Fractured Neck of Femur
Pathophysiology and causative factors
A fracture is a break in the continuity of a bone, separating it into two or more parts (Walsh and Crumbie 2007). In the case of a fractured neck of femur following a fall, the fracture is caused by the direct violence applied to the body; hence the fracture occurs at or near the site of the applied force (Walsh and Crumbie 2007). The soft tissues surrounding the area are also involved in the injury (Walsh and Crumbie 2007). Blood vessels within the bone, the periosteum and surrounding tissues are torn, resulting in haemorrhage and then the formation of a haematoma (Walsh and Crumbie 2007). There may also be haemorrhage into adjacent muscles and joints and damage to ligaments, tendons and nerves (Walsh and Crumbie 2007). Soon after a fracture occurs, the muscles in the area go into spasm, causing severe pain and the shortened and rotated appearance of the affected leg in the case of a fractured neck of femur (Walsh and Crumbie 2007).
However, it is unlikely that a young, fit and healthy person would suffer a fractured neck of femur following a fall. Fracture of the neck of femur occurs most often in elderly women, due in part to hormonal changes and the effect this has on bone reabsorption, leading to osteoporosis (Walsh and Crumbie 2007). Osteoporosis is a condition where bone mass is reduced because its deposition does not keep pace with reabsorption (Waugh and Grant 2001). Lowered oestrogen levels after the menopause are associated with a period of accelerated bone loss in women (Waugh and Grant 2001). As bone mass decreases, susceptibility to fractures increases (Waugh and Grant 2001). The weakened bone is less able to resist the force of impact should the person fall (Walsh and Crumbie 2007). Additionally, elderly people are much more likely to fall (Walsh and Crumbie 2007). Cox and Newton (2005) cite data suggesting in excess of 400,000 older people attend accident and emergency departments each year in the UK as a result of falls which are the leading cause of mortality due to injury in those over 75. This follows from the fact that falls in older people are estimated to result in hip fracture in approximately one quarter of those affected (Minns et al 2004).
There are two categories of fractures involving the femoral neck region: intracapsular fractures (occurring through the joint and capsule) and extracapsular fractures (occurring in the intertrochanteric area) (Walsh and Crumbie 2007).
Assessment and planned care
In all acute trauma situations the priority is to assess the ???ABCDE??™ of resuscitation (Walsh and Crumbie 2007). This primary assessment should always precede the primary assessment, which should then focus on pain and psychological status alongside the main injury itself (Walsh and Crumbie 2007). Assessment should then move on to consider the rest of the patient, checking for other less obvious injuries, unrelated but coexisting medical conditions (e.g. is the patient diabetic) as well as social factors (Walsh and Crumbie 2007).
A ??“ Airway
??? Look, listen and feel for the signs of airway obstruction (Jevon 2007).
??? Assess cervical spine (Walsh and Crumbie 2007).
B ??“ Breathing
??? Count the respiratory rate, normal is 12-20/min (Resuscitation Council UK 2006). Bradypnoea is an ominous sign and could indicate imminent respiratory arrest; causes include opiates and hypothermia (Jevon 2007).
??? Evaluate chest movement: chest movement should be symmetrical (Jevon 2007).
??? Evaluate depth of breathing (Jevon 2007).
??? Evaluate respiratory pattern (Jevon 2007).
??? Note the oxygen saturation (SaO2) reading: normal is 97-100% (Jevon 2007). A low SaO2 could indicate respiratory distress or compromise (Jevon 2007).
??? Listen to breathing (Jevon 2007).
??? Record peak expiratory flow rate (Jevon 2007).
C ??“ Circulation
??? Palpate peripheral and central pulses: presence, rate, quality, regularity and equality (Smith 2003).
??? Check the colour and temperature of the hands and fingers (Jevon 2007).
??? Measure the capillary refill time (CRT): normal CRT is