Injuries of hip &femur

Injuries of hip &femur
Dislocation of the hip: according to the position of head
of femur relative to the acetabulum, it can be: posterior,
anterior or central (with acet. #).
Posterior dislocation: is the commonest.
MOI: usually dashboard injury to the knee with hip flexed &adducted;
if abducted, there is in also a # of the posterior acet. wall (hip #- ?).
CF: the leg is short, adducted, internally rotated &flexed(unless the femur is #). The sciatic nerve may be injured.
X-ray: AP view: the FH is out & above the acet.
If any # is suspected, CT scan is needed.
Classification: type ?: ? without # or minor chip #.
?? : ? with single large fragment of post. acet. wall.
???: comminuted posterior wall.
?V: ? with acet. floor #.
V: ? with femoral head #.
?: urgent closed reduction UGA: apply leg
traction while flexing hip &knee 90? then ? upward traction with hip internal &external rotation; if reduction is successful, you will feel a clunk . Checking x-ray to confirm reduction & CT to exclude a #.
If type ?(stable): 3wks traction? 3wks partial weight bearing(PWB).
The other less stable types ??, ??? , ?V &V: 6wks skeletal traction ? 6wks PWB. In any type, if post reduction CT shows a trapped bone fragment inside hip joint or a still displaced large bone segment (which may ? hip stability), then surgery is indicated: ORIF of large segment & removal of small segment? 6 wks traction ? 6 wks PWB.
Comp.: Early: 1-Sciatic nerve injury (?10%); 2-Vascular injury(rare); 3-Associated femoral shaft #(the ? may be missed).
Late: 1-Avascular necrosis(AVN): the incidence is 10%; if reduction
is delayed ?12 hours, it ? to 40%. MRI will detect early changes while
x-ray changes (? FH density) need ? 6 wk to be seen.
2-Myositis ossificans. 3-Unreduced ?: ? few weeks needs open reduction. 4-OA: due to: a- cartilage damage; b- retained bone
fragment in the joint; c- AVN.
Anterior dislocation: is rare.
MOI: RTA or FFH.
CF: leg is abducted, externally rotated &flexed.
X-ray: FH lies in front of acet. & either superior
(over pubis or ilium) or inferior(over obturator foramen).
? : the same as posterior ?.
Comp.: 1-in superior type, FH may press on the
femoral NV bundle; 2- AVN: less common(<10%).
Central dislocation(Acetabular floor fracture)
MOI: fall on the side or blow on gr. trochanter.
CF: the leg is in normal position.
X-ray: FH is pushed medially with acet. floor #.
?: 12 wks skeletal traction, with or without
lateral traction in the gr. trochanter.
Comp.: OA.
Fractures of the femoral neck: common in old osteoporotic.
Risk factors: 1-Weak bone like osteoporosis, osteomalacia, DM,
stroke (disuse), alcoholism &chronic diseases; 2- Old people
have weak muscles &poor balance with ? tendency to fall.
MOI: In elderly: simple fall or even catching toe in a carpet.
In young: RTA or FFH (20% have also femoral shaft #).
Garden s classification: 4 stages of progressive displacement:
Stage ?: incomplete impacted #.
Stage ?? : complete undisplaced #.
Stage ??? : moderately displaced #.
Stage ?V: severely displaced #.
Healing problems:1-Bone ischemia: FH gets it s blood from:
a- lig. teres vessels(poor in elderly &in 20% not present);
b- intramedullary vessels (always interrupted by the #);
c- capsular vessels (usually kinked or torn in displaced #).
Hence the high incidence of AVN in displaced #.
2-Poor healing: due to: a- FH has poor bl. supply; b- femoral neck has no soft tissue attachment which could promote callus formation.
c-the femoral neck # is intra-capsular # &the synovial fluid prevents clotting of # hematoma; Hence the high incidence of nonunion.
CF: short &externally rotated leg.
