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Proximal Femoral Fractures For Postgraduate Orthopaedic Exams
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Proximal Femoral Fractures For Postgraduate Orthopaedic Exams
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Language: EN.
Segment:0 .
And good evening, everyone, and welcome to our teaching session, which is the orthopedic Academy in combination with orthopedic Research UK.
This evening, I'm delighted to welcome Mr. Sharma, a consultant at Luton and Dunstable hospitals, for our talk on femoral proximal femoral fractures. And I'm accompanied by Hani and Imogen and Hannah from the UK. My name is Nicky Evans and I'll be your host for this evening. So the we apologize for the slightly late start, but we're going to proceed with the lecture shortly.
Then we're going to follow with some invited questions. So if you do have any questions for Mr Sharma, if you would put them in the chat and we'll keep an eye out and we'll ask him at the end and we will be doing some viable practice for three candidates. So if you would like to partake in this, if you let Hannah and image, you know, then we'll get your names. For the end of that, we'll only have time for 3 this evening.
It is quite stressful, but we do believe it's the best way to prepare for the clinical and the vivisection of the exams. So as always, we recommend our concise orthopedic notes, as well as the truck provision books, which are invaluable. I use them in mind in my preparation for the exam. And so without any further ado, I will hand you over to Mr. Sharma for the lecture. Thank you very much.
Hi hello, everyone. Sorry for the late start because of me, some computer problems. I mean, just today, I thought we would talk about proximal femur fractures, which is one of the most commonest things you come across in your daily clinical practice. By that measure, you would also find them in orthopedic FRC exams.
This is one of those topics that you would be considered to in and out. So what I. I'm going to do here is. Can everybody see me? Yes, we can see your presentation. Great So I thought I'll take you through a journey of a patient who comes through. In our anc, it's a very common thing we see patients presenting to us with proximal femur fracture.
It seems like an everyday practice, but you'll be surprised to see how much controversy and how much evidence based practices we undertake in that small journey that this frail woman is going to take through your hospital. I'm sure this is occurrence everywhere in each of your hospitals. So myself and I would share my work in using Dunstable hospital as part of Bedfordshire hospitals.
That's my hospital surrounded by a nice chondrocyte. Yes now let's talk about hip fracture, so everybody knows this one of the Communist structures that we deal with in trauma. The mean age in the UK is around 80 years, and 2/3 of those are found in females. So as life expectancy is improving, we are expecting a global increase, rather pandemic of hip fractures.
So you might have something like a Corona pandemic in 90 and 2050, it'll be hip fracture pandemic. Then there is a high risk of mortality associated with these fractures, so one year mortality is anywhere from 20 to 40 percent, 30 day mortality being around 8% to 10% So you cannot change that in operation theater or we are called orthopedic surgeons and we believe we can solve all the problems in the theaters.
But this is one fracture that cannot be changed. Our mortality and the outcomes cannot completely be changed by just operating on these patients. So the journey of this patient, the outcome is determined by exactly how the patient is taken care of at each step of the journey. So what I'm going to talk about is evidence regarding the best practice or the recommended best practice for the evidence is controversial or incomplete.
So this. These things will be based on expert consensus opinion. I'm sure you would come across things being done differently at different places, but what I'm talking about is what things are done most commonly. And which has got an expert consensus. So intervention, as we all know, starts right from the knee. For a patient presenting to us with the phone. So we have to have a protocol driven fast track admission of patients with hip fracture to the A&E departments.
This has shown a good improvement in the outcomes instead of letting them wait in queues or sitting on them. We know what process and what, what needs to be done for these patients, so they are straightaway rushed to a protocol within four hours of hospital arrival. In fact, the patient should be admitted to an appropriate clinical Ward. Now, imaging options for fractures is simple, you will get an x-ray, but in some patients you find that the.
A fracture is not clearly visible, so the best imaging option for that is MRI scan. In some places, you might get a CT scan, but the evidence base is now that MRI scan for the hip. For a suspected hip fracture is the gold standard. If MRI is not available within 24 hours or is contraindicated, then consider a C scan right now. Next thing, as I was saying, all the fractures we think are an orthopedic domain, but no, not the fragility hip fractures.
So patients with hip fractures require a multidisciplinary approach. And that also not led by orthopedic surgeon should be led by also geriatricians. All right. Now, the multidisciplinary team should consist of these various people, at least, if not more, a trauma coordinator.
