CLINICAL
ORTHOPAEDICS
The management of fractures of the hip Paul Wicker BSc (Nurs), RGN, RMN. is Theatre Charge Nurse, Princess Margaret Rose Orthopaedic Hospital, Edinburgh.
r
i A
l'ig. 1. Right hip joint, anterior and frontal section
Proximalfemoralfractures are a common reason for admission to orthopaedic units, and one which may become even more regular as the population ages. Despite this, newcomers to the orthopaedic arena, such as nursing students, may be confused when faced by different hip fractures and the treatments which may be offered. This article seeks to clarify some of these points by outlining the anatomy of the proxi mal femora! region, various common fractures, the treatments available to the surgeon and aspects of nursing care associated with the pre and post oper ative phases of the patient’s care.
The hip joint is a ball and socket joint formed by the acetabular portion (socket) of the pelvic bone, and the proximal portion of the femur (the ball). The hip joint is surrounded by a capsule, ligaments and muscles (Fig. 1). The proximal portion of the femur consists of the femoral head and neck, the upper por tion of the shaft and the greater and lesser trochanters. The greater trochanter serves as the point of insertion of the abductor and short rotator muscles of the hip. The lesser trochanter serves as the insertion of the iliop soas muscle. Fractures of the proximal femoral region can disrupt the blood supply, leading to avas cular necrosis of the femoral head. The blood supply to the head of the femur comes from three sources: • The obturator artery in the ligamentum teres • The retinacular vessels in the capsule • The intraosseus vessels running up from the metaphysis (1).
The main blood supply is provided by the reti nacular vessels which are derived from the medial femoral circumflex artery. Generally speaking, an intracapsular fracture ruptures these vessels and an extra capsular fracture does not. Intracapsular fractures therefore lead to a high incidence of avascular necrosis which, if left untreated, leads to a painful and stiff hip. Types of hip fractures Hip fractures can be clas sified under two main headings - extracapsular and intracapsular (Fig. 2). Extracapsular fractures include inter trochanteric and subtrochanteric fractures, which are very common in elderly people. They usually unite without difficulty since the blood supply to the femoral head - the capsu lar vessels - is sufficient to prevent avascular necrosis. Internal fixation of the fracture site is necessary to prevent external rotation result ing in malunion. Although it is possible to apply traction on a long term basis as a treat ment, internal fixation allows early mobilisation of the patient and so prevents complications such as thrombophlebitis, decubitus ulcers and pulmonary emboli (2).
Immediate attention The patient’s education must emphasise the danger of placing too much stress on the frac ture site and implant, and must raise awareness of the local danger signs of swelling, redness, pain and heat which may develop dur ing the period of bone consolidation. Swelling is treated with elevation of the affected limb; pain and redness may signify instability or Joint cavity Acetabular labrum.
Tendon of rectus femovis muscle ^
Pelvic
bone
Joint capsule Head of femur ^ Neck of femur Greater \ trochanter
Neofemoral ligaments.
Transverse acetabular ligament
Pubofemoral ligament
Ligamentum tenes Greater trochanter Femur----
Lesser trochanter
Femur
Joint capsule esser trochanter
September 1 Volume 6 Numl)er 50 1992 Nursing Standard 25
CLINICAL
ORTHOPAEDICS
< Fig. 2. Common fractures. A, B and C are intracapsular. D is extracapsular. screws and plates, but the principles of treat ment remain the same regardless of which is used. A large diameter screw is inserted through the femoral neck. The distal (thread ed) part of the screw locks onto the distal part of the fracture, while the proximal (barrel) part of the screw slides through the bone of the proximal part of the fracture. A plate is then slid over the screw and attached to the femur using bone screws. The angle of the screw/plate combination is normally 135 degrees, which matches the normal anatomi cal angle of the femoral head and shaft. This angle must be maintained as a smaller angle will make the hip unstable and a greater will reduce mobility. Various angles of plate are available to cope with anatomical differences and procedural requirements related to cor rection osteotomies . The main advantages of the screw and plate system are that the two components slide together allowing for shortening of the femoral neck during the normal period of resorption following fracture. This allows the fracture to settle into a posi Internal fixation tion of mechanical equilibrium with the In an undisplaced fracture, the blood supply implant, leading to a reduction in implant via the capsular vessels may still be intact and failure - the screw cutting out of the head, the internal fixation will be an option. If the joint plate snapping, or loosening of the plate on has undergone arthritic changes, however, it the femur. It also allows for compression of the is likely that either an arthroplasty or a hemi fracture site when weight is put on the leg, arthroplasty will be performed. Traditionally, encouraging healing while maintaining the internal fixation has been undertaken with crucial shaft/neck angle. cannulated screws, but a lag screw and plate This type of screw and plate can be used for long subtrochanteric fractures extending into is also an option (3). Treatment for extracapsular fractures: Lag screw the shaft of the femur. and plate Various manufacturers make lag The main disadvantage with the longer
