7. Emily Wilkins - A Case of Falls

Pre-reading - Session 1

Anatomy Videos

• Anatomy of the hip joint

  • Joint between the head of the femur and the acetabulum of the pelvis

  • Acetabulum is the name of the articulating surface for where the pelvis attaches to

  • Hip joint is a ball and socket joint

    • Ball - ball of the hip joint

    • Socket - acetabulum of the pelvis

  • Hip joints can perform flexion and extension

    • Flexion - raising the thigh upwards

    • Etension - bringing the thigh back down to standing position

    • Abduction - taking the lower limb away from the midline (outwards)

    • Adduction - taking the lower limb back towards the midline (inwards)

    • Rotation - two types: external and internation

      • External - lateral movement of the head of the femur within the acetabulum (used when crossing the legs)

      • Internal - medial movement of the head of the femur within the acetabulum (return thighs after having crossed legs)

    • Circumduction - flexion, extension, abduction, adduction, external and internal rotation put together

  • Circumduction can only happen at the hip and the shoulder

    • Free range of movement means there is a compromise in the stability (more mobile = less stable)

    • However hip joint is more stable than the shoulder joint - important because hip joint is a weight bearing

• Features of the Femur:

  • Head of the femur forms the ball aspect of the hip joint

  • Neck of the femur connects the head to the shaft of the femur

    • Slightly diferent angle to the shaft

    • Two lumps of bones called trochanter

      • Large trochanter - greater trochanter

      • Lesser trochanter is lower than the greater trochanter

      • Trochanter - bony process which serves as an attachment for the muscles which move the hip joint

    • Inter-trochanteric line - ridge of bone which joions the greater and lesser trochanter together

• Joint capsule - increases stability of the hip joint

  • Connective tissue sheath wrapping around head and neck of the femur and attaches to the outer rib of acetabulum

  • Serves to pull the head of femur into the acetabulum providing stability and preventing dislocation

  • Joint capsule attaches just above the intertrochanteric line

• Blood Supply to the hip joint

  • Arises from the femoral artery

    • Pulse can be felt in the groin region

    • Femoral artery branches in the profunda femorus (deep femoral) artery

    • Arising from the profunda femorous is the lateral and medial circumflex artery - wraps around the hip joint to provide circular blood flow.

      • Circumflex artery travels upwards (instead of travelling distally)

    • Retrograde blood flow - arteries travel upwards back towards the proximal blood supply

    • Arteries supply the head and the neck of the femur and the vessels lie within the joint capsule itself.

Lecture - Session 2

• Task 1

  • When to suspect delirium

    • Behaiour changes that develop acutely (hours to days)

    • Behaviour changes include:

      • Altered cognitive function

      • Inattention

      • Disorganised thinking

      • Altered perception, physical funciton, social behaviour and level of conciousness

  • Diagnosing delirium

    • Use the CAM criteria for delirium

      • Confusion - developed suddenly

      • Inattention - ask if the patient is easily distracted or has difficulty focusing

      • Disorganised thinking - ask if the person’s thinking is disorganised, incoherent, illogical or unpredictable

      • Altered level of conciousness - ask about changes in level of conciousness from alertness to lethargy (drowsiness, stupor, comatose or hypervigilance).

  • Types of delirium

    • Hyperactive - inappropriate behaviour, hallucinations or agitations

    • Hypoactive - lethargy, reduced concentration and reduced appetite

  • Predisposing risk factors

    • Age (>65)

    • Pre-existing cognitive impairment

    • Previous delirium

    • Poor mobility

    • Severe current illness (hip fractures/emergency)

    • Visual or hearing problems

    • Drugs (sedatives, steroids, antidepressants can all make people more drowsy)

    • Social isolation and substance misuse

  • Triggers for Delirium

    • Infection

    • Drugs - opiod analgesics, steroids and sedative

    • Surgery

    • Substance misuse or withdrawal symptoms from addictive drugs and alcohol

    • Vtiamin deficiencies

    • Intra-cerebral trauma from head injury or stroke

• Task 2

  • Risk factors for falls in the elderly

    

• Task 3

  • X-rays and 4 diagnoses

    • Mrs J - normal X-ray

    • Mrs L - extracapsular necofemur fracture

    • Mr K - around the neck of the femur and on the right

  • Extracapsular vs Intracapsular

    • Everything from the neck and up is intracapsular

    • Everything from below the neck of the femur is extracapsular