The gp, of course, is always a part of any team. The community falls assessment nurses, emergency staff, physio Ortiz, bad managers, orthopedic nursing staff, surgeon, anaesthetists, also geriatrician, social workers and rehabilitation service. They all are part of the team that will help improve the outcome of the hip fractures, which are going to be a pandemic soon. So all of the people have to be on board to treat these fractures.
I evidence basis that dedicated hip fracture, what gives better results. So it lead to appropriately trained staff, patients do not move around to multiple areas that has been shown by evidence to decrease delirium. Now the big six that is provision of pain relief. Delirium screening. Early Warning, scoring. Lead investigation.
Fluid therapy and pressure area inspection. These all are improved with dedicated hip fracture wards. Pain relief. Now that is our role basically in this whole treatment of a fraction of thema. Is this surgery is the best painkiller we have. But short of that, we assess and alleviate the pain within 30 minutes of admission.
Then every hour till settled. This is paramount. And I say it's not recommended and opioids have should be limited. You should be limited. The star is the most important pain lifting that we use, especially a lack of rocks nowadays. This can be repeated every 12 hours and this can be given in and, you know, should be given an excellent emergency and do not use nerve blocks as a substitute for early surgery.
Our next controversy is time to surge. It's been shown by multiple studies that surgical repair of hip fractures should occur within 48 hours of hospital admission. And for even better outcome, it should be done within 24 hours. So the evidence for that is weak. Pre-operative assessment is mandatory now.
So, as I said, foot anesthetic team role in influencing time to date is very important, then allowing for planning of anesthetic technique, which has got a big importance in the outcome of patient assessment and communication of perioperative risk and free optimisation. These are all things are needed from the anesthetic colleagues. Now, this is an important slide, so these things are.
To be identified and treated, but not to delay the surgery, more than 48 hours outcome, as I said, is best if this surgery is done within 48 hours. So these things we try to treat. Anemia can be reversed to a degree anticoagulation and electrolyte imbalances. Volume depletion, uncontrolled diabetes and heart failure. Correct correctable cardiac arrhythmia as an ischemic. Acute chest infection and exacerbation of chronic chest conditions.
So we can give up to 48 hours to try to optimize these conditions. And nothing else beyond them. Of course, there would be a few exceptions, but we should try not to take them into consideration and delay the surgery based on anything else. So nowadays, most of our patients have got some kind of anticoagulation, and that has led to delay in surgery many times.
So the consensus in most of the hospitals now with the exceptions, of course, is that we do not stop clopidogrel. Aspirin is discontinued, but don't delay surgery because of that warfarin we should have protocols in place to reverse the warfarin get INR below one point five, either on anticoagulant anticoagulation agents. You discontinue them on admission, but try not to delay surgery based on if the renal function is fine.
That is, a screening clearance is more than minute. People have now sort of agreeing to carry on with the surgery without delay within 48 hours with these patients. Now anesthesia. Consider intraoperative nerve blocks for all patients and recommend surgery and spinal anesthesia is considered safer for the hip surgeries.
Again, some of the anesthetic colleagues don't agree with this, but as I said, consensus is it's easier for hip fractures. Now you might and you will come across patients who are considered too sick to operate, so should we let them just stay in the bed? That is probably not right, we should still consider them for surgery.
There's a rule this is called for palliative care. This will minimize their pain and other symptoms. It will establish patient's own priorities for rehabilitation. And you should, of course, consider that end of life care wishes. As I mentioned earlier, surgery is one of the best painkillers we have for hip fracture. Of course, we should have cardiologists.
Now we come to something that will interest us as orthopedic surgeons, the d'aliments with the surgical decisions that if we come across and displaced fractures, what do we do? Do we fix, replace or give trial without fixation? There is 30% to 50% risk of subsequent displacement. If we give trial without fixation and current preference in most of the hospitals.
Is that all on this place, intraoperatively fractures should be treated by internal fixation. What should we do if there's an international fracture, which is not very displaced, should we go ahead with dynamic fixation or minimally displaced fractures? Or should we give multiple screws? So there is weak evidence that DHS has better outcome and it has got biomechanical advantage over multiple screws?
