frac. neck femur

Fractured neck of femur for nurses 1

FRACTUREDNECK OFFEMUR

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A Guide for Immediate-Care Nursesin the

Accident & Emergency Department

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V A C Reece, RD, FRCS, FFAEM

Consultant in Accident & Emergency MedicineSouth Tyneside Health Care NHS Trust


ANATOMY OF THE HIP JOINT

The hip joint is a ball-and-socket joint between the upper end of thefemur and the pelvis. The rounded upper end of the femur is called thehead, connected to the main shaft of the femur by an angulated neck.At the base of the neck are two bony lumps for muscle attachments: thelarger one on top is the Greater Trochanter and a smaller one on themedial side of the upper end of the shaft is the Lesser Trochanter. Atthe outer part of the pelvis is the socket component of the joint, theacetabulum, which surrounds the head of the femur by about 2/3 to ¾.The hip is very similar in some ways to the shoulder joint but, because ithas to withstand much greater stresses than the shoulder, some range ofmobility has been sacrificed in favour of stability. (In fact it is possibleto cut all the ligaments and muscles connecting the femur with the pelvisand the joint would still stay in place.)As in the shoulder, there are short muscles around the joint to stabilise itand longer ones passing from the pelvis to lower down on the femur tomove the joint.The centre of the head of the femur (the hip joint) corresponds on thesurface of the body to a point about an inch (2.5 cm) below the midpointof the groin.The head of the femur gets most of its blood supply from vesselsrunning from the trochanteric area along the neck. Fractures of the neckare therefore likely to disrupt the blood supply to the head and result innecrosis and crumbling of the head later on.


THE SKELETON OF THE PELVIS AND THIGH


INJURIES TO THE HIP AREA

Because the hip is such a stable joint, it takes a great deal of force todislocate it. If force is applied, the neck is more likely to break than thejoint is to dislocate, especially in the elderly patient with weakened bones.Most fractures in the hip area are the result of indirect force – usually atwisting force to the lower limb applied past the permissible range of hipmovement, resulting in the neck of the femur snapping; occasionally theymay occur by falling directly on to the greater trochanter.

FRACTURES OF THE FEMORAL NECKThese are described as occurring in one of three sites: clinically they areimpossible to tell apart and have no relevance to the initial emergencymanagement at all; they are only relevant to the operative managementand to the likely outcome.Subcapital FractureThe fracture is across the neck of the femur immediately below the head.For practical purposes it is a variety of theTrans-cervical FractureThe fracture line here is usually about halfway down the neck. Like thesubcapital fracture, if this fracture is displaced, the head of the femur islikely to lose its blood supply and crumble later. For this reason, a lot ofthese fractures are treated by replacement of the head by a metal implant,rather than trying to put together a fracture which will not heal and thencollapse.Inter-trochanteric (or Per-trochanteric) FractureThe fracture line runs diagonally between the two trochanters. The areahas an excellent blood supply and fractures here are unlikely to affect theviability of the head. They are usually treated by internal fixation, oftenwith very good results.Any of the above fractures may be undisplaced, grossly displaced, orimpacted. Injury to nerves and vessels is extremely rare.


WHY IS IT ALWAYS LITTLE OLD LADIESWHO FRACTURE THEIR FEMORAL NECKS?

The short answer is that it isn’t. The femoral neck can be fractured byeither sex at any age.However, the usual patient is a little old lady because:

The elderly are relatively unsteady on their feet and have poor eyesightand tend to trip over things.Poor bone density from osteoporosis is still common in the elderly,especially in women for hormonal reasons, gradual vertebral collapsebeing what makes them “little” old ladies.There are more elderly women than elderly men in the populationanyway, for a lot of reasons.

THE CLINICAL PICTURE

The History is usually one of a minor stumble or fall in an elderlypatient, although of course it is perfectly possible to fracture a femoralneck as part of more serious multiple trauma. If no clear history can beobtained, consult a doctor.The Symptoms are usually of pain in the groin area, worse on movingthe hip joint or trying to weight-bear. The elderly have, on the whole, ahigher pain threshold than younger people and may even walk into A&Eon a broken femoral neck, especially if the fracture is impacted. Mostpatients, however, cannot put weight on the affected leg.The Signs may be very minimal. Pain on moving the hip, gentlyrotating it, is the commonest finding, together with tenderness over theupper thigh, just below the groin.The Deformity beloved of first-aid books, the classic shortening andexternal rotation, is in fact not very common. It requires a displacedfracture and usually a fairly thin patient to spot it. However, if it ispresent, there is little else the diagnosis can be. (If you are interested inhow this happens, see Appendix 1 at the end).


