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I give uh myself uh and Mrs to talk about femur fractures and we're gonna start off with basics of hip fractures. Um So next slide, please. Matt. Yeah, sorry for the delay with the er issues. So I'll put some slides for a bit of interaction if we can. Although the way things are going, it's not looking hopeful at the moment. Um So one point we'll get some votes going and then there's also if there's hands up in the slide, then I ask for a volunteer, if you can to speak up to give us some answers to some of the questions right. Next slide. So gonna try and talk a little bit about hip fractures. I'm gonna start at the basics that maybe some of you think was a bit too basic medical school, but just to make sure that we understand everything, got everything fully um going through the assessment, classifying and management from an orthopedic point of view. Um and taking things from there, I've got some cases to go through. Um and that should er, hopefully lead us on to different topics. Um If you're getting through the cases easily we can go to some of the more difficult ones or we can stick towards the ones at the beginning. Um And hopefully this will give you everything you need to know for when you guys are on call. And for those thinking about applying for orthopedics, uh registrar jobs, uh a bit of information for the uh for those interviews. Ok. Fixed just brief guidelines of what I've taken the information from. So you're aware the key uh literature around hip fractures. Looking at the nice guidance, um There's Royal College of Physician Guidance, we're looking at there's both guidelines looking at the care of the elderly, elderly or frail patients and also the National Hip Fracture Database, which um gives us a lot of information about how we manage and how we look after the hip fractures. OK. Next slide. So, OK, this uh hopefully with a PDF now doesn't have any animation. So the answer is there for you. But the question is, is what is a hip fracture? And where do you define the hip? Um what becomes the proximal femur, what becomes the neck of femur, what becomes a hip fracture? And actually the hips are joint. So that's part of the pelvis and the acetabulum, but we don't tend to call those hip fractures. So we're concentrating today on the classic hip fracture, which is the proximal femur fracture, which is nice, defined as a fracture occurring in the area between the edge of the femoral head and five centimeters below the lesser trochanter. OK. So it's really a proximal femur fracture right up to the head rather than a hip fracture. But uh that's what we're commonly talking about. OK. Next slide, why is it important? So it huge numbers of your patients and in most of the hospitals, you guys are working probably about half of the trauma workload if not more is made up of hip fractures. Um And so the data from 2020 from the hip fracture database report, uh 63,000 patients in the UK had hip fractures and it costs the UK about a billion pounds in healthcare funds. It's also really important that we manage these properly, manage these properly because the 30 day mortality of these patients is 8.3% which is huge. Um That's a slight increase in the 2020 data than what the baseline was probably due to COVID. But er if you say that nearly one in 10 of the patients that comes in with a hip fracture isn't going to last a month. Um We've got to really manage these people properly um to try and improve that and try and get as best quality of life for these patients as possible. And we know multiple studies and multiple things have told us that early management of these patients uh that gives them better outcomes. Uh epidemiology of patients. It's quite simple. It's usually the older patients as with all trauma, older patients with low energy or younger patients with higher trauma. Um I'm not gonna concentrate on the young, proper young hip fracture patients. Um We're talking more about the osteoporotic or the elderly patients with the hip fractures. They also usually have a associated soft tissue, a poor soft tissue Embron um around them to try and uh the that, that um contributes to this fracture. Uh Yeah. Uh women more than men as expected with osteoporosis. All right. Next slide. So a bit about the anatomy because this really guides what we do. And so if you don't understand the anatomy of the proximal femur and the blood supply to the femoral head, you won't understand why we do the different operations. So it is straightforward, the majority in, in adults, the vast majority of the uh blood supply comes from the circumflex arteries, the median lateral femoral circumflex arteries coming from me. Um or you might be able to see my mouse because I'm not percent. Um but coming from the profunda femoris artery. Um So that's sort of looking at 90% of that blood supply. So that femoral head is coming from that ring around the base of the neck. There's a very little supply from the intraosseous and very little supply from the artery of the ligaments and teres. But that mainly is more prominent in younger Children. And the reason that's important is we think about whether a fracture disrupts the blood supply to the femoral head or doesn't disrupt the blood supply to the femoral head, leading us to decide how we're then gonna uh manage the patient. And the way we look at