Entrega axilo fractures in young patients. What do you do? Fixation irrespective of the displacement? Yes so in young patients, even if it is completely displaced fractures, you go ahead with trying to reduce them and fixing them. Now what is the cutoff age? Is that second, crossing anywhere around 50 would be my cutoff age, but it depends more on the physiological age.
Elderly patients, what do you do for a minimally displace entry capsule fracture fixation or outer plastic? This is based on multiple fractures. Medical practice have patients physiological age mainly. And displacement of the fractures, we continue with controversy and intrigue, axilo fractures, which is better off of blast or total hip replacement. Now we all are aware that ice is push to work to lift replacements.
We have to take this decision based on the patient. Each patient has to be taken on their own merit. They should be independently mobile with intact cognition, and they should be medically fit. And then they want a total hip replacement. Age is not a factor there. You should not. Then hemi outward velocity, which should be used to cement it around cement, it cemented stem has been shown to increase embolism and leading to cardiopulmonary complications and cemented stems are known for its very, very periprosthetic fractures.
And they are known for inferior functional outcomes. So the consensus is to try to use cement. It stems in fractured creamers. As we said, this is a dilemma everywhere for total hip replacements and still stands true for patients who are undergoing surgery for a hip, for fractured hip. Whether we do cemented and cemented or hybrid.
Uh, as I said, my preference personally is cemented, but there's no strong evidence for either of them. He'd say, should it be 28 to 30 six? Or should it be higher? And should we use a dual mobility for total hip replacements in fractional noffs that still stays controversial? US now, head size, how big is big enough, we all like to put big heads to prevent dislocation, that is the common myth we have, but we know that large head sizes lead to volumetric bear and there is elevated metal ions.
So as we know from our experience, from metal on metal hips and hip resurfacing, there is ongoing concerns about LTI allegiance and Allen allegiance. There has been shown to be no benefit in hip function when the head size is more than 36 mm, that's been proven. But long term total hip survivorship with weak evidence has proved that 32 millimeter heads are the best, with, of course, excellent quality Allen bearings.
This is better than smaller and larger ones now, dual mobility or a conventional hip again, dual mobility is a good concept. Looks like it would help in decreasing the increased rate of possible dislocation that is present in total hips after fracture nerves. But early designs of dual mobility have their own complications.
But the newer generation are dual mobility prostheses are demonstrating these problems have been overcome. The evidence hasn't come to be very sure yet. So it's still needed. Approaches, of course, various approaches have been described, but the sort of basic expert consensus, again, that anterolateral approach is favored or a positive approach when doing heaviest losses.
Extra axilo fractures, they have their own dilemmas now for New classification, a 1 and a 2 fractures, which are fractures which are about the lesser rock and the DHS that is on a sliding hip screw is preferable to an internal email. This has been impressed upon us by neisloss, but we use intermittently nailing when there is compromised medial kalka by a combination or a large posterior medial fragment, or fractures that extend into the enteric region.
Of course, reverse obliquity fractures trance to Kendrick fractures that involve the lateral corticospinal wall they all warrant. Internal emails do better than. These are a few examples of these fractures the soft rock extension with the reverse obliquity, the lateral wall combination and soft rock Kendrick extensions.
And we're using nails this again, decision to be made about whether we use short nail or a long nail in some study that has been shown, long nail has prevents re fracture of the femur because it's osteoporotic. That helical fracture, which we are fixing. And the tip of the short nail, has a possibility that fractures can happen there or as such, fractures can happen in the femur because of osteoporosis.
And it's been shown that post-op hip and type pain is less with long, long nails. Now, there are some measures we can take intraoperatively like tranexamic acid, there's evidence that it helps in reducing bleeding. Local anesthetic injection failure like a blocker already stressed on that, that can be done intraoperatively. And increasingly in some trusts, they're using these devices, which are continuous infusion local anesthetic pumps.
The evidence for them is lacking. Went to wait there, invariably the consensus is the aim is to the whole. Process, we have been doing everything we have been doing so far surgery, letting them, optimizing them for the surgery, and everything has been done just for this purpose so that we can allow them to weight and walk without restriction as soon as possible.
So we should not defeat that purpose by not letting the patient mobilized as soon as possible. So offer patient physiotherapy within 24 hours, unless medically or surgically contraindicated. Cognitive assessment is important. That should be part of the hip fracture treatment, nutritional assessment and fall prevention or other things that are important. They cannot be overlooked.
