A 29-year-old man presents with acute onset severe lower back pain and bilateral leg weakness after heavy lifting. He has saddle anesthesia and urinary retention. MRI shows central disc herniation at L4-L5. What is the expected outcome with prompt treatment?

Variable outcome depending on delay

Good functional recovery in most cases

Poor prognosis regardless of treatment

Recovery limited to bladder function

A 33-year-old man presents with acute onset severe lower back pain radiating down both legs. He has bilateral leg weakness and urinary retention. MRI shows large central disc herniation at L4-L5. What is the most appropriate management?

Emergency surgical decompression

A 31-year-old man presents with acute severe lower back pain and bilateral leg weakness developing over 6 hours. He has urinary retention and saddle anesthesia. What is the most appropriate immediate management?

Emergency surgical decompression

A 23-year-old man presents with acute onset severe lower back pain after lifting heavy weights. He has bilateral leg weakness, saddle anesthesia, and urinary retention. What is the most appropriate immediate management?

Emergency surgical decompression

A 49-year-old woman presents with an 18-month history of lower back pain and bilateral buttock pain. She reports morning stiffness lasting 75 minutes that improves with activity. She has a history of psoriasis and inflammatory bowel disease. HLA-B27 is positive. MRI sacroiliac joints shows bilateral bone marrow oedema and erosions. She has tried NSAIDs with partial relief. What is the most appropriate next step in management according to NICE guidelines?

Trial of two different NSAIDs at maximum dose for 4 weeks each with physiotherapy before considering biologics

Add sulfasalazine to current treatment

Commence anti-TNF biological therapy (e.g., adalimumab)

Add methotrexate to current treatment

Commence oral prednisolone 20mg daily

A 74-year-old woman undergoes hemiarthroplasty for a displaced intracapsular neck of femur fracture. She has a history of atrial fibrillation, ischaemic heart disease, and type 2 diabetes mellitus. Post-operatively she develops confusion, pyrexia of 38.2°C, and a wound with purulent discharge on day 4. Blood cultures grow Staphylococcus aureus sensitive to flucloxacillin. What is the most appropriate definitive management?

Revision surgery to remove prosthesis with antibiotic spacer insertion

Six weeks of intravenous flucloxacillin

Washout of joint and debridement with prosthesis retention and long-term antibiotics

Two weeks intravenous flucloxacillin followed by four weeks oral flucloxacillin

Arthroscopic washout and two weeks intravenous antibiotics

Neck of femur fracture: High-Yield Surgery & Musculoskeletal Lessons

Quick Overview

Neck of femur (NOF) fractures are common orthopaedic emergencies, predominantly affecting elderly patients with osteoporosis. Time-critical management within 36 hours reduces mortality and complications. NICE CG124 mandates orthogeriatric co-management and structured perioperative care bundles. Classification determines surgical approach: intracapsular fractures risk avascular necrosis (AVN) due to disrupted blood supply; extracapsular fractures preserve blood supply but cause significant blood loss.

Core Facts & Concepts

📊 Classification & Blood Supply

Fracture Type	Location	Blood Supply	AVN Risk	Surgical Options
Intracapsular	Within joint capsule	Disrupted (retrograde vessels)	High (10-30%)	DHS if undisplaced; hemiarthroplasty/THR if displaced
Extracapsular	Intertrochanteric/subtrochanteric	Preserved (periosteal)	Low	DHS (intertrochanteric); intramedullary nail (subtrochanteric)

$Figure 1: AP pelvis X-ray showing displaced intracapsular neck of femur fracture with disrupted Shenton's line$

⏰ Time-Critical Thresholds (NICE CG124)

Surgery within 36 hours of admission (or diagnosis if already inpatient)
Delays >36h increase 30-day mortality by 30%
Pre-op assessment by orthogeriatrician within 72 hours of admission

Garden Classification (Intracapsular)

Type I: Incomplete/impacted (undisplaced)
Type II: Complete but undisplaced
Type III: Complete, partially displaced
Type IV: Complete, fully displaced
Types III-IV have highest AVN risk (30%)

🚩 Red Flags

Age <60 with NOF fracture → investigate pathological cause (metastases, myeloma)
Inability to straight leg raise → suggests fracture
Shortened, externally rotated leg (classic presentation)

Problem-Solving Approach

1️⃣ Immediate Management (First Hour)

Analgesia: Fascia iliaca block (preferred) or femoral nerve block
NBM status, IV access, bloods (FBC, U&E, coagulation, G&S)
Pressure area care (heel protection)
VTE prophylaxis (LMWH unless contraindicated)

$Figure 2: Lateral hip X-ray showing basicervical neck of femur fracture$

2️⃣ Surgical Decision Algorithm

Intracapsular undisplaced (Garden I-II) → Internal fixation (cannulated screws/DHS)
Intracapsular displaced (Garden III-IV):
- Independent walker → Total hip replacement (THR)
- Limited mobility/comorbidities → Hemiarthroplasty (cemented if age >70)
Extracapsular intertrochanteric → Dynamic hip screw (DHS)
Extracapsular subtrochanteric → Intramedullary nail (higher biomechanical stress)

3️⃣ Perioperative Care Bundle (NICE CG124)

Orthogeriatric review within 72h
Bone protection: Calcium/Vitamin D supplementation
Falls assessment and prevention plan
Mobilise day 1 post-op with physiotherapy
FRAX score for future fracture risk

Analysis Framework

Surgical Option Selection by Patient Factors

Patient Profile	Fracture Type	Preferred Surgery	Rationale
Independent, mobile, cognitively intact	Displaced intracapsular	THR (cemented/uncemented)	Lower revision rate, better function
Limited mobility, dementia, frail	Displaced intracapsular	Cemented hemiarthroplasty	Faster surgery, adequate for low demand
Any mobility status	Undisplaced intracapsular	Internal fixation (screws)	Preserve native joint, lower morbidity
Any mobility status	Intertrochanteric	DHS	Gold standard, stable fixation
Any mobility status	Subtrochanteric	Intramedullary nail	Biomechanically superior for shaft extension

🚩 Complications by Timeframe

Immediate: Fat embolism, blood loss (500-1000ml extracapsular)
Early (<6 weeks): DVT/PE, pneumonia, pressure sores, delirium
Late (>6 weeks): AVN (intracapsular), non-union, implant failure, leg length discrepancy

Visual Aid

Key Points Summary

✓ 36-hour rule: Surgery within 36h of admission/diagnosis mandatory (NICE CG124) - delays increase mortality 30%

✓ Intracapsular fractures: High AVN risk (disrupted blood supply); displaced → arthroplasty; undisplaced → internal fixation

✓ Extracapsular fractures: Preserved blood supply, low AVN risk; DHS for intertrochanteric, IM nail for subtrochanteric

✓ Surgical selection: Independent mobile patients with displaced intracapsular → THR; limited mobility → cemented hemiarthroplasty

✓ Perioperative bundle: Fascia iliaca block, orthogeriatric co-management within 72h, mobilise day 1, bone protection (calcium/vitamin D)

✓ Garden classification: I-II undisplaced (fixation), III-IV displaced (arthroplasty) - higher numbers = higher AVN risk

✓ Red flags: Age <60 (pathological fracture?), inability to straight leg raise, shortened externally rotated leg

⚠️ Warning: Never delay surgery for "medical optimization" beyond 36h unless life-threatening condition - mortality benefit of early surgery outweighs most medical risks

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