Neck of Femur Fractures

Royal London Practical Orthopaedic Course

Neck of Femur Fractures

This educational tool is intended to act as a guide to the acute management of hip fractures. Contact x3u00@students.keele.ac.uk if any issues

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Hip Fracture Theory

Acute Management

Surgical Management

Further Reading

Hip Fracture Theory

Anatomy

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Classification

X-rays

Guidelines

Acute Management

Orthogeriatrics

Rule out other injuries

Consent

Analgesia

Inform Anaesthetics and Theatres

ECG, Chest X-ray, Cross-sectional imaging, Bloods

Key Components of History

Cognitive Assessment

Functional Assessment

Anticoagulation

Surgical Management

Consent Forms

Further Reading

Hip fractures are broadly categorised into 'intra-' and 'extra-' capsular dependent on the area of the fracture, which dictates their management. These are further divided into displaced or undisplaced fractures

Riks: Infection, Bleeding, DVT/PE, Nerve/Vessel/Tendon Injury, Fracture, Stiffness, Dislocation, Leg-length discrepency, Further procedure, Death.

AO - Hemiarthroplasty

Riks: Infection, Bleeding, DVT/PE, Nerve/Vessel/Tendon Injury, Fracture, Stiffness, Dislocation, Leg-length discrepency, Further procedure, Death.

AO - Total Hip Replacement

Riks: Infection, Bleeding, DVT/PE, Nerve/Vessel/Tendon Injury, Fracture, Non-union, Mal-union, Stiffness, Metalwork complications/removal, Failure, Further procedure, Death.

AO - DHS

Functional Assessment

For intra-capsular hip fractures, patient's mobility status helps dictate management between hemiarthroplasty vs total hip replacement. NICE guidance recommends a THR if:

• Able to walk independently out of doors with no more than the use of a stick
• Able to carry out activities of daily living independently beyond 2 years.

Riks: Infection, Bleeding, DVT/PE, Nerve/Vessel/Tendon Injury, Fracture, Non-union, Mal-union, Stiffness, Compartment Syndrome, Metalwork complications/removal, Failure, Further procedure, Death.

AO - IM Nail

Consent

Consent will either be form 1 or 4 depending on patient's capacity. If Consent 4 required, needs an MCA simultaneously. Often good to do in A&E as relatives may be present to discuss surgery. See section on surgical options for further information.

Concominent Injuries

Depending on the mechanism of injury, patients may have asscoiated MSK Injuries or medical isssues that lead to the injury

• Fractures:
• Pelvis, femur, periprosthetic fractures, tibia, upper limb, spine
• Medical Issues:
• Long lie, head injury, CVS, CVA

Cognition

Assessment of cognition dicates surgical treatment, therefore is vital to complete. This is done via a 4AT score as below. Each category scores points. ≥4 points = cognitive impairment, 1-3 = possible impairment, 0 = unlikely

Alertness

• Normal, fully alert (0 points)
• Mild sleepiness (0 points)
• Clearly abnormal (4 points)

AMT4

Ask Age, DOB, Place, Current Year

• No mistakes (0 points)
• 1 mistake (1 point)
• 2 or more mistakes (2 points)

Attention

Ask patient to tell you the months in reverse from December

• Achieves 7 months correctly (0 points)
• Starts but scores <7 months (1 point)
• Untestable (2 points)

Acute change

Evidence of significant change in: alertness or cognition in last 2 weeks and evident in last 24 hours

• No (0 points
• Yes (4 points)

Anticoagulation

Elderly patients are often on anticoagulation, which can delay surgery so need to be identified and managed. Warfarin can easily be reveresed. DOACs however need a 24 hour gap between last dose and surgery if renal function normal. Below are links to further guidance on timing and reversal agents.

Anticoagulation Guidelines NHS

Reversal of Anticoagulation

Analgesia

Hip fractures are highly painful injuries. Appropriate analgesia should be offered in the form of medical and regional options. 1. Offer adequate opiate analgesia to suspected hip fracture patients. 2. Perform a Fascia-iliaca nerve block in A&E. 3. Ensure patients with cognitive impairement recieve appropriate analgesia.

Orthogeriatrics

It is important to work in an MDT seting, and involve orthogeriatrics early as per NICE to help optimise patients peri-operatively. If out of hours, discuss patients with the on-call medical team for input. Common areas to address are reversal of anticoagulation, optimising CVS system, managing AKI.

1. Displaced Intracapsular
2. Undisplaced Intracapsular
3. Intertrochanteric
4. Subtrochanteric

Prioritise Surgery

As per NICE and BPT guidance, hip fractures should be operated on as a priority and within 36 hours to meet the BPT target. Inform on-call anaesthetist to review perioperative morbidity. Inform theatre staff to ensure patient is prioritised for following day's trauma list and appropriate kit available.

Adjunct Investigations

Obtain peri-operative investigations required for both anaesthetic and surgical planning. These are essential to perform whilst in A&E.

• ECG: Elderly patients may have arrhythmias, and also may have lead to the injury.
• Chest X-ray: To identifiy chest infections or effusions.
• CT/MRI/furter X-rays: To assess for occult hip fractures and other injuries.
• FBC, U&E, G&S x 2: Appropriate pre-operative bloods, and consider transfusion if anaemic.

There are 3 sets of guidelines used in orthopaedics for the management of hip fractures. 1. NICE Guidelines 2. BOAST 3. Best Practice Tariff

The main component of hip anatomy to understand is the blood supply to the femoral head. This dicates management due to the risk of avascular necrosis. Medial and lateral circumflex arteries create an anastamosis with a retrograde supply to the femoral head within hip capsule. Disruption leads to Avascular Necrosis.

National Hip Fracture DatabaseAO Surgical Reference NICE Guidance Patient Information Reference