Assessment and management of proximal femur fractures
by James Donaldson

Scenario: called to A&E to assess a 89 year old lady with low energy fall and shortened externally rotated leg.

History:

Age

Time/date of injury

Past medical/surgical history

Fitness for anaesthesia
Co-morbidity
Anticoagulation

Medication/drugs and allergies

Social history

Where do they live? House/flat/bungalow, nursing home
Social support, mobility aids, home help, carer, family involvement

AP pelvis and lateral hip X-rays

If the diagnosis is in doubt MRI (CT if not available) should be performed as soon as possible.

                                Injury features

Low energy injury in elderly



Consider stress fracture in young patient with unaccustomed or repetitive strenuous activity


High energy trauma in young


Secondary to metastatic disease
                            Signs and Symptoms

Short, externally rotated leg following innocuous fall
Unable to walk


Recent change in activity
Insidious onset
Relief of pain with rest


Associated with multiple injuries.
ATLS protocol

History of cancer (breast, lung, thyroid, kidney, prostate commonly)

X-rays & Management

Intra-capsular fracture
                        Management
  • Resuscitation with IV fluids, oxygen and analgesia. Fascia iliaca block if possible.
  • Medical work-up with appropriate care of the elderly/physician involvement
  • Discuss with family associated mortality (up to 30% at one year)
  • Admit for surgery
  • DVT prophylaxis
  • If young (<45 years) call senior regarding urgent reduction and fixation
Classification and Treatment
  • Dependent on Garden Classification
  • Consider fixation in all young patients and in Garden 1 – 2
  • Cemented hemi-arthroplasty in frail and elderly
  • Total hip replacement if independently mobile prior to injury
Extra-capsular fracture
                        Management
Principles as above except for the urgent need for fixation – capsular blood supply is not compromised
                        Treatment
  • Dynamic hip screw (DHS) in majority
  • Consider intra-medullary nail in reverse oblique, subtrochanteric fractures and where the lateral wall is compromised

British Orthopaedic Association Standards of Care for patients with fragility hip fractures:

  • Prompt admission (<4 hours) to ward
  • Secondary prevention and falls assessment
  • Multidisciplinary team management
  • MRI if X-rays are inconclusive
  • Immediate and sufficient analgesia
  • Identify and treat co-morbidities so as not to delay surgery
  • Operate within 36 hours on a planned trauma list
  • Operate to allow the patient to fully weight bear
  • Orthogeriatric input and assessment within 72 hours
  • Assess for cognitive impairment and delirium
  • Consider surgery even if it is palliative
  • DVT prophylaxis
  • Educate patient and family about treatment, care and rehabilitation
  • Submit data to National Hip Fracture database