5-Traumatic Conditions of the Hip

7/27/2019 5-Traumatic Conditions of the Hip

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Traumatic conditions of

the hip


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Dislocation of the hip

1. Anterior dislocation

2. Posterior dislocation, more common

3. Central dislocation (direct thrust along the line ofthe femoral neck fracture acetabulum

femoral head displaced into the pelvic cavity


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Posterior dislocation of the hip

Longitudinal thrust along shaft of femur when hip isflexed & adducted (dash board accident)

head of femur displaced backward out of the

acetabulum

Clinically:

The affected leg is:

1. Internally rotated2. Adducted

3. Shortened (fig.)


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Complications

Immediate complications:

Sciatic nerve injury drop foot & numbnessover the outside of the calf

Late complications:

avulsion of ligamentum teres from the acetabulum cut off blood supply to femoral head

avascular necrosis OA


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TREATMENT

1. Manipulative reduction

2. Traction (4 weeks) healing of capsular tear

3. Weight bearing4. Regular x rays monthly for the 1st 4 months

for early detection of avascular necrosis


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Treatment of complications

Operation may be necessary to free the sciatic nerve

Avascular necrosis is treated

1. in early stages by avoidance of WT bearing untiltexture of femoral head returns to normal.

2. In late stages by total hip replacement, arthrodesis,

osteotomy, or bone grafting


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Anterior dislocation of the hip

Force that abducts the extended hip femoral headdisplaced below & in front of the acetabulum

Clinically:

the affected leg is:1. Abducted

2. Externally rotated

Treatment:

1. Manipulative reduction

2. 3 weeks traction


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Central dislocation of the hip

Direct violence drives femoral head through floor ofacetabulum

1. Damage of articular surfaces

2. Intrapelvic haemorrhage

3. Hypovolemic shock Conservative treatment

1. Longitudinal traction for 6 weeks

2. Mobility of the hip Surgical treatment

1. Reconstruction of the destroyed acetabulum

2. Total hip replacement


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Fractures of upper end of femur

Risk factore:

1. Age: risk doubles over age of 50

2. Sex: women > men 2-3 times3. Race: caucasian > negroes 2-3 times

4. Medical history of previous hip fracture


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Subcapital fracture of the femoral neck

Grade I

Head of femur is abducted & impacted with the neck

Clinically:1. Little pain

2. Trivial injury

3. No shortening or rotational deformity4. Active movement may be possible


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Grade II

Undisplaced fracture

ST are attached providing blood supply

Grade III

- Femur is adducted at fracture site

- Head is separated from the neck

- Severe pain in hip when standing or moving theaffected limb

- Injured foot & leg are externally rotated


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Grade IV

Gross rotation of both fragments with complete lossof contact between the fragments


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Treatment

1. Grade II - compression screws

2. Grade III & IV

- hemiarthroplasty (Austin-more prosthesis)- Total hip replacement


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Intertrochanteric fractures

Common in elderly people

Equal frequency in men & women

Often comminuted

Lesser trochanter frequently

avulsed & pulled upwards byiliopsoas

Treatment

1. Compressiom screws and plate

2. Early mobilization

3. Early ambulation


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Fractures of femoral shafts in adults

Vigorous trauma

Hypovolaemic shock

Fracture line is transverse or comminuted Severe displacement

residual stiffness of knee

Non-union with open fractures


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Conservative treatment

Temporary traction for 8 weeks (fixedor balanced- skin or skeletal) (fig.)

Followed by hinged cast brace

Weight bearing is then encouraged

Operative treatment Locked intramedullary nail


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Femoral shaft fractures in infancy

Causes:

1. Indirect rotatory twisting strain

2. Difficult delivery with breech

presentation

Treatment:

1. 3-4 weeks fixed traction on Thomassplint

2. In infants less than 3 years gallowstraction


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Supracondylar fractures

Treated by Thomas splint with knee flexion

Fractures of femoral condyles Intra-articular fracture

Internal fixation with plate and screws is necessry to:

1. Reduce the fractured articular surfaces accurately

2. Allow early mobilization

Ph i l h d i


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Physical therapy program during

immobilization period

1. To prevent respiratory complications breathing exercises.2. To prevent circulatory complications

- circulatory exercises

- changing position every 2 hours

- alternating air mattress

3. To prevent stiffness, weakness & atrophy of the free parts

- ROM exercises

- strengthening exercises

4. To prevent weakness of immobilized parts static &

isometric exercises

R h bilit ti ft ORIF f hip


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Rehabilitation after ORIF of hip

fractures

1. Bed mobility while maintaining proper alignment ofthe operative limb

2. Lying flat on back for 1 hour/day to avoid hipflexion contractures.

3. Forced hip flexion or rotation (e.g. twisting forwardor to either side)is to be avoided for the 1st 7-10 dayspostoperatively.

4. Patients are allowed to assume a semireclinedposition after 24 houurs.


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5. Patients are assisted into protectively positionedside-lying as soon as possible(2-3 days

postoperatively).

Side lying position greatly aids in:

- toiletry

- pulmonary postural drainage

- prevention of decubitus ulcers

6. An over head trapeze is essential during the 1st

fewdays postoperatively (using elbows & heels to

elevate hips 4 times body weight force acts on the

hip).


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7. Gait training with walker or crutches if balance &mobility are good. (touch down gait takes about 90-95% of load off hip joint, compared to 80% weightreduction with NWB gait

8. Over 12-16 weeks gait pattern will evolve into full

weight bearing based on:

- surgical procedure

- area of fracture

- radiographic findings

- patient comfort


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9. Active exercises through a comfortable range

10. Pool exercises to regain strength, proprioceptivesense & mobility.

Nb.

Tying a shoe with foot on floor requires 124o

hipflexion

Ascending stairs requires 67o hip flexion

Sitting down on a chair requires 104o hip flexion


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Fractures of upper end of

femur(ORIF)

Day 1:- Quadriceps sets

- hamstrings sets

- gluteal sets

- ankle pumps


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- Active assisted hipabduction & adduction

- Supine leg slides forflexion of hip & knee

- Upper extremity exercise


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Day 2:

Ambulation with TDWB with walker, then PWBwith walker

Days 3-7- SLR in all directions

- Thomas stretch of anterior capsule and hip flexors

1 2 k


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1-2 weeks- Discharge criteria:

1. Get out of bed independently2. Able to ambulate 50 feet with assistive device

3. In & out of bathroom independently.

- Standing hip abduction, adduction, flexion, andextension & hip and knee flexion exercises.

2 -6 weeks- Stationary bicycle, pool exercises, and treadmill- Progress ambulation from walker to use of a cane (if

Trendelendburg test isve)


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Femoral shaft fracture treated with

intramedullary nail

Phase 1: 0-6 weeks:

- Quadriceps, hamstrings, gluteal sets & ankle pumps

- SLR in all planes

- Knee active ROM exercises

- Stationary bicycle

- Weight bearing to tolerance (if nail diameter is 12mm

or more) an progress to full weight bearing astolerated within 6-12 weeks. If nail diameter is less,begin weight bearing with 25kg.

Ph 2 (6 k 3 h )


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Phase 2 (6 weeks -3 months)

- Scale technique for weight bearing (5-10 kg increase weekly)

- Isokinetic exercises- CKC exercises

Phase 3 (3-6 months)- Full weight bearing

- Full knee & hip ROM- Full squat- Ascend & descend stairs full weight bearing- Thigh circumference = uninjured side

Phase 4 (> 6 months)- Return to athletic activity- Full work & recreational activity


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Femoral shaft fracture treated with

plate & screws

- Same as for intra-medullary nail with exception that:

1. NWB for 8-12 weeks

2. Weight bearing is not progressed until radiologicalunion (3-6 months)


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Intraarticular fractures with IF

Phase 1 (0-6 weeks)- CPM in first 24-48 hours (0-90 degrees)

- OKC exercise e.g. SLR, quadriceps sets

- TDWB

Phase 2 (6-12 weeks)

- Stationary bicycle

- PWB using the scale technique

- CKC exercises


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Phase 3 (3-6 months)

- FWB

Phase 4 (>6 months)

- Return to work & recreational activity

- Avoid excessive squatting & jumping & contactsports for 6-12 months

Documents

5-Traumatic Conditions of the Hip