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Jan 19th 2010 Clinical Series Hip by Widad
Citation preview
Dr. Widad Nasser
Introduction
Hip and femur fracture
Hip / femur dislocation
Other common condition of hip and femur
Special pead. consideration
The predominant bone in proximal part is cancellous and distal to intertrochantric is cortical
The arterial supply to femoral head arise from 3 source , the major
source is the intraoasseous cervical arteries
Regarding anatomy of hip and femur ,, what's FALSE :
The common femoral vein is posterior and medial to the common femoral artery,,, at the inguinal ligament
Sciatica nerve arise from L 4 to S 3
anterior
medial
posterior
Quadriceps,femoris,sartorius,iliacus, psous,pectineus
Gracilis,add. Longus & magnus,obt. externus
Biceps femoris ,semitendinous,smimembranosus,add. magnus
Lat.femoral cutanous
obturator
Sciatica,pos. femoral cutaneous
Femoral a/v
Profounds femoris a.& obt. a/v
Profundus femoris branches
compartments muscles nerves vesssels
Age and gender are prediposing factors for specifi injury (stress#/patho. #/oesteop.)
Mechanism of trauma may aid in predicting injury pattern
Ch. medical condition predipose pt to certain complication e.g. AVN in ch. Steroid used
Femoral /hip # may lead to hypotention ---diagnosis of exclusion
After stabilizing pt --- examine limb for asymerical , neurovascular
When femoral # supected ,, the pt will be transported from the area to A/E with traction ,,,,, whats FALSEregarding traction :
Traction should be discontinued once the pt arrives in the A/E
Traction should not be used in open fracture with exposed bone
Traction should not be used in pt suggested to have
neurological involvement
Injured exterimities should be immobilized with traction when
moving the pt
Which of the following statements about femoral neck fractures is FALSE?
The injury is most common in older women after a minor fall, but it occurs at all ages with significant trauma.
Stress fracture may not show on initial films; treat
conservatively and repeat x-rays in 10-14 days.
Rest pain and inability to walk are always present
With complete displaced fracture, the leg will be held in slight external rotation and abduction and shortening will be noted
Subtle rt femoral neck #displaced # rtFemoral Neck
Fig 53-16
Fig. 53-24
Which of the following statements describing the treatment for femoral neck fractures is FALSE?
Nondisplaced: a prosthesis is always required
Displaced: open reduction and internal fixation or a joint prosthesis
Stress fracture: either internal fixation or expectant treatment may be used.
Non-displaced : early ambulation and internal fixation
Hip arthroplasty
Indication :Joint damage 2ndry to arthritisHip #AVNTumor
Complication :Aspetic losning of prosthesisInfectionDVTPost op. femoral dislocation
Undisplaced # of neck femur treated with screw and plate
Associated mortality rate is > 80 % due to risk of hemodynamic instability
The leg apperas internaly rotated and shorter on examination
In patient with other medical condition mortality rate increased if patient taken to OT on the day of injury
Internal fixation is preferable on urgent but not emergent basis
Intertrochentric fracture exetended between greater and lesser trochenter of femur ,,, whats FALSE :
10-30 % only
In trochentric fracture , whats FALSE :
Fracture of lesser and greater trochenter is rare
Is more common on female than in male
Result of direct fall over trochenter or avulsed by iliopsoas muscle
If avulsed, the fragment will be displaced superiorly and anteriorly
Sup.& pos.
The treatment for trochanteric hip fracture (avulsion of the trochanter) is __.
1. internal fixation
2. bed rest with progressive rehabilitation or internal fixation depending on the degree of displacement
3. hip replacement
1 and 2 but not 3 since primary closure is best
1, 2, and 3 are correct
The proximal fragment produce flexion,abduction and external rotation
Often accompaine femoral nerve and artery injury
Its mostly comminuated fracture and increase the risk of non-union
Fracture fastly heal because highly vascular region
Delay union and non-union are rare
Subtrochentric fracture occur between the lesser trochenter and proximal 5 cm of femoral shaft ,,, whats FALSE :
It is poor vascular region
Classsification of subtrochentric fracture
Subtrochanteric hip fracture may occur with high-speed trauma or due to a fall in elderly patients. Which of the following statements regarding the treatment of subtrochanteric hip fractures is correct?