Don t miss: 1-impacted #: patient is still able to walk with normal
x-ray; 2-stress #: hip pain, no trauma, normal x-ray but MRI or bone scan: hot lesion. 3-painless # in bed-ridden patients.
4-multiple #: every patient with femoral shaft # should x-ray his
pelvis to exclude hip #.
X-ray: according to site of #(anatomical classification), it can be: subcapital, mid-cervical or basal. Assess the degree of #
displacement by matching of bone trabeculae-Garden s
stages.
?: is operative. The aim is:
1-To keep the patient active to prevent comp. of recumbency.
2-To ensure # union by perfect reduction &secure fixation.
If the patient is left without operation:
1-stage ?& ?? will progress to ??? &?V.
2-displaced # never unite without fixation.
3-lying in bed? DVT, pulmonary embolism,
pneumonia &bed sore. 4- too painful.
Initial ?: skin traction to relief pain; preoperative preparation.
Surgery: depends on patient age &activity & on # site &stage:
1-Internal fixation(IF)(cannulated screws or DHS):
Stage ?&?(all ages)? closed reduction(CR) + (IF);
Stage ?&?V(?65)? CR + IF & if CR fails? open
reduction+ IF only when healing is predictable in
younger age group; if healing is unlikely as in older age,
then should go to hip replacement?
2-Prosthetic replacement: For older less active, use:
Partial hip replacement(PHR): replacing femoral part
only using unipolar or bipolar prosthesis ± cement.
Total hip replacement(THR): for more active pt.
or those with acet. damage as in old # or metastasis
Post-operative: sit up in bed or chair &start activity
from the 1st day.
Comp.: 1-General: DVT, pul. embolism, pneumonia
&bed sore. 2-AVN in 30% of displaced #&10% of
undisplaced #. 3-Non-union in 30% of displaced #
bec. of poor bl. supply, poor reduction, poor fixation
&poor healing.4-Osteoarthritis:due to AVN
&FH collapse.
Intertrochanteric fractures: like neck #, are common in
elderly but are extracapsular, so unite quickly without AVN.
MOI: either direct fall on gr. trochanter
or indirect twisting injury.
CF: tender swelling &bruise of the upper
thigh with short &externally rotated leg.
X-ray: the # line pass from lesser to gr. trochanter.
AO classification: arranged in ? degree of instability ?
simple, multifragmentary & reverse oblique.
A fracture is considered unstable if:
1-widely separated 4 parts # or comminuted posteromedial
cortex; 2- reverse oblique or subtrochanteric extension;
3-severe osteoporosis.
?: is almost always by internal fixation in order to:
1-obtain the best possible reduction &2-mobilize patient early
thus reducing the complications of prolonged recumbency.
Types of internal fixation: closed or open reduction &
fixation by a device that can maintain neck / shaft angle.
According to the degree of # stability, use one of these:
Conservative ? by traction is an alternative
to ORIF if have no facility or unfit patient.
Comp.: Early: DVT &pulmonary complications.
Late: 1-failed fixation; 2-malunion(varus &ext. rotation);
3-nonunion(rare).
Proximal femoral fractures in children:
are uncommon.
MOI: severe trauma like RTA or FFH.
Delbet classification: ?: transepiphyseal,
?? : transcervical, ??? : cervicotrochanteric,
?V: intertrochanteric.
?: undisplaced #? 6-8 weeks hip spica.
Displaced #? CRPP or ORIF.
Comp.: 1-AVN(40% in displaced type ?&?).
2- Coxa vara( malunion or physeal arrest), 3- shortening.
Subtrochanteric fractures: occur at any age
following severe trauma.
CF: swollen tender thigh with short &externally rotated leg.
X-ray: # line is through or below lesser troch.(transverse, oblique or spiral).
The upper fragment is flexed &abducted while the
distal is pulled up & adducted.
?: ORIF: DHS, DCS, locked plate, blade plate,
IM nail with locking screw .
Conservative ? by traction is possible but difficult:
3 mths skeletal traction in the sitting position.
Comp.: 1- malunion; 2- nonunion(5%).