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Hip Fractures Mr Benjamin Davies ST5 Registrar East of England DeaneryPoll to be answered Volunteer to answer/shout out/write in chatLearning objectives • Epidemiology • Assessment • Classify • Ma• Surgical • Medical • When to operate? • Guidance and other key topics • Target: • Get ready for ST3 interviews/MRCS examsGuidelinesDefinition • Hip fracture vs proximal femoral vs neck of femur fracture • Does it include pelvis/acetabulum? • NICE: • A fracture occurring in the area between the edge of the femoral head and 5cm below the lesser trochanterWhy is it such a key topic? • In 2020: • 30-day mortality: 8.3% (6.5%, increase due to COVID-19) • NHFD 2020 report • Cost of UK hip fracture cases approx. £1bn • Early recognition and management (medical and surgical) improves outcomesEpidemiology • Older patients: Can also be low energy in patients with poor soft tissue envelope. • Women > Men • Younger patients: High energy traumaAnatomy Blood supply to the femoral head: 1. Medial femoral circumflex artery 2. Interosseous 3. Artery of ligamentum teresWhy is this important?Anatomy à ClassifyClassificationClassification (Intracapsular) • Garden • Pauwels Stability Risk of AVNManagement • Surgery • Pain relief • Allow mobilisation ASAP (FWB if possible) • Combined Orthopaedic and Geriatric ManagementCase 1 • 78F • Tripped and fell on paving stone at home • Witnessed by husband • Pain in left hip • Assessment?Assessment • ATLS • Rule out any life threatening injuries • AMPLE • CCRISP • Rule out like threatening conditions (why have they fallen?) • Mechanical fall is a diagnosis not a history • Limb specific • Vascular status • Neurological status • This should be repeated systematically, particularly after reduction manoeuvres or the application of splints.Case 1 • PMH: HTN, High cholesterol • DHx: Amlodipine, Atorvastatin • SHx: Mobilises independently, enjoys walking and knitting, 1-2 units alcohol/week, non-smoker. • Lives with husband in house • AMTS: 9/10 • What next?Case 1 • Pain in left hip • Left hip externally rotated, NV intact • General examination NAD • What next? • Bloods: Hb 115, Wcc 8.7, INR 1.0, U&Es N, eGFR 78Case 11. Body Weight 3.Controlled compression at fracture site 2.Screw slides in plateManagementTip-Apex Distance • <25mm • Baumgartner 1995Alternative surgery? • Why? • Defect/extension into lateral wall • Subtrochanteric extension • Reverse oblique • Reduced lever arm • Medialisation of constructCase 2 • 88F • Tripped and fell on at care home • Witnessed by staff • Pain in right hip • Assessment?Case 2 • PMH: HTN, High cholesterol, CKD, Previous TIA • DHx: Amlodipine, Atorvastatin, Aspirin 75mg OD • SHx: Mobilises with 2 sticks, enjoys knitting, no alcohol, non-smoker. • Lives in care home • AMTS: 6/10 • What next?Case 2 • Pain in right hip • Right hip externally rotated, NV intact • General examination NAD • Bloods: Hb 115, Wcc 8.7, INR 1.0, eGFR 48 • What next?Case 2• Cemented versus uncemented hemiarthroplasty for intracapsular hip fractures, Parker M et al, 2009, JBJS(Br) • The use of a cemented Thompson hemiarthroplasty resulted in less pain and less deterioration in mobility than an uncemented Austin-Moore prosthesis with no increase in complications. Approach? Anterior approach (Smith- Anterolateral approach Direct lateral approach Posterior approach Peterson) (Watson-Jones) (Hardinge, Transgluteal) (Moore, Southern) Anterior half of the iliac 2.5cm posteroinferior to Incision crest and ASIS down ASIS and curving over GT Centred over GT 1 inch posterior to GT Sartorius and TFL (don’t Medial to gluteus medius Split gluteus medius and Muscle plane (retracted not cut) but vastus lateralis and reflect Gluteus maximus split disturb glutes) lateral to TFL cuff anteriorly Window between TFL and Interval between TFL and Vastus lateralis and splitting Superficial Sartorius Gluteus medius Through TFL to expose GT gluteus max Window between rectus Detach abductor Gluteus medius and Detach short external Deep femoris and gluteus medius mechanism minimus taken off as cuff rotators and reflect Femoral nerve, lateral Femoral nerve, femoral Superior gluteal nerve, Sciatic nerve, inferior Dangers femoral cutaneous nerve artery femoral nerve gluteal artery Posterior approaches have a greater risk of dislocation and anterolateral/lateral approaches pose a greater risk to the superior gluteal nerve which can result in trendelenberg gait if damaged.When to go to theatre?Best practice tariff • Why? • Worth £445/spell of care if completed! • It’s best practice, best outcomes for patient • Improved outcome • Increased number of independent individuals and reduced mortality • Shorter length of stay • More cost-effective careBest practice tariff All patients aged ≥60 years 1. Time to surgery within 36h from arrival in ED, or time of diagnosis in inpatient to the start time of anaesthesia 2. Admitted under the joint care of a consultant geriatrician and a consultant orthopaedic surgeon 3. Admitted using an assessment protocol agreed by geriatric medicine, orthopaedic surgery and anaesthesisa 4. Assessed by a geriatrician in the pre-operative period: within 72h of admission 5. Postoperative geriatrician-directed multi-professional rehabilitation