that is, I'm sure you're all aware crap the, the capsule and beca the reason for that is because those blood supply runs from the base of the capsule approximately. So if the fractures inside the capsule, you know, there's damage to the blood supply or outside the capsule, the blood supply is likely to be remaining. Ok. So the blood supply is there, we can keep the femoral head and we can try and keep it. And if there's damage to the blood supply, then the chances are that even if you fix it back together, the blood supply is gone. So the bone is gonna die off. Ok. Next slide and again, this just shows you. So you can see if you have a fracture higher up in the neck of the uh of the femur that blood supply is gonna be damaged. So you're unlikely to get a good blood supply back up to that femoral head even if you fix it back together. Ok. Excellent. Ben. It's just uh worth just saying that, you know, the reason that the blood supply gets damaged when they break is simply because of the fact that you get capsular tears as well. So that's the reason why when you get an intracapsular fracture, the energy tears the capsules and tears the blood vessels. And that's why we tend to use either the the lining of the capsule or, you know, radiologically, we keep that little line in mind and see anything beyond it. Assume the blood supply is gone. Indeed. And the way we do well, the anatomy of the capsule, which is next slide is here. So the capsule of the hip runs anteriorly, use the, we use the in intertrochanteric line to mark the uh the distal extent of the, of the capsule. And it's about one centime proximal to that line posteriorly. So that's your, that's where we're thinking about the capsule. Then when we're trying to relate that to when we look at x-rays and think about what we're going to manage the patients in. And then, and that's how we can then use that to classify them as intra capsular or extracapsular. Next slide. And you can get into a different name ture about where the fracture is. Um So if it's an intra cap fracture, you can have a fracture of the head just under the head, which is subcapital across the neck, transcervical or the bottom of the neck bas um then you look at intra enteric and then below. So, per trochanteric or subtrochanteric, this is the, make sure that's used. But actually, in terms of guiding your management is a little bit limited until you come to the nuances of the surgery that you're doing. Ok. Next slide please. And then when we talk about the classification. So when the classification of intracapsular fractures is um defined a bit further. So the one that you've probably commonly heard of is the Garden classification, which is 1 to 4, which it depends on the amount of uh the extent of the fracture and the displacement of the femoral head. So one is an incomplete fracture of the neck. Two is a complete fracture but with no displacement, uh three is complete fracture with 50% dis well up to 50% displacement and four is complete fracture with complete displacement over 50%. Um The reason that that's important is because I don't know, I was taught at medical school, I don't know what you guys are but 12 screw screw 34 Austin Moore, which is a type of hemiarthroplasty prosthesis that we use. But if you look at one and two, as Mr Singh commented, if you think about the blood supply as a tear to the capsule, well, one and two haven't moved from where the bones meant to be. So the chances of the capsule being torn and the blood supply being damaged are low. So we can hopefully leave them where they are. And although I said it's intracapsular, so it the blood supply is damaged. Actually, we can think about fixing that. Instead. 34, obviously, you can see significant displacement likely to damage the capsule, likely to damage the blood supply. So we need to do something to replace that femoral head. There is also a second classification called powers classification which looking at the displacement and stability and the risk of avascular necrosis, I think at the sho level, if you're uh getting into this level of information, you, you're doing pretty well. So I wouldn't worry too much about it, but just to be aware that it's there, OK. Next slide and when it comes down to the overall aims of the management, you'll notice that it, unless the patient is really sick and unlikely to survive an operation, we do tend to go to surgery in these patients because we know that um if we can give them good pain relief and allow them to mobilize as soon as possible, reduce the risks of other complications of elderly patients, staying in hospital, things like pressure sores, chest infections, urine infections, which in, in the elderly population, we're talking about getting these fractures are almost certainly premorbid events, especially with a hip fracture and inability to mobilize abdomen. So we do it to get them up and to treat their pain and the majority of hospitals now, as per the guidance, it's a combined orthopedic and geriatric management of the patient. So, orthopedics doing the surgical side of things and the geriatrics managing the uh complications from being uh elderly population that we're, that are having these fractures. Um, but it doesn't mean that just because you're the orthopedic surgeon or the orthopedic doctor, you don't have any concept of the geriatric management because uh