Emergency Medicine

304 Orthopaedic Emergencies

INJURIES TO THE HIP AND UPPER FEMUR

MANAGEMENT

1 Commence i.v. f luid resuscitation, as a comminuted extracapsular neck of

femur fracture may be associated with up to 1.5 L blood loss.

2 Give i.v. ana lgesia titrated to response.

3 Consider a femoral nerve block (see p. 489) for proximal neck of femur

fractures, especially in the elderly when opiates must be given with caution.

4 Keep the patient fasted until consultation with the orthopaedic team.

Fractures of the shaft of the femur

DIAGNOSIS

1 These fractures are due to considerable violence, as in a traffic crash, crush-

ing injury or fall from a height.

2 They may be associated with a hip dislocation, pelvic fracture or fracture of

the patella, and may cause concealed haemorrhage of 1–2 L in a closed injury

(more if compound).

3 Rarely there is damage to the femoral vessels or sciatic nerve.

4 Gain large-bore i.v. access and send blood for FBC, U&Es, blood sugar and

cross-match 4 units of blood.

5 X-ray the pelvis, hip and knee, as well as the shaft of femur, to avoid missing

other injuries.

MANAGEMENT

1 Give high-f low ox ygen by face mask.

2 Commence an infusion of normal saline or Hartmann’s (compound sodium

lactate).

3 Perform a femoral nerve block to help relieve the pain (see p. 489).

4 Supplement the femoral nerve block with morphine 5–10 mg i.v. and an

antiemetic such as metoclopramide 10 mg i.v. if required.

5 Apply traction as quickly as possible to reduce the pain and blood loss, and to

facilitate movement of the patient during X-ray, which should not be done

until after t he splint is in place.

(i) Use a commercially available Donway™ or Hare™ traction

splint, or alternatively use a traditional skin traction device such

as the Thomas splint.

(ii) Get help to apply the splint, which cannot easily be placed alone.

6 Reassess lower limb neurovascular status after the traction splint has been

applied.

7 Refer the patient to the orthopaedic team.