Post-operatively, physiotherapy, as I said, the risk of bad bedbound complications. Also, look at the fragility fracture risk. It should be done with the help of our medical colleagues. And, of course, data collection. We know that UK has got a national database that has been instrumental in changes of all our practice. We have made small changes in our practice, but they have all had important outcomes in the results we have been able to produce for our hip fracture care.
And of course, audit and data should be prior priority in our practice, which sometimes gets missed. Thank you. Thank you, everybody. Thanks for your patience. As I said, a very common topic, very simple topic, but common things are common both in your medical life and also in your exams.
Thank you very much, Mr Sharma. That was a really nice walk through the hip hip fractures and the best practice tariff, which is a common topic in exams, and it's a topic that you can't afford to get wrong. You do need to know this in detail in some ways. You know, you think it's an easy topic because it's something we deal with every day. But in fact, you need to know the guidelines and exactly the details that Mr. Sharma's outlined in that lecture.
So are there any questions? Honey, do you have any questions? Yes, so beautiful. Someone asking about the paper, which says a teacher is better than the screws. I'm sorry, the paper that says the DHS is better than the schools, I can provide the exact papers, I mean, as I said, most of these evidence that we have produced would come across.
Some papers which have said that they're both equally good, but there are few papers that are suggesting that the DHS has got a better physiology, physiologically more structural support to the proximal femur to allow early mobilization. Exact papers. If you drop me an email address, I can find out and send to you.
OK, so. OK, so just a question, so what is the criteria to say I will do DHS here in this case? No, DHS, I couldn't do that. I will do Neal. All right. Shall I take you back to my slide? OK right, so if you look at our extremity fractures, so extra axilo fractures, the divided A0 class a one, two and three, so one and two, we should invariably do d.h.s. We can do internal bleeding also.
But the evidence base is that DHS does equally well. With a 1 and a 2 fractures, the outcomes is equal in some papers they have suggested that it is decreased blood loss and decreased operating time with VHS, which is controversial, but it is equally well in error. Now if we go beyond that to these. All these things that I've emulated here, where compromise media, kalka, you should are in favor of intermittently nailing.
Of course, if there is some softer Kendrick extension, intimidating large posterior medial fragment. Intimidating does better reverse oblique fractures in nailing does better, and chance took a risk factor that involves the lateral corticospinal wall. Right, and these are a few of the examples, like if you get a fracture like that, it's just a typical example of reverse oblique fracture.
Is it culminated calcar and also such an extension, the lateral side air is blown out. And again, this patient has got a slap traject extension, so some of them might still be fixed with DHS, but the outcome would be better with nailing in these. OK, so actually, there is a paper published in 2016. And they mentioned that if you draw a line about 3 centimeters below the inferior end of the GT and you measure the distance between this point to the fracture line, if it's less than 2 centimeters you shouldn't do a d.h.s. What do you think about that?
Mr Sharma. And so I draw a line from great traject. Yeah, from the inferior the distal part of the gti, about 3 centimeters distal to that, and they measure the distance between this point and the fracture line. So you need 20.5 millimeter of the lateral wall to do a chest. Yeah I mean, you can still do DHS for them, but this is now we are going to the area of Scarborough country, which inherently, as I mentioned, several factors don't do well with DHS.
There's the DHS is based on a principle of controlled collapse. So it does need to collapse on to something the fracture needs to collapse onto something if there is no support to collapse on the lateral wall. Then the pressure would go 100% on the plate. So it's more likely to fail in that situation where there's the nail, inherently because it is the fulcrum why it's more nearer the fulcrum of the center.
It's more likely to function better in that situation. OK Uh, there's no more questions. OK, thanks, honey. I'm surprised because every slide of mine is full of controversy, and it is, as I said, the Communist tropics have got any controversies, you wouldn't even understand a simple hip fracture.
We walk through so many controversial decisions, but this is just to evoke your interest in how many controversies we traverse every day. The best of luck, everybody for your fastest. Thank you so much, Mr Sharma, on behalf of everybody else, thank you for giving up your time today and educating us all on that topic, which, you know, it's like diabetes in medical school, you think you know, it's don't learn it when in fact it's what's going to trip you up in the middle of an exam and then you'll be kicking yourself afterwards.
So thank you so much for joining us. Thank you, Mr Sharma. Thank you. Take care. All right. Thank you. OK, guys. So I am going to stop the recording and we will move on to the Viber section.
