedicine.com 21 Shortened and externally rotated leg

22 Investigations Primary investigations • Plain radiographs: AP pelvis and lateral hip x-rays should be taken; sensitivity up to 98% • Bloods: vital pre-operatively • FBC: anaemia may necessitate preoperative transfusion • U&Es: elderly patients often have a long-lie after a fall • Blood glucose: screen for hypoglycaemia as an underlying cause of the fall • Coagulation screen • Group & save and crossmatch • ECG: obtain a baseline ECG before surgery, and to assess for any cardiogenic causes of the fall

23 Investigations Investigations to consider • CT or MRI pelvis: can occasionally be difficult to visualise subtle fractures on an X-ray • NICE: conducting MRI as second line (100% sensitive), or CT if MRI is not available within 24 hours

Case history History A 78-year-old female presents to the emergency department via ambulance after a fall from standing whilst shopping with her grandson. She has received paracetamol, dihydrocodeine and morphine with the paramedics. She is slightly more comfortable now, but still in pain. She suffers from hypertension and is independent at home.

Observations: HR 105, BP 110/80 mmHg, RR 23, SpO2 94%, Temp 37.2 Plain radiographs: Complete, displaced right-sided subcapital fracture

Q1 Q2 Q3 Q4 Q5 Q6

What is this patient’s Garden Classification?

Garden stage I

Garden stage II

Garden stage III

Garden stage IV

Garden stage V

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Explanations Q1 Q2 Q3 Q4 Q5 Q6

What is this patient’s Garden Classification?

Garden stage I This would be an undisplaced, incomplete fracture, including valgus impacted fractures

Garden stage II This would be an undisplaced, complete fracture

Garden stage III This would be an incompletely displaced, complete fracture

Garden stage IV This describes a completely displaced, complete fracture

Garden stage V This is fictitious

app.bitemedicine.com 30 31 Management: general principles

Analgesia • Offer immediate analgesia and reassess regularly (WHO pain ladder); NOT NSAIDs (NICE) • Consider nerve blocks

Other • IV fluids • Look for and manage other injuries

Optimise the patient • Identify and manage co-morbidities, such as anaemia, anticoagulation, electrolyte imbalance, diabetes and heart failure

32 Multidisciplinary management

All patients require a formal, acute, orthogeriatric or orthopaedic ward-based Hip Fracture Programme: • Orthogeriatric assessment • Optimisation of fitness for surgery • Identification of goals for rehab and recovering mobility • Continued MDT review and orthogeriatric assessment • Integration with other services: mental health, falls prevention, bone health, primary care etc. • Minimise delirium

33 Case history History A 78-year-old female presents to the emergency department via ambulance after a fall from standing whilst shopping with her grandson. She has received paracetamol, dihydrocodeine and morphine with the paramedics. She is slightly more comfortable now, but still in pain. She suffers from hypertension and is independent at home.

Observations: HR 105, BP 110/80 mmHg, RR 23, SpO2 94%, Temp 37.2 Plain radiographs: Complete, displaced right-sided subcapital fracture

Q1 Q2 Q3 Q4 Q5 Q6

What is the most appropriate management option?

Total arthroplasty

Dynamic hip screw

Hemi-arthroplasty

Intramedullary nail

Conservative management only

app.bitemedicine.com 34

Explanations Q1 Q2 Q3 Q4 Q5 Q6

What is the most appropriate management option?

Total arthroplasty A displaced intracapsular fracture in a patient with minimal co-morbidities and independent at home

Dynamic hip screw Consider for undisplaced intracapsular fracture with minimal co-morbidities or intertrochanteric

Hemi-arthroplasty May be considered the best option if significant co-morbidities, immobility or cognitive impairment

Intramedullary nail Usually performed for subtrochanteric fractures

Conservative management only Not appropriate, this patient requires surgical intervention

app.bitemedicine.com 36 Management

37 Management

38 Management

39 Management: total arthroplasty

40 Management: hemiarthroplasty

41 Management: DHS

42 Case history History A 78-year-old female presents to the emergency department via ambulance after a fall from standing whilst shopping with her grandson. She has received paracetamol, dihydrocodeine and morphine with the paramedics. She is slightly more comfortable now, but still in pain. She suffers from hypertension and is independent at home.

Observations: HR 105, BP 110/80 mmHg, RR 23, SpO2 94%, Temp 37.2 The procedure goes smoothly and the patient is now 3-days post-op.

