Fractured Hip

•73 year old •Fallen at home •Painful hip •Unable to weight bear •Has been lying on the floor for 18 hours before being found •Incontinent of urine

The circumstances and various forces involved at the time of injury may give an indication of the type, severity and location of possible injuries

Injury can also be affected by the age and build of the injured person

•Penetrating force

•Blunt force

•Axial/referred forces

•Acceleration/deceleration forces

•Blast forces

•Thermal

Direct Force – Violence, trauma, fall
Indirect Force –twisting, bending, compression 
Muscular pull – Patella
Pathological defect of bone - Tumour, Osteoperosis 

Simple (closed)     

Compound (open)  

Complicated 

• Pain 
• loss of function 
• Abnormal mobility 
• Deformity 
• Local tenderness, swelling, brusing 
• Crepitus, crunching
• Shortening and external rotation 

•Compact (Cortical)  bone - outer area of all bones - dense  and strong 

•Spongy (Trabecular) – inner section
of bones - ‘Crunchie Bar’ appearance  

•Red / yellow bone marrow fills cavities in spongy bone

•Bone marrow produces red and white blood cells plus platelets

Compact bone - a matrix of organic and inorganic matter makes bone light but with great strength

Organic matter – mainly collagen

Inorganic matter - mainly calcium phosphate

Bone growth, repair and maintenance relies on normal 

      bone cell function (microscopic)

Bone health relies on…

• Stress- weigh bearing & Muscle pull

• Good nutrition- protein, calcium, phosphate, Vitamin D

•Hormones- growth hormones, sex hormones, cortisol (Bad in high amounts), Thyroid hormones

Imbalance  can cause  bone disease e.g. Osteoporosis, osteomalacia and rickets

Osteoclast (carver)

Osteoblast (builder)

Osteocyte (prisoner)

Haematoma formation- Bone ends bleed - haematoma, periosteum stripped,? Soft tissue damage

Cellular proliferation- Inflammation, cell proliferation within periosteum, ingrowth of blood vessels

Callus formation (soft)-Dead bone resorbed, immature woven bone laid down by osteoblasts

Callus ossification (hard)-Immature woven bone replaced by lamellar bone, mineralisation, # united

Remodelling- Medullary cavity restored, bone shape restored (osteoclasts)– can take up to 2yrs    

Diabetes Mellitus- 

Malnutrition- 

Smoking-

Drugs

•Resuscitate- volume replacement 
•Reduce (closed/open)- move fracture into a good position 
•Restrict – external and/or internal (Imobalise, Splint/metal work) • •Restore – function & prevent complications • •Rehabilitate - To as normal as possible

                           Injury and whole person

•Immediate     damage to blood vessels, nerves, muscle, skin, joints •Early    Hypovolaemic shock

        Acute Compartment Syndrome (ACS)  

         Fat Embolism Syndrome (FES)

        Deep vein thrombosis (DVT)

        Infections – wound, chest, urine

         Acute lung injury due to the trauma response

  Exacerbation of underlying illness

•Late   Delayed union, malunion, non union of fracture

         Joint stiffness

        Reduced mobility

        Limb shortening

       Renal calculi (stones)

        Osteoarthritis

Treat with spinal injury, Cervical spinal control (blocks and spinal board) - Airway, Carol is alert and awake= open airway

- Breathing- 20 RPM, Shallow= Tachypnea

SATS: 93% on air (Start O2 therapy)

-  Circulation 110 BPM

BP: 110/70 (Known hypotensive)

CRT Delayed 3 secs = vaso constriction 

- Urine output and analysis 

- Disability 

Blood glucose= 3.5mmols- low havent eaten 

AVPU= Alert 

Do GCS due to ? head injury Eyes E&R

- Exposure, Temp 35- hypothermic (Warm up with warm fluids)

Skin assessment, bruising, temp, colour, clamy, sacral redness, dry skin (Pressure ulcer)

Intracapsular

•Subcapital •Transcervical •Basal

Extracapsular (Carol has)

•Pertrochanteric •Intertrochanteric •Subtrochanteric

•Fast tracking – admitted to orthopaedic ward within 4 hours

•Early surgery – same or next day, so within 48 hours

•Orthogeriatric medical support - treat any co-morbidities immediately (Diabetes Mellitus, anaemia, volume depletion etc) cognitive screening

•Pressure ulcer risk assessment and minimisation

•Adequate pain relief / femoral block/spinal

•B  Oxygen therapy and sats

      Physiotherapist – breathing exercises

•C  Volume replacement  Bloods - Group and xmatch, FBC,   U/E   ECG   CXR  

  Urinary output

•D  Cognitive assessment

  Blood glucose monitoring

  Pain management

•E  Keep warm

  Waterlow - Pressure relieving devices

  VTE prophylaxis     Compression devices

  Skin assessment – infection prevention, FES signs

  Limb assessment - Colour Sensation Movement

Infection prevention and control

Prevention of VTE

Keep hydrated and maintain electrolyte balance

Nutrition

Skin care

Pain relief

Safe mobilisation, falls risk

•Keep limbs in abduction – wedge/trough

•Limb blood supply - CSM

•Cognitive assessment

•Mobilise next day

•Avoid hip flexion over 90 degrees -  Choice of chair Toilet seat raise

•Abduction exercise     Gentle knee flexion

•Education of do’s and don’ts

  DO NOT CROSS LEG

Good discharge management

Suitable home environment

No bending more than 90 degrees, no twisting on hip

No long periods of standing

No sitting on low chairs

12 week restriction – driving, gardening, heavy household chores

Antibiotic cover for further surgery/dental/GU/GI

Sleeping at home – back or side lying with pillow

•Early mobilisation

•Early discharge schemes (hospital to home)

•Bone health assessment/ nutrition assessment - Vitamin D, calcium supplementation

•Care pathways

•Multidisciplinary falls risk assessment

•Falls lead nurses - Champions