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Good morning, everyone today we'll be discussing. Yeah, the topic head fracture, which is an important orthopedic topic, hip fractures can be major public health concern particularly in older adults where there is an association of high morbidity mortality and substantial impact on their quality of life. Hopefully, by the end of the session, you should have solid understanding of the mechanism behind hip fractures, how to diagnose them, how to manage them and treat them. And we're also going to be taking a look at some X rays of the hip just to see the different types of fractures and how they present there. Just a quick overview of hip fracture. Basically, it refers to break in the upper part of femur. This type of fracture typically occurs in the region where the femur meets the pelvis to form the hip joint. We will also be speaking about the different types of hip fractures. So, intracapsular and extracapsular fractures later into this session, we're also going to be discussing the causes of hip fracture in more detail as well in the next slides. But again, most commonly causes and the contributing factors are osteoporosis and trauma. Now, we're going to be discussing the anatomy of the hip, starting with its deepest structural layer, the bones, the Piron composed of two key bones. We have the femur and the pelvis. And let's start by examining the femur and its specific components within the hip. At the top of the femur, we have the femoral head followed by the femoral neck and the greater trochanter. Well, looking at the femoral head, it is covered with articular cartilage and this provides a smooth, frictionless surface, facilitating smooth and efficient movements at the hip joint. The femoral head fits into the acetabulum, which is basically a socket located on the side of the pelvis forming a ball and socket joint covering the head joint is the joint capsule, which is composed of ligaments that attach the femur to the stab pro providing stability to the joint. Moving on from this. It's crucial to understand both the blood supply and the nerve innervation of the hip. There are three primary nerves that pass through the hip region. The first one being the femoral head apologies. The femoral nerve which runs along the front of the hi. The second one is the sciatic nerve and this one runs from the back of the hip. And the third one is the obturator nerve, which is a smaller one and basically this one runs through the inner side of the hip. Now we'll speak about the vascular supply of the hip. As you can see on this PowerPoint slide, you can see the main blood vessels that supply the hip. One particularly important vessel that you should know of is the medial femoral circumflex artery. This artery serves as a primary blood supply to the femoral head and any trauma to this vessel. For instance, a fracture of the femoral neck can lead to avascular necrosis, which is basically a condition where bone tissue dies due to the lack of blood supply. Now, just going over some epidemiology about her fractures. As discussed previously, hip fractures are much more common in the elderly population. This correlates with the increase in the incidence to the Asian population that most often occur due to trauma, particularly in uh older patients. This most commonly occurs due to a fall often from standing height which can lead to a break of the femur. Another contributing factor to be aware of as discussed previously is osteoporosis, which is basically a condition that weakens the bones and makes uh makes them more fragile, making the bones easier to fracture. Such individuals even minor falls can lead to a fracture. In younger population, hip fractures tend to occur from high energy trauma. So an example of this would be car accidents, sports injuries and significant falls from height just to go over some other contributing factors. Uh We have some medical conditions that weaken bones as described previously again. But uh different conditions such as cancer, prolonged use of steroids, all reduce the bone density, making it easier for the bone to fracture all over poor vision impaired balance, muscle weakness, increase the likelihood of falls in elderlies. Further elevating the risk of hip fractures moving on when assisting a patient with a potential hip fracture. There are several hallmark clinical features to be aware of. Most patients will present with a severe pain, localized to the hip or groin area. And these tend to be exacerbated with uh movements. This pain may also radiate towards the knee which might make it a little bit more difficult to diagnose. Many patients who have fractures may be unable to bear weight on the affected leg. And when physically examining these patients, the affected leg tends to be shortened and externally rotated and this is more evident in displaced fractures to do uh the disruption of the normal alignment of the femur all over patients tend to have a significant tenderness on palpating the affected hip, especially over the area of the femoral neck, which is where most fractures occur. Internal rotation of the affected hip will also provoke pain. And in every patient with suspected hip fracture, it is important to have a thorough neurovascular assessment as it is essential to ensure there is no damage to the surrounding nerves or blood vessels. Now moving on to uh investigations but investigating patients with suspected hip fractures, it is important to perform a series of laboratory tests. So these include focal count coagulation profile, especially for pre surgical patients. Additionally, it is important to assess bone health, particularly the possibility of osteoporosis. Hence, it's important to carry out ene and bone density test. Imaging plays a critical role in the diagnosis of hip fractures. And the first line investigation is typically an X ray which is effective in identifying the type of fracture and determining whether there is displacement or not for complex fractures or when the X ray results are inconclusive. A CT scan can be conducted providing a more detailed image and in certain cases, MRI may be useful especially before the ding go fractures or assistance, soft tissue involvement. Now, I'm going to be speaking about the classifications of hip fractures. So hip fractures can be divided into two main categories, intracapsular and extracapsular fractures depending on the location of the fracture. Firstly, let's talk about intracapsular hip fractures. So these fractures occur within the joint capsule. These involve the area between the head of the femur and just below the femural neck. And due to the location, this can cause a disruption to the blood supply to the femoral head due to the potential damage to the medial femoral circumflex artery, which can lead to avascular necrosis of the affected hip. And when s sing intracapsular hip fractures. One of the most widely used systems is guards classification and this is basically a system that's used to assess intracapsular fractures by categorizing the femoral neck fractures based on the degree of the displacement and the alignment of the bone fragments. So I'm just gonna be walking through the s classification. Now, there are four stages. Stage one is where there is an incomplete or minimally displaced fracture and the femoral head remains well aligned with acetum and the fracture is stable on this one. There is a low risk of avascular necrosis because there's a low risk of the disruption of the blood supply and the neck of femur. In stage two, uh it's characterized by a complete fracture without displacement, meaning that the bone fragments remain aligned and the risk of