Q1 Q2 Q3 Q4 Q5 Q6

The patient asks you what proportion of patients return to their baseline mobility post-op. What do you answer?

10%

30%

50%

70%

90% app.bitemedicine.com 43

Explanations Q1 Q2 Q3 Q4 Q5 Q6

The patient asks you what proportion of patients return to their baseline mobility post-op. What do you answer?

10% Incorrect

30% Incorrect

50% 40-60% of patients recover their pre-fracture level of mobility (Dyer et al. 2016)

70% Incorrect

90% Incorrect

app.bitemedicine.com 45 Top-Decile Q1 Explanations A patient has a total arthroplasty using a lateral approach. He develops weak abduction of the affected hip. What nerve is affected?

Femoral nerve Rare but catastrophic complication of anterior approach à pain and quadriceps muscle weakness

Sciatic nerve Affected via the posterior approach à foot drop, buttock pain down posterior thigh, paraesthesia

Superior gluteal nerve May be damaged using the direct lateral approach when the gluteus medius is split and retracted anteriorly à weak abduction and Trendelenburg gait

Inferior gluteal nerve Rarely entrapped as a complication of the posterior approach à gluteus maximus lurch

Obturator nerve Extremely rare à medial thigh paraesthesia, groin pain, and/or adductor weakness

app.bitemedicine.com 46

Complications

System Complication

Musculoskeletal • Avascular necrosis

Surgical complications • General: VTE, bleeding, infection • Non-union and fixation failure • Sciatic nerve injury • Lateral femoral cutaneous nerve injury • Superior gluteal nerve injury

Insane facts (NICE and CDC)

10% of people with a hip fracture 1/3 of people with a hip fracture die die within 1 month within one year

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54 References

Slide 5: DocP at German Wikipedia / CC BY-SA 3.0 DE (https://creativecommons.org/licenses/by-sa/3.0/de/deed.en). https://commons.wikimedia.org/wiki/File:Heupfractuur.jpg Slide 9: BruceBlaus / CC BY (https://creativecommons.org/licenses/by/3.0). https://commons.wikimedia.org/wiki/File:Blausen_0488_HipAnatomy.png Slide 10: Henry Vandyke Carter / Public domain. https://commons.wikimedia.org/wiki/File:Gray548.png Slide 11: Henry Vandyke Carter / Public domain. https://commons.wikimedia.org/wiki/File:Gray342.png Slide 12 and 13: Modified. Mikael Häggström, M.D. https://commons.wikimedia.org/wiki/File:X-ray_of_a_normal_hip.jpg Slide 19: https://commons.wikimedia.org/wiki/File:Iliopsoas.png%20Thieme%20- %20General%20Anatomy%20and%20Musculoskeletal%20System%20/%20CC%20BY-SA%20(https://creativecommons.org/licenses/by-sa/4.0) Slide 22: https://commons.wikimedia.org/wiki/File:Shf_ohne_dislokation_medial_ap.jpg Slide 23: The original uploader was Eucla at French Wikipedia. / CC BY-SA (http://creativecommons.org/licenses/by-sa/3.0/). https://commons.wikimedia.org/wiki/File:Fracture_du_col_du_f%C3%A9mur.jpg Slide 24: Booyabazooka / CC BY-SA (http://creativecommons.org/licenses/by-sa/3.0/). https://commons.wikimedia.org/wiki/File:Cdm_hip_fracture_343.jpg Slide 27: http://emdidactic.blogspot.com/2019/04/proximal-femur-fractures.html Slide 35: Mikael Häggström, M.D. https://commons.wikimedia.org/wiki/File:X-ray_of_hip_with_total_arthroplasty_-_Anteroposterior.jpg Slide 36: Carl Jones, Nikolai Briffa, Joshua Jacob2 and Richard Hargrove / CC BY (https://creativecommons.org/licenses/by/4.0). https://commons.wikimedia.org/wiki/File:X-ray_of_hips_with_a_hemiarthroplasty.jpg

All other diagrams and flowcharts are copyrighted and owned by © BiteMedicine (2020). These images/figures may not be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without prior written permission of BiteMedicine, except in the case of brief quotations embodied in critical reviews and certain other noncommercial uses permitted by copyright law. For permission requests, please email us at [email protected] 55 References

Slide 37: Booyabazooka / CC BY-SA (http://creativecommons.org/licenses/by-sa/3.0/). https://upload.wikimedia.org/wikipedia/commons/5/5c/Cdm_hip_implant_348.jpg