Hip Injuries PDF

Injuries around the Hip BY Samer M. Ali, MD Associate professor Orthopaedic Surgery Mansoura University Objectives: Hip dislocation. Fracture neck of femur.  Hip Dislocation ▫ Rare, but high incidence of associated...

Injuries around the Hip BY Samer M. Ali, MD Associate professor Orthopaedic Surgery Mansoura University Objectives: Hip dislocation. Fracture neck of femur.  Hip Dislocation ▫ Rare, but high incidence of associated injuries. ▫ Mechanism is usually young patients with high energy trauma. ▫ Orthopaedic emergency. Classification: Simple vs. Complex ▫ Simple:  Pure dislocation without associated fr. ▫ Complex:  Dislocation associated with fr. of acetabulum or proximal femur.  Anatomic Classification ▫ Posterior Dislocation (90%):  It occurs with axial load on femur, typically with hip flexed & adducted.  Axial load through flexed knee (dashboard injury).  Associated with:  AVN (Osteonecrosis) of femoral head.  Posterior wall acetabular fr.  Femoral head fr.  Sciatic nerve injuries.  Ipsilateral knee injuries (up to 25%). ▫ Anterior Dislocation:  Associated with femoral head impaction or chondral injury.  Occurs with the hip in abduction & external rotation.  Clinical Presentation History. Symptoms: ▫ Acute pain, inability to bear weight, deformity. Physical Exam.: ▫ ATLS.  95% of dislocations with associated injuries. ▫ Posterior Dislocation:  Associated with posterior wall & anterior femoral head fr.  Hip & leg in slight flexion, adduction & internal rotation  Detailed neurovascular exam (10-20% sciatic nerve injury)  Examine knee for associated injury. ▫ Anterior Dislocation:  Hip & leg in flexion, abduction & external rotation.  Radiology X-ray: ▫ It can typically shows posterior dislocation on AP pelvis.  Femoral head smaller than contralateral side.  Shenton's line broken.  Absent lesser trochanter shadow (internally rotated limb).  CT: ▫ It Helps to determine direction of dislocation, loose bodies & associated fr.  Treatment Orthopaedic emergency. ATLS protocol. Nonoperative Treatment: Emergent closed reduction UGA within 6 h. ▫ Perform with patient supine & apply traction in line with deformity. ▫ Adequate sedation & muscular relaxation. ▫ Assess hip stability after reduction. ▫ Post-reduction CT scan required to :  Rule out associated fr.  Assess concentricity of reduction (incarcerated fragments). ▫ Post-reduction:  For simple dislocation: protected weight bearing for 4-6 w.  Operative Open reduction &/or removal of incarcerated fragments on urgent basis.  Irreducible dislocation.  Radiographic evidence of incarcerated fragment.  Delayed presentation.  Non-concentric reduction. ▫ ORIF:  Associated fr. of:  Acetabulum.  Femoral head.  Femoral neck: it should be stabilized prior to reduction of hip.  Complications: ▫ Post-traumatic OA:  Up to 20% for simple dislocation, markedly increased for complex dislocation. ▫ Femoral head osteonecrosis:  5-40% incidence.  Associated with longer time to reduction. ▫ Sciatic nerve injury:  8-20% incidence.  Associated with longer time to reduction. ▫ Associated fr. Femoral Neck Fracture  Epidemiology: ▫ One of the most common fr. in aging population. ▫ Women > men (postmenopausal). Mechanism of trauma: ▫ High energy in young patients. ▫ Low energy falls in older patients.  Associated injuries: ▫ Femoral shaft fr.:  6-9% associated with femoral neck fr. Prognosis: ▫ Mortality  25-30% at 1 year (higher than vertebral compression fr.).  Pre-injury mobility is the most significant determinant for post-operative survival.  Pathophysiology Healing potential:  Femoral neck is intracapsular, bathed in synovial fluid.  Lacks periosteal layer.  Callus formation limited, which affects healing.  Blood Supply to Femoral Head ▫ Major contributor is medial femoral circumflex A. ▫ Some contribution to anterior & inferior head from lateral femoral circumflex A. ▫ Small & insignificant supply from A. of ligamentum teres. ▫ Displacement of femoral neck fr. will disrupt the blood supply & cause an intracapsular hematoma.  Classification Garden Classification:  Pauwels Classification:  Anatomical Classification:  Clinical Presentation Symptoms: ▫ Impacted & stress fr.  Slight pain in the groin or pain referred along the medial side of the thigh & knee. ▫ Displaced fr.  Pain in the entire hip region.  Physical exam.: ▫ Impacted & stress fr.  No obvious clinical deformity (patient can walk).  Minor discomfort with active or passive hip ROM, muscle spasms at extremes of motion.  Pain with percussion over greater trochanter. ▫ Displaced fr.  Leg in external rotation & abduction, with shortening.  Radiology Obtain AP pelvis & cross-table lateral & full length femur film of ipsilateral side. Traction-internal rotation AP hip is best for defining fr. type. Garden classification is based on AP pelvis.  Treatment Nonoperative: ▫ Bed rest.  Indications:  May be considered in some patients who are non-ambulators, have minimal pain & who are at high risk for surgical intervention.  Operative: ▫ CRIF:  Indications:  Displaced fr. in young or physiologically young patients.  CRIF indicated for most pts