infection which need immediate medical attention (2). Intracapsular fractures include femoral neck fractures such as the transccrvical and subcapital types. If the fracture is displaced then the blood supply to the femoral head is almost completely ruptured; the blood is then supplied via the ligamentum teres, which is insufficient to prevent avascular necrosis. In this situation, the femoral head will need to be replaced in a procedure known as a hemi arthroplasty. If the patient also suffers from arthritic changes, it is likely that a total hip replace ment - an arthroplasty - will be carried out. In either of these operations, the immediate post-operative danger is dislocation of the affected hip. This is prevented by the use of a ‘Charnley wedge’ or pillows which are insert ed between the knees, designed to keep the legs abducted in a stable position. Rolling the patient by grasping the affected limb must also be avoided.
26 Nursing Standard September 2 Volume 6 Number 50 1992
CLINICAL
ORTHOPAEDICS
plates arc that surgical access will require a long wound site and is likely to lead to increased pain, blood loss and infection rates. Rehabilitation is started in the immediate post-operative period. The leg is supported in a neutral position avoiding external rotation, and pressure care is initiated to prevent skin breakdown over the buttock, ankles and heels. The patient may be mobilised in a chair on the first post-operative day, providing there are no unexpected complications, and progress to walking with partial weight bearing (using crutches or a walking aid) on the second post operative day (4).
Wheelchair confinement
References 1. Muller M E et al. Manual of Internal Fixation. New York NY, Springer Verlag. 19792. Meeker M H, Rothrock J C. Alexander's Care of the Patient in Surgery. Ninth edition. St Louis MO, Mosby-Year Book Inc. 1991 3. Smith and Nephew Ltd. Richard’s Classic Hip Screu and Condylar Plate. Memphis TN, Smith and Nephew Ltd. 1988. 4. Chapman M W. Operative Orthopaedics. Philadelphia PA, JB Lipincott & Co. 1988. 5 Brown C. Continuity of care for the orthopaedic patient. AORSJournal. 1980. 31,6, 1128. 6. Howmedica International. Taking the 'Trauma out of Fracture. London, Howmedica International. 1991. 7. Seligson D. Richard’s 6.5mm Universal Cannulated Screw. Memphis TN, Smith and Nephew Ltd. 1991 8. Dorr L D. Proximal metaphyseal porous-coated implants for hip replacement arthroplasty. Contemporary Orthopaedics. 1984. 9, 5. 15.
If partial weight bearing is not possible, then the patient may be confined to a wheelchair until the fracture is stable. Assistance with toi leting, dressing, bathing and other daily activities which put strain on the affected limb will have to be given until consolidation of the fracture is well under way (5). Intramedullar}’ nailing Nails such as the Gamma or the Russell-Tailor Reconstruction nail are introduced through a small incision over the area of the greater trochanter and down the length of the femur. One or more screws are inserted up into the femoral neck. The screws in the Gamma nail work on the same principle as the sliding screw' described above and hence allow dynamic osteosynthe sis by compression (6). The nails have several advantages over plates, the main ones being associated low blood loss, low infection rates and reduced pain, each of which is a result of the short inci sion. Post-operatively, the patient can usually be allowed to mobilise immediately with par tial weight bearing. Treatment of intracapsular fractures (non-displaced subcapital fractures): Cannulated screws These are smaller in diameter than the lag screws and are cannulated to allow guide wires to pass down the centre. In the hip, they are only used forstable, non-displaced femoral neck and subcapital fractures, and for slipped femoral ephiphyses (7). They may also be used to sup plement a compression hip screw and plate. One of the advantages of using these screw’s is that they can be introduced percutaneously, resulting in less trauma and less post operative discomfort for the patient. There is, however, a high incidence of nonunion and avascular necrosis of the femoral head as a result of the disruption of the blood supply following the fracture. Post-operatively, great care must be taken not to put strain on the fracture site and the advantages of early weight
