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Chapter13

Hipfractures

Guideline: NICE CG124 (Hip fracture: management):

https://www.nice.org.uk/guidance/cg124/

OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.

Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.

Overview

Hip fractures commonly occur in the elderly population. The aetiology is often multifactorial, with contributing factors including osteoporosis and frailty. Mortality followinghipfractureisupto30%intheyearfollowingthefractureandup to50%do notreturntotheirbaselineleveloffunctioning.

Diagnosis

History

Historyoffallintheelderly/severetrauma(roadtrafficaccident,high-impactfall)intheyoung May be atraumatic in pathological fractures (secondary to primary bone tumour or metastatic deposits) Acutepaininthehipand/orgroinareaandmayhavereferredpaintotheknee Associatedinabilitytoweightbearonaffectedside.

Examination

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Oninspection,affectedlegisshortened,abducted,andexternallyrotated Tendernessonpalpationofthegreatertrochanterandbyrotationofthehipjoint Assessneurovascularstatusoftheaffectedlimb Perform an ABCDEexamination toidentify any causes leading tothefall andother injuries or fractures Screenforcognitiveimpairment/acuteconfusiononadmissionandregularlyreassessthepatient fordelirium(seeChapter10)withAMTSandCAMorequivalent.

Investigations

Bedside

UrinalysisandBenceJonesprotein(ifpathologicalfractureissuspected) ECGtoinvestigatethecauseofthefall(seeChapter12).

Bloods

FBC,U&E,coagulationprofile,groupandsave,vitaminD,TFT,calcium Prostate-specific antigen (PSA) (in men) andserumelectrophoresis if a pathologicalfractureis suspected Creatinekinaseifhistoryoflonglie.

Imaging

Anteroposterior(AP)pelvis(Fig.13.1andTable13.1)andlateralhipradiographs Obtainfull-lengthfemoralviewsifpathologicalfractureissuspected ChestX-raytoinvestigatethecauseofthefall Ifahipfractureissuspectedclinicallydespitenegativehipradiographsofanadequatestandard, offer further imaging, e.g. MRI, or CT if MRI is not available within 24 hours or is contraindicated.

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Table13.1Classificationofneckoffemurfractures

Classification Description

Intracapsular GardenI Non-displaced Impactedincompletefracture

GardenII Non-displacedcompletefracture

GardenIII Displaced Partiallydisplacedcompletefracture

GardenIV Fullydisplacedcompletefracture

Extracapsular Inter-trochantericfracture Fracturebetweenthetwotrochanters

Sub-trochantericfracture Fracture<5cmdistaltothelessertrochanter

Source:datafromTheJournalofBoneandJointSurgery.Vol.43-B,No.4,Low-anglefixationin fracturesofthefemoralneck,R.S.Garden,1Nov1961.

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Fig.13.1AneckoffemurfractureseenonanAPX-rayofthelefthip.

CourtesyofTheNorfolkandNorwichUniversityHospitals(NNUH)RadiologyDept.

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Management

Multidisciplinarymanagement

Offerpatientsaformalhipfractureprogrammewhichincludes:

Orthogeriatricassessmentandcontinuedmultidisciplinaryreview Earlyoptimizationforsurgery Earlyidentificationofindividualgoalsforrehabilitation Involvement of related services including mental health, falls prevention, bone health, primary care,andsocialservices.

Acutemanagement

InitialmanagementshouldconsistofanABCDEapproachtostabilizethepatient Assessandtreatpainimmediatelyonpresentation,30minutesafteranalgesiaisadministeredand hourlythereafteruntilthepatientissettledontheward Prescribe according to the World Health Organization (WHO) analgesia ladder, starting with regular paracetamol, unless contraindicated. Opioids may also be required. NSAIDs are not recommended Considerafemoralnerveblockifparacetamolandopioidsdonotprovidesufficientanalgesia Analgesia should be sufficient to allow small movements for imaging, nursing care, and rehabilitation Optimize comorbidities early to prevent delays to surgery such as anaemia, reversing anticoagulation, dehydration, electrolyte disturbance, glycaemic control, decompensated heart failure, cardiac arrhythmia or ischaemia, chest infection, or exacerbation of chronic chest conditions.

Surgicalmanagement

Definitivemanagementissurgical(Table13.2).Thisshouldbedoneonthedayof,orthedayafter, admission Ifthepatienthasaparticularlycomplexorterminalillness,surgeryshouldstillbeconsideredasa palliative measure to minimize pain. The multidisciplinary team (MDT) should consider the patient’sprioritiesforrehabilitationandtheirwishesforend-of-lifecare.

