Format

• Short Cases• A series of short questions• Review of answers• Discussions

Case 1

• 28 y.o. male• Front seat passenger• Car ran into lamp post• Brought to A&E• No other injury except for severe pain in right

hip

28 y.o. maleFront seat passenger

Questions

1. What is the diagnosis?2. What is the usual position of the limb in this

condition?3. What are the radiological signs?4. What other investigations?5. What are the potential complications? 6. What is the definitive treatment?

1. What is the diagnosis?

2. What is the usual position of the

limb in this condition?

3. What are the radiological signs?

4. What other investigations?

5. What are the potential

complications?

6. What is the definitive treatment?

Anatomy:Hip Joint

Ball and socket joint.Femoral head: slightly asymmetric, forms 2/3 sphere.Acetabulum: inverted “U” shaped articular surface.Ligamentum teres, with artery to femoral head,

passes through middle of inverted “U”.

Hip Dislocation: Mechanism of Injury

Almost always due to high-energy trauma.Most commonly involve unrestrained

occupants in MVAs.Can also occur in pedestrian-MVAs, falls from

heights, industrial accidents and sporting injuries.

Physical Examination: Classical Appearance

Posterior Dislocation: Hip flexed, internally rotated, adducted.

Position of Limb

Adducted, flexed and

Internally Rotated

Diagnosis:Posterior

Dislocation

What are the radiological signs?

Shenton’s LineHead is higherLess trochanter is higher

How do you know that this hip is internally rotated?

Potential Complications

1. Recurring instablility2. Traumatic degenerative arthritis3. Avascular Necrosis4. Sciatic Nerve injury5. High energy injury – watch out for other

blunt trauma that may not be apparently initially

Blood Supply to Femoral Head

1. Artery of Ligamentum Teres2. Ascending Cervical Branches

Sciatic Nerve

Composed from roots of L4 to S3.Peroneal and tibial components differentiate early,

sometimes as proximal as in pelvis.Passes posterior to posterior wall of acetabulum.Generally passes inferior to piriformis muscle, but

occasionally the piriformis will split the peroneal and tibial components

Associated Injuries

Mechanism: high-energy, unrestrained occupants

Thus, associated injuries are common:

• Head and facial injuries• Chest injuries• Intra-abdominal injuries• Extremity fractures and dislocations

Clinical Management: Emergent Treatment

• Dislocated hip is an emergency.

• Goal is to reduce risk of AVN and DJD.

Emergent Reduction

• Allows restoration of flow through occluded or compressed vessels.

• Decreased AVN with earlier reduction.• Requires proper anesthesia.• Requires “team” (i.e. more than one person).

Summary of Posterior Dislocation of the Hip

• Hip is very stable• Require high energy to dislocate• Reduce early with adequate sedate of GA• Patient usually young so complications has

long lasting disability– AVN– Traumatic Arthritis– Recurrent instability– Sciatic nerve injury

Case 2Presenting complaints • 52/ F/ Chinese/ Hawker by profession had to

give up her profession as she was having progressive right hip pain x 4/12 before seeking the consultation

• No significant past medical history of taking any long term medication, trauma or steroid or alcohol use

Clinical examination

• Could still squat with difficulty• Internal and external rotations grossly

restricted and painful

TAH/52/F/Chinese

TAH/52/F/Chinese

Case 2

1. What is the diagnosis? 2. What are the possible causes?3. What are the radiological signs?4. What are the treatment options?

Answer

• What is the diagnosis?– Avascular Necrosis

Answer

• What is the diagnosis?– Avascular Necrosis

• What are the possible causes?

Answer

• What is the diagnosis?– Avascular Necrosis

• What are the possible causes?– Excessive Alcohol consumption– Steroid Use– Rapid Decompression– Trauma– Inflamatory Disease – Lupus (vasculitis)– Gaucher’s Disease

What are the radiological signs?

Crescent Sign

What is the reason for increase density in avascular necrosis?

• Impaction of trabecular bone• New bone on dead trabecular bone• Relative disuse osteopenia

What are the treatment options?