bearing must be calculated against the poten tial risks of implant failure. Displaced subcapital fractures: Hemiarthroplas ty The prosthetic replacement of the femoral head is necessary because avascular necrosis usually results from the ruptured blood sup ply. Monopolar prostheses include the Austin-Moore and Thomsons designs. During this procedure, the fractured femoral head and neck are removed, the femoral shaft is reamed and the prosthesis is inserted with or without cement as appropriate. There are various disadvantages with this method of treatment such as persistent dislo cations caused by an unstable hip joint, infection (sometimes years after the implant has been inserted) and allergic reactions to the methylmethocrylate cement (2). Manufac turers are constantly updating their products in an attempt to overcome these problems. One recent advance is the use of a porous coat ing on the prosthesis which improves adhesion to the cancellous bone and reduces the indi cations for bone cement (8). Bipolar prostheses were introduced to reduce the shear stresses affecting the acetab ulum. The friction between the head of the prosthesis and the acetabulum can lead to per foration of the femoral head through the acetabulum and into the pelvic cavity. The bipolar system consists of a femoral compo nent which is snapped onto a rotating polyethylene cup. The bipolar design helps to reduce the prob lem of perforation of the acetabulum since the friction occurs between the ball and the plas tic head instead of between the head and the acetabulum (4). Total hip replacement (arthroplasty') This pro cedure is carried out for intracapsular fractures in the presence of arthritic changes and for avascular necrosis of the femoral head associ ated with subcapital fractures. The femoral head, neck and acetabulum are replaced with prostheses. Normally, the short term results are excellent, but the same long term problems which complicate patients post hemiarthroplasties persist. Because of the potentially catastrophic effects of wound infection, asepsis is rigorously controlled. Conclusion The treatment of hip fractures is constantly changing and improving. The main aims of developments are to find treatments which are minimally invasive when internal fix ation is appropriate and w’hich provide stable and long-term improvements when joint replacement is required. Nursing care of these patients tends to be complex due to the under lying and associated problems presented by the trauma and subsequent surgery. September 2/Volume 6/Number 50/1992 Nursing Standard 27
ORTHOPAEDICS
The management of fractures of the hip Paul Wicker BSc (Nurs), RGN, RMN. is Theatre Charge Nurse, Princess Margaret Rose Orthopaedic Hospital, Edinburgh.
r
i A
l'ig. 1. Right hip joint, anterior and frontal section
Proximalfemoralfractures are a common reason for admission to orthopaedic units, and one which may become even more regular as the population ages. Despite this, newcomers to the orthopaedic arena, such as nursing students, may be confused when faced by different hip fractures and the treatments which may be offered. This article seeks to clarify some of these points by outlining the anatomy of the proxi mal femora! region, various common fractures, the treatments available to the surgeon and aspects of nursing care associated with the pre and post oper ative phases of the patient’s care.
The hip joint is a ball and socket joint formed by the acetabular portion (socket) of the pelvic bone, and the proximal portion of the femur (the ball). The hip joint is surrounded by a capsule, ligaments and muscles (Fig. 1). The proximal portion of the femur consists of the femoral head and neck, the upper por tion of the shaft and the greater and lesser trochanters. The greater trochanter serves as the point of insertion of the abductor and short rotator muscles of the hip. The lesser trochanter serves as the insertion of the iliop soas muscle. Fractures of the proximal femoral region can disrupt the blood supply, leading to avas cular necrosis of the femoral head. The blood supply to the head of the femur comes from three sources: • The obturator artery in the ligamentum teres • The retinacular vessels in the capsule • The intraosseus vessels running up from the metaphysis (1).
The main blood supply is provided by the reti nacular vessels which are derived from the medial femoral circumflex artery. Generally speaking, an intracapsular fracture ruptures these vessels and an extra capsular fracture does not. Intracapsular fractures therefore lead to a high incidence of avascular necrosis which, if left untreated, leads to a painful and stiff hip. Types of hip fractures Hip fractures can be clas sified under two main headings - extracapsular and intracapsular (Fig. 2). Extracapsular fractures include inter trochanteric and subtrochanteric fractures, which are very common in elderly people. They usually unite without difficulty since the blood supply to the femoral head - the capsu lar vessels - is sufficient to prevent avascular necrosis. Internal fixation of the fracture site is necessary to prevent external rotation result ing in malunion. Although it is possible to apply traction on a long term basis as a treat ment, internal fixation allows early mobilisation of the patient and so prevents complications such as thrombophlebitis, decubitus ulcers and pulmonary emboli (2).
