Fractured Neck of Femur

You are the orthopaedic CT1 called to A&E to assess a 75-year old lady who has had a fall whilst out shopping. She is complaining of pain in her right hip and the ambulance crew tell you she is unable to weight bear at the scene. The busy A&E doctor has ordered an x-ray of the pelvis and given analgesia. How would you proceed?

Example answer introduction
This is an AP radiograph of the pelvis showing an intra-trochenteric fracture of the left neck of femur. I would like to see another view for confirmation and an  A-P film showing both hips. This will likely require surgical management and I would focus on ensuring the patient is stabilised and then optimised for surgery and then escalate to the orthopaedic registrar.
Initial Assessment and Simultaneous Resuscitation:
On arrival, manage the patient using an A to E approach according to the Advance Trauma Life Support Algorithm.
  • Airway with C-spine control
    • Check that airway is patient
  • Breathing
    • oxygen saturations, examine chest, examine work of breathing, breathing depth
    • if concerns give high flow oxygen through a non-rebreathe mask
  • Circulation
    • pulse, blood pressure, capillary refill time, skin turgor, fluid input/output
    • ensure IV access- 2 large bore etc- bloods as above, consider catheter
    • Give fluid challenge 500ml of crystalloid solution. If evidence of heavy bleeding apply pressure and activate Major Haemorrhage Protocol. Avoid deep probing open any neck wounds
    • If hypovolaemic think “blood on the floor + four more” - intrathoracic, intraperitoneal, retroperitoneal, pelvis/thigh – areas of internal haemorrhage
  • Disability - GCS, pupils, blood sugar, temperature
  • Exposure-  systemic signs of shock, other injuries
Provide constant reassessment during this acute phase.
Specific Chest Examination
  • Lower limb position – I would expect it to be shortened and externally rotated

  • Groin pain

  • Active and passive range of movement

  • Neurovascular status – Documenting this is key!

 

Cover patient with blanket at the end to prevent hypothermia.

Focused history​​

  • Allergies

  • Medications - if on anticoagulation and the procedure is likely soon - consider reversal

  • Past medical history including previous surgery

  • Last meal

  • Events leading up to this point

Example questions to progress the station

Q1 - What are the differentials for post-traumatic hip pain. 

  • Fractured Neck of Femur

  • Fractured pelvis - various areas

  • Haematoma

  • Soft tissue injury

  • DONT FORGET REFERRED PAIN FROM OTHER JOINTS!

Q2 - What is your initial management?

See below

Immediate management and further investigations

​​Management

  • Adequate fluid resuscitation, consider catheterisation

  • Analgesia according to WHO pain ladder. Femoral nerve block can be performed by some A&E departments. 

  • Prep for theatre – Bloods, urine dip, chest x-ray, ECG, echo if indicated, keep nil by mouth

  • VTE Prophylaxis

  • Arrange foam gutter splint to alleviate heel pressure

  • Escalate to Orthopaedic Registrar

  • Keep patient and any relatives informed

  • Document, document, document!!!

Always ask yourself WHY they had the fall in the first place. Are there any underlying infections that may have caused the fall? Any patient over 65 years should have a chest x-ray and an ECG. Heart failure patients will need an up to date echocardiogram. All pacemakers should be checked prior to surgery.

Investigations

Many patients with neck of femur fractures are elderly and frail with multiple comorbidities. Ensure the required views have been performed – AP pelvis, AP and lateral hip. Which will help confirm diagnosis and aid with surgical planning. In cases where the x-ray is equivocal a CT hip may shed more light. 

Remember to document your findings and management plan and inform the patient/parents.​

Escalation
This patient should be discussed with your registrar or with the team at the Trauma meeting. NICE guidelines state that surgery should be performed on the day of, or the day after, admission. Therefore, a prompt and thorough assessment by the admitting doctor should pick up ongoing medical issues that need to be stabilised to avoid delays to surgery.  
Consider discussion with:
- Orthopaedic registrar
- ED major trauma team
- ICU / HDU - if patient requires admission for monitoring
- Haematology for anticoagulation reversal
Useful Resources
NICE Hip fracture: management: Clinical guideline 
Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.
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