Femoral neck fractures

Hip fractures represent a significant public health burden with around 70,000-75,000 cases a year with an estimated cost of  £2 billion per a year, 10% of cases die within one month and a third die within 12 months(10). This is a marker of the complex co-morbidities of these patients, thus a thorough history into the cause of the fall needs to be undertaken and all patients should be managed within a multi-disciplinary environment with orthogeriatric input.

Management is nearly exclusively surgical with NICE recommending surgery on the day or day after admission with rapid correction or control of manageable co-morbidities to facility surgery(10).

Surgical options depend on the type of fracture. Firstly one must deduce if the fracture is intra or extra-capsular. In extra-capsular fractures blood supply to the femoral head is preserved and not threatened. If the fracture is above or including the lesser trochanter extramedullary fixation such as a sliding hip screw should be used, if subtrochanteric intramedullary fixation is advisable(10).

Intracapsular fractures are more complex. Due to the blood supply, as described above, the viability of the femoral head is threatened and avascular necrosis may occur. Fixation technique decision is dependent on the degree of displacement. Displacement is judged on plain film radiographs with both AP and lateral views assessed. Gardens classification is used to classify femoral neck fractures. Non displaced fractures (Gardners I and II) undergo fixation with cancellous scews or sliding hip screw. Displaced fractures (Gardners III and IV) require arthroplasty due to disruption of the blood and high risk of avascular necrosis , this can be total hip replacement or hemiarthroplasty(10). Indications for total hip replacement are defined by NICE as the following:

·      Were able to walk independently out of doors with no more than the use of a stick and

·      Are not cognitively impaired and

·      Are medically fit for anaesthesia and the procedure

Post operatively early mobilization is the aim with multi-disciplinary rehabilitation and future falls prevention.

Osteoarthritis

Pain secondary to osteoarthritis of the hip joint is present in 12% of adults of 65 years and above(11). Osteoarthritis of the hip may be primary or secondary to previous infection, injury or disease. Osteoarthritis of the hip joint has a worse prognosis than that of the hand or knee with a significant proportion requiring operative management at five years(11).

Pain is often the primary complaint, this can be felt in the anterior groin or it can be more generalized over the buttock and down to the knee. Patients may well complain that they find it hard to put on their shoes or cut their toe nails. Key signs on examination are an antalgic gait, muscle wasting, painful/reduced range of motion (internal rotation is the first effected), in later stages a fixed flexion deformity can be found(11).

Diagnosis can be made clinically, however AP plain film radiographs of the pelvis may well be useful.

Treatment should be individualized to patient factors. Education, strengthening with physiotherapy input, weight loss (if required), activity modification and assistive devices should be provided. Alongside this appropriate analgesia is needed. This should initially be paracetamol +/- non-steroidal anti-inflammatory drugs (NSAIDs). If prescribing a NSAID a proton-pump inhibitor should be co-prescribed and NSAIDs are not suitable/appropriate for all patients. Some may add weak opioids such as codeine however the evidence for this is poor(11). Intra-articular injection can also be considered; this may also provide diagnostic information.

If a patient continues to suffer from significant symptoms and pain operative intervention may be considered. Surgical options consist of arthroscopy, osteotomy, hip resurfacing and replacement(12). Patients age and degree of arthritic changes are key factors in the decision making process.

Developmental dysplasia of the hip (DDH)

DDH is a spectrum of disease ranging from mild dysplasia of the acetabulum to irreducible dislocation. 1-1.5 in 1000 live births are affected and it is more common in female patients, breech presentation and intra-uterine overcrowding(13, 14). The left hip is more commonly affected(13, 14).

In the neonate DDH is asymptomatic and therefore is screened for with Barlow and Ortolani tests. After the age of around 3 months the tissues begin to tighten and the aforementioned tests become unreliable, signs at this stage will be loss of abduction, apparent shortening of the thigh (Galeazzi sign) and asymmetrical skinfolds (however may be present in normal individuals)(13). After the child begins to walk other signs such as a trandelenburg gait and leg-length discrepancy will become apparent.

Ultrasonography prior to femoral head ossification (4-6 months) and plain film radiographs after ossification are the mainstay of investigation(13, 14).

Treatment depends on the age of diagnosis. Ultimately the aim is to maintain a reduced hip joint providing the optimal environment for normal hip development. As age at diagnosis increases this is harder to achieve, potential for hip remodeling reduces and more complex treatments are required. The following gives an overview of treatment options available according to age(13-15):

Under 6 months

·      Splintage usually with a Pavlik harness

·      Monitor with USS

6 months to 18 months

·      Closed reduction (+/- adductor tenotomy)

o   If difficulty in reduction consider arthrogram to assess if soft tissue is blocking reduction

·      If closed reduction fails open reduction

·      Reduction (closed or open) is held with a hip spica cast

18 months to 3 years

·      Open reduction (+/- osteotomy)

3 to 8 years

·      Open reduction and osteotomy

Over 8 years

·      Can be treated non-surgically or with osteotomy

·      Irrespective of above management choice must plan for a total hip replacement in adult life