Immediate attention The patient’s education must emphasise the danger of placing too much stress on the frac ture site and implant, and must raise awareness of the local danger signs of swelling, redness, pain and heat which may develop dur ing the period of bone consolidation. Swelling is treated with elevation of the affected limb; pain and redness may signify instability or Joint cavity Acetabular labrum.
Tendon of rectus femovis muscle ^
Pelvic
bone
Joint capsule Head of femur ^ Neck of femur Greater \ trochanter
Neofemoral ligaments.
Transverse acetabular ligament
Pubofemoral ligament
Ligamentum tenes Greater trochanter Femur----
Lesser trochanter
Femur
Joint capsule esser trochanter
September 1 Volume 6 Numl)er 50 1992 Nursing Standard 25
CLINICAL
ORTHOPAEDICS
< Fig. 2. Common fractures. A, B and C are intracapsular. D is extracapsular. screws and plates, but the principles of treat ment remain the same regardless of which is used. A large diameter screw is inserted through the femoral neck. The distal (thread ed) part of the screw locks onto the distal part of the fracture, while the proximal (barrel) part of the screw slides through the bone of the proximal part of the fracture. A plate is then slid over the screw and attached to the femur using bone screws. The angle of the screw/plate combination is normally 135 degrees, which matches the normal anatomi cal angle of the femoral head and shaft. This angle must be maintained as a smaller angle will make the hip unstable and a greater will reduce mobility. Various angles of plate are available to cope with anatomical differences and procedural requirements related to cor rection osteotomies . The main advantages of the screw and plate system are that the two components slide together allowing for shortening of the femoral neck during the normal period of resorption following fracture. This allows the fracture to settle into a posi Internal fixation tion of mechanical equilibrium with the In an undisplaced fracture, the blood supply implant, leading to a reduction in implant via the capsular vessels may still be intact and failure - the screw cutting out of the head, the internal fixation will be an option. If the joint plate snapping, or loosening of the plate on has undergone arthritic changes, however, it the femur. It also allows for compression of the is likely that either an arthroplasty or a hemi fracture site when weight is put on the leg, arthroplasty will be performed. Traditionally, encouraging healing while maintaining the internal fixation has been undertaken with crucial shaft/neck angle. cannulated screws, but a lag screw and plate This type of screw and plate can be used for long subtrochanteric fractures extending into is also an option (3). Treatment for extracapsular fractures: Lag screw the shaft of the femur. and plate Various manufacturers make lag The main disadvantage with the longer
infection which need immediate medical attention (2). Intracapsular fractures include femoral neck fractures such as the transccrvical and subcapital types. If the fracture is displaced then the blood supply to the femoral head is almost completely ruptured; the blood is then supplied via the ligamentum teres, which is insufficient to prevent avascular necrosis. In this situation, the femoral head will need to be replaced in a procedure known as a hemi arthroplasty. If the patient also suffers from arthritic changes, it is likely that a total hip replace ment - an arthroplasty - will be carried out. In either of these operations, the immediate post-operative danger is dislocation of the affected hip. This is prevented by the use of a ‘Charnley wedge’ or pillows which are insert ed between the knees, designed to keep the legs abducted in a stable position. Rolling the patient by grasping the affected limb must also be avoided.
26 Nursing Standard September 2 Volume 6 Number 50 1992
CLINICAL
ORTHOPAEDICS
plates arc that surgical access will require a long wound site and is likely to lead to increased pain, blood loss and infection rates. Rehabilitation is started in the immediate post-operative period. The leg is supported in a neutral position avoiding external rotation, and pressure care is initiated to prevent skin breakdown over the buttock, ankles and heels. The patient may be mobilised in a chair on the first post-operative day, providing there are no unexpected complications, and progress to walking with partial weight bearing (using crutches or a walking aid) on the second post operative day (4).