sure as everyone who works in orthopedics would be aware. It's very important that we manage these patients properly from the moment they come into hospital and under our care. Ok. Next slide. So I don't know whether there are people around that can talk, use this. But if there is, does anyone want to come and have a go at talking me through this case? Hello, be go on then Matt, they start, they start easy. So you've definitely gone, done the good one out. So, yeah, so we talk about a 78 year old old, elderly female patient tripped and fell at home, the husband saw it. She's got pain in her left hip. That's all the information you've been given. You're going down to A&E. So how are you going to assess the patient? So I would classify this as sort of well without knowing her pre state because he's approaching potentially a silver trauma kind of situation. So I'd like to put uh assess his patient by A T and S principles and look for, you know, a primary survey initially, potentially immediately lifethreatening injuries, not to a secondary survey. Uh We've identified by a painful left hip but also ensuring there's no other injuries that uh you may have. Um my initial assessment would first include, sorry, I'm taking my probably um introducing myself and making sure the patient has adequate pain relief on board in the first instance. Um, and then starting with some simple, uh simple investigations such as blood tests, including a group and say, I think theater and some plain A P and lateral radiographs of the left hip. Is there anything else you want to know as you said? So it's an isolated injury but um anything else you want to know from the history? Um I want to know from, from history of her. So a little more about her surgery history. So the, so the history of the of the injury uh trip to uh when was the fall pretty important? Um We know, well, assuming isolated injury with your husband, did she hit? Her head is also super important, especially with our comorbid patients, whether they're on do ax. Uh Yeah. So yeah, so I mean, this is a, this is a fairly straightforward case at the moment but the other thing to look at and to think about is, is, did she just have a trip and fall? Make sure, yeah, make sure that um it purely was a, was a mechanical fall on a trip. Um, rather than something else that's happened, even though the husband saw it, make sure she didn't feel faint and fall over or have some chest pain and fall over and there's some other medical cause for her fall. Oh, no good. Next slide then. So you can probably see the answers ahead of you better. Um Yeah, so talked about a TLS, you've talked about ruling out any lifethreatening injuries, taking a ample history, which is what you were going on to briefly mention, but drag it out. So ruling out any life threatening injuries, doing your crisp assessment, um These are all just key words just to put in when you're thinking about exam or interview techniques. Um A mechanical f so this is something that I get frustrated by with a and Ian, you're asking for the uh the history of what's happened and the pain and they tell you it was a mechanical fall. Well, a mechanical fall is a diagnosis that you write at the end, not a history of the, the problem. OK. So tripping and falling uh is the history. Mechanical fall is therefore the diagnosis at the end. Um and then a general limb specific uh assessment of the leg. OK. Neurovascular status as well. OK. Next slide. So there's your basic information. So she's got a bit of BP, high cholesterol. She's on some basic medication. Fairly independent. Enjoy enjoys walking, knitting. Bit of alcohol. Nonsmoker lives with her husband at home. A MS is nine out of 10. Say what next. But you've already told me you're gonna send some blood tests so you can open up the next slide, examine her there. So she examined, she's got pain in the left hip uh and she's done some blood test as Well. Ok, so what you're gonna do next, you're gonna get an x-ray. So next slide please. Ok. So let me see if I can launch this pole. So there you go. So you might to move it out of the way. So yeah, x-ray and have a think about what you're gonna do for the patient. Everyone can a everyone can answer. Not just Matt anyone else out there. Ok, sir. I'll leave it up there. But uh is that true? Five responses? Good word. Two people or 40% of people have said to fix it with a DH S 40% said fix it with a short nail and 20 or one person wants to do a total hip replacement for this lady. So you're right. This is going back to talking about what we were talking about earlier. This is an extra capture the fracture. So you can see the intro lines intact um on the A P and the lateral. So it's sort of just below that level. So it's extra capsule so we can go ahead and fix it. And uh you could either do a DH S or a, a short nail. Um They're both fairly reasonable options, but I'll show you what we did next. So next slide we did a DH S OK. Um Thought I had some x-rays but maybe not. Uh oh they're coming up next. Ma do you want to just flash the next slide? So there you go. So we did a DH S for this patient. OK. So we put a screw up into the femoral head pla it on the outside of the femur and fixed it back together for them. OK. This allows them to walk on it straight away because if you go back a slide, trying to explain how DH S works. So you've got the screw