Fracture neck of femur: operation theatre notes

• Undisplaced fracture: usually internal fixation with cannulated screws or femoral neck system.
• Displaced fracture in a younger patient: urgent reduction and internal fixation, aiming to preserve the femoral head.
• Displaced intracapsular fracture in an older patient: usually hemiarthroplasty; selected independent, active patients may receive total hip arthroplasty. NICE hip-fracture guidance recommends replacement arthroplasty for displaced intracapsular fractures.

1. Position of patient

A. Internal fixation

• Patient is usually supine on a radiolucent, flat-top table or a fracture table.
• If a fracture table is used:
  • Both feet are secured in boots.
  • The affected limb is positioned for gentle traction, adduction, and internal rotation as required for reduction.
  • The unaffected limb is flexed, abducted, or placed in a scissored position to permit lateral fluoroscopic imaging.
  • Perineal post must be well padded, with no excessive traction time.
• C-arm should obtain clear AP and lateral views of the hip before skin preparation and draping.
• Pressure areas, heels, sacrum, elbows, and perineum must be protected.

B. Hemiarthroplasty or total hip arthroplasty

• Usually lateral decubitus position for posterior or direct lateral approaches.
• The patient is supported with anterior and posterior pelvic supports and all bony prominences are padded.
• The pelvis must be stable and perpendicular to the floor to enable correct component placement.
• A direct lateral approach is frequently used in hip-fracture arthroplasty and is associated with a lower dislocation rate than a posterior approach. Rockwood and Green's Fractures in Adults, 10th ed., p. 2653.

2. Anaesthesia

• Spinal anaesthesia or general anaesthesia may be used after discussion of risks and benefits.
• Consider a fascia iliaca block, femoral nerve block, or other regional analgesic technique as an adjunct for perioperative analgesia.
• Standard monitoring:
  • ECG
  • Non-invasive blood pressure
  • Pulse oximetry
  • Capnography if sedated or under general anaesthesia
  • Temperature monitoring
• Large-bore IV access, blood group/cross-match, and warming measures are especially important in frail older patients.
• For cemented hemiarthroplasty:
  • Inform the anaesthetist before femoral canal instrumentation and cement insertion.
  • Watch closely for hypotension, hypoxia, arrhythmia, or collapse due to bone cement implantation syndrome.

3. Trolley layout

A. Common sterile trolley

B. Internal-fixation trolley

• Orthopaedic basic set
• Cannulated screw or femoral-neck-system set
• Guidewires, drill, drill sleeves, depth gauge, taps, screwdrivers
• Reduction instruments, including bone hook, joystick pins, clamps, or Farabeuf clamp if required
• Image intensifier/C-arm with sterile cover
• Power drill and battery backup
• Appropriate implants, with backup screw sizes and lengths available
• Suction, irrigation, and sterile marking pen

C. Hemiarthroplasty/THA trolley

• Hip arthroplasty instrument set
• Femoral rasps/broaches, reamers, neck-cut guide, trials, introducers and impactors
• Appropriate prosthesis components and backup sizes
• Cement gun, cement restrictor, cement plug, bowl, vacuum-mixing system if a cemented stem is planned
• Pulse lavage and suction
• Hip retractors and dislocation instruments
• C-arm is not routinely required for every arthroplasty but should be accessible if requested.

4. Transfer of the patient

Transfer from ward to OT

1. Confirm identity, consent, operative side, procedure, allergies, fasting status, blood availability, imaging, and anticoagulant status.
2. Give prescribed analgesia before movement. A nerve block can reduce pain during positioning.
3. Maintain the injured leg in its position of comfort. Do not force the hip straight or rotate it.
4. Transfer with a slide sheet, transfer board, or hoist, using enough staff to avoid pain, falls, and staff injury.
5. One staff member supports the affected limb throughout the move.
6. Keep the patient warm and ensure pressure-area protection.
7. Complete the WHO Surgical Safety Checklist before anaesthesia and incision.

Transfer after operation

• Transfer from operating table to trolley using a slide sheet and adequate staff.
• For arthroplasty, avoid extreme hip flexion, adduction, and internal rotation, particularly after a posterior approach.
• Send the patient to recovery with:
  • Clear handover of procedure, implant, blood loss, fluids, antibiotics, analgesia, neurovascular status, and weight-bearing instructions
  • Wound dressing and drain details
  • VTE prophylaxis plan
  • Any intraoperative complication or concern.

5. Management

Preoperative management

• ABCDE assessment and treatment of associated injuries.
• Analgesia: paracetamol plus titrated opioid if needed; consider fascia iliaca/femoral nerve block.
• AP pelvis and lateral hip radiographs. If radiographs are negative but suspicion remains high, MRI is preferred; CT is an alternative if MRI is unavailable or contraindicated. NICE imaging guidance
• Baseline investigations: CBC, renal function/electrolytes, glucose, coagulation profile, ECG, group and save/cross-match.
• Correct reversible problems promptly: dehydration, anaemia, electrolyte imbalance, uncontrolled diabetes, anticoagulation issues, chest infection, or heart failure.
• Pressure-area care, delirium prevention, nutritional assessment, and VTE prophylaxis.
• Surgery should generally occur on the day of, or day after, admission once correctable problems are addressed. NICE timing recommendation

Intraoperative management

• Antibiotic prophylaxis before incision, as per local policy.
• Maintain normothermia and careful fluid balance.
• Minimise blood loss and monitor haemodynamics.
• Confirm reduction and implant placement with fluoroscopy during internal fixation.
• Document implant details, blood loss, complications, and postoperative weight-bearing status.
• For arthroplasty, cemented implants are generally recommended for hip-fracture arthroplasty, with precautions for cement-related cardiovascular compromise. NICE arthroplasty guidance

Postoperative management

• Monitor pain, consciousness, oxygenation, haemodynamics, wound, drain output, limb perfusion, and neurological status.
• Continue multimodal analgesia. Avoid routine NSAIDs in many frail hip-fracture patients unless specifically appropriate.
• Start VTE prophylaxis according to local protocol.
• Early physiotherapy, chest exercises, sitting out of bed, and mobilisation are priorities.
• After arthroplasty, patients are commonly mobilised weight-bearing as tolerated, unless the surgeon specifies otherwise.
• Following internal fixation, weight bearing depends on fixation stability, fracture pattern, bone quality, and surgeon instructions. Campbell describes touch-down weight bearing for about 10 weeks after high-energy femoral-neck fractures, while older patients may use protected weight bearing with a walker. Campbell's Operative Orthopaedics, 15th ed., p. 3437.
• Monitor for delirium, pressure injury, constipation, urinary retention, infection, DVT/PE, dislocation, wound problems, non-union, avascular necrosis, and implant failure.
• Start secondary fracture prevention: falls assessment, vitamin D/calcium where indicated, osteoporosis evaluation and treatment.