Give me 1 minute.
Segment:0 .
And good evening, everyone, and welcome to our teaching session, which is the orthopedic Academy in combination with orthopedic Research UK.
This evening, I'm delighted to welcome Mr. Sharma, a consultant at Luton and Dunstable hospitals, for our talk on femoral proximal femoral fractures. And I'm accompanied by Hani and Imogen and Hannah from the UK. My name is Nicky Evans and I'll be your host for this evening. So the we apologize for the slightly late start, but we're going to proceed with the lecture shortly.
Then we're going to follow with some invited questions. So if you do have any questions for Mr Sharma, if you would put them in the chat and we'll keep an eye out and we'll ask him at the end and we will be doing some viable practice for three candidates. So if you would like to partake in this, if you let Hannah and image, you know, then we'll get your names. For the end of that, we'll only have time for 3 this evening.
It is quite stressful, but we do believe it's the best way to prepare for the clinical and the vivisection of the exams. So as always, we recommend our concise orthopedic notes, as well as the truck provision books, which are invaluable. I use them in mind in my preparation for the exam. And so without any further ado, I will hand you over to Mr. Sharma for the lecture. Thank you very much.
Hi hello, everyone. Sorry for the late start because of me, some computer problems. I mean, just today, I thought we would talk about proximal femur fractures, which is one of the most commonest things you come across in your daily clinical practice. By that measure, you would also find them in orthopedic FRC exams.
This is one of those topics that you would be considered to in and out. So what I. I'm going to do here is. Can everybody see me? Yes, we can see your presentation. Great So I thought I'll take you through a journey of a patient who comes through. In our anc, it's a very common thing we see patients presenting to us with proximal femur fracture.
It seems like an everyday practice, but you'll be surprised to see how much controversy and how much evidence based practices we undertake in that small journey that this frail woman is going to take through your hospital. I'm sure this is occurrence everywhere in each of your hospitals. So myself and I would share my work in using Dunstable hospital as part of Bedfordshire hospitals.
That's my hospital surrounded by a nice chondrocyte. Yes now let's talk about hip fracture, so everybody knows this one of the Communist structures that we deal with in trauma. The mean age in the UK is around 80 years, and 2/3 of those are found in females. So as life expectancy is improving, we are expecting a global increase, rather pandemic of hip fractures.
So you might have something like a Corona pandemic in 90 and 2050, it'll be hip fracture pandemic. Then there is a high risk of mortality associated with these fractures, so one year mortality is anywhere from 20 to 40 percent, 30 day mortality being around 8% to 10% So you cannot change that in operation theater or we are called orthopedic surgeons and we believe we can solve all the problems in the theaters.
But this is one fracture that cannot be changed. Our mortality and the outcomes cannot completely be changed by just operating on these patients. So the journey of this patient, the outcome is determined by exactly how the patient is taken care of at each step of the journey. So what I'm going to talk about is evidence regarding the best practice or the recommended best practice for the evidence is controversial or incomplete.
So this. These things will be based on expert consensus opinion. I'm sure you would come across things being done differently at different places, but what I'm talking about is what things are done most commonly. And which has got an expert consensus. So intervention, as we all know, starts right from the knee. For a patient presenting to us with the phone. So we have to have a protocol driven fast track admission of patients with hip fracture to the A&E departments.
This has shown a good improvement in the outcomes instead of letting them wait in queues or sitting on them. We know what process and what, what needs to be done for these patients, so they are straightaway rushed to a protocol within four hours of hospital arrival. In fact, the patient should be admitted to an appropriate clinical Ward. Now, imaging options for fractures is simple, you will get an x-ray, but in some patients you find that the.
A fracture is not clearly visible, so the best imaging option for that is MRI scan. In some places, you might get a CT scan, but the evidence base is now that MRI scan for the hip. For a suspected hip fracture is the gold standard. If MRI is not available within 24 hours or is contraindicated, then consider a C scan right now. Next thing, as I was saying, all the fractures we think are an orthopedic domain, but no, not the fragility hip fractures.
So patients with hip fractures require a multidisciplinary approach. And that also not led by orthopedic surgeon should be led by also geriatricians. All right. Now, the multidisciplinary team should consist of these various people, at least, if not more, a trauma coordinator.
