Intra-capsular Neck Of Femur Fractures

Sheweidin AZIZ – Sep 2015

Aim1. Background2. Anatomy + Patho-anatomy3. Predisposing factors4. Mechanism of injury5. Clinical presentation/Radiological investigation6. Classification7. Aims of treatment 8. Management9. Complications

Background About 70-75,000 hip fractures per year in UK

(10/1000)

Average age 77 years

Commonest cause of admission to orthopaedic wards

Usually fragility fracture

Background Lifetime risk 15% ♀ and 5% ♂

High mortality rate ~10% in 30 days and up to30% in a year

Annual cost of over £2 billion

About 10-20% admitted from home will move to institutional care

Anatomy

Borders x2 Surfaces x2 Calcar

Anatomy

Described by Crock Extra-capsular ring Retinacular Ligamentun Teres

Anatomy

Predisposing factors1. Loss of bone strength

2. Loss of local shock absorbers

3. Reduction in protective responses

4. Increased risk of falls

Mechanism of injury Low Energy

Direct Indirect

High Energy

Cyclical Loading Stress fracture

Clinical Presentation History

Injury Predisposing factors Inability to weight bear

Clinical examination Shortening and external rotation Inability to SLR Groin tenderness

Clinical Presentation

Radiological investigations

Plain radiograph (Antero-posterior and Lateral)

MRI

CT

Classification

Anatomical Location

Garden

Pauwels

Anatomical Location

Garden

Garden

Pauwels

Goals of treatment

Patient comfort

Restore hip function / independence

Reduce length of immobility

Management - Multidisciplinary team1. General

1. Identify +/- treat cause of injury2. Secondary prevention3. Rehabilitation

2. Specific 1. Management of hip fracture:

Conservative/Operative

Specific management1. Analgesia

2. Hydration

3. Investigations (Bloods, CXR, ECG, Echo .. etc)

4. Identify and treat co-morbidities to avoid delay

Operative management1. Internal Fixation

1. Cannulated screws2. Dynamic Hip screws

2. Arthroplasty1. Cemented Thompson2. Cemented bipolar3. Uncemented Austin Moore4. Total hip Replacement

Cannulated Screws

Dynamic Hip Screw

Cemented Thompsons

Cemented bipolar

Austin Moore

Total Hip Replacement

Complications - General VTE / PE

Infections (UTI / LRTI / Wound)

Bed sores

Osteoarthritis

Avscaulr necrosis

Non union

Complications – Arthroplasty Revision surgery 10%

Higher mortality

Longer hospital stay

Dislocation

Complications – Arthroplasty Leg length discrepancy

Acetabular erosion

Implant infection

Fracture around prosthesis

Expensive

Complications – Internal Fixation

Non union 20-30%

Avascular necrosis 10-20%

Revision surgery 25-30%

Post Operative care1. Check Hb / U&Es

2. VTE prophylaxis

3. Rehabilitation with physio - Mobilise Full weight bearing

4. +/- check X-Rays

Further reading1. Orthopaedic Trauma Association Classification

2. BOAST guidelines on Fragility Hip Fractures

3. National Hip Fracture Database

4. NICE clinical guidance – Management of hip fractures in adults

QUESTIONS