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Table13.2Examplesofsurgicalmanagementofneckoffemurfractures

Fracture type

Undisplaced intracapsular fractures (GardenIand II)

Displacedintracapsularfractures(GardenIII andIV)

Extracapsular

Surgical option

Internalfixation withdynamichip

screwor cannulatedhip screws

Totalhipreplacementispreferredinpatients

whowereactive,mobilizingindependently,are notcognitivelyimpaired,andaremedicallyfitfor anaesthesiaandtheprocedure Hemiarthroplastyisoftenrecommendedinthe elderlywhodonotmeettheabove-listedcriteria

Trochantericfracturesaboveand includingthelessertrochanter: extramedullaryimplantssuchas adynamichipscrew Subtrochantericfracture: intramedullarynailisusually preferred

Source:datafromNICECG124.

Treatmentafterstabilization

Mobilization should be attempted on day 1 postoperatively and daily thereafter with regular physiotherapyreview Thromboprophylaxis OngoingMDTapproachwithorthogeriatricinvolvement Review bone protection including calcium and vitamin D supplements, bisphosphonates, and considerationforDXAscanning If fracture was due to a fall, measure postural blood pressure postoperatively and review medicationsforiatrogeniccauses(seeChapter12) Consider continued rehabilitationinthe community as partof earlysupporteddischarge or ina communityhospitalorresidentialcareunit.

Specialconsiderations

Complicationsofhipsurgeryincludeinfection,bleeding,riskofthromboembolicevents, avascularnecrosisoffemoralheadandleg-lengthdiscrepancy.Long-termcomplications includejointdislocation,asepticloosening,andperiprostheticfracture.

Furtherreading

1.BaldwinA(ed)(2020).Proximalfemoralfractures.In:OxfordHandbookofClinicalSpecialties,11th

ed. Oxford: Oxford University Press. Available at:

https://doi.org/10.1093/med/9780198827191.003.0008

https://t.me/med1917

2.BaldwinA(ed)(2020).Hipfracturesintheelderly.In:OxfordHandbookofClinicalSpecialties,11th

ed. Oxford: Oxford University Press. Available at:

https://doi.org/10.1093/med/9780198827191.003.0008

https://t.me/med1917

Part3

Endocrinology

Adrenalinsufficiency

Diabeticketoacidosis

Hypercalemia

Hyperglycaemia

Hyperglycaemichyperosmolarsyndrome

Hyperthyroidism

Hypocalcaemia

Hypoglycaemia

Hyponatraemia

Hypothyroidism

Osteoporosis

Type1diabetesmellitus

Type2diabetesmellitusanddiabeticfootproblems

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Chapter14

Adrenalinsufficiency

Guideline: Society for Endocrinology Endocrine Emergency Guidance

(Emergency management of acute adrenal insufficiency (adrenal crisis) in adultpatients):https://ec.bioscientifica.com/view/journals/ec/5/5/G1.xml

Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.

Overview

Chronic adrenal insufficiency may be primary (the adrenal gland is unable to produce cortisol)orsecondary(thepituitaryglanddoesnotstimulatetheadrenalglandtoproduce cortisol). The most common cause is iatrogenic secondary (sometimes called tertiary) adrenalinsufficiency.SeeBox14.1foralistofcauses.

Acuteadrenalinsufficiencymaybetheconsequenceof amissed diagnosisofchronic insufficiency. Alternatively, it may be due to abruptly stopping long-term steroid medication, or it may result from an ↑ body requirement for cortisol without adequate adjustmentofmedications,e.g.inacuteillnessorperioperatively.

Box14.1Causesofadrenalinsufficiency

Primary

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Autoimmune(Addison’sdisease) Congenitaladrenalhyperplasia Adrenalmalignancy Depositswithintheadrenalgland,e.g.sarcoidosis,amyloidosis,haemochromatosis Infection,e.g.TB Bleedingwithintheadrenalglands,e.g.followingmeningococcalsepticaemia Surgicalremovaloftheadrenalglands.

Secondary

Hypopituitarism, e.g. tumour compressing the pituitary gland, infection, hypophysitis (particularly associated with checkpoint inhibitor treatment of malignancy, or postpartum), trauma,apoplexy Iatrogenic—followingdiscontinuationoflong-termsteroidtreatmentwherethedoseofsteroidis equivalentto>5mgprednisolone/dayfor>4weeks.

Diagnosis

History

Chronicsymptoms

Thesymptomsofadrenalinsufficiencymaydevelopslowlyandarenon-specific.Typical symptomsinclude:

Fatigue Weightloss Dizziness and postural collapse (more commonly in primary insufficiency because of mineralocorticoiddeficiency,whichisnotseeninsecondaryinsufficiency) Abdominalpain Nauseaandvomiting Fever Confusion Backandlegcramps Tanned appearance and/or pigmentation of scars, buccal mucosa, and skin creases (if primary adrenalfailure).

Ifapatienthasabdominalpainorisvomitingandthecauseisnotclear,consideradrenal insufficiency.

Ask whether the patient has any autoimmune conditions, e.g. vitiligo, T1DM (see

Chapter21), or anyfamilyhistoryof theseconditions.Askaboutheadachesand visual

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