HIP FRACTURE

This 79-year-old woman fell in the street after getting off the bus, sustaining the above injury.

1. Can you describe the radiograph, and how would you classify this fracture?

This is an AP radiograph of both hips showing a displaced intracapsular hip fracture on the right side. This can be classified according to the Garden classification but, in practice, I would describe it as undisplaced or displaced as this is what would determine my management. This radiograph in particular shows a displaced intra- capsular hip fracture.

2. What is the blood supply to the femoral head?

The vascular supply to the femoral head arises from three sources. One of these is the ligamentum teres: this contains a branch of the obturator artery which, in adults, provides a negligible source of blood supply to the femoral head, in contrast to children.

The second source is from the medullary canal, which is of course disrupted in a femoral neck fracture.

The third source is from the lateral and medial circumflex femoral arteries, which are branches of the profunda femoris artery. The medial circumflex femoral artery provides a larger proportion of blood supply than its lateral counterpart. These form a vascular anastamosis at the base of the capsule and, from this, retinacular vessels

run along the femoral neck underneath the capsule to supply the femoral head. These are potentially disrupted in displaced intracapsular hip fractures.

3. What information would you want to gather from taking a history?

Assuming this is an isolated injury and the patient has been given suitable analgesia, I would like to take a full history in order to rule out a medical cause for her fall and if she is suitable for a total hip replacement or best managed with a hemiarthroplasty. To determine if a medical cause was responsible for her fall, I would start with a history regarding preceding symptoms, such as chest pain, palpitations, dizziness, weakness or SOB, and any history of previous falls. I would take a full systematic enquiry to look for evidence of infection, particular urinary and respiratory infec- tions. Regarding a pathological fracture, I would ask about constitutional symptoms of malignancy (weight loss, loss of appetite, night sweats) and preceding hip pain

prior to the fall.

I would go on to ask about her past medical history, drug history (particularly warfarin), social history, including level of mobility and mobility aids, fall risks as well as a mental state examination. I would perform a DVT risk assessment and consider whether this patient is at risk of further fragility fractures and should have investigation to determine bone quality and treatment if required.

4. What examination and investigations would you perform in the emergency department, and what initial treatments would you commence?

Examination would consist of a full set of observations and confirmation of pain on movement of the affected limb in a gentle fashion. I would assess the neurovascular status of the leg and examine the skin around the planned incision site. I would assess for other injuries, common sites including the distal radius and proximal humerus, as well as perform a cardiovascular and respiratory examination.

Routine bloods would include FBC, U&Es and group and save, plus a coagulation screen if indicated.

A chest radiograph is generally indicated in all elderly patients with a hip fracture

+/– full-length femur views depending on local protocols. An ECG would also be performed in the emergency department.

IV fluids should be initiated as patients are generally dehydrated and oral intake will be minimal in the ward owing to pain +/– confusion.

To be suitable for a THR, patients should be medically fit for a longer operation with more blood loss, must be cognitively intact in order to implement standard hip precautions and should be independent ambulators who will benefit from the improved patient reported outcomes. There is good evidence to support the use of THR in the fit elderly patient. This should be discussed with the patient in order to gain informed consent, making sure to mention a slightly increased rate of disloca- tion compared to hemiarthroplasty.

All patients should ideally be admitted to a dedicated hip fracture ward within 4 hours of arrival in A&E and should be seen both pre- and postoperatively by an orthogeriatrician. Their operation should be performed within 48 hours in order to prevent a worse outcome unless there is a readily reversible medical problem.

5. Do you know of any guidelines that direct your management of hip fracture patients?

Several guidelines exist to provide an overview of the available evidence and guide best practise when treating hip fractures. These include the Scottish Intercollegiate