Hip Fractures (NOF's) - An Overview PDF

Hip Fractures (NOF’s) - An overview Contents Review of anatomy Occurrence and incidence Aetiology of hip fractures Classification Types of hip fracture Surgical interventions for Treatment Physiotherapy - in and outpatient(community) Complications Girdlestones operation Anatomy o...

Hip Fractures (NOF’s) - An overview Contents Review of anatomy Occurrence and incidence Aetiology of hip fractures Classification Types of hip fracture Surgical interventions for Treatment Physiotherapy - in and outpatient(community) Complications Girdlestones operation Anatomy of the hip joint  The articulations of the hip joint are between the head of the femur and the acetabulum (see figure 1)  The head of the femur is attached to the shaft by the thin neck region (this is an area of weakness particularly for patient’s who are osteopeanic or osteoporotic)  The hip joint is a synovial ball and socket joint which permits a wide range of movements(flexion/extension, ab/adduction, internal/external rotation)  Primary job of the hip is to support the weight of the body both statically and dynamically and therefore is a highly stable joint, the stability of the joint is determined by a. The deep socket of the acetabulum holding the head of femur, b. The strong capsule and ligaments across the joint c. The insertion of the muscles crossing the joint Diagram 1 Ligaments of the hip joint The ligaments of the hip joint completely encompass it and combine to form the joint capsule (see diagrams 2 and 3), there are 3 ligaments:- Iliofemoral ligament Very strong triangular shaped ligament (is the strongest ligament in the body) Strengthens the hip anteriorly Attaches to the ASIS running downwards and laterally across the front of the capsule to attach to the trochanteric line of the femur Ischiofemoral ligament Spiral ligament Attaches to the medial border of the acetabulum and spirals up and laterally around the neck of the femur to attach to the anterior of the greater trochanter Pubofemoral ligament Strengthens inferiorly and anterior aspects of the hip joint Attachments- runs from the superior pubic ramus to the lower part of the intertrochanteric line Ligamentum Teres The ligamentum Teres plays no specific part in the hips stability however attaches from the femoral head to the transverse ligament of the acetabulum which fills the gap in the acetabulum Research suggests this ligament contributes little influence as a ligament past childhood but can be important in transmitting the arterial blood supply as an artery runs directly beside it, when it is present as a small percentage of humans will not have the ligament present Capsule of the hip joint Diagram 3, of attachment of hip joint capsule Diagrams of the hip ligaments Muscles of the hip The muscles of the hip and lower back work together to maintain the stability and alignment and movement of the hip The hip muscles do not directly attach at the hip joint they attach across it thereby providing it with more stability The hip muscles can be divided into 4 groups: Gluteal group, Adductor group, Iliopsoas and Lateral Rotator group Muscle group and the individual muscles of the hip (see diagram 4) Gluteal group; Gluteus maximus, Gluteus Medius, Gluteus Minimas and Tensor Fascia Latae Adductor Group; Adductor Brevis, Longus and Magnus, Pectineus and gracillis Ilipsoas Group; Iliospoas, Psoas Major Lateral Rotator Group Internus and Externus Obturatus, Piriformis, Inferior and Superior Gemellis and Quadratus Femoris Muscles of the hip, Diagram 4 Movements by the muscles of the hip  Flexion; Psoas, Iliacis, Extension; Gluteus Sartorius, Rectus Femoris Maximus, Rectus Femoris  Abduction; Gluteus Adduction; Adductor Medius and Gluteus Minimas Magnus/Brevis/Longus, Pectineus and Gracilis Lateral Rotation;  Medial Rotation; Gluteus Medius, and Obturator Internus and Minimas, Iliospoas, Externus, Gluteus Piriformis(when hip Maximus and >90degrees) Piriformis( when hip is at < 90 degrees) Blood supply of the hip (see also diagram 5) The blood supply of the femoral head is supplied from the vessels that branch off from the femoral artery (becoming the lateral and medial circumflex arteries), a small branch alongside the ligamentum teres of the hip may also be present arising from the obturator artery (this is only present in approximately 80 percent of people), this blood supply can be important in preventing AVN (avascular necrosis of the femoral head) when the femoral artery supply to the head and neck of femur is disrupted as is often so in fracture of the NOF Blood supply to the femoral neck and head Diagram 5 Hip Fractures Proximal Femoral Fracture (PFF) but most commonly referred to as a fractured neck of femur (NOF) it means a fracture occurring in the area between the edge of the femoral head and 5cm below the lesser trochanter, any further down the femur than this is a shaft of femur fracture (SOF). Aetiology  Hip fractures are a major public health issue especially with our ever increasing aging population  In the UK approximately 70,000-75,000 hip fractures occur every year  Financially this equates to a cost of 2 billion pounds per year (social, health and economical)  Hip fracture is the most common reason for admission to the orthopaedic trauma ward and is usually caused by a fall of less than 1 meter affecting an older person with osteopenia or osteoporosis  10 % of patient’s with a hip fracture die within the first month and 1/3 within 1 year therefore it can be a life threatening event (National Clinical guidelines Centre, 2011) Mechanism and presentation of person with a hip fracture Fracture NOF usually occur in the over 40’s due to a fall from less than 1 meter In the under 40’s it usually occurs due to high energy collision eg hit by a car Fracture NOF can also occur at any age due to pathological weakness eg osteoporosis, Pagets disease, metastatic cancer, anything that affects the bone density When somebody has fractured their hip the usual presentation is of a patient unable to weight bear with severe pain in the hip and a shortened lower limb in external rotation (see figure 1) however this may not be the case if