Emergency Medicine

Orthopaedic Emergencies 303

INJURIES TO THE HIP AND UPPER FEMUR

(a) risk of avascular necrosis developing is related to the length

of time the hip remains dislocated, and increases dramatically

after 6 h.

(ii) Sciatic nerve neurapraxia occurs in 15% and is usually relieved by

reduction.

(iii) Missed knee injuries occur in up to 15% of cases.

MANAGEMENT

1 Commence an inf usion of norma l sa line.

2 Give morphine 5–10 mg i.v. and an antiemetic such as metoclopramide
10 mg i.v.

3 Refer all cases to the orthopaedic team for immediate reduction under
general anaesthesia.

Fractures of the neck of the femur

DIAGNOSIS

1 These fractures are most common in elderly women following a fall, and may
be divided into two groups:
(i) Intracapsular
(a) subcapital – may be displaced or non-displaced
(b) femoral head – rare and normally associated with hip
dislocation.
(ii) Extracapsular
(a) intertrochanteric
(b) pertrochanteric
(c) subtrochanteric.

2 Typically, after a fall the patient is unable to bear weight, and the leg is
shortened and externally rotated.

3 Occasionally the patient may be able to limp if the fracture impacts, and
examination reveals localized tenderness and pain on rotating the hip.

4 Gain i.v. access and send blood for FBC, U&Es, blood sugar and G&S.

5 Record an ECG.

6 Request X-rays and include the pelvis, as well as anteroposterior and lateral
views of the hip.
(i) Request a chest radiograph (CXR) in addition as a pre-operative
aid for the anaesthetist.
(ii) Look carefully for a fractured pubic ramus on the pelvic X-ray
if no femoral neck fracture is seen, as this also presents with hip
pain and a limp.