The gp, of course, is always a part of any team. The community falls assessment nurses, emergency staff, physio Ortiz, bad managers, orthopedic nursing staff, surgeon, anaesthetists, also geriatrician, social workers and rehabilitation service. They all are part of the team that will help improve the outcome of the hip fractures, which are going to be a pandemic soon. So all of the people have to be on board to treat these fractures.
I evidence basis that dedicated hip fracture, what gives better results. So it lead to appropriately trained staff, patients do not move around to multiple areas that has been shown by evidence to decrease delirium. Now the big six that is provision of pain relief. Delirium screening. Early Warning, scoring. Lead investigation.
Fluid therapy and pressure area inspection. These all are improved with dedicated hip fracture wards. Pain relief. Now that is our role basically in this whole treatment of a fraction of thema. Is this surgery is the best painkiller we have. But short of that, we assess and alleviate the pain within 30 minutes of admission.
Then every hour till settled. This is paramount. And I say it's not recommended and opioids have should be limited. You should be limited. The star is the most important pain lifting that we use, especially a lack of rocks nowadays. This can be repeated every 12 hours and this can be given in and, you know, should be given an excellent emergency and do not use nerve blocks as a substitute for early surgery.
Our next controversy is time to surge. It's been shown by multiple studies that surgical repair of hip fractures should occur within 48 hours of hospital admission. And for even better outcome, it should be done within 24 hours. So the evidence for that is weak. Pre-operative assessment is mandatory now.
So, as I said, foot anesthetic team role in influencing time to date is very important, then allowing for planning of anesthetic technique, which has got a big importance in the outcome of patient assessment and communication of perioperative risk and free optimisation. These are all things are needed from the anesthetic colleagues. Now, this is an important slide, so these things are.
To be identified and treated, but not to delay the surgery, more than 48 hours outcome, as I said, is best if this surgery is done within 48 hours. So these things we try to treat. Anemia can be reversed to a degree anticoagulation and electrolyte imbalances. Volume depletion, uncontrolled diabetes and heart failure. Correct correctable cardiac arrhythmia as an ischemic. Acute chest infection and exacerbation of chronic chest conditions.
So we can give up to 48 hours to try to optimize these conditions. And nothing else beyond them. Of course, there would be a few exceptions, but we should try not to take them into consideration and delay the surgery based on anything else. So nowadays, most of our patients have got some kind of anticoagulation, and that has led to delay in surgery many times.
So the consensus in most of the hospitals now with the exceptions, of course, is that we do not stop clopidogrel. Aspirin is discontinued, but don't delay surgery because of that warfarin we should have protocols in place to reverse the warfarin get INR below one point five, either on anticoagulant anticoagulation agents. You discontinue them on admission, but try not to delay surgery based on if the renal function is fine.
That is, a screening clearance is more than minute. People have now sort of agreeing to carry on with the surgery without delay within 48 hours with these patients. Now anesthesia. Consider intraoperative nerve blocks for all patients and recommend surgery and spinal anesthesia is considered safer for the hip surgeries.
Again, some of the anesthetic colleagues don't agree with this, but as I said, consensus is it's easier for hip fractures. Now you might and you will come across patients who are considered too sick to operate, so should we let them just stay in the bed? That is probably not right, we should still consider them for surgery.
There's a rule this is called for palliative care. This will minimize their pain and other symptoms. It will establish patient's own priorities for rehabilitation. And you should, of course, consider that end of life care wishes. As I mentioned earlier, surgery is one of the best painkillers we have for hip fracture. Of course, we should have cardiologists.
Now we come to something that will interest us as orthopedic surgeons, the d'aliments with the surgical decisions that if we come across and displaced fractures, what do we do? Do we fix, replace or give trial without fixation? There is 30% to 50% risk of subsequent displacement. If we give trial without fixation and current preference in most of the hospitals.
Is that all on this place, intraoperatively fractures should be treated by internal fixation. What should we do if there's an international fracture, which is not very displaced, should we go ahead with dynamic fixation or minimally displaced fractures? Or should we give multiple screws? So there is weak evidence that DHS has better outcome and it has got biomechanical advantage over multiple screws?
Entrega axilo fractures in young patients. What do you do? Fixation irrespective of the displacement? Yes so in young patients, even if it is completely displaced fractures, you go ahead with trying to reduce them and fixing them. Now what is the cutoff age? Is that second, crossing anywhere around 50 would be my cutoff age, but it depends more on the physiological age.
