EXAMINER: What does the radiograph show (Figure 10.1)?

CANDIDATE: The radiograph is inadequate because it does not show the full pelvis and hips. Otherwise the radiograph shows a displaced subcapital intracapsular neck of femur fracture. I would obtain radiographs in orthogonal views to assess this fracture and consider requesting a CT scan to more fully understand the fracture pattern if necessary.

EXAMINER: Why would you want a CT? You don’t normally get CT scans for every hip fracture that presents in casualty.

CANIDATE: A CT could be obtained as part of a pan-trauma series to look for any other associated injuries. A CT can be useful to more accurately classify a fracture pattern to then guide treatment options.

COMMENT: The main role of CT would be in identifying occult femoral neck fractures in a painful hip with normal or equivocal radiographs where MRI is contraindicated or cannot be performed within 24 hours.

EXAMINER: This is the radiograph of a 29-year-old male who fell off his motorbike at 40 mph after slipping on ice. Discuss your management of this patient.

CANDIDATE: This is a high-energy injury and as with any such injury I would assess this patient using an ATLS approach. I would assess distal neurology and pulses.

EXAMINER: What are the key elements in this patient’s management?

CANDIDATE: Assessing the pattern of the fracture to ensure and plan for anatomical fracture reduction and fixation. Preservation of the femoral head without developing ON is paramount to avoid future THA.

EXAMINER: What is the blood supply to the femoral head?

CANDIDATE: The majority of the blood supply to the femoral head comes from the medial and lateral femoral circumflex arteries with minimal contribution from the obturator vessels. The medial and lateral femoral circumflex arteries arise from the profunda femoral artery and curl around the trochanteric region before branching proximally to supply the head.

EXAMINER: The patient presented to casualty at 11 pm having sustained the fracture 2 hours beforehand. The SHO has booked the emergency theatre for the fixation to be done straight after a laparotomy as they have been told the risk of ON significantly increases after 6 hours. What will you do?

CANDIDATE: Timing to surgery used to be believed to be very relevant to avoid ON; however, this has recently been refuted in the literature. It is more important to obtain as accurate a reduction as possible including open reduction if needed rather than undertaking emergency hip fixation in the middle of the night. The general scrub staff may be unfamiliar with the trauma kit and it is not the ideal time to be doing this type of surgery. Up to about 10 pm is fine but otherwise I would prefer to put the patient first on the trauma list in the morning when I am at my best so as to reduce the risk of possible surgical errors occurring. The delay also gives me some extra time to more fully explain the risk factors associated with fracture fixation such as non-union, ON and post-traumatic osteoarthritis to the patient.

EXAMINER: If this was not reduced, what method would you do to improve it closed?

CANDIDATE: The Leadbetter is the technique that is described. I have seen it twice, and it has worked on one of those occasions. This is performed under fluoroscopic guidance where the reduction is performed in a non-traumatic manner to avoid causing further injury and damage. The hip is flexed with axial traction, then adducted and brought into abduction and extension. This manoeuvre should not be attempted more than once to avoid the increased risk of ON.

EXAMINER: How would you assess your reduction?

CANDIDATE: I would do so on both the AP and lateral views with fluoroscopy. Garden described the Garden Alignment Index which refers to the angle of the compression trabeculae on the AP and lateral views relative to the longitudinal axis of the femoral shaft. Acceptable reduction is between 155° and 180°, respectively, but ideally 160°. Beyond those ranges the rate of ON is said to increase from 7% to 53%.

EXAMINER: If the hip did not reduce adequately in a closed manner, what would be your next step?

CANDIDATE: I would perform an open reduction via the anterolateral approach and joy-sticking the femoral head into a reduced position followed by three cannulated screws in a triangular configuration. Although biomechanical studies have shown no significant difference between the triangle vs. inverted triangle configuration, I personally prefer having the triangle configuration with two screws along the calcar and compression side of the neck of femur.

EXAMINER: Any other methods of fixation?

