Injuries Around The Hip.www.1aim.net

Fractures around the hip Risk Factors  Age:

incidence doubles for each decade after 50ys  Sex: 2-3 times higher in women  2-3 times higher in white women than in nonwhite women 

 Physical

inactivity  Low body weight  Previous hip fracture  Dementia  Psychotropic meds  Visual impairment

FRACTURES OF THE PROXIMAL FEMUR

Fractures around the hip  250.000

hip fractures/year  90% in patients >50ys old  Mortality related to hip fracture – 25% at one year  80% of patients recover their walking ability,  Only 70% recover their ability to perform ADLs (activities of daily living)

Risk Factors  Age:

incidence doubles for each decade after 50ys  Sex: 2-3 times higher in women  Race 2-3 times higher in white women than in nonwhite women  Habits Excessive alcohol or caffeine      

Physical inactivity Low body weight Previous hip fracture Dementia Psychotropic meds Visual impairment

Osteoporosis

Hip Fractures 

Femoral neck 45%   

intracapsular, disruption of blood supply to femoral head, high incidence of healing complications (nonunion, osteonecrosis)

Intertrochanteric 45%  

 

extracapsular, no interference with the blood supply of the femoral head, less complications Malunion

Subtrochanteric  

extracapsular Malunion

Clinical Assessment History: H/o fall – in a small percentage it occurs spontaneously C/o pain and inability to move the hip or put weight H/o other osteoporotic fractures: Colles

TRAUMA Direct Indirect  Vehicular

accedents  Fall from height  Crushing accidents  Avulsion fractures

Clinical Assessment – Physical Exam  Leg

externally rotated  Shortening  May show trochanteric ecchymosis  Inability to lift the extended leg  ROM is limited and painful  Distal neurovascular exam  Check the pelvis -

Move posterior to anterior at the level of iliac crests Lateral to medial through the iliac crests

CLINICAL PICTURE

SYMPTOMS:

History of trauma, Pain, Swelling, Limited

movements.

SIGNS

:LOCAL ,Swelling ,Ecchymosis ,Tenderness Limited movements ,Deformity Length ,discrepancy

EXTERNAL ROTATION INABILITY TO LIFT EXTENDED LEG

DIAGNOSTIC Xray: AP and lateral. Check the neck shaft angle 120130°. No results but fracture still suspected: AP rotated 10-12° - best visualization of femoral neck CT for osteoporosis Check

Femoral Neck fracture

Femoral Neck fracture

Trochanteric Fracture

Subtrochanteric Fracture

.PATHOLOGICAL FR

Diagnostic Imaging 

Xray:

AP and lateral.  Check the neck shaft angle 120-130°.  No results but fracture still suspected: AP rotated 10-12° - best visualization of femoral neck MRI  most sensitive  order if Xray negative but fracture still suspected Bone scan: sensitive, but has many interferences with the degenerative 



Treatment Principles  Early

surgery / 24-48h in patients who are medically stable  May wait up to 72h to stabilize the pt.  Assess cardiac risk  Delay in surgery/prolonged bed rest means: increased

risk of DVT, UTI, pulmonary complications, skin breakdown, delayed functional recovery

Treatment Principles DVT Prophylaxis  Fatal

PE in 4-7% of patients undergoing hip surgery,  Risk of bleeding 3.5% compared to 2.9% without anticoagulation  Heparin 5000U q12h or LMWH upon admission  Pneumatic compression additional to heparin  Continue prophylaxis until patient is fully ambulatory

treatment Coservative tractoin: skin traction skeletal traction

Operative reduction and internal fixation arthroplasty : Hemiarthroplasty total arthroplasty

TREATMENT OF CLOCED FRACTURES UNDISPLACED REDUCIBLE  CONSERVATIVE TREATMENT 1-TRACTION

SKELETAL TRACTION

Types of Surgery

Minimally displaced femoral neck fracture

Internal fixation with multiple screws

Prosthetic replacement

Displaced Femoral neck Fracture esp. in elderly pt. HEMIARTHROPLASTY TOTAL ARTHROPLASTY

Prosthetic replacement: HIP PROSTHESIS

TOTAL ARTHROPLASTY

HEMIARTHROPLASTY

Types of Surgery

Displaced Femoral neck Fracture

Prosthetic replacement

Types of Surgery

Intertrochanteric fracture

Internal fixation with dynamic hip screw

INTER TROCHANTERIC FRACTURE DHS

DCS

GAMMA NAIL

Post-operative Care  

Nutrition: oral protein supplementation with shorter hospital stay Foley - for 24h only,

- early removal is a/w less retention, earlier spontaneous voiding, less UTI  

Anticoagulant prophylaxis Total hip precautions: - No adduction past midline – use abduction pillows, - No hip flexion beyond 90° (tall comode, no bending >90 ° - No internal rotation – keep toes upright in bed

Rehabilitation  Goal

– independent living  Rehabilitation should begin first day after surgery with transfer from bed to chair  Progress as soon as possible to standing and walking (2nd day post op)  Promote weight bearing with assistance – walker

SYSTEMIC COMPLICATIONS  LONG

RECOMBANCY IN BED  DVT, PE,…,…,…  MORTALITY

LOCAL COMPLICATIONS  Loss

of fixation – 15%of patients: internal fixation for displaced fractures  Malunion – COXA VARA  Nonunion – mo/years after internal fixation for displaced fractures  Avascular necrosis of femoral head (osteonecrosis)  Dislocation of the prosthesis – early, related to infections or mal-insertion  Loosening of prosthesis – years after surgery

Coxa vara Neck shaft angle

HIP DISLOCATIONS - Posterior (most common)

- Anterior - Central

posterior Hip Dislocation (most common) POSTERIOR · 80% of hip dislocations · Limb internally rotated and adducted · Neutral/adduction at time of injury - simple dislocation only ·  Abduction at time of injury fracture posterior acetabular wall Complications · Associated knee ligament injuries especially PCL, posterolateral complex · Sciatic nerve injury 10-14% · AVN (Osteonecrosis) . Myositis ossificans

POSTERIOR DISLOCATION OF THE HIP FRACTURE - DISLOCATION

CT

& 3D-CT

FRACTURE PELVIS FR. ACETABULUM CENTRAL HIP DISLOCATION

ANTERIOR DISLOCATION OF THE HIP

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