Wheelchair confinement
References 1. Muller M E et al. Manual of Internal Fixation. New York NY, Springer Verlag. 19792. Meeker M H, Rothrock J C. Alexander's Care of the Patient in Surgery. Ninth edition. St Louis MO, Mosby-Year Book Inc. 1991 3. Smith and Nephew Ltd. Richard’s Classic Hip Screu and Condylar Plate. Memphis TN, Smith and Nephew Ltd. 1988. 4. Chapman M W. Operative Orthopaedics. Philadelphia PA, JB Lipincott & Co. 1988. 5 Brown C. Continuity of care for the orthopaedic patient. AORSJournal. 1980. 31,6, 1128. 6. Howmedica International. Taking the 'Trauma out of Fracture. London, Howmedica International. 1991. 7. Seligson D. Richard’s 6.5mm Universal Cannulated Screw. Memphis TN, Smith and Nephew Ltd. 1991 8. Dorr L D. Proximal metaphyseal porous-coated implants for hip replacement arthroplasty. Contemporary Orthopaedics. 1984. 9, 5. 15.
If partial weight bearing is not possible, then the patient may be confined to a wheelchair until the fracture is stable. Assistance with toi leting, dressing, bathing and other daily activities which put strain on the affected limb will have to be given until consolidation of the fracture is well under way (5). Intramedullar}’ nailing Nails such as the Gamma or the Russell-Tailor Reconstruction nail are introduced through a small incision over the area of the greater trochanter and down the length of the femur. One or more screws are inserted up into the femoral neck. The screws in the Gamma nail work on the same principle as the sliding screw' described above and hence allow dynamic osteosynthe sis by compression (6). The nails have several advantages over plates, the main ones being associated low blood loss, low infection rates and reduced pain, each of which is a result of the short inci sion. Post-operatively, the patient can usually be allowed to mobilise immediately with par tial weight bearing. Treatment of intracapsular fractures (non-displaced subcapital fractures): Cannulated screws These are smaller in diameter than the lag screws and are cannulated to allow guide wires to pass down the centre. In the hip, they are only used forstable, non-displaced femoral neck and subcapital fractures, and for slipped femoral ephiphyses (7). They may also be used to sup plement a compression hip screw and plate. One of the advantages of using these screw’s is that they can be introduced percutaneously, resulting in less trauma and less post operative discomfort for the patient. There is, however, a high incidence of nonunion and avascular necrosis of the femoral head as a result of the disruption of the blood supply following the fracture. Post-operatively, great care must be taken not to put strain on the fracture site and the advantages of early weight
bearing must be calculated against the poten tial risks of implant failure. Displaced subcapital fractures: Hemiarthroplas ty The prosthetic replacement of the femoral head is necessary because avascular necrosis usually results from the ruptured blood sup ply. Monopolar prostheses include the Austin-Moore and Thomsons designs. During this procedure, the fractured femoral head and neck are removed, the femoral shaft is reamed and the prosthesis is inserted with or without cement as appropriate. There are various disadvantages with this method of treatment such as persistent dislo cations caused by an unstable hip joint, infection (sometimes years after the implant has been inserted) and allergic reactions to the methylmethocrylate cement (2). Manufac turers are constantly updating their products in an attempt to overcome these problems. One recent advance is the use of a porous coat ing on the prosthesis which improves adhesion to the cancellous bone and reduces the indi cations for bone cement (8). Bipolar prostheses were introduced to reduce the shear stresses affecting the acetab ulum. The friction between the head of the prosthesis and the acetabulum can lead to per foration of the femoral head through the acetabulum and into the pelvic cavity. The bipolar system consists of a femoral compo nent which is snapped onto a rotating polyethylene cup. The bipolar design helps to reduce the prob lem of perforation of the acetabulum since the friction occurs between the ball and the plas tic head instead of between the head and the acetabulum (4). Total hip replacement (arthroplasty') This pro cedure is carried out for intracapsular fractures in the presence of arthritic changes and for avascular necrosis of the femoral head associ ated with subcapital fractures. The femoral head, neck and acetabulum are replaced with prostheses. Normally, the short term results are excellent, but the same long term problems which complicate patients post hemiarthroplasties persist. Because of the potentially catastrophic effects of wound infection, asepsis is rigorously controlled. Conclusion The treatment of hip fractures is constantly changing and improving. The main aims of developments are to find treatments which are minimally invasive when internal fix ation is appropriate and w’hich provide stable and long-term improvements when joint replacement is required. Nursing care of these patients tends to be complex due to the under lying and associated problems presented by the trauma and subsequent surgery. September 2/Volume 6/Number 50/1992 Nursing Standard 27