that's fixed up in the proximal fragment and the plate that's fixed to the bottom to the distal fragment. And that screw slides within the barrel of the plate. OK. Which means that as your body weight of the patient that pushes down, you end up the screws sliding within the plate and you get controlled compression at the fracture site. And as you know, from previous sessions, you've had what we want to fracture sites is compression to allow them to heal. OK? And then over time, this fracture will heal with the patient walking on it. But the weight's coming through the metal works. So they, they've got a significant improvement in the pain. Um And they're allowed for the fracture to heal next slide how to go and then this is sort of your higher level. So this is the next um the guys coming up to the or thinking about applying for training numbers and this type of thing is the tip apex distance. This is a seminal paper of talking about DH S and screws up into the femoral head when we're talking about fixing fractures. Um And we want to keep that tip of that screw as close to the center of the femoral head as possible. So Baum Gartner wrote this paper in 95 saying that if your tip apex distance is less than 25 millimeters, the screw doesn't cut out in his series. OK. So that's why when you're putting the guidewire for those that have been in surgery, we aim for the middle of the femoral head as much as possible to reduce this, make this tip apex distance as small as possible. Um Give the chance, best chance of everything healing up and the screw not pulling out of the me uh screw, not pulling out of the bone. OK? He also showed that if you're gonna miss the center of the femoral head to i to be posterior and inferior. So, although this one's down the posterior side, it's quite a lot superior to that femoral head. OK? But that's the one paper I would say you'd be expected to know that the numbers for um coming up to interview. OK. Next slide. And the alternative, I think someone's already mentioned it was on the pole and actually half the people went for it was to do a um short intimate nail and that sort of works in the same principle, you have the, the nail that's fixed to the distal part or the shaft of the bone screw into the proximal part and that allows a bit of sliding within the nail itself. The reason that we would choose that there's three reasons why in a hip fracture, that extra capture the hip fracture that would lead us to choosing a nail over a plate. Um And the answers are up there. So I won't ask for a volunteer. But so if the, the lateral wall is not intact, OK. Um Have got a little. So I don't know whether you guys can see, I've got a little DH S here. So this is the plate of a DH S on a femur. OK? And then it's reliant on this, this bone to be intact. If that's not intact, this metal work is gonna float in the breeze so you can't use that so we can use a rod inside the bone. Um If it extends below the bottom of where DH S would fix the subtrochanteric, you can put a long DH S in. But the uh common practice now is to put a na down or if it's a reversi leak. And the reason that doesn't work is because the sliding of the, the screw within the plate is in the same direction. So you don't get that compression at the fracture site. OK? You also get a reduced le on with me of the construct if you use in that. So those are your two sort of options for your basic uh extracapsular fracture. OK. Next slide. OK. So, moving on. Is there anyone else that wants to volunteer and speak up? Sure. I'll give it a go if that's right. Yeah. So, yeah, I, I probably follow a very similar kind of pattern to mat. Um, I don't know if the N and N does Silver Trauma call but, um, put out a silver trauma call, um, go and assess the patient kind of following A TS, um, a s principles. Um, and then, yeah, once I've done that and gather a bit more of a history from the, from the patient or from any, um, relatives or care home staff who were there to witness it and see what kind of fall was it mechanical. Um, any other kind of past medical history that would be relevant, um, and kind of like follow the kind of guidance in terms of getting a further, bit more, further history. Um, and then look at the kind of investigations after that. Yeah, good. So it's a very similar management. But again, you just, you think about getting collateral history and everything else there. Um, fine. Do you want to go on to the next one? The only thing I say, someone that's just had a trip and fall at a care home. If there's nothing else, you wouldn't necessarily put out a steal the trauma call, but it's something to consider with all these patients. Um, it's becoming more and more common that patients are getting steal the trauma call. Ok. Next slide back. So, there you go. So she's got a little bit more going on than the first patient. Ok. So high BP, but she's also had a previous TIA, which she's on Aspirin. She doesn't get around quite as well. Lives in her care home and her AMS isn't quite as good. What's next? Um, so, yeah, I guess it's, um, get blood work, uh, two view imaging. So a p and lateral of the, the hip. Um, uh, yeah, and I'd want a blood gas and, uh, group and save just along with kind of standard bloods. Um, yeah, and maybe just a clotting screen just because we know that she's on a, uh, on Aspirin as well. Ok. Are you going to do