Hip Injuries
Remember analgesia (see analgesia section). Always assess and record the patient’s ability to bear weight
Hip fractures or dislocations
1. Subcapital 2. Transcervical 3. Basicervical
4 Inter or Sub trochanteric (Extracapsular)
AP and lateral X-rays required plus CXR if fractured. Check sciatic nerve and pulses. For fractures - complete fast-track documentation, add femoral nerve block to opiate analgesia. Refer fractures to the on-call Orthopaedic Team.
Undisplaced fractures of the femoral neck
- may not be evident radiologically
- 1% of hip fractures will have a completely normal x-ray
- Patients may be able to walk (albeit painfully) with an undisplaced fracture
- In 5% of cases there may be no history of trauma (osteoporotic or pathological fracture likely)
Intracapsular (subcapital) fractures in young patients are an orthopaedic emergencies.
- Refer immediately to the duty orthopaedic SpR.
- If inability to bear weight or significant pain on walking obtain an orthopaedic opinion
- For fractures of pubic rami, please see under 'pelvic fractures'
- In children beware of Perthes' disease (avascular necrosis aged 3 - 8) and slipped upper femoral epiphysis (occurring around puberty) which requires a lateral radiograph for diagnosis. Please see Hip Pain in Children
Hip prostheses dislocation
- Check and document ABCDs, other injuries, pulses and and sciatic nerve function.
- If your senior is training in both reduction methods and safe conscious sedation, reduction can safely be attempted in the emergency department [Bestbets].
- Full sedation protocols and resuscitation facility guidelines must be followed.
- Most methods employ either in:
- In-line axial traction and lateral traction on the proximal femur
- In-line traction with the hip and knee flexed to 900 (+/- adduction to help the femoral head clear the acetabulum)
- In-line traction with the hip and knee flexes and additional lateral traction on the proximal femur.
- Most hips dislocated for more that 12 hours require a general anaesthetic.
- Check x-ray and record neurovascular status in all post reduction.
Femoral shaft fractures
- Check and treat ABCs
- Document sciatic nerve function
- Establish IV access and x-match 4 units
- Consider femoral nerve block.
- Confirm distal perfusion and sciatic nerve function
- Apply Thomas or Donway traction splint worn until the patient goes to theatre
FABER (flexion, abduction, external rotation) test
- Helps discriminate hip from spine pathology
- Patient makes "4" with legs (hip flex, abd, ext rotated)
- Non-painful reduced ROM - ? joint pathology
- Groin pain but ROM good ? ileopsoas sprain or pull off fracture
- If pain behind hip - ?SIJ pathology (e.g. ank spond)
- Push knee towards bed - if pain medially ? adductor sprain or rupture
