Band 5 Presentation

Fractured Neck of Femur

Rónán Donohoe, 11 May ‘10

Fractured Neck of Femur
Outline: 1. Facts & Figures 2. Classification of the hip fractures 3. Surgery 4. Complications 5. Mobilisation after hip fracture 1. Facts & Figures
Incidence • An estimated 80,000 hip fractures occur per annum in the UK (2005/6 figures) • Prevalence of hip fractures is increasing: current predictions suggest it may reach 120,000 per annum by 2015, a 6% increase each year • 90% of hip fractures occur in people aged over 65. • Female to male ratio 3:1 • In the UK lifetime incidence of hip fracture is 18% for women and 6% for men. • Occupies 20% of Orthopaedic beds • Average length of stay 20 days • Hip fractures cost the NHS £840m a year [NHS review] Mortality rates: • Mortality rates can be up to 30% at 1 year. • Mortality rates are higher in men than women. • Mortality is usually due to: Infection e.g. pneumonia, septicaemia, influenza, Myocardial infarction, CVA, Cardiac decompensation Causes of Hip fractures: 1. Osteoporosis - The National Osteoporosis Society estimates that: • 33% of women and 8% of men in the UK over the age of 50 will have osteoporosis • Each year over 70,000 osteoporotic hip fractures occur. • 1,150 people die every month in the UK as a result of hip fractures. • Combined cost of hospital and social care for patients with a hip fracture amounts to more than £2.3billion per year in the UK (approximately £6 million a day) 2. Low energy trauma in elderly patients • Direct: Fall on greater trochanter or forced external rotation • Indirect: Muscle forces overwhelming bone strength 3. High energy trauma in younger patients – e.g. RTA, Fall from height 4. Pathologic fracture (bone weakened from tumor or infection)

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Band 5 Presentation

Fractured Neck of Femur

Rónán Donohoe, 11 May ‘10

2. Classifications of hip fracture
• • • Lots of different classification systems for hip fractures based on site of fracture, trabecular lines, displaced or undisplaced. #NOF not to be confused with intertrochanteric #s (across gtr trochanter) Other types of #NOFs: Subcapital, Transcervical

Garden’s Classification I - Incomplete or Impacted II - Complete no displacement III - Complete with partial displacement IV- Complete with total displacement

3. Surgery
The primary concern with femoral neck fractures is that the damaged blood supply to the bone will lead to avascular necrosis (AVN) of the femoral head. In these cases, patients may require a THR. Treatment depends on several factors such as: • The amount of displacement of the fracture • The age of the patient (Hip replacements tend to wear out in younger, more active patients but work well for less active or older patients)

• The degree of osteoporosis present
ORIF / Bone Screws Generally only done in patients with a well aligned and minimally displaced femoral neck fracture. In young patients, hip pinning may be attempted even if the bones not properly aligned. Can generally weight bear as much as is tolerated (WBAT)

• Cannulated Cancellous Screw (CCS) 6.5mm • Dynamic Hip Screw (DHS)

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Band 5 Presentation

Fractured Neck of Femur

Rónán Donohoe, 11 May ‘10

Arthroplasty / Prostheses Usually for # NOF in Elderly > 60 years Involves prosthetic replacement of one or both sides of a joint • Hemiarthroplasty 1. Unipolar prosthesis (where only the head is replaced) • Austin Moore prosthesis (cementless) • Thompson prosthesis (cemented) Note: titanium implants are capable of osteointegrating without cement 2. Bipolar prosthesis (A two component prosthesis) • E.g. prosthetic femoral head articulating with a polyethylene liner in the acetabular component

• Total joint arthroplasty (THR) - when acetabular erosion is present Precautions for patients to prevent hip dislocation after total hip replacement 1. No hip flexion beyond 90° 2. No crossing of the legs (hip adduction beyond neutral) 3. No hip internal rotation past neutral

4. Complicaitons
Main Risks Following ORIF: • Non–Union 20-30% • Avascular Necrosis 10-20% • Conversion needed 25-30% Main Risks Following Arthroplasty: • Sepsis <5% (mortality >50%) • Dislocation: 4% Hemi, 10% Total • Re-operation 10% Reasons for non union 1. Intra-articular fracture (synovial fluid a deterrrent to union) 2. Poor vascular supply 3. Lacking periosteum & union is endosteal 4. # subjected to high shearing forces 5. Bone quality may poor Page 3 of 5

Band 5 Presentation

Fractured Neck of Femur

Rónán Donohoe, 11 May ‘10

5. Mobilisation & rehab after hip surgery
• • Patients with cemented joint replacements can weight bear as tolerated (WBAT) unless the operative procedure involved a soft-tissue repair or internal fixation of bone. Patients with cementless, or ingrowth, joint replacements are put on partial weight bearing (PWB) or toe-touch weight bearing (TTWB) for 6 weeks to allow maximum bony ingrowth to take place. - a progressive weight bearing program is initiated - 1/3 body weight on at 6/52 post-operative; - at 8/52 progress to 2/3 body weight; - at 10/52 progress to full body weight, continuing to use the walker/crutches for 2 more weeks; - at 12/52post operative, patients are progressed to stick; - when the patient is able to ambulate without a positive Tredenlenberg, the stick is discontinued and the patient is encouraged to mobilise without any assistive devices. (Vanderbelt Med. Ctr. online) Initiation of bedside exercises - Such as ankle pumps, quadriceps sets, and gluteal sets Review of hip precautions and weight-bearing status Initiation of bed mobility and transfer training - Bed to/from chair Initiation of gait training with the use of assistive devices, such as crutches and a walker Continuation of functional transfer training Progression of ROM and strengthening exercises to the patient's tolerance Progression of ambulation on level surfaces and stairs (if applicable) with the least restrictive device14 Progression of ADL training lying/standing hip abduction, standing hip extension and hip abduction, knee bends, bridging

Postoperative (day 1)
• •

• Postoperative (day 2)

• Postoperative (days 3-5 or on discharge to the rehabilitation unit)
• • •

Postoperative (day 5 to 4 weeks) • Strengthening exercises - For example, seated leg extensions, side-

Handoll HHG, Sherrington C. Mobilisation strategies after hip fracture surgery in adults. Cochrane Database of Systematic Reviews 2007, Issue 1.
“There is insufficient evidence from randomised trials to establish the effectiveness of the various mobilisation strategies used in rehabilitation after hip fracture surgery. Further research is required to establish the possible benefits of the additional provision of interventions, including intensive supervised exercises, primarily aimed at enhancing mobility.”

References:
• Lawrence TM, White CT, Wenn R, Moran CG. The current hospital costs of treating hip fractures. Injury. 2005; 36(1):88-91. • Parrott S. (2000). The Economic Cost of Hip Fracture in the UK.

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Band 5 Presentation

Fractured Neck of Femur

Rónán Donohoe, 11 May ‘10

The University of York. website: http://www.dti.gov.uk/homesafetynetwork/pdf/hipfracture.pdf • Scottish Intercollegiate Guidelines Network. (2002). Prevention and Management of Hip Fracture in Older People, A national clinical guideline. Royal college of Physicians Edinburg. • Vanderbilt University Medical Center: http://www.greatseminarsandbooks.com/Tips/Entries/TotalHipProtocol.htm • Verma R, Rigby A, Shaw C, Mohsen A. (2010) Femoral Neck Fractures: Does Age Influence Acute Hospital Stay, Delay to Surgery, and Acute Care Costs? Orthopedics: Mar 10:160-165.

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