anything about the aspirin, um, potentially, consider holding it? Um, it takes, uh, I can't remember, is it two or three days to clear from the system? So maybe just, uh, uh, suspend it when we're, we're kind of clocking her in. Yeah. So the half life is quite long. It's about seven days for Aspirin. So, um, actually by the time you're going to operate on her, which you're going to try and do as soon as possible, um, it's probably going to have no effect whether you keep her on it or not. Um, so what if the tia was recent then you certainly wouldn't necessarily want to stop it. Ok. Um, ok, so some blood work and anything else you're gonna do? You've taken a history, um, x-ray, so a P and natural of the hip. Um, uh, and then obviously if there's any other kind of distracting injuries, imaging of those and, uh, I mean, she's got a low A s, it's a question of whether that's new or if that's uh long standing. So, consider a CT head, if that's, if that is potentially something new good. Yeah. So think along this line of say, is the sick patients with other comorbidities? Is there something else going on? Has she had a, has she hit her head? Has she had a bleed? Something like that? But so there's no history of hitting her head. Nothing like that. Ok. Next month and your I MS is that's normal for her. Um So she's got pain in her hip Nevas intact bloods are fairly unremarkable. Um So you said you're gonna get an x-ray, which I think is the next slide. Ok. So have a go at this one, see what you would do for this patient. Good. So majority of patients, um majority of people going for the uh hip hemiarthroplasty is a replacement option. Um One person being on it and I don't know that's why you're here. So we'll try and explain everything from now. So, yeah, so we can see from this fracture pattern. If you look at where the two trach are, the greater and the lesser trach intertrochanteric line, the fracture is more proximal to that. So this isn't in capture the fracture. We go back to our garden classification. The fractures gone all the way through the neck and there's displacement of the fracture by at least 50%. So this is a, got a garden three or four. OK. Um Which means we're gonna replace it. So your replacement options really are hemiarthroplasty or a total hip replacement. Um Discussion is then whether you're gonna do. Oh, sorry. Um, I it a total or a, uh, hemiarthroplasty. Um, but in a patient with an NGA six out of 10 with other medical comorbidities, um, you're probably gonna do a hemiarthroplasty and we'll come to discuss the differences. Why you pick one over the other in a minute. Ok. So next slide, please. So indeed, uh this patient went on to have a, a hip hemiarthroplasty on that right hand side, cemented hemiarthroplasty again, I've just thrown another paper in for people that are interested at looking for getting, hitting those extra points in the, er, interview or Mr I CS and, and beyond. Um, if you ever need to quote anything, a paper about hip fractures, the chances are that Martin Parker who works at Peterborough has written about them. So, if you just throw his name in, you're probably doing, going down the right line. Ok. Um, this is a slightly older paper from 2009, but so cemented or uncemented. So, previously, historically, it used to be uncemented hip, um hemiarthroplasty used and then it moves towards cemented. Um And they found that uh cemented was less pain and less deterioration in mobility than uncemented with no change in the complication rates. OK. Next slide, we'll skip over this one. So this is just a slide about what approach you're going to use. So those coming up to the interview, think about how you're going to do the operation. Um uh, that's something you need to know different approaches to the hip, but I won't go on too much about that tonight. Next slide. So something we talked about Edward, I don't know whether you're still there, um, about when to go to theater. So we've talked about trying to get them up and mobilizing as soon as possible, um, trying to help with their pain relief. But when do we want these patients to go to theater? Um, it's a bit of time since I've, uh done this, but I think it's, I, I think it is, it both guidelines, it says 72 hours. Is that a number? The, the only number that springs to mind? Ok. Not quite, not quite, not quite. So we want them to go a bit sooner than that. Ok. So the best practice tariff, which is how we get paid says should be within 36 hours of admission to hospital. So that's coming through the front doors of A&E or diagnosis. Ok. So if they're an inpatient have a fall and then it's the time they had the x-ray. So 36 hours from time of um essentially time of diagnosis when, when either attendance to A&E or x-ray to getting them under the an or entering the anesthetic room and that looks at how we get paid. So next slide, so yeah, best practice tariffs important. The next slide in a minute would show you about what, what accounts for it. But it's a list of guidance that as hospitals and departments they try and reach um to ensure the best care for patients is actually the most important reason they'll put the money first. It's money that talks in the NHS. But if we can achieve the best practice tariff, we know that those, those give us the best outcomes for the patients. Ok. So long term outcome, increased number of patients who