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☺

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