CANDIDATE: It is possible to fix the fracture with a two-hole sliding hip screw. Some surgeons believe it is biomechanically more advantageous because it resists shear forces better, particularly in more vertical, higher-energy fracture types. I would temporary stabilize the fracture with a de-rotation K-wire to prevent rotation and go on to use a cannulated derotation screw over the initial K-wire for additional rotational stability. Inserting the cannulated screw can cause the femoral head to rotate stripping the posterior capsular blood supply of the femoral head and increasing the risk of ON.

EXAMINER: What does the literature say?

CANDIDATE: At present there is no clear difference in the literature with clinical outcome for young patients treated with either two-hole DHS or cannulated screw fixation for displaced femoral neck fractures in terms of non-union, ON or the need for revision surgery. The literature would suggest quality of reduction is more important than implant choice.

COMMENT: Biomechanical studies have reported the DHS construct is stronger than CS. A recent paper by Gardner et al. from Boston reported DHS fixation had significantly lower short-term failure rates compared to cannulated screws.¹ Quality of reduction (fair vs. good/excellent) was an independent predictor of early implant failure. Singh et al. reported a better outcome (less hip pain, better hip function, higher patient satisfaction) in young patients with Pauwels type II and III treated with two-hole DHS fixation but complication rate (re-operation rate, conversion to THA) did not depend on the implant used but quality of fracture reduction.²

EXAMINER: Any other approaches that can be considered?

CANDIDATE: Yes, the Smith Peterson approach where you are able to get better direct visualization of the fracture, but it can be challenging in muscular young male patients. This requires two separate incisions, one anteriorly to reduce the fracture and the other laterally to insert the fixation device.

EXAMINER: If you reduced the fracture closed, can you think of a surgical step that can be performed to reduce the rate of ON?

CANDIDATE: Yes, hip decompression by performing a capsulotomy. Although this is controversial it is said to reduce intra-articular pressure which in the acute setting of fracture haematoma can theoretically occlude the trochanteric anastomosis. This has been studied in acute slipped capital femoral epiphysis and shown to reduce ON, so it can possibly be extrapolated to the adult population in a similar fashion. However, there is no good evidence to support this additional step in the literature and it is not something that I would routinely do unless guided by new research supporting its use.

EXAMINER: Apart from ON, what other complication are you concerned about in this patient?

CANDIDATE: The early complications would include wound infection, thromboembolic events and deep infection. In the intermediate to long term I would be concerned about loss of reduction and implant failure, non-union which I would quote in the displaced fractures up to 30%, ON and secondary osteoarthritis, all potentially requiring THA. If using CS, I would touch weight-bear the patient for at least 6 weeks and follow him up closely with radiological monitoring until the 3-year mark to ensure that the femoral head has survived without untoward complications.

EXAMINER: And with a DHS fixation?

CANDIDATE: Weight-bearing status would depend on adequacy of fixation and bone quality.

EXAMINER: So, would you allow full weight-bearing or not?

CANDIDATE: It is unlikely that osteoporosis would be present in a 29-year-old male and a DHS construct has been shown biomechanically to be more robust than CS, so I cautiously partial weight-bear with crutches.

EXAMINER: What does the literature say?

CANDIDATE: I am not sure any difference in outcome has been shown regarding weight-bearing status postoperatively [guess].

[Bell]

EXAMINER: Thank you.

EXAMINER: This is an 83-year-old male who fell while gardening, sustaining this injury. He lives with his wife, who he cares for. He mobilized indoors with no aids but uses a stick outdoors. He has a history of hypertension, hypothyroidism and angina. He is a non-smoker and rarely drinks. What does the radiograph show (Figure 10.2)?

CANDIDATE: The AP pelvis radiograph reveals a left sided displaced intracapsular fracture of the neck of femur. There is evidence of osteopenia and a Dorr type C femoral canal. Minimal degenerative changes are present in either hip. I cannot see any evidence of a pelvic or pubic ramus fracture. I would like to see a lateral radiograph of the hip.

EXAMINER: How will you assess this patient and what areas will you ask about?

CANDIDATE: I would clinically assess the whole patient and ensure that this is an isolated injury. I would find out more about his degree of mobility prior to his injury and ask about any comorbidities, systemic illness, red flag signs for any pathological lesion, as well as assess the reason for the fall. I would want to establish any preceding symptoms before the fall such as palpitations, chest pain, dizziness, weakness or shortness of breath and if there was a previous history of falls. I would establish if he is oriented in time, place and person, take an AMTS and obtain a collateral history.

