Makindo Medical Notes

⚠️ Key Point: Intracapsular fractures have a higher incidence of AVN (Avascular Necrosis) and non-union due to the femoral head blood supply. 👉 If displacement is minimal → internal fixation gives best outcome. 👉 If displaced → high risk of AVN, so prosthesis insertion is usually required.

ℹ️ About

• 🦴 Intracapsular fractures carry high AVN risk.
• ☠️ 30% of patients die within 1 year.
• 👵 Most common in the elderly due to frailty and falls.
• 🧓 Patients often have multiple co-morbidities.
• 🦴 Osteoporosis is the major underlying factor.

📊 Epidemiology

• ~80,000 hip fractures per year in the UK.
• Numbers are rising as the population ages.

🧠 Anatomy

🧬 Aetiology

• Falls + Osteoporosis are the commonest causes.
• The medial femoral circumflex artery supplies the femoral head ➝ vulnerable in NOF fractures.
• Vascular compromise ➝ ischaemia ➝ AVN.

📉 Risk Factors for Bone Fragility

• Osteoporosis: age, inactivity, smoking, alcohol, low BMI, family history.
• Previous fragility fracture ➝ doubles future fracture risk.
• Other causes: metastases, Paget’s disease, osteomalacia, hyperparathyroidism, myeloma.

🤕 Risk Factors for Falls

• Muscle weakness, gait or balance problems.
• Neurological diseases: Parkinson’s, stroke.
• Poor vision.
• Medications: sedatives, hypnotics, diuretics, antihypertensives, alcohol.

🩺 Clinical Features

• Pain + external rotation, adduction, and shortening of the affected leg.
• History: establish whether mechanical fall or medical cause (syncope, arrhythmia, hypotension).
• Check co-morbidities that influence management.

📌 Types of Fracture

• Intracapsular: High risk of AVN + non-union. Tx = hemiarthroplasty/THR.
• Subcapital & Transcervical: Common intracapsular fracture patterns.

🗂️ Garden Classification

• Type I: Incomplete fracture
• Type II: Complete, undisplaced
• Type III: Complete, partially displaced
• Type IV: Complete, fully displaced

📌 Extracapsular Fractures

• Trochanteric
• Transtrochanteric
• Subtrochanteric

Other Fractures

• Pubic ramus fractures (usually conservative).
• Acetabular fractures (conservative unless complex).

🔍 Investigations

• Baseline bloods: FBC, U&E, clotting, group & save.
• CXR + ECG (pre-op assessment).
• Pelvic AP X-ray (compare both hips, check pubic rami).
• Lateral hip X-ray (often diagnostic when AP is normal).
• MRI/CT if X-rays inconclusive (10% occult fractures).

🛡️ Prevention

• Falls risk assessment + home/environment modifications.
• Muscle strengthening + balance retraining (e.g. Tai Chi).
• Bisphosphonates increase bone density, reduce fracture risk.
• Calcium, Vitamin D, ± HRT can reduce risk.

📊 Mortality: 10% at 30 days, 30% at 12 months (reflecting frailty + co-morbidities).

🛠️ Treatment Options

• Conservative: For patients unfit for surgery ➝ bed rest, analgesia, physio. Poor outcomes.
• Surgical: Standard of care.
  • Internal fixation: For undisplaced intracapsular (cannulated screws/DHS). Also for young with displaced fractures.
  • Hemiarthroplasty: For older patients with displaced fractures ➝ faster recovery.
  • Total Hip Replacement (THR): For active elderly/younger displaced fractures ➝ better function long term, higher surgical risk.
  • Intramedullary nailing: For extracapsular/subtrochanteric fractures ➝ early mobilisation.
  • DHS: For intertrochanteric fractures ➝ controlled collapse and healing.

In frail elderly after a hip fracture, annual IV zoledronate not only prevents further fractures but also reduces mortality. This is unique among osteoporosis treatments and why geriatricians are so keen to give it post-fracture. 5 mg IV once yearly, infused over at least 15 minutes. Ensure adequate vitamin D and calcium before infusion (correct hypocalcaemia).

🩺 Management

• ABC resuscitation.
• Analgesia (including fascia iliaca block).
• IV fluids & electrolyte correction.
• Orthogeriatric review early.
• Admit + imaging if unable to walk or occult fracture suspected.
• Assess mental state, pressure sore risk, nutrition.
• Surgery:
  • Intracapsular undisplaced ➝ cannulated screws.
  • Intracapsular displaced ➝ hemiarthroplasty or THR if fit.
  • Extracapsular ➝ screws/nailing depending on pattern.
• VTE prophylaxis ➝ stockings + LMWH/DOAC until mobilising.

🏃‍♀️ Post-Surgical Care & Rehabilitation

• Early mobilisation with physio ➝ prevents DVT, improves outcomes.
• Pain management + infection prophylaxis.
• Monitor for complications: infection, non-union, prosthetic dislocation.
• Rehab programmes: strength, balance, gait training ➝ reduce future falls.

⚠️ Complications

• AVN (esp. intracapsular fractures).
• Non-union (esp. displaced fractures).
• Osteoarthritis.
• DVT/PE.
• Surgical site infection, prosthetic dislocation.

📈 Prognosis

• Outcome depends on age, co-morbidities, and rapidity of surgery.
• Mortality: ~30% at 1 year, largely due to frailty not fracture itself.
• Good surgical + rehab care ➝ mobility and independence can be maintained.

✅ Conclusion

Fractured neck of femur is a major orthopaedic emergency, common in elderly patients with osteoporosis and falls. Intracapsular fractures are particularly high risk due to compromised blood supply ➝ AVN + non-union. Prompt surgical management (fixation or replacement), multidisciplinary orthogeriatric input, and effective rehab are key to improving survival and function.

📚 References

• Royal College of Physicians – Fractured Neck of Femur
• NICE – Hip Fracture Management Guidelines
• Mayo Clinic – Hip Fracture
• UpToDate – Hip Fracture Overview
• British Orthopaedic Association – Hip Fracture Guidance