Summary

Hip fractures are the defining injury of frailty, representing a catastrophic health event for the elderly. The incidence is rising (75,000/year in UK), with a 30-day mortality of 7-10% and 1-year mortality of 30%. The anatomical location of the fracture relative to the capsule defines the biological risk: Intracapsular fractures disrupt the retrograde blood supply (Medial Circumflex Femoral Artery), risking Avascular Necrosis (AVN), and usually require Arthroplasty (Replacement). Extracapsular fractures occur in the cancellous vascular bed, retain blood supply, but are mechanically unstable, requiring Fixation (DHS or Nail). Management is strictly protocolised (e.g., UK National Hip Fracture Database), emphasizing surgery within 36 hours, Fascia Iliaca Block for analgesia, and shared Orthogeriatric care. [1,2,3]

Key Facts

• The "Big 6" Care Standards:
  1. Admit to Orthopaedics <4 hours.
  2. Surgery <36 hours.
  3. Orthogeriatric Assessment <72 hours.
  4. Pressure Ulcer prevention.
  5. Bone Health Assessment.
  6. Delirium/Falls Assessment.
• Mortality: Peri-operative fluid optimisation and prompt fixation significantly reduce death. Delay >48h doubles mortality.
• Fascia Iliaca Block: The gold standard analgesic. Single shot 30-40ml Levobupivacaine (0.25%). It blocks the Femoral, Obturator, and Lateral Cutaneous nerves safely in the ward setting. Opioid sparing.

Clinical Pearls

"The <60 Rule": A displaced Intracapsular fracture in a young patient is a Vascular Emergency. The femoral head is salvageable if reduced and fixed within 6 hours. This is the only hip fracture that goes to theatre at 3 AM. The risk of AVN increases exponentially with time.

"The Occult Fracture": Elderly patient falls. Hip pain. Not shortened. CANNOT straight leg raise. X-rays normal. This is a fracture until proven otherwise. MRI within 24 hours. Do not mobilize. If MRI contraindicated, CT is second line.

"Tip Apex Distance (TAD)": For DHS fixation, the screw tip must be deep and central. The sum of the distance from the tip to the apex on AP and Lateral views must be <25mm. >25mm = High risk of screw "cut-out" (tearing through the head).

"The One Year Rule": 1/3 die, 1/3 lose independence/institutionalised, 1/3 regain previous function.

                 HIP FRACTURE (NOF)
                         ↓
                FRACTURE LOCATION?
               ┌──────────┴──────────┐
         INTRACAPSULAR           EXTRACAPSULAR
       (Vascular Risk)          (Mechanical Risk)
              ↓                        ↓
        DISPLACEMENT?            FRACTURE LEVEL?
        ┌─────┴─────┐           ┌──────┴──────┐
    UNDISPLACED  DISPLACED   INTERTROCH    SUBTROCH
  (Garden I/II) (Garden III-IV)    ↓          ↓
        ↓           ↓           STABLE?     IM NAIL
     FIXATION      AGE?       ┌────┴────┐
   (Cannulated      ↓       YES         NO
     Screws)       <60     (2-Part)  (Reverse Oblq)
                URGENT       ↓          ↓
               FIXATION     DHS      IM NAIL
              (DHS/Screw)
                    ↓
                   >60
              FIT FOR THR? (NICE)
              ┌─────┴─────┐
             YES          NO
              ↓           ↓
             THR         HEMI

A. Cannulated Screws

• Indication: Undisplaced Intracapsular (Garden I/II).
• Technique: Percutaneous insertion of 2 or 3 parallel screws. Minimally invasive. Preserves natural hip.
• Risk: 10% failure (later displacement or AVN).
• Mobilisation: Full weight bearing immediately.

B. Hemiarthroplasty (Half-Hip)

• Indication: Displaced Intracapsular in Elderly/Frail/Demented/Low Demand.
• Technique: Replace the femoral head with a metal ball. Leave the acetabulum alone.
• Cement: Cemented stems perform better (less pain, less loosening, better function) than uncemented in osteoporotic bone.
• Risk: Acetabular erosion over time (Acetabularitus). Dislocation rate 1-3%.

C. Total Hip Replacement (THR)

• Indication: Displaced Intracapsular in "Fit" Elderly.
• NICE Criteria (Must have ALL):
  1. Walk independently out of doors with no more than 1 stick.
  2. Cognitively intact (AMT >8/10) - Can engage with rehab.
  3. Medically fit for anaesthesia (ASA 1-3).
• Benefit: Better functional outcome, less pain, lower re-operation rate than Hemi.
• Risk: Higher dislocation rate (3-5%). Longer operation.

D. Dynamic Hip Screw (DHS)

• Indication: Stable Intertrochanteric fractures.
• Mechanism: A large lag screw slides inside a barrel plate side-arm. This allows "Controlled Collapse" of the fracture site when the patient walks, compressing the fracture surfaces together.
• Key Step: The lag screw thread must be in the head, but the smooth shank must cross the fracture line to allow sliding.

