Fractured Neck of Femur

(NOF)

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Definition

-  Fracture through neck of femur +/- displacement

 

Features

-  Ass w significant mortality & morbidity

-  15-20% mortality in 1 yr

-  Most commonly ass w fall

-  Highest prev in white women

 

Risk Factors

-  Osteoporosis

-  4-8% osteomalacia

-  Fall

-  Dementia

-  Pathological fracture

 

Associated S/S

-  Shock: loss of up to 1.5L

-  If ass w fall: rhabdomyolysis

-  Concurrent pubic rami fracture

-  Avascular necrosis (AVN) of femoral head

-  11% incidence in undisplaced fractures

-  <80% in displaced fractures

-  Exam

-  Ipsilateral abrasion & trauma: haematoma, laceration

-  Limb shortening w external rotation & abduction

-  Internal rotaion elicits pain in hip/groin

-  Neurovascular exam

 

Ix

-  U&E, CK: rhabdomyolysis

-  X-rays

-  AP, lateral & internal rotation views

-  Pubic rami fracture

-  Non-displaced or minimally difficult to Dx on x-ray

-  AVN: stage 0-4

-  Osteoporosis work up

-  LFTs, Ca, Vit D, PTH, TSH, Serum Testosterone (men)

-  BMD

 

Classification

-  Garden I

-  Incomplete/impacted #, inf neck still intact

-  Femoral head tilted poterolat, valgus angulation at # site

 

 

-  Garden II

-  Complete # wo displacement

-  Slight varus deformity

-  Nil impaction

 

 

-  Garden III

-  Complete fracture w partial displacement

-  Continuity btwn fragments

-  Shortening & ext rotation of distal fragment

 

 

-  Garden IV

-  Complete fracture w total displacement

-  Nil continuity btwn prox & dist fragments

-  Femoral head has normal alignment w acetabulum

 

 

Mx

-  IV fluids

-  Analgesia: Morphine 0.1 mg/kg IV/IM/SC 4/24

-  Muscle relxant

-  Based on Garden score I-IV

-  Sx

-  Pre-op

-   DVT prophylaxis

-   Osteoporosis Mx

-   Vitamin D: 400-800 Units/day

-   Calcium

-   Bisphosphanates

-   Abx

-   Cephazolin 1g (Adult > 80kg 2g) IV 15-30min prior to first incision

-   Then 1g (Adult > 80kg 2g) IV 8/24 x2 doses

-  Procedures

-   Garden I, II

-   Closed reduction & internal fixation w cannulated screws or pins

-   Garden III, IV

-   Closed reduction & internal fixation w cannulated screws OR

-   Hemiarthroplaty: femoral head & neck

-  Austin Moore’s prosthesis

 

 

-   Open reduction

-   Total Hip Replacement (THR)

-   Usually for pts w RA or hip arthrosis

-   Femoral head + acetabulum

 

 

-  Complications

-   DVT

-   Pressure ulcers: sacral, ischial, trochanteris, heel

-   Non-union

-   AVN: usually 8-12/52 but upto 2yrs