are independent afterwards, reduced mortality, shorter length of stay in hospital and giving us some more cost effective care. And also if you get them all, then you get 445 lbs per sp of care if you manage to hit them. So next slide please. And this is the best practice tas. Ok. So these are the the targets that uh as a hospital department you're trying to hit. Um So time to surgery within 36 hours. Ok. Admitted under the care of a consultant geriatrician and an orthopedic surgeon. Ok. So goes back to that joint care, um has an assessment protocol agreed by all um assessment by a geriatrician within 72 hours and, and ideally preoperatively and then postoperative geriatrician directed uh rehab and then further fracture prevention. So that's looking at both the reason for the falls and the bone health. So we've already mentioned that these patients are more likely to be female and osteoporotic. Um So how can we manage those? Um and how can we prevent the falls? Um What can we do to help these patients? So, again, hip fractures, it's not all just about the surgery and the orthopedic side of things. Um There's a lot of medical management involved as well. Ok. Next slide, please. Matt. Uh I won't ask for a volunteer because it gets a bit repetitive. But um, so this patient slipped and fell at home. It's very similar history to the first one. ok, so we know she had a mechanical fall, tripped on a paving stone pain in her right hip this time. Next, uh next slide, a very similar history except this patient's got af and she's on Apixaban, which is another thing to think about. We talked briefly about the aspirin in the first one, but Apixaban, another anticoagulant is gonna affect what we can do surgery wise or when we can operate surgery wise otherwise fairly well. And with it next slide, uh blood's unremarkable and problems with the right hip. Next slide. So let me go back to. But uh what's that p So what are you gonna offer for this patient? Ok. Yeah, good. So all 66 respondents have said for an intramedullary nail and I'll try and show you why with my little model here. OK. So I've drawn on the blue line effectively showing where the fracture is. And if you look at the DH S plate that finishes just at the top, yeah, you can go longer and fix it, but actually doing a nail, we can drop it all the way down the middle of the bone to try and fix everything back together. Ok. Next slide. Uh So going back to this patient, one thing we would do because it might be a bit of a wait for them to go to surgery and that come in a minute is try and help with their pain relief. We can do something called skin traction. Um especially for the subtrochanteric or more distal femoral fractures, putting them in skin traction can really help. It helps the patient keeping the bone fragments still. It stretches the muscles so they don't shorten. So that helps us with the operation. Ok. Um And it does give good pain relief to the patients. It does look a little bit medieval in the sense that you're strapping someone's leg to a uh a bandage and then hanging a weight off the end of their bed. Um But it really does work. Um If you warn the patients, it's gonna look a bit funny. Uh They're all fairly uh good with ha and happy with having it. Uh and can do quite well and the pain relief they get is quite significant and people are very happy with it. Uh And is a stock gap until they get their operation. The reason why it might be important in this patient's case is because they're on Edoxaban, uh sorry, Apixaban. Um They have got a high risk of bleeding when it comes to doing the operation. Um And every hospital you have will have guidelines as to um what uh and when to do an operation after having uh the Apixaban or blood thinners, especially the dox. Um And if you just go to the next slide, so this is a copy of it doesn't really project particularly well, but this is a copy of uh one of the local hospitals guidance as to when you can have uh the surgery after taking your last dose of the, of any anticoagulants. So you can see at the top, um you can get on with surgery as soon as possible with the aspirin for the previous case. And then down the bottom. When you look at the uh Edoxaban, if they've got normal renal function, you can do it after 24 hours, uh or 48 hours. Uh If there, if their EGFR is less than 60 obviously, that does come into quite significant contrast with the best, best practice tariffs. Um So it's something to consider you got, there's ongoing trials at the moment, looking at anticoagulants in hip fracture patients and whether it affects their outcome, whether we operate on them early or wait till uh there's been uh a reversal to it. Ok. Maxzide. Yeah. So this is the operation that we did. So we uh a long femoral nail all the way down the length of the femur try and fix that that fracture in place. OK. Uh Just conscious of time, what would do it? I think you guys should be able to access these slides because I've uploaded them if you go to the next slide. One of the things that's um commonly asked in er ST three interviews is about displacement of fractures and subtrochanteric proximal femur fractures are a real easy one for them to ask about they very common. Um and being aware of where the fracture moves um as a result of the muscle pull on the different er fragments of the fracture um is quite important um Both surgically