E. Intramedullary (IM) Nail (Long or Short)

• Indication: Unstable Intertrochanteric / Subtrochanteric / Reverse Oblique.
• Rationale: The nail sits in the centre of the femoral shaft. This moves the load closer to the anatomical axis (lever arm reduced), reducing stress on the implant. It prevents excessive collapse.
• Locked Distally: To prevent rotation.

Anterolateral (Hardinge)

• Splits: Gluteus Medius (Abductor).
• Pros: Low dislocation rate.
• Cons: Post-op limp (Trendelenburg gait) due to abductor damage.
• Note: Preferred for confused patients who can't follow precautions.

Posterior (Southern / Moore)

• Splits: Gluteus Maximus. Detaches Short External Rotators.
• Pros: Spares abductors (No limp). Better visualization.
• Cons: Higher posterior dislocation rate. (Must repair capsule/rotators meticulously).

Day 0 (Admission)

• Fast track to ortho ward.
• Nerve Block (Fascia Iliaca).
• Optimise fluids.

Day 1 (Post-Op)

• Check Haemoglobin (Transfuse if <80 with symptoms).
• Mobilise: Out of bed to chair. Full Weight Bearing (FWB) as tolerated.
• CXR check.

Day 2-5

• Physio: Walking with frame/sticks.
• OT: Home assessment, stairs assessment.
• Bone Protection: start Bisphosphonates (Alendronic acid) + Ca/VitD.

Discharge Criteria

• Safe transfer.
• Medically stable.
• Pain controlled.
• Social package of care in place.

NICE CG124 (Hip Fracture)

• Timing: Surgery on day of or day after admission.
• Analgesia: Nerve blocks (Fascia Iliaca) should be standard. Paracetamol. Opiates.
• MDT: Orthogeriatrician led care reduces mortality.

The FAITH Trial (2017)

• Question: Sliding Hip Screw vs Cannulated Screws for Undisplaced Neck Fractures?
• Result: DHS had slightly lower re-operation rate but is a bigger operation. Screws remain standard for minimally displaced, but DHS is a valid option for "smokers/diabetics" (poor healers).

The HEALTH Trial (2019)

• Question: THR vs Hemiarthroplasty for Displaced Neck?
• Result: THR had small functional benefit but higher complication risk. It validated the selective use of THR for fitter patients (NICE criteria) rather than "THR for everyone".

The WHiTE Trials (UK)

• Ongoing series answering questions like Hemi type (Cemented vs Uncemented) and Dressing types (PICO vs Standard).
• White 5: Cemented Hemis are superior to Uncemented (better mobility, less pain).

The Injury

You (or your relative) have broken the "neck" of the thigh bone. This is the ball-and-socket joint of the hip. It is a very serious injury, particularly for the heart and lungs as it forces you to stay in bed.

Why Surgery?

If we leave you in bed, the pain is severe, and the risks of pneumonia, pressure sores, and clots are fatal. Surgery is effectively a "pain relief" procedure - it fixes the bone so you can get out of bed tomorrow.

What operation?

• Fixing: If the break is outside the joint, we pin it with a metal plate or rod. You keep your own hip.
• Replacing: If the break is inside the joint, the blood supply to the ball is cut off. The ball will die. So we remove the dead ball and give you a metal one (Half Hip Replacement).

Recovery

• Walking: You will walk TOMORROW. You can put full weight on it. It won't break.
• Hospital: 5-10 days depending on fitness/social support.
• Life: Most people get back to walking, but you may need a stick or frame longer term. It is a major knock to confidence, but we will support you.

Q1: What are the NICE criteria for Total Hip Replacement in NOF? A: (1) Walk independently outdoors with no more than 1 stick. (2) Not cognitively impaired. (3) Medically fit for procedure (ASA 1-3). This targets "fit" patients with a long life expectancy who benefit from the longevity and function of a THR.

Q2: Describe the deformity of a displaced hip fracture and why it occurs. A: Shortened and Externally Rotated.

• Shortening: Pull of the Ilio-Psoas, Rectus Femoris, and Hamstrings on the distal fragment.
• External Rotation: The Ilio-Psoas attaches to the Lesser Trochanter and acts as a specialized external rotator once the neck is broken (lever arm changes). Gravity also contributes in the supine patient.
• (Note: Anterior Dislocation is Long + ER. Posterior Dislocation is Short + IR).

Q3: What constitutes a "Reverse Obliquity" fracture and why does it change management? A: An intertrochanteric fracture where the fracture line runs from Medial-Proximal to Lateral-Distal (parallel to the pull of the Gluteus Medius). This implies that as the muscles contract, they pull the shaft medially and the fracture opens up distraction. A DHS sliding mechanism would fail here (the shaft would slide medially and the screw would cut out). It requires an Intramedullary Nail to act as a buttress against medialization.

(End of Topic)