WHO NEEDS MEDICAL ASSESSMENTRATHER THAN (OR BEFORE)

FAST-TRACKING?

The great majority of people with fractured femoral necks are otherwisereasonably fit, apart from background chronic diseases associated withbeing elderly, such as diabetes, ischaemic heart disease, hypertension etc.,usually under some sort of control.However, it is important to make sure that this is in fact the case andthat the supposed fracture is the only acute matter needing attentionbefore the patient leaves A&E for the relatively uncontrolledenvironment of corridors, lifts and X-ray department.It is usually a matter of clinical judgement based on experience combinedwith common sense to decide when a patient is ill and needs attention tostabilise the situation.However, the following are pointers to getting a doctor to assess thepatient, but the list is not exhaustive:-1. There is no clear history of how the fall occurred. (The patient mayhave lost consciousness from cardiac or neurological causes and fallen)2. The patient fell from a height greater than a chair. (May have otherinjuries)3. There are signs and symptoms suggestive of other injuries(e.g.chest or abdominal pain, other fractures, such as wrist).4. Pulse and/or blood pressure may be abnormal (Pulse < 60 or >100, &/or BP low or high for age).5. Patient clinically dehydrated (poor skin tone, dry tongue).6. The patient is clearly dyspnoeic, with or without abnormal O2

saturation, or “ill” (clinical judgement).


ANALGESIA

In any clinical situation, the need for pain relief will vary widely frompatient to patient. It is worth bearing in mind that, although the patientmay be fairly comfortable lying still on the trolley, there will be a need tomove around later, particularly in X-ray and this should be anticipated.The elderly have a higher pain threshold than younger people and oftendo not want to “bother” people asking for pain relief.Bearing the above in mind, analgesia should be offered (possibly with alittle persuasion) according to the pain scale.For mild pain (1 – 2): Paracetamol 1 G. orally is usually adequate.For moderate pain (3 – 6) (usual): Tramadol has been recommended bythe Pain Team in a dose of 50 mg by injection (i.v. or i.m.).This drug sometimes causes nausea and vomiting and, if this side-effectoccurs (not prophylactically), Cyclizine should be given, again 50 mgparenterally.More severe pain (7 or more) is unusual in fractures of the femoral neckbut, if this level of pain is identified, an opiate, given carefullyintravenously and titrated against the pain by a doctor, will be required.

Respiratory Suppression Both Tramadol, being related to the opiates,and the opiates themselves have a potential for causing respiratorydepression, and the respiratory rate and depth should be carefullymonitored.If the respiratory rate goes below 10 per minute, administer high-concentration O2 (reservoir bag) and get medical help. If the rate dropsbelow 8 per minute, do the above but also administer Naloxone 4 mgintravenously. If the breathing stops, take over ventilation (bag & mask)with high-flow O2 and put out a crash call for medical attention.


BLOOD SAMPLES

The A&E phase is only part of the patient’s journey from fracture tohome again. Another part is to ensure that surgery is not delayed, as ithas been shown that patients in whom surgery is delayed more than aday or so do badly long-term. For this reason it has been decided thatblood samples should be taken as soon as possible after the patientarrives in hospital and their results available on the ward as early aspossible, so that the medical team can be involved and any remediableaction be taken immediately, rather than finding out the next day that thepatient has a condition which will delay surgery. The tests required arethose the anaesthetist needs (e.g. blood count and electrolytes), togetherwith those a geriatrician will want as part of a screen for conditionscommon in the elderly, of which they may be unaware. The whole lotare taken on arrival to avoid multiple needling of the patient and, again,to get results as early as possible.


Appendix 1: How the Classic Deformity Happens

The classical deformity of shortening and external rotation is the resultof abnormal pull of the muscles round the hip. The Iliopsoas musclecomes from the inside of the pelvis, crosses the front of the hip andpulls on the lesser trochanter which is slightly round the back of themedial side of the upper femur. Normally this flexes the hip jointbecause the whole femur moves in one piece. If the neck of the femur isbroken, however, the muscle just pulls the lesser trochanter forwards andtwists the femoral shaft into external rotation. The short stabilisingGluteus Medius and Gluteus Minimus muscles, from the outer pelvis tothe greater trochanter, pull up on the now free femoral shaft, resulting inshortening. You must be very sad if you found this interesting.

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