Hip Fractures

Scenario

60 Year Old Male brought into ED after a fall. Complaining of pain in their Right hip.

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“This is an AP and Lateral plane radiograph of a skeletally mature unknown individual’s pelvis and right hip. The radiograph is undated. The most obvious abnormality is that there is an un-displaced intracapsular neck of femur fracture on the right. There are no other fractures. The fracture would be classified according to the Garden’s Classification as a Gardens type 2 fracture.”

Garden’s Classification

  1. Incomplete, undisplaced fracture
  2. Complete, minimally displaced fracture
  3. Complete, minimally displaced fracture
  4. Complete, completely displaced fracture

Pauwel’s Classification (Angle between fracture line and horizontal)

  1. <30 from horizontal
  2. 30-50 from horizontal
  3. >50 from horizontal

Fixations of type 3 Pauwel’s fractures must be with a fixed angle construct. 

  • Time to surgery 36h
  • assessment by a geriatrician (within 72 hours of admission)
  • Fracture prevention assessment
  • AMTS
  • Nutritional assessment during admission
  • 4AT on admission
  • Assessed by a PT on the day of or day following surgery

The blood supply to the femoral head is mostly retrograde:

– Main supply is via an anastamosis 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)

In an appropriately marked and consented anaesthetised patient. I would complete a WHO checklist.

Patient would be positioned supine on a traction table.
I would reduce the hip under II 
Incision: just inferior to the GT down the midshaft of the femur 8cm in length
Superficial dissection: Skin, subcut fat, split fascia lata.
Deep dissection: recheck position centre split vastas lateralis
Place 135 angled guide onto the bone.
Guidewire (2.5mm) into centre of femoral head 25mm (AP and lateral)
Measure and select a screw that is 10mm shorter than the measured length
(if less than 80 use a short barrel)
Tripple ream (ream for screw, barrel, barrel/plate junction)
Screw DHS 12.5
Tap
Insert DHS
cortical screws
closure: 1 vicryl to muscle and fascia, 2/0 to subcut, 3-0 monocryl to skin.
Pressure dressing