Neck of Femur Fracture

Scenario

70 Year Old Female brought into ED after a fall. Confused with an AMTS 5/10. 

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This is an AP and Lateral plane film radiograph of an unknown skeletally mature individual’s pelvis and right hip. There are no patient identifiers and the radiograph is undated. The most obvious abnormality is that there is a: discontinuity of Shenton’s line with a completely displaced right sided intracapsular fracture. There is shortening of the distal fragment. There are no other fractures. The fracture would be classified according to the Garden’s Classification as a Gardens type 4 fracture.

I would manage this patient according to ATLS principles (Silver Trauma).

I would complete a full primary survey to rule out life threatening injury. I would then assess the limb in question as part of the secondary survey.

I would assess the neurovascular status of the limb (sciatic nerve function, cap refill, distal pulses).

I would manage the patient using a local NOF proforma, NICE guidelines, BOAST guidelines and Best practice tariffs. 

The patient should have a full set of trauma bloods, CXR, ECG and anaesthetic review. They should also have appropriate analgesia. A fascia iliaca block should also be performed. 

BOAST 1 guidelines

– Secondary prevention assessments provided
– Hip fractures managed by MDT
– MRI or CT if X-Rays negative and non weight bearing
– Immediate analgesia should be given
– Co-morbidities should be treated
– Perform hip fracture surgery on the day of or day after
– PT once a day
– Acute orthogeries input
– Data should be submitted to the National Hip Fracture Datbase
 
Best Practice Tariff
– Time to surgery 36 hours from arrival in ED to anaesthesia
– Involvement of an (Ortho) geriatrician
– Admitted under joint care
– Assessment protocol 
– Post operative geriatrician directed MDT rehab
– Compliance monitored via the National Hip Fracture Database
 

Nottingham Hip Score

  • Age 66-85, >86
  • Male
  • HB <10
  • AMTS <8
  • Living in an institution
  • More than 1 co-morbidity
  • Acute malignancy within the last 20 years

The blood supply to the femoral head is mostly retrograde:

  • Main supply is via an anastomosis of the lateral and medial circumflex femoral artery and superior gluteal artery
  • Small nutrient artery which is intramedullary
  • Small supply via artery of the ligamentum teres (obturator artery)

Ligaments: iliofemoral ligament, pubofemoral and ischiofemoral

Capsule
Labrum
Bone morphology
Muscle

Anterior attachment – Intertrochanteric line

Posterior attachment – More proximal midway along the femoral neck

This patient has a AMTS of 5/10 and a completely displaced NOF fracture. They would qualify for a Hemiarthroplasty as per NICE guidelines.

In an appropriately marked, consented WHO checklisted patient

Lateral on the table in blocks
ABx+TXA on induction
Prepped and drapped + Leg bag
Incision – longitudinal incision centred over the Greater Trochanter
Superficial Dissection – Split iliotibial band
Deep Dissection – Split gluteus medius leave superior aspect. Split gluteus minimus and then T capsulotomy

2007

Joint venture between BOA and british Geriatric society
It allows care to be audited against 6 evidence based standards set out in the BOA blue book
– All patients should be admitted to an acute ortho ward within 4 hours of presentation
– All patients who are medically fit should have surgery within 48hours or admission
– All patients with hip fractures should be assessed and cared for to minimise their risk of developing a pressure ulcer
– Orthogeries input
– Secondary prevention
– MDT input for falls prevention