because we need to know about what we're reducing um to, to ensure that we get everything back anatomically and help everything, right? So this just gives a brief outline that you can find that online next slide. OK. If we, so if you just wanna skip a couple of head to the x-ray mat, so again, fairly straightforward history from a patient who's had a mechanical fall and they've now got this, but in this case, the patient's only 72 they live at home alone. Er, they're fairly independently mobile. Um, and they've got this hip fracture. So case number four. Yeah. So. Mm. Ok. So people are going for a fixation here. So it probably doesn't project particularly well. But um this is actually an intracapsular fracture. Ok. Um You can see the in intertrochanteric line and the fracture line is, yeah, I think it's probably due to the projection. I've got it on my screen on. Um but it is an inter CAPP fracture in a fairly mobile patient. So going back to our previous discussion about this is a displaced inter CAPP fracture. I know someone's mentioned having cannulated screws, that's a more complex high level discussions. So we won't go into that too much. But essentially if we call this a garden three cl fracture, we're gonna want to replace it. But this patient is very different to the previous patient we had previously, we had an 88 year old lady who was in a care home. You didn't really get round much. This is a 72 year old lady who gets round quite comfortably, does a lot of walking and wants to get back to the best mobility she can get so we can have that discussion about total hip or half a hip replacement. So next slide please. And so this is what nice guidance is. OK? So if patients are able to walk independently outdoors with no more than the use of one stick and not cognitively impaired and are medically fit for anesthesia, then they should, then it should be considered to have a total hip replacement replacement. So it doesn't say you have to but considered for it. So we should offer it. Ok. There are risks and benefits of both. Um So we know that in patients with uh who have total hip replacements after a hip fracture, they are at higher risk of dislocating as compared to patients that have a total hip replacement for uh arthritis. Um We also know it's a slightly longer operation. Um But chances are they get a bit better mobility afterwards. Um And they have reduced risk of acetabular wear. Ok. So if you think about having a metal ball as you do in a hemiarthroplasty rubbing on your pelvis, chances are that your, your acetabulum is gonna wear out from the metal ball rubbing on it. Whereas with a total hip replacement, you're replacing the two surfaces and you're less likely to get the work. Ok. So next slide. So this patient could go on and have a total hip replacement. So there's the picture for you. OK. What we'll do? I've got one more. OK? And then we can hand over soap to go to the next slide. So we're getting slightly younger. We've got a 62 year old gentleman who's a painter. Fell from a ladder, no other injuries. So this is where it's really important to do your A TLS management. Ok. He, he's had a quite significant injury, pain in his right hip. Has he got a distracting injury? Is there anything else going on? Uh, next slide? Uh, he's otherwise fit and well enjoys cycling. Lives with his wife. A MS is 10 out of 10 ex slide. He's got pain in his right hip. He's not able to lift it up to straight leg raises, but he's holding his hip. Normally. He's got no other problems. He did go through a trauma ct and there was nothing else that was uh pain in his right hip. So if you show the x-ray. Mhm. So it's pain in the right hip. So what are you gonna do for this patient? Good. Ok. So everyone said you're gonna fix it. So this is sort of the final option when we talk about different hip fractures. So this is your intracapsular Garden two fracture. So it's, it's at the base of the, the head, um at the top of the neck, it's gone all the way through, but it's very minimally displaced. He's a fairly fit and well gentleman. And so if you can, you want to try and save the femoral head as much as possible. So the blood supply may have been damaged or it may not have been, it's difficult to know. Um But if we can, we can try and save it as much as possible. So, uh we did indeed do cannulated screws for this gentleman to hold that head where it is and try and allow everything to heal. But someone answered DH S and it's not unknown to do too old, too whole short DH S for these patients. Um, if you go to the next slide show you some of the options. 