#NoF – Fractured Neck of Femur

BOAST Guidance

#NoF patients (or other fragility fracture) who requiring CT Head (for head injury) also be performed a CT Neck
- Fragility fractures indicate the patient is at high risk of also sustain C-Spine injury.
- Also the pain is likely distracting and the patient is often over 65yrs old so Canadian C-Spine rules will not apply.

Hx/Exam

Why did They Fall? – was this a collapse?
Are they sick? – Co-morbidity/illness is common in this group and must be recognised
Anticoagulants? – This affects treatment
- On Warfarin – If INR >1.5 (or unavailable) Vit-K 5mg
Other injuries? – >65’s the most common mechanism of TARN major trauma is fall <2m
Typically – Pain hip/buttock, shortened, externally rotated
Atypical – Few signs (can they lift their leg & is rotation at the hip painful)

Investigations

X-ray (Hip, pelvis, CXR)
- X-ray femur if pathological
- BEWARE Occult Hip Fracture (approx 1%)
Bloods: FBC, Clotting, Group/Save, U&E, Bone profile
ECG
CT Head & Neck: if the patient requires CT Head, a CT Neck should also be performed [BOAST Guidelines]. #NoF is a fragility fracture and painful, hence not only is the patient at a high risk of C-Spine fracture if they receive a head injury but also has a distracting injury

On EPR all required investigations can be found on the: Adult NoF order set

Analgesia

These are generally frail elderly patients, and OPIATES have been show to both significantly INCREASE MORTALITY & TIME TO RECOVERY

IV Paracetamol should be first line
Use Opiates sparingly
Perform Block (FNB/FIB)

FNB/FIB, can reduce pain for the patient for many hours and often upto the point of operation. It reduces opiate requirements, and aids recovery.

Femoral Nerve OR Fascia Iliaca Block

Either technique works well as long as you are trained in the technique

Trained operator
Ultrasound guided
Aseptic
Use Nerve block needle
Recommended mix:
- 0.25% Levobupivicaine only Max doses:
  - >50kg – 40ml
  - 30-50kg – 30ml
  - Child <30kg – 0.8ml/kg (ie 2mg/kg)
Document – ADHOC > ED procedure
Post-Block
- Obs. every 5min (for 15min)
- 3 Lead ECG
- BP
- SaO2
- Symptoms of Toxicity – Use LA-toxicity Guide

Block for Kids

Consent child and parent as appropriate
Nasal Diamorph – they will need it and it removes the need for lidocaine in the block (as long as done within 30min)
Nerve block mix – MAX: 1 millilitre/kg of 0.25% Levobupivicaine (i.e 2.5mg/kg) – however only need to flush around nerve as adult.

Unable to Block?

Our aim within the ED is to offer a Block to ALL NoF patients. However in some cases such as Anticoagulated patients there is a relative contraindication to performing a Block and the ED senior may decide that we are unable to perform this within the ED. In these cases:

If you have a #NoF patient who you feel we wont be able to offer a Never Block in ED (please escalate to)

Monday to Friday 0900-1700 please call theatre 5 and ask for the consultant anaesthetist of the day. (they are often doubled up)
Weekend and OOH call the CEPOD anaesthetist. -LIMITED USEFULLNESS
- Unfortunately this is a junior who probably cant do blocks themselves
- However if their consultant is in they might be able to help , (but not all of them can do block)

You should receive a decision from anaesthetics promptly <30min as to weather this will be possible