EXAMINER: What would you look for in your examination and how would you work the patient up for surgery?

CANDIDATE: I would check the affected leg for shortening and external rotation. Perform a neurovascular examination. I would check the skin and soft tissues surrounding the fracture and proposed incision site. I would very gently confirm pain on movement of the hip. I would also want to perform a cardiovascular and respiratory examination of the patient. I would make sure the patient had a recent chest X-ray and order a new ECG to identify underlying cardiac comorbidities. I would give the patient analgesia for pain and insert a cannula and start IV fluids. Bloods should be sent for FBC, U&E and a group and save. I would want to get an INR/bone profile and stop any anticoagulation that may delay surgery. I would risk-assess warfarin reversal with Vit K.

I would attempt to get the patient as quickly as possible out of the A&E department onto an orthopaedic ward and certainly within 4 hours of admission to the A&E department. I would let the ward doctor know about the admission to ensure a good comprehensive handover with his drug kardex written up. As per NICE guidelines I would liaise with the anaesthetist on call to consider performing a fascia iliaca block as pain management preoperatively can be otherwise difficult to manage with paracetamol and opioids.

EXAMINER: He has well-controlled angina, takes thyroxine for his hypothyroidism and is relatively independent but does have two carers who come and help twice a week. How do you want to treat him?

CANDIDATE: A displaced intracapsular neck of femur requires surgery and, in this case, given the degree of displacement, which seems like a Garden IV (JBJS Garden 1964) I would perform a cemented hip hemiarthroplasty using a polished double-tapered stem with a bipolar head. I would use the lateral approach for my neck of femur fracture surgery as it tends to offer more stability and is not reliant on the soft tissues as much. I prefer an intraosseous abductor repair.

EXAMINER: As you see this was done as per your suggestion (Figure 10.3). Would your management differ if this was an independent and healthy 68-year-old patient who goes for 5-mile daily walks?

CANDIDATE: My initial assessment would be the same, but if the patient is independently mobile I would treat him in accordance with the NICE and the BOAST guidelines and would offer him a total hip replacement. THR offers a better functional outcome in comparison with a hemiarthroplasty, with better survivorship results which is supported by the Swedish registry. My choice would remain a double-tapered polished stem with long-term proven results such as an Exeter stem, with a cemented, highly cross-linked polyethylene cup with a preferably 36-mm head. The NICE guidelines support such practice in a selected population, which include the mentally alert patient with good pre-injury mobility and who is relatively healthy. The patient described seems to comply with the criteria for a THR. I would prefer to perform a fracture neck of femur THR via the lateral approach as opposed to a posterior approach that I would choose for an arthritic hip. This is to reduce the risk of a dislocation. I would also prefer to use a larger head for that reason. I would aim to restore his leg length and ensure soft-tissue tension is restored.

Postoperatively I would aim for early mobilization with full weight-bearing and discharge back to his usual residence once he has passed physiotherapy and occupational therapy assessment.

Osteoporosis treatment, falls risk assessment and nutritional deficiency should be addressed. The patient’s pre- and postoperative care should be carried out via an MDT approach.

EXAMINER: What time would you plan to do this case if the patient arrived in your hospital at 5 pm?

CANDIDATE: This case should not be done after hours and should be done in a scheduled trauma list ensuring the necessary skill, staff and kit is available, especially if a THR is going to be undertaken. The patient should be reviewed by an orthogeriatrician, to be optimized preoperatively, as per national guidelines. The operation should be performed as soon as safe and possible, ideally within 24 hours, but no later than 36 hours as per the national guidelines.

EXAMINER: What are the criteria for best-practice tariffs in patients who have sustained a hip fracture?

CANDIDATE: Best-practice tariff for fragility fractures was introduced to improve patient outcomes, reduce mortality and shorten length of stay. Key features include:

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  Surgery within 36 hours of admission.

  
  
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  Shared care by orthopaedic surgeon and orthogeriatrician.