Elderly patients, what do you do for a minimally displace entry capsule fracture fixation or outer plastic? This is based on multiple fractures. Medical practice have patients physiological age mainly. And displacement of the fractures, we continue with controversy and intrigue, axilo fractures, which is better off of blast or total hip replacement. Now we all are aware that ice is push to work to lift replacements.
We have to take this decision based on the patient. Each patient has to be taken on their own merit. They should be independently mobile with intact cognition, and they should be medically fit. And then they want a total hip replacement. Age is not a factor there. You should not. Then hemi outward velocity, which should be used to cement it around cement, it cemented stem has been shown to increase embolism and leading to cardiopulmonary complications and cemented stems are known for its very, very periprosthetic fractures.
And they are known for inferior functional outcomes. So the consensus is to try to use cement. It stems in fractured creamers. As we said, this is a dilemma everywhere for total hip replacements and still stands true for patients who are undergoing surgery for a hip, for fractured hip. Whether we do cemented and cemented or hybrid.
Uh, as I said, my preference personally is cemented, but there's no strong evidence for either of them. He'd say, should it be 28 to 30 six? Or should it be higher? And should we use a dual mobility for total hip replacements in fractional noffs that still stays controversial? US now, head size, how big is big enough, we all like to put big heads to prevent dislocation, that is the common myth we have, but we know that large head sizes lead to volumetric bear and there is elevated metal ions.
So as we know from our experience, from metal on metal hips and hip resurfacing, there is ongoing concerns about LTI allegiance and Allen allegiance. There has been shown to be no benefit in hip function when the head size is more than 36 mm, that's been proven. But long term total hip survivorship with weak evidence has proved that 32 millimeter heads are the best, with, of course, excellent quality Allen bearings.
This is better than smaller and larger ones now, dual mobility or a conventional hip again, dual mobility is a good concept. Looks like it would help in decreasing the increased rate of possible dislocation that is present in total hips after fracture nerves. But early designs of dual mobility have their own complications.
But the newer generation are dual mobility prostheses are demonstrating these problems have been overcome. The evidence hasn't come to be very sure yet. So it's still needed. Approaches, of course, various approaches have been described, but the sort of basic expert consensus, again, that anterolateral approach is favored or a positive approach when doing heaviest losses.
Extra axilo fractures, they have their own dilemmas now for New classification, a 1 and a 2 fractures, which are fractures which are about the lesser rock and the DHS that is on a sliding hip screw is preferable to an internal email. This has been impressed upon us by neisloss, but we use intermittently nailing when there is compromised medial kalka by a combination or a large posterior medial fragment, or fractures that extend into the enteric region.
Of course, reverse obliquity fractures trance to Kendrick fractures that involve the lateral corticospinal wall they all warrant. Internal emails do better than. These are a few examples of these fractures the soft rock extension with the reverse obliquity, the lateral wall combination and soft rock Kendrick extensions.
And we're using nails this again, decision to be made about whether we use short nail or a long nail in some study that has been shown, long nail has prevents re fracture of the femur because it's osteoporotic. That helical fracture, which we are fixing. And the tip of the short nail, has a possibility that fractures can happen there or as such, fractures can happen in the femur because of osteoporosis.
And it's been shown that post-op hip and type pain is less with long, long nails. Now, there are some measures we can take intraoperatively like tranexamic acid, there's evidence that it helps in reducing bleeding. Local anesthetic injection failure like a blocker already stressed on that, that can be done intraoperatively. And increasingly in some trusts, they're using these devices, which are continuous infusion local anesthetic pumps.
The evidence for them is lacking. Went to wait there, invariably the consensus is the aim is to the whole. Process, we have been doing everything we have been doing so far surgery, letting them, optimizing them for the surgery, and everything has been done just for this purpose so that we can allow them to weight and walk without restriction as soon as possible.
So we should not defeat that purpose by not letting the patient mobilized as soon as possible. So offer patient physiotherapy within 24 hours, unless medically or surgically contraindicated. Cognitive assessment is important. That should be part of the hip fracture treatment, nutritional assessment and fall prevention or other things that are important. They cannot be overlooked.
