Obtain adequate history from the patient such as any
syncopal episodes and loss of consciousness. The preinjury ambulatory status
may determine the treatment selected for the patient. Falls and low sodium will
increase the risk of hip fractures. Check for comorbidities. The number of
comorbidities is directly related to 1-year mortality rate. Patients with 4 or
more comorbidities are reported to have a higher 1-year mortality rate than
patients with 3 comorbidities or less. Position of the leg is usually
shortening and external rotation. You will be able to tell which hip is broken
by looking at the feet of the patient. If the leg is shortened and externally
rotated, then this is the broken hip. AP view and cross-table lateral view. In
cross-table lateral view, you move the uninjured hip away. Cross-table lateral
view is better than frog leg lateral view. Consider doing traction-internal
view if the fracture is occult or comminuted. Check for hip arthritis and
pathological fracture. If you have a comminuted femoral shaft fracture, you may
look for an associated femoral neck fracture. In patients with femoral shaft
fracture, the rate of associated femoral neck fracture is precisely
undetermined, however it is approximately 5%, and the fracture may be
overlooked in about 30% of the time. Normal x-rays of the hip do not mean that
the patient with hip pain does not have a hip fracture. 8% of the patients may
have an occult hip fracture. It may be important to get a CT scan of the neck
of the femur when you have a comminuted femoral shaft fracture. This will help
to diagnose an occult femoral neck fracture. You may see the fracture in
abdomen/pelvic CT scan cuts, usually before surgery. Good for occult and stress
fractures (if the patient cannot bear weight- get an MRI). If there is
contraindication for an MRI, get a CT scan or bone scan. Bone scan increases
sensitivity by waiting up to 72 hours after the injury. Deep vein thrombosis
(DVT) can occur in about 80% of patients. Patients will need chemical and
mechanical prophylaxis. The duration and the type of prophylaxis is not determined
(no unanimity). Get the patient out of bed and allow weight-bearing as
tolerated. The patient will autoregulate their ambulation. Preoperative
cognitive impairment will lead to a higher incidence of delirium in patients
with hip fractures. Delirium and time of surgery affected the length of stay in
the hospital. Most patients with hip fractures between the ages of 50-80 years
old were able to regain their mobility and independence. If the patient is
older than 80 years old, the patient was able to regain their independence, but
not their mobility with 70% of these patients requiring a walking aid at 12
months. The factors associated with the increased ability to ambulate and to
live independently 1 year after surgery for femoral neck fracture are patients
age 50-80 years old, ASA class 1, and pre-fracture independence. Some patients
may delay coming to the hospital. They may have been lying on the floor for
many hours or even days. Check the patient for DVT, ulcers, dehydration, and
malnutrition (the patient may be very sick). May need comedical management with
the medical team. Early surgery (within 48 hours) is associated with a
decreased one-year mortality. Expedited definitive surgery of less than 24
hours will reduce the mortality rate at 30 days and at 1 year. A delay of more
than 24 hours of surgery significantly increased the incidence of 30 day
mortality, and 1 year mortality, as well as increased incidence of pulmonary
embolism, myocardial infarction and pneumonia. If the patient has ASA 3 and ASA
4, this will increase the mortality rate for the patient (means that the
patient’s condition is medically complicated and the patient is high risk).
Types of ASA is classification of American Society of Anesthesiologists. ASA 1
is a lot better than ASA 4. In younger trauma patients, the femoral neck
fracture should be dealt with urgently and after the overall condition of the
patient is thoroughly evaluated to exclude other injuries. Early surgery may
decrease the incidence of osteonecrosis.