  
  
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  Admission using a care protocol agreed by orthogeriatrician, orthopaedic surgeon and anaesthetist.

  
  
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  Assessment by orthogeriatrician within 72 hours of admission.

  
  
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  Pre- and postoperative abbreviated mental test score (AMTS) assessment.

  
  
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  Orthogeriatrician-led multidisciplinary rehabilitation.

  
  
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  Secondary prevention of falls.

  
  
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  Bone health assessment.

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  Evidence of THA in NOF fractures.

  
  
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  Higher complication rates of THR in NOF vs arthritic hip?

  
  
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  Infection rates.

  
  
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  Thromboprophylaxis.

EXAMINER: A 23-year-old motorcyclist has been involved in a high-speed head-on collision. He is brought into the A&E department and this radiograph has been taken in the resuscitation bay. Describe the radiograph and explain how you would manage this patient (Figure 10.4).

CANDIDATE: This is an AP radiograph of the patient’s pelvis with what appears to be a fracture–dislocation of the left hip.

EXAMINER: Appears or is?

CANDIDATE: Is a fracture–dislocation of the left hip.

There is also a cystogram with a catheter in situ with no evidence of extravasation indicating no bladder injury. With the benefit of the lateral radiographs as well as the mechanism described this is likely to be a posterior dislocation. These injuries are commonly associated with both factures to the femoral head and/or fracture to the acetabular wall, in this case a posterior wall fracture. The sciatic nerve is also at risk and would be a main point of concern. This is a high-energy injury and with such a mechanism there is the possibility of associated visceral and musculoskeletal injuries. This is a trauma call requiring all teams to be ready to receive the patient in the emergency department. I would approach this patient according to the ATLS protocol, ensuring his C-spine is immobilized and making sure no life-threatening injuries are missed.

EXAMINER: That’s fine. How would you proceed to manage his hip?

CANDIDATE: I would want to first assess his vascular status and check his pulses throughout his limb, starting with his femoral all the way down to his dorsalis pedis. If I have any concerns I would engage a vascular surgeon, or if one is not available then either plastics or general surgery. I would then assess his neurology as I would be worried about a sciatic nerve injury. Once that has been documented the relevant radiographs would be obtained, which would include a full-length femur and a knee radiograph.

EXAMINER: Why would you get a full-length femur and a knee radiograph – it’s a surgical emergency, this will just delay hip reduction?

CANDIDATE: I would want to exclude a coexisting femoral shaft fracture or knee injury which could be missed otherwise. Ideally, I would also get a preoperative hip CT scan if this did not delay the patient’s treatment significantly. Assuming there are no large intra-articular fragments requiring urgent open surgery, I would then proceed to attempt a closed reduction, preferably in theatre under GA and with fluoroscopy guidance.

If there would be a significant delay getting into theatre I may consider attempting to reduce the dislocation under appropriate sedation and analgesia in the emergency department. However, these are high-velocity injuries, they can be very difficult to reduce without full muscle relaxation and also have the potential for serious long-term morbidity so I would very much prefer not to go down that route. In theatre, I would perform the reduction with the patient supine on a radiolucent table, with my assistant applying pressure on the pelvis over the anterior superior iliac spines, while I apply longitudinal traction with hip flexion beyond 90°, with adduction and internal rotation, followed by abduction, external rotation and extension. This is known as the Bigelow manoeuvre. Once reduced, I would perform a test of stability. I would then place the patient on skin traction and obtain a postop CT scan, looking at any intra-articular fragments and fractures. As soon as the patient is awake I would repeat the neurovascular observations and document my findings. I would then refer this patient to a pelvic and acetabular surgeon for posterior wall fixation.

EXAMINER: How would your management differ in an anterior dislocation?

CANDIDATE: I would need to perform a reverse Bigelow manoeuvre.

EXAMINER: And if you were unable to reduce it closed?

CANDIDATE: In a posterior dislocation I would have to open via an extended posterior approach (Kocher–Langenbeck) while I would use a modified Smith–Peterson approach in an anterior dislocation.

EXAMINER: How will you manage the CT findings?