avascular necrosis remains relatively low in garden stage three, however, is different because the fracture is complete and there is partial displacement, meaning that there is no longer proper alignment between the femoral head and neck. And this increases the risk of damaging the blood vessel, supplying the humoral head, which again increases the risk of avascular necrosis, which is similar to uh guardia stage four. But on this one, the fracture is fully displaced with a complete loss of alignment. So the risk of avascular necrosis is significantly higher in this stage. On the other hand, speaking about extra capsular hip fractures, these occur on the outside a hip joint capsule and are divided into two categories. So they're either intratrochanteric fractures. And these tend to involve the area between the greater and lesser trochanter of the femur or subtrochanteric hip fractures which are fractures located just below the tr cancers and the actual capsule, hip fractures tend to be less likely to disturb the blood supply to the femoral head. Meaning that there is less of a risk of avascular necrosis in these type of fractures. It is important to understand how to properly interpret an X ray of the hip when assisted for hip fractures. This also entails understanding the normal hip and how it looks like and how this is for proper alignment of the hip. This is reflected in the presence of Chantal's line. It is a crucial anatomical landmark for evaluating hip joint alignment on an X ray of a healthy individual. Chantal's line would be smooth continuous curve that can be traced along the inferior border of the superior pubic cmas and the inferior medial border of the femoral neck. If this line appears to be disrupted or irregular, then it would be highly suggestive of a hip fracture or dislocation. The treatment of hip fracture can be categorized into two primary approaches surgical or non surgical management. So for non surgical management, this is indicated for non ambulatory patients and those with significant comorbidities or significant frail. The primary focus in this is pain management, which may involve the use of analgesics and nerve blocks alongside memorization and bed rest. In addition, physiotherapy plays a crucial role in rehabilitation. Moving over to the surgical management. This can be further divided into management for intracapsular or extracapsular fractures as the treatment surgery differs depending on the type of fracture within the intra capsular management. The management strategy varies depending on whether the fracture is displaced or non displaced for displaced fractures. The preferred treatment option is internal fixation or hemiarthroplasty. On the other hand, for non displaced fractures, total hip replacement is often the favored procedure. It's important to know that hemiarthroplasty is generally recommended for patients who are considered unfit for more excessive surgery. For example, in case of displaced fracture, the patient is medically stable, independent and mobility and free from any cognitive impairment. Then total hip replacement is usually the procedure of choice. On the other hand, the management of extra capsular fractures is a little bit different for patients with intratrochanteric fractures. A dynamic hip screw is often suggested while those with subtrochanteric fractures may be treated using an intramedullary nail, it is important to note that postoperative care is critical for patients. Regarding the type of fractures, they've sustained early immobilization is advisable to prevent complications such as deep vein thrombosis and pressure ulcers. And it also helps facilitate recovery. Alongside this pain management. With a autistics, rehabilitation through physiotherapy and occupational therapy are both essential continuous monitoring of the patient is also important to ensure favorable outcomes and to keep an eye on any possible complications. Now, into complications, hip fractures can lead to a range of complications, potentially having significant impact on the patient outcome. These complications can be classified into early and late complications So for the early complications, these typically occur within the first few weeks, POSTOP. They include deviant thrombosis, which is basically the increased risk of developing a clot within the deep veins in the legs. Due to immobility. This can lead to pulmonary embolism if the clot is dislodged, which can lead to respiratory distress and even death. Infection is another risk just like any surgery. There is a risk of infection, particularly in cases where the implant or a prosthetic device are used. Infections can lead to a longer hospital stays and complications such as osteomyelitis. Late complications are those that manifest within from weeks to months after the initial injury. And some of these are avascular necrosis. So, this condition occurs when the blood supply to the femur to the femoral head is compromised, leading to bone death. It can result from both the fracture itself and the surgical management. Next, we have nonunion or malunion. This occurs when the fracture fails to heal properly, which is called nonunion or heals in an improper position, which is known as malunion. And this leads to persistent pain alongside functional impairment. Lastly to, to both the injury and the altered mechanics of the hip. Following hip surgery, this can lead to the development of osteoarthritis over time which can result in both pain and decreased in mobility in elderly patients. Bone health is a critical factor in determining the risk of fractures. Therefore, it is essential to conduct appropriate investigations to assess their fracture risk and prevent potential injuries. There are two main methods for developing the risk. The first one is called the fracture risk assessment tool, also known as Frax, which is used as a first line investigation for low risk patients and it calculates the 10 year probability of fracture based on the clinical risk factors. The second one is called bone mineral density scan. It's known as Dexa, it is the preferred first line investigations for patients at a high risk of fractures. And this scan measures bone density and helps diagnose conditions such as osteoporosis for patients who are diagnosed with osteoporosis. The management typically involves calcium and Vitamin D supplementation along with anti osteoporotic medications such as bisphosphonates which all help to reduce the risk of further fractures, moving on to prognosis and fractures in elderly patients are associated with high morbidity and mortality, particularly due to the frailty of this population. Some fractures that influence prognosis including the patient's age existing comorbidities, the type of fracture and the promptness of the surgical intervention. It is also crucial to understand the different strategies that can be used to prevent further fractures strategies including implementing fall prevention measures such as installing handrails, using non slip surfaces and ensuring a proper footwear is worn can all help prevent the risk of future fractures. This in addition to maintaining bone health through regular exercise, osteoporosis management and nutritional supplements is crucial. In conclusion, fractures are common and serious condition, particularly in the elderly population, early diagnosis, prompt treatment and effective rehab are key to improving patient outcome. It will be interesting to observe how fracture management evolves in the future. With advancement in surgical techniques, early immobilization protocols, osteoporosis management, which may further enhance the recovery and long term prognosis of such patients.