Treatment of the fracture should take priority regardless of the other injuries sustained.
Traction immobilization; it is usually followed by internal fixation
Internal fixation is seldom required
Long-leg cast.
Surgical intervention is preferable in children < 10 years old
Rt Femur shaft # AP view
Femoral shaft fracture are common injury in young adult after high energy trauma ,,, what is FALSE :
Open fracture are less frequent and often the result of gunshot wound
Almost half are a/w ligmantous damage in knee , so knee examination is unremarkable
Severly comminuted fracture are more likely to be treated by open reduction and internal fixation
Refracture commonly occur during early healing and period immediately after hardware removed
Severly comm. Rx mostly close reduction
Fracture of the femoral shaft requires significant trauma, and is most often caused by a motor vehicle accident, fall or child abuse. The victim is most often a younger male. Several units of blood may be lost into the thigh, resulting in hemorrhagic shock. Which of the
following statements regarding treatment is true?
An intramedullary rod or nail allows early mobilization (within a few days) in uncomplicated fractures.
A traction splint should never be applied in the field
Prolonged bed rest with traction is the treatment of choice
Treat with 6-8 weeks of skeletal traction progressing to a cast brace
Plate fixation is never required for comminution
The capsule of the hip joint is weakest __, where it inserts on the femoral neck rather than the intertrochanteric crest. This partly explains why most hip joint dislocations are __.
Anteriorly; anterior
Posteriorly; anterior
Posteriorly; posterior
Anteriorly ; posterior
Which of the following statements about the classifications of hip dislocation is FALSE?
Anterior: less common than posterior dislocation
Posterior: the most common type (about 90%)
Central (impaction through the acetabulum): the second most common type
Inferior : occur exculusively in children younger than 7 years
Post./ant./cent.
About 90% of hip dislocations are posterior. Which of the following statements about posterior hip dislocations is FALSE?
Use traction in line with the femoral axis with flexion of the hip and gentle manipulation while an assistant fixates the pelvis.
The leg is shortened and internally rotated
It usually results from a posteriorly-directed force applied to the flexed knee.
Posterior acetabular fracture is common and can be seen on oblique views.
The thigh is abducted
Treat with closed reduction as soon as possible to avoid avascular necrosis of the femoral head or neurovascular injury to the extremity
adducted
About 5-10% of hip dislocations are anterior. Which of the following statements about anterior hip dislocations is FALSE?
Apply persistent traction in line with the femur with gentle manipulation while an assistant fixates the pelvis. Flexion, adduction, and/or internal rotation manipulation while maintaining in-line traction may be required
Closed reduction should be performed as soon as possible to minimize the chance of avascular necrosis of the hip or neurovascular injury to the extremity.
Rule out associated fracture prior to manipulation
The leg is abducted and externally rotated
The hip is extended
Hip is flexed
Fig. 53-21,,,,53-22
Post. Dislocation of hip with adduct thigh and
internally roated ansd shorten
Posterior Dislocation of the Left Hip - AP View
Posterior Dislocation of the Left Hip - Oblique View
Fig. 53-26 ,,,53-27
Femoral Shaft Fracture & Fracture/Dislocation of the Hip - Hip X-Ray
Traumatic myositis result from # or direct severe trauma and repaited minor trauma
The incidince is 2 % after treatment of close hip dislocation and 40 % in when open reduction required
In X-ray it appears as irregularly shaped masses of hetarogeneous bone in the soft tissuearound the joint
Surgical intervention is contraindicated if the lession is near joint
Myositis ossification is pathological bone formation at a site where a bone is not normally found ,,, what is FALSE :
Its indicated not C.I.
Motion of the muscles, tendons and skin about the hip joint is facilitated by more than a dozen bursae, any of which can become inflamed. Which of the following statements about hip bursitis is FALSE?
