Hip Fractures

1. Hip Fractures

2. Hip Fractures • Aims • Normal hip anatomy/radiography • 3 hypothetical cases • How to approach a question on hip fracture with differentials. • Recognising important fracture patterns. • Suggesting relevant investigations • Deciding sensible management • Osteoporosis summary

3. Hip Fractures “Normal” – No fracture but shows arthritic changes

4. Hip Fractures • Fracture (break) • Any incongruity of the periosteum. • Look for steps/buckles • A soft tissue injury with a broken bone in the middle!

5. Hip Fractures http://www.wikiradiography.com/page/Neck+of+Femur+Fractures

6. Hip Fractures http://www.wikiradiography.com/page/Neck+of+Femur+Fractures

7. Hip Fractures • Blood supply to femoral neck is largely from profunda femoris via medial and lateral circumflex femoral. • Fractures proximal to the hip capsule insertion risk AVN.

8. Hip Fractures • Case 1 • An 89 year old nursing home resident presents to the ED after an unwitnessed fall. • Complaining of right groin pain, unable to weight bear.

9. Hip Fractures • What is your differential diagnosis at this point. • Femoral neck fracture • Pubic ramus fracture • Osteoarthritis • Hernia? • UTI • MI • Stroke

10. Hip Fractures • Examination demonstrates externally rotated, shortened right leg and pain on rolling her right leg, she is unable to straight leg raise. • You can hear an ejection systolic murmur radiating to her carotids. • You organise radiographs - AP Pelvis and AP and Lateral right hip.

11. Extra capsular, intertrochanteric fracture

12. Hip Fractures • You discuss the case with your senior, they say to prepare her for theatre. What additional investigations are needed? • ECG • Chest X-Ray • Bloods • FBC, U/Es, LFTs • ?Troponin etc • ?Echo

13. Hip Fractures • Her ECG shows atrial fibrillation and it has just transpired she is on warfarin. What do you need to do? • INR - Comes back as 2.5 • What do you need to give the patient. • Vitamin K

14. Hip Fractures • This lady has been confused for some time now. • What legislation is relevant to her operation? • Adults with Incapacity

15. Dynamic Hip Screw (DHS)

16. Hip Fractures • Case 2 • A 65 year old active lady falls from a stool whilst fixing the curtains. • Complaining of a painful left hip and unable to weight bear. • Previous history of breast Ca treated with mastectomy and chemo. • Hip has been painful for a while anyway

17. Hip Fractures • What is your differential diagnosis • Femoral neck fracture • Metastatic breast Ca • Osteoarthritis • You Organise X-Ray AP Pelvis, AP and Lateral Left hip

18. Intra capsular Femoral Neck fracture

19. Hip Fractures • After routine stuff, what other investigations are important in cases like this? • Full length femur x-rays • Bone Scan • Chest x-ray • PSA in males • Myeloma screen in other circumstances

20. Hemiarthroplasty

21. Total hip replacement

22. Hip Fractures • Case 3 • 85 year old man out walking the dog slips on wet leaves and lands hard on his left hand side. • Complaining of left hip and wrist pain.

23. Hip Fractures • You arrange appropriate imaging. • Pelvis • Hip • Wrist

24. Extra capsular, subtrochanteric fracture on left and hemiarthroplasty on right.

25. Minimally displaced, intra-articular distal radius fracture with associated ulnar styloid fracture

26. Gamma nail

27. Osteoporosis • Reduced bone mineral density • Thin trabeculae • Increased risk of fractures • Hip • Wrist • Vertebrae • Defect in attaining peak bone mass or accelerated loss

28. Osteoporosis • Risk Factors • Menopause (particularly if early) • Smoking • Alcohol abuse (also increased falling) • Steroids • Co-Morbidity • RA • Cushing’s • Other drugs • Aromatase inhibitors • GnRH agonists

29. Osteoporosis • Clinical Features • Often asymptomatic until fracture • Back pain/Height loss/Kyphosis • Investigations • X-ray may show osteopenia (not an investigation for diagnosis!) • Dual X-Ray Absorptiometry (DEXA) • Lumbar spine • Femoral Neck

30. Osteoporosis • DEXA • Weak x-ray beams attenuated proportionally to mineral present in bone. • T-Score • StDev from a young healthy control • <-2.5 = Osteoporotic • Z-Score • StDev from an age matched control • Indications • Multiple

31. Osteoporosis • FRAX analysis • DEXA Score • Co-Morbidities • Family History • 10 Year fracture risk

33. Osteoporosis • Management • Lifestyle advice • Smoking cessation, alcohol moderation, weight bearing exercise • Falls prevention • Drug treatment • T-score <-2.5 or <-1.5 on steroids • Bisphosphonates • Oral Alendronate (Adherence problems) • IV Zolendronate • Calcium and Vitamin D in institutionalised • Strontium Ranelate (Side effects) • PTH expensive but ok if T-Score <-3.5 • Not more than 25-50% improvement in fracture risk!

34. Osteoporosis • Surgery • As indicated for fractures • Balloon Kyphoplasty/Vertebroplasty in acute painful vertebral fractures

35. Hip Fractures • Summary • Intracapsular • Hemiarthroplasty • Total Hip Replacement • ? Fixation in young or undisplaced! • Extracapsular • Dynamic Hip Screw • Gamma Nail • Remember multiple co-morbidities. • Always exclude other injuries • Osteoporosis is a common factor.

36. Questions

37. Further Reading • Adams’s Outline of Fractures including joint injuries (Hamblen and Simpson). • Good undergraduate/foundation level stuff. • Pocketbook of Orthopaedics and Fractures (McRae) • Perfect for an Ortho FY2 job. • A and E radiology: A survival guide (Raby) • Practical Fracture Treatment (McCrae). • Great for Ortho FY2 and early Ortho trainee level.