Post-operatively, physiotherapy, as I said, the risk of bad bedbound complications. Also, look at the fragility fracture risk. It should be done with the help of our medical colleagues. And, of course, data collection. We know that UK has got a national database that has been instrumental in changes of all our practice. We have made small changes in our practice, but they have all had important outcomes in the results we have been able to produce for our hip fracture care.
And of course, audit and data should be prior priority in our practice, which sometimes gets missed. Thank you. Thank you, everybody. Thanks for your patience. As I said, a very common topic, very simple topic, but common things are common both in your medical life and also in your exams.
Thank you very much, Mr Sharma. That was a really nice walk through the hip hip fractures and the best practice tariff, which is a common topic in exams, and it's a topic that you can't afford to get wrong. You do need to know this in detail in some ways. You know, you think it's an easy topic because it's something we deal with every day. But in fact, you need to know the guidelines and exactly the details that Mr. Sharma's outlined in that lecture.
So are there any questions? Honey, do you have any questions? Yes, so beautiful. Someone asking about the paper, which says a teacher is better than the screws. I'm sorry, the paper that says the DHS is better than the schools, I can provide the exact papers, I mean, as I said, most of these evidence that we have produced would come across.
Some papers which have said that they're both equally good, but there are few papers that are suggesting that the DHS has got a better physiology, physiologically more structural support to the proximal femur to allow early mobilization. Exact papers. If you drop me an email address, I can find out and send to you.
OK, so. OK, so just a question, so what is the criteria to say I will do DHS here in this case? No, DHS, I couldn't do that. I will do Neal. All right. Shall I take you back to my slide? OK right, so if you look at our extremity fractures, so extra axilo fractures, the divided A0 class a one, two and three, so one and two, we should invariably do d.h.s. We can do internal bleeding also.
But the evidence base is that DHS does equally well. With a 1 and a 2 fractures, the outcomes is equal in some papers they have suggested that it is decreased blood loss and decreased operating time with VHS, which is controversial, but it is equally well in error. Now if we go beyond that to these. All these things that I've emulated here, where compromise media, kalka, you should are in favor of intermittently nailing.
Of course, if there is some softer Kendrick extension, intimidating large posterior medial fragment. Intimidating does better reverse oblique fractures in nailing does better, and chance took a risk factor that involves the lateral corticospinal wall. Right, and these are a few of the examples, like if you get a fracture like that, it's just a typical example of reverse oblique fracture.
Is it culminated calcar and also such an extension, the lateral side air is blown out. And again, this patient has got a slap traject extension, so some of them might still be fixed with DHS, but the outcome would be better with nailing in these. OK, so actually, there is a paper published in 2016. And they mentioned that if you draw a line about 3 centimeters below the inferior end of the GT and you measure the distance between this point to the fracture line, if it's less than 2 centimeters you shouldn't do a d.h.s. What do you think about that?
Mr Sharma. And so I draw a line from great traject. Yeah, from the inferior the distal part of the gti, about 3 centimeters distal to that, and they measure the distance between this point and the fracture line. So you need 20.5 millimeter of the lateral wall to do a chest. Yeah I mean, you can still do DHS for them, but this is now we are going to the area of Scarborough country, which inherently, as I mentioned, several factors don't do well with DHS.
There's the DHS is based on a principle of controlled collapse. So it does need to collapse on to something the fracture needs to collapse onto something if there is no support to collapse on the lateral wall. Then the pressure would go 100% on the plate. So it's more likely to fail in that situation where there's the nail, inherently because it is the fulcrum why it's more nearer the fulcrum of the center.
It's more likely to function better in that situation. OK Uh, there's no more questions. OK, thanks, honey. I'm surprised because every slide of mine is full of controversy, and it is, as I said, the Communist tropics have got any controversies, you wouldn't even understand a simple hip fracture.
We walk through so many controversial decisions, but this is just to evoke your interest in how many controversies we traverse every day. The best of luck, everybody for your fastest. Thank you so much, Mr Sharma, on behalf of everybody else, thank you for giving up your time today and educating us all on that topic, which, you know, it's like diabetes in medical school, you think you know, it's don't learn it when in fact it's what's going to trip you up in the middle of an exam and then you'll be kicking yourself afterwards.
So thank you so much for joining us. Thank you, Mr Sharma. Thank you. Take care. All right. Thank you. OK, guys. So I am going to stop the recording and we will move on to the Viber section.
Give me 1 minute.
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