the fracture is stable  Classic presentation of fractured NOF, figure 1 The affected broken hip Classification of hip fractures Intracapsular (IC), within the Extracapsular (EC) outside of joint capsule the joint capsule * High risk of avascular necrosis * Still a risk of avascular with these types of fracture due necrosis but lower risk with to high risk of interuption of the extracapsular fracture blood supply to the femoral head Subcapital Intertrochanteric Trancervical Peritrochanteric (see diagram 6) (see diagram 6) IC fractures can be categorised into displaced which will always require surgical fixation EC always require surgical or non displaced fractures intervention, unless medical which can be treated reasons conservatively Diagram of intra and extracapsular hip fractures Diagram 6 Xray of a right subcapital fractured NOF, compare the right hip to the normal left hip Types of hip surgery  It is recommended by NICE that all hip fractures where surgery is indicated are treated surgically within 24 hours of admission  Arthroplasty; this is where part (hemiarthroplasty) or the whole of the hip joint surfaces (THR) are replaced Examples of hemiarthroplasy; Thompsons, Austin- Moore, they may be cemented or non cemented Surgical approach in these operations s is anterolateral or posterior THR may be indicated where the patient has pre existing joint disease and expects to return to high levels of activity Figure 2, Xray of a Thompsons Hemiarthroplasty Internal fixation; Extramedullary; sliding hip screws Intramedullary; Gamma Nail/Intramedullary hip screw (IMHS) Dynamic Hip Screw(DHS)  :- Figure 3 Xray of a Dynamic hip screw patient Treatment of fractured NOF (post surgery)  Previously patient’s who had a hemiarthroplasy were routinely on hip precautions for up to 16 weeks dependent on the consultant due to the small risk of hip dislocation however at the LRI …………..**  Patient’s who have had an ORIF will not usually be on precautions however this should always be confirmed on the ward  All patients post surgery, unless stated in the notes will be able to fully weight bear. Hip precautions following hip surgery = 1. No hip flexion beyond 90 degrees (assess seat heights, bed, toilet etc) 2. No hip adduction past neutral (avoid crossing legs/ adjust how put on shoes) 3. No internal hip rotation past neutral (no twisting at the hips whilst sitting/ standing) Aims of Physiotherapy The overall aim of intervention is to progress patient back to their baseline, however this will not be possible for all patients. * Reduce fear/confidence building* Many patient’s will be extremely fearful due to the traumatic nature of a fractured NOF particularly if they have had a long lie following the fracture  Increase ROM/muscle power (weakness of the hip abductors is common therefore look out for the trendelenburg sign, see figure5)  Transfer practise/progression  Progression of mobility (eg start with frame and progress to elbow crutches to sticks and /? Unaided, dependent on the patient’s baseline and other medical problems)  Balance re-education  Falls prevention including care alarm, assistive technology  Educate and practise Steps/stairs/uneven surface practise  Increase exercise tolerance  Outdoor mobility practise +/- provision of aids and rails via OT/ half steps etc  Set SMART goals with patients  Referral to OT for ADL/PADL progression Trendelenburg Sign Weakness of the hip abductors Pain following a fractured NOF - Pain is inevitable post surgery for a Fractured NOF patient - Pain may persist for a few weeks and therefore activity should only increase as the patient’s pain allows - If the patient experiences severe pain which takes hours to settle contact the patient’s GP - If patient experiences a sharp intensive pain during treatment stop the activity immediately and if it does not resolve, depending on the severity contact the GP or paramedics - If the area over the hip has increased pain, redness, discharge or increased temperature and patient has feverish symptoms contact the GP urgently (patient may not have all of these symptoms) Complications post operatively for fractured NOF Avascular necrosis of the head of femur, this is where the head of the femur dies due to an interrupted blood supply (higher risk in intra- capsular fractures due to more likely the blood supply is damaged) see figure 4, patient presents with groin and buttock pain progressing to anterior thigh pain on weight bearing and treatment is usually THR Non union through poor fixation (pathological fracture and severe osteoporosis increase this risk), patient again presents with worsening groin and buttock pain on weight bearing, again treatment is THR Complications post operatively for fractured NOF continued …. Nail extrusion (presentation and treatment as previous) Infection Dislocation/re-dislocation (this can be treated after relocation in surgery with abductor brace or abductor wedge), patient will present unable to weight bear with extreme pain if has dislocated and shortened /externally rotated leg on affected side Figure 4, shows avascular necrosis (AVN) of the femoral head Girdlestone arthroplasty (also known as femoral osteotomy)  First described by the surgeon Gathorne Girdlestone in 1945, he performed the operation on the hips of patients with infection due to Tuberculosis.  The operation removes part or all of the head of the femur allowing it to fuse with the acetabulum by allowing fibrous scar tissue to develop and form a pseudo joint in the straightened position  The operation is performed due to infection, pain or recurrent dislocation  Shortening of the leg will always occur varying between 3-11 cm  The energy used to mobilise following the Girdlestone is comparable with that of a patient with an above knee amputation Treatment following Girdlestone operation:- Surgeons usually allow patient to mobilise as soon as pain allows Patients should be measured for a shoe raise for the inevitable leg shortening Xray of a Girdlestone hip operation patient Head of femur removed Conclusion Not all of our patient’s will achieve their pre fracture baseline however with our patient’s agreement this should be our ultimate aim