Hip
Fracture Neck of Femur
Garden Classification of Intracapsular fractures - based on AP view only
- Type I - Incomplete, ie. valgus impacted
- Type II - Complete. non-displaced
- Type III - Complete, partially displaced
- Type IV - Complete, fully displaced
Often referred to only as displaced or not. (ie I&II or III&IV)
Pauwels Classification
- Type I: ≤30°. Compressive forces are dominant
- Type II: 30°–50°. Shearing force occurs and may have a negative effect on bone healing
- Type III: ≥50°. Shearing force is predominant & with significant varus force leading to fracture displacement and varus collapse
Intracapsular fractures
- high rate of non-union and avascular necrosis due to vascular compromise (View Vascular supply)close
Extracapsular fractures these are not generally classified any further
- Trochanteric fractures
- Transtrochanteric fractures
- Subtrochanteric fractures
Clinical
- may have only minor pain in groin or medial side of thigh or knee but displaced fractures generally have pain in entire hip area
- no clinical deformity unless displaced fracture
- displaced fractures - external rotation and abduction with shortening due to action of psoas
- 25-30% 1year mortality
- important to identify causation of fall
Nottingham Hip Fracture score
- Summative score of seven preoperative variables which give an estimated risk of 30 day post-operative mortality
| Variable | Value | Score |
|---|---|---|
| Age | <66yr | 0 |
| 66-85yr | 3 | |
| ≥85yr | 4 | |
| Admission Hb | ≤10g/dl | 1 |
| MMTS | ≤6 | 1 |
| Living in institution | Yes | 1 |
| no. of comorbidities | ≥2 | 1 |
| Malignancy | Yes | 1 |
score
Management
- analgesia - oral, parenteral, regional
- fluid replacement
- VTE prophylaxis
- antibiotic prophylaxis
- surgery
Fascia Iliaca Block - Landmark approach
Cochrane review found that Peripheral N block reduced pain and need for opoids and that analgesia control was superior compared with systemic analgesia and reduced the adverse effects associated with the latter.
Sensory Nerve supply to the hip joint includes - femoral N, obturator N, articular branches of sciatic N, and N's supplying quadratis femoris and Superior Gluteal N. Therefore, Fascia Iliaca Block does not provide complete anaesthesia of the joint.
Procedure:
- Landmarks - a point 1cm caudad to the junction of medial and lateral thirds of a line joining the ant sup iliac spine (ASIS) and the ipsilateal pubic tubercle
- Lignocaine injection to local area for skin anaesthesia prior to penetration with large gauge needle for infiltrative anaesthesia
- A blunt, short-bevel needle is inserted perpendicular to the skin and the needle angle adjusted to approximately 60° and directed cranially
- A ‘give’ or ‘pop’ should be felt as the needle passes through fascia lata, and a second ‘give’ as it passes through the iliacus fascia
- adjust needle to approximately 30° and advance a further 1–2 mm
- LA should be injected without resistance
- Usually 0.25% Bupivacaine with volume around 30-40ml, withdrawing every 5ml to ensure correct placement
References include
https://www.rcem.ac.uk/docs/QI%20+%20Clinical%20Audit/FIB%20guideline%20document%20for%20the%20ED.pdf
article from bjaed.org
BJ anaesthesia article
http://www.partone.lifeinthefastlane.com/local_anaesthetics.html
https://www.orthobullets.com/trauma/1037/femoral-neck-fractures
https://www.rcemlearning.co.uk/reference/fractured-neck-of-femur/#1569411438082-5f6502c5-526f
https://emedicine.medscape.com/article/86659-overview
BrJAn Nottingham Hip Fracture Score review