00, ok. So just go to the one after that, we'll come back to that. So here you go. On the left hand side, you can see what cannulated screws look like. So tends to be three in, in, in an inverted triangle pattern, going up into the femoral head to try and hold everything where it should be, allow that fracture to heal. What you'll see on the right hand side is a very similar device that's used um in one of the hospitals in our region, a newer device that has shown to have better outcomes than cannulated screws. Um but it's not taken off everywhere yet, but may well be more coming out which is a plate and screw construct very similar to how you would expect a short DH s to look as well. OK. So if you just go back one slide back, so talk about the management. So fix or replace is really the discussion at this stage. So you can fix it, you get a shorter operation, reduced hospital, uh reduced hospital stay lower incidence of perioperative complications, lower one year mortality, less pain, a year, less reduction in mobility and lower dependence on the walking aids. But you do have a higher chance of it not healing. Ok. So nonunion or the blood supply has been damaged and it may be that they end up with avascular necrosis of that femoral head and require further operations. If you were to do a replacement surgery, we know that there's a lower reoperation rate and a lower readmission rate. And again, Parker the paper to quote. Ok. Um So there are risks and benefits and it's about having a discussion with the patient regarding this and what they want to r take the risks of. Ok. So keeping their femoral head is obviously gonna be uh better for them. Uh But yeah, as long as it survives. Ok. Ok. I think what we'll do is I'll stop there. Do you wanna just go slide 66 mat? I don't know whether you can jump to the end. There you go. So this is just a summary of the management options that we have. So we talked about cannulated screws, DH s inu nails, the partial hip replacement, the hemiarthroplasty or the total hip replacement to manage these proximal femur or hip fractures. Does anyone have any questions? Thanks, Ben. Um Yeah, I, I do. Um So 5 to 10% of body weight for skeletal traction in a sort of a distal femur or midshaft form of fracture, realistically with skin traction. What should we be aiming for? Is it a percentage of body weight or it always seems to be uh 35? The? Yeah, so I've, I've never found uh a good reference to tell you how much to wear, to how much to weigh on it. Um I've, yeah, had a lot, a lot of look trying to find it. So, yeah, up to 10% body weight tends to be the max you would use. Um That's the numbers quoted in definitely in Children and in adults, you're right. It does seem to be on skeletal traction, does seem as though you can use it on skin traction, but that's a hell of a lot of weight on some patients. Um It tends to be the 3 to 5 kg dependent on their body size and their response. So you can, it's all about reviewing and put a lower weight on, see what happens. Um And you can always increase it as needed. I don't know whether Mr Singh has a no, I mean, the only other thing to be wary of Matt is um the only other thing to be considered is um this condition of the skin. So you have to be really careful if the skin looks papery thin and then you just put on either 10% body weight or like 6 to 8 lbs that we normally put on. And then you get a deep loving injury. So it's just um it's all good in theory, but a lot of it is just what the patient's skin is like and what you'll think they'll tolerate. Ok. Thank you, Ben. One other thing I was just going to sort of say, perhaps that could have been very, very much spelt out is that the premise of this, as you've mentioned is pain relief. But the only other thing that I think you might have mentioned is that everybody after all of these operations should be fully weight bearing. So, one of the key principles in the management of neck of femur fractures or indeed, most femoral fractures, er, particularly those in the frail elderly. Are, are, are that on the op note, the invariable weight bearing status should be fully weight bearing. If you can't fully weight bear, bear your patient, you haven't done the right operation, er, for these frail elderly, these guys don't partially weight bear, they don't toe touch weight, bear. And if you leave them in bed, they don't do well. Yeah, I did. Yeah. Ok. What do you want to stop sharing those slides? Ben just ma said, even with cannulated screws, and the argument is yes, even with cannulated screws. And so as you'll probably notice actually, particularly in the frail elderly. So traditionally, you were taught that when you did canny screws, you did non weight bearing for six weeks, partial weight bearing for six weeks and then let them go after that, but old people cannot non-weight bear, they just can't. And so if you're gonna do cannulated screws, you have to have the faith of your convictions and your screws and just let them fully weight bear on them. Or as the most of us now, in fairness, we very rarely use cannulated screws. And most of us would just say, right. Do you know what? Particularly if you're old bit frail, You just want one operation and you just want uh a hemiarthroplasty for an intra capsular fracture. So most of us would do a, a hemiarthroplasty for intra capsular fractures even if they're relatively under space because in our minds, it's one operation fire and forget. You never see them again with cannulated screws. You are required to follow up patients for two years because otherwise we don't normally follow neck of femurs up. And the reason you have to follow them up for two years is because of the risk of a VN uh uh of the femoral head. Yeah, indeed. I think the uh the evidence is suggesting that um two whole DH SS and these other newer tech devices like the target plate um are better because you can fully weight, bear them and uh straight away. Um Yeah. Right. Ben. Shall I have a go and see if I can share mine having uh what you struggle with yours. Yeah, let me see if uh it's asking about. Um So I think I have to share my entire screen. Can you?