Usually due to overuse or trauma
Infection or gout: should also be considered as possible causes
Seen on exam: hip or lateral thigh pain, increased with abduction and external rotation, as well as with straight-leg raising or impaction of the heel with the leg extended
Seen on exam: tenderness and possibly heat and swelling over the greater trochanter
May be helpful: ice, rest, and anti-inflammatory medications; intrabursal local anesthetic and steroid injections
Pain not with straight leg or impaction
Treatment of an open wound of the hip joint includes:
1. irrigation and debridement in the operating room
2. tetanus prophylaxis and antibiotics
3. secondary closure
1 and 2 but not 3 since primary closure is best
1, 2, and 3 are correct
X-ray of the head of femur can quantify the degree of osteoporosis even n non-fractured bones
The singh score contains six score depend on five trabecular groups,, the worses is grade VI
Singh intreduce a grading system involving the trabecular pattern of proximal end of femur that’s useful in evaluating the degree of osteoprosis ,,,What is FALSE regarding singh score :
As osteoprosis progress,,the trabecular groups dissapear one at a time in predictable pattern
All five grup of trabeculae are seen normally in AP view of non-diseased head,neck ,proximal end of femur
Worser grade I
Fig. 53-6
Which statement is FALSE :
Hamstring muscle starin : toe-touch weight bearing i.e. walking with crutches with toes of inj. Limb rest on ground w/o wt bearing
Quadriceps tear : surgical repair and extensive rehabilitation
Iliopsoas strain : partial flexion at knee and hip for 7-10 D
Hip adductor strain : complete bed rest for 3 mnths
On normal person ,,,,,, non-traumatic painful hip doesn’t R/O AVN
AVN rarly complicated intertrochanteric fracture
Hip dislocation should reduced within 48-72 hrs to significantly reduced incidence of AVN
With optimal treatment, femoral neck fracture are complicated by AVN in 11% to 19% of cases
AVN result of ischemic bone death of femoral head after compromise of its blood supply ,,,, whats FALSE :
Within 24 hrs
Box 53-1
86 male pt present with h/o hip pain since 3 months , no h/o recent trauma ,the pain is more in the morning and progressivly increased with time , o/e no deformities or shorthining , only minor active and passive tenderness on motion ,,, whats best answer :
If plain film is negative ,, discharge pt with analgesia
If plain film is negative ,, discharge pt with analgesia and to repait xray after 10-14 days
Addmit the pt for pain mangment
Order CT/MRI hip
Development of femoral head and neck with its growth palates and two primary ossification center
New born
4mnth 1 yr 4 yr 6 yr
Physis # transcervical
cervicotrochentric intertrochentric
Delbet classification of femoral head fracture in peads
2 years old child present with h/o fever,limp and pain in lt hip , gram +ve bacteria are recovered from the hip joint , which of the following is most correct :
Causative organism include Neisseria and group B streptoccocus
Culture will be positive in approximatl 50 %
Girls are afftected more than boys
The hip is most commonly affected joint
Sed rate is superior to CRP in making diagnosis
8 years boy with no h/o fever or trauma , present with pain in his groin ,Legg-Calve- perthes disease is suspected ,,, which of following is correct :
Disease is bilateral in 50 % of cases
Finding in initial LCP inclde widning of medial joint space and irregularity of physis
Peak year of incidence is 10 – 12 yrs
Radionnuclear scan give more information than plain film regarding femoral head necrosis
There is limited adduction and internl rotaion on examination
☺ Perthes disease is AVN to femoral head of peads resulted in softining and break down of femoral head
☺ B/w 2 -10 yrs of age. ,,,, male > female
☺ 20 % b/l ,, limitation abd. & ext. rotation
☺Rx immobilization or limitations on usual activities or surgical
☺ After 18 months to 2 years of treatment, most children return to normal activities without major limitations.
14 yrs old obese boy present with acute onset of pain in his lt hip after a football injury ,, xray of affected hip demonistrate a Slipped Cappital Femoral Head ,,, which of following is most correct :
Xray of controlateral hip is indicated
AVN would not be a complication on this pateient
Boy present at younger age than girl
This injury can be classify as stable
☺ SCFEis a Salter-Harris type 1 fracture through the proximal femoral physis.
☺ Stress around the hip causes a shear force to be applied at the growth plate and epiphysis to move posteriorly and medially.
☺ The almost exclusive incidence of SCFE during the adolescent growth spurt indicates a hormonal role.
☺ Obesity is another key predisposing factor in the development of SCFE.
☺ Because the physis has yet to close, the blood supply to the epiphysis still should be derived from the femoral neck; however, this late in childhood, the supply is tenuous and frequently lost after the fracture occurs.
☺ Clinical presentation often is misleading, with only 50% of patients presenting with hip pain and 25% presenting with knee pain☺