Band 5 Presentation Fractured Neck of Femur Rónán Donohoe, 11 May ‘10

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Fractured Neck of Femur

Outline:1. Facts & Figures2. Classification of the hip fractures3. Surgery4. Complications5. Mobilisation after hip fracture

1. Facts & FiguresIncidence• An estimated 80,000 hip fractures occur perannum 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 haveosteoporosis

• 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 £6million 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 height4. Pathologic fracture (bone weakened from tumor or infection)

Band 5 Presentation Fractured Neck of Femur Rónán Donohoe, 11 May ‘10

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2. Classifications of hip fracture

• Lots of different classification systems for hip fractures based on site offracture, trabecular lines, displaced or undisplaced.

• #NOF not to be confused withintertrochanteric #s (across gtr trochanter)

• Other types of #NOFs: Subcapital,Transcervical

Garden’s ClassificationI - Incomplete or ImpactedII - Complete no displacementIII - Complete with partial displacementIV- Complete with total displacement

3. SurgeryThe primary concern with femoral neckfractures is that the damaged blood supply tothe 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 wellfor less active or older patients)• The degree of osteoporosis present

ORIF / Bone ScrewsGenerally only done in patients with a well aligned and minimally displacedfemoral neck fracture.In young patients, hip pinning may be attempted even if the bones not properlyaligned. Can generally weight bear as much as is tolerated (WBAT)

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

Band 5 Presentation Fractured Neck of Femur Rónán Donohoe, 11 May ‘10

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Arthroplasty / ProsthesesUsually for # NOF in Elderly > 60 yearsInvolves 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 acetabularerosion is presentPrecautions for patients to prevent hip dislocation aftertotal hip replacement1. No hip flexion beyond 90°2. No crossing of the legs (hip adduction beyond neutral)3. No hip internal rotation past neutral

4. ComplicaitonsMain 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 union1. Intra-articular fracture (synovial fluid a deterrrent to union)2. Poor vascular supply3. Lacking periosteum & union is endosteal4. # subjected to high shearing forces5. Bone quality may poor

Band 5 Presentation Fractured Neck of Femur Rónán Donohoe, 11 May ‘10

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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 orinternal fixation of bone.

• Patients with cementless, or ingrowth, joint replacements are put on partialweight bearing (PWB) or toe-touch weight bearing (TTWB) for 6 weeks toallow 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 mobilisewithout any assistive devices. (Vanderbelt Med. Ctr. online)

Postoperative (day 1)• 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 chairPostoperative (day 2)• Initiation of gait training with the use of assistive devices, such as crutches

and a walker• Continuation of functional transfer trainingPostoperative (days 3-5 or on discharge to the rehabilitation unit)• 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 trainingPostoperative (day 5 to 4 weeks)• Strengthening exercises - For example, seated leg extensions, side-

lying/standing hip abduction, standing hip extension and hip abduction, kneebends, bridging

Handoll HHG, Sherrington C. Mobilisation strategies after hip fracture surgery inadults. Cochrane Database of Systematic Reviews 2007, Issue 1.

“There is insufficient evidence from randomised trials to establish the effectiveness of thevarious mobilisation strategies used in rehabilitation after hip fracture surgery. Furtherresearch is required to establish the possible benefits of the additional provision ofinterventions, including intensive supervised exercises, primarily aimed at enhancingmobility.”

References:• Lawrence TM, White CT, Wenn R, Moran CG. The current hospital costs oftreating hip fractures. Injury. 2005; 36(1):88-91.

• Parrott S. (2000). The Economic Cost of Hip Fracture in the UK.

Band 5 Presentation Fractured Neck of Femur Rónán Donohoe, 11 May ‘10

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The University of York. website:http://www.dti.gov.uk/homesafetynetwork/pdf/hipfracture.pdf

• Scottish Intercollegiate Guidelines Network. (2002). Preventionand Management of Hip Fracture in Older People, A nationalclinical 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: DoesAge Influence Acute Hospital Stay, Delay to Surgery, and Acute Care Costs?Orthopedics: Mar 10:160-165.