team 6. Fracture prevention assessments (falls and bone health)Case 3 • 78F • Tripped and fell on paving stone at home • Witnessed by husband • Pain in right hip • Assessment?Case 3 • PMH: HTN, High cholesterol, AF • DHx: Amlodipine, Atorvastatin, Apixaban • SHx: Mobilises independently, enjoys walking and knitting, 1-2 units alcohol/week, non-smoker. • Lives with husband in house • AMTS: 9/10 • What next?Case 3 • Pain in right thigh • Right hip externally rotated, NV intact • General examination NAD • Bloods: Hb 115, Wcc 8.7, INR 1.3, U&Es N, eGFR 78 • What next?When to operate?How to manage? Surgical challenges? (displacement) • proximal fragment • abducted • Abductors (gluteus medius and minimus) abduct as they insert on greater trochanter • Flexion and External rotation • iliopsoas flexes and externally rotates fragment as it inserts on lesser trochanter • distal segment • varus/adduction + shortening • adductors inserting on medial aspect of distal femur, somewhat restricts the adductors • Tlege in addition with hamstings will shorten • extension (??Flexion) • gastrocnemius attaches on distal aspect of posterior femur (posterior angulationCase 4 • 72F • Tripped and fell on paving stone at home • Witnessed by husband • Pain in left hip • Assessment?Case 4 • PMH: HTN, High cholesterol • DHx: Amlodipine, Atorvastatin • SHx: Mobilises independently, enjoys walking and knitting, 1-2 units alcohol/week, non-smoker. • Lives with husband in house • AMTS: 9/10 • What next?Case 4 • Pain in left hip • Left hip externally rotated, NV intact • General examination NAD • What next? • Bloods: Hb 115, Wcc 8.7, INR 1.0, U&Es N, eGFR 78Case 4 – Surgical options? • NICE guidance on hip fracture management (CG124) states that you should offer total hip replacements to patients with a displaced intracapsular fracture who were: • Able to walk independently out of doors with no more than the use of a stick • Are not cognitively impaired • Are medically fit for anaesthesia and the procedureTHRCase 5 • 62M • Painter • Fall 6ft from ladder • No head injury • Pain in right hip • Assessment?Case 5 • PMH: Nil • DHx: Nil • SHx: Mobilises independently, enjoys cycling, 8-10 units alcohol/week, non-smoker. • Lives with wife and 2 children in house • AMTS: 10/10 • What next?Case 5 • Pain in right hip, unable to SLR • Right hip held in normal rotation, NV intact • General examination NAD • What next? • Bloods: Hb 115, Wcc 8.7, INR 1.0, U&Es N, eGFR 78 Management? • FIX • OR REPLACE (Hemiarthroplasty) • A shorter operation time • Lower re-admission rate Lower re- • Reduced orthopaedic ward stay operation rate • lower incidence of peri-operative complications • Lower 1-year mortality • Less pain at 1 year, • Less reduction in mobility and • Lower dependence on walking aids Fixation versus hemiarthroplasty for undisplaced intracapsular hip fractures, Parker et al. Injury. 2008• How to we record and review hip fracture outcomes?National hip fracture database (NHFD) • It is a clinically led web-based audit of hip fracture care and secondary prevention in England, Wales and Northern Ireland. It collects data on all patients admitted to hospital with hip fractures and improves their care through auditing which is fed back to hospitals through targeted reports. • Tracks BPT, anaesthetic, orthogeriatric review, LoS, mortality etc.. All data reported annually and monthly and allows comparison to other trusts. • Allows for audit. E.g. able to look at effect of BPT implementation (Pay for performance and hip fracture outcomes, Metcalfe et al. 2019)National hip fracture database (NHFD) • Collects indicators related to BPT: • Time to surgery • Geriatrician assessment undertaken • Bone protection medication • Cognitive assessment (pre-op AMTS) • Specialist falls assessment • Nutrition assessment • Delirium assessment • Physiotherapist assessment • Trust discharge date • Also collected but not displayed on results: • Patient NHS number, GMC number of consultants (ortho + geri), joint protocol assessment obtained, post-op AMTS, rehab assessmentCase 6 • 78F • Tripped at home and got worsening of right thigh pain • Witnessed by husband • No fall • Assessment?Case 6 • PMH: HTN, High cholesterol • DHx: Amlodipine, Atorvastatin • SHx: Mobilises independently, enjoys walking and knitting, 1-2 units alcohol/week, non-smoker. • Lives with husband in house • AMTS: 9/10 • What next?Case 6 • Pain in right hip and thigh • NV intact • Unable to WB • General examination NAD • Bloods: Hb 101, Wcc 8.7, INR 1.0, U&Es N, eGFR 78 • What next?Other key info points • Hip fracture not clear on XR: • Offer MRI if hip fracture suspected in the presence of adequate negative XRs. If MRI not available within 24h or contraindicated, consider CT (NICE) • Pain management is vital • See NICE guidance for detailed information • Anaesthetisa: • Offer spinal or GA, with consideration of intra-operative blockWhat next? • Raised ALP, • Mildy elevated Ca • CRP 40, ESR 60What do you do next?What do you do next? • MDT/Joint care with oncology • Referral to tertiary orthopaedic centre for bone tumours (RNOH, Stanmore; ROH, Birmingham)Management options? • Multiple mets, prognosis <6 monthsManagement options? • Solitary met, good prognosisThank You • Any questions?