• Analgesic• Weight Reduction• Walking aids• Coring decompresion• Bone Graft• Osteotomy• Hip Replacement

Treatment – Hip Replacement

Case 370 y.o. patient with bilateral hip pain started about 10 years ago. He underwent right hip surgery 5 years ago and left hip surgery 3 years ago.1.What surgeries have been performed?2.What is the indication for surgery?3.Name 3 possible complications of this type of surgery?

Case 3What surgeries have been performed?Bilateral Cement Total Hip Replacements

Case 3What is the indication for surgery?Severe pain and limited walking

Case 3Name 3 possible complications of this type of surgery?1.Neuro-vascular injury2.Dislocation3.Leg length discrepancy4.Infection5.Loosening of implant6.Deep vein thrombosis

Case 4

• 80 yo women, fell at home and sustain this fracture

• Except for hypertension she has no other medical problem

• Lives at home with her daughter and grandchildren

Case 4

1. What is the injury?2. What are the risk factors

for this type of injury?3. What is the

recommended treatment?

4. Name 3 factors that would affect this patient’s post-op recovery

Case 4

• What is the injury?Displaced femoral neck fracture.

Femoral Neck Fracture

• Intracapsular• Subcapital, Transcervical, Basilar• Displaced vs Undisplaced

Un-displaced

Caution!

• Elderly patient • Hx of fall • Subsequently unable to walk• Xray is negative for fracture

Fracture until proven otherwise

Impacted

Displaced

Hip FractureFemoral Neck

Hip Fracture

Leg is:

-Shorten

-Externally Rotated

Case 4

What are the risk factors for this type of injury?

• Smoking• Estrogen Deficiency• Low Calcium Intake• Sedentary lifestyle• Recurrent Fall• Impaired Eyesight• Alcoholism

OsteoporosisSingh Index

Case 4

• What is the recommended treatment?

Hemiarthroplasty

Un-displaced femoral neck fracture

Pinning for Undisplaced or Impacted Fracture of the Femoral Neck

Case 4

• Name 3 factors that would affect this patient’s post-op recovery

1. Pre-morbid ambulatory status

2. Pre-morbid medical condition

3. Pre-morbid mental status

Complications of Femoral Neck Fractures

• Fracture– Avascular Necrosis– Non-union

• Patient– Morbidity– Mortality

Case 5

• 75 y.o. man slip and fell at shopping mall

• Previously healthy.• On no medication• Lives alone in HDB flat

Case 5

1. What are characteristics of this fracture that determine its prognosis?

2. What is the standard of care for this type of fracture?

3. What are the potential complications directly related to the fracture?

Case 5

• What are characteristics of this fracture that determine its prognosis?

Stable versus unstableAs determined by the

fragmentations of the fracture.

Stable vs Unstable Fractures

Stable Unstable

Stable vs Unstable Fractures

Stable Unstable

Case 5

• What is the standard of care for this type of fracture?

Closed reduction and internal fixation with dynamic hip screw

Treatment of Inter-trochanteric Fractures

• Fracture– Closed Reduction and Internal Fixation

• Patient– Early mobilization– Medical management

Closed Reduction

Internal Fixation withSliding Hip Screw

Internal Fixation withSliding Hip Screw

Case 5

• What are the potential complications directly related to the fracture?

Failure of fixation Malunion

Complications of Intertrochanteric Fractures

• Fracture– Stability– Failure of Fixation

• Patient– Morbidity– Mortality

Failure of Fixation

5% in Stable Fractures

20% in Unstable Fractures

Patients with Hip Fractures General Principle of Treatment

Principles of Treatment of Hip Fractures

• Fracture – Provide Stability of Fracture• Patient– Early mobilization – Day 1 post-operative– Minimize medical complications

Aim is to Decrease Medical Complications

• Bed sore• Confusion• Proactive management of bowel and bladder

function (UTI and Constipation)• Deep vein thrombosis• Pneumonia • Careful management of co-morbid medical condition• Adherence to “Pathways” Protocol

Factors influencing Hip Fracture Outcome

• Pre-injury physical status• Pre-injury mental status• Home companion• Nutrition• Independent community ambulation• Post-op ambulation• Post-op complication

Factors Influencing Discharge to Home

• General Medical Condition• Living with someone at Home• Ability to walk 2 weeks after surgery• Mental status

Range from 95% to 25%

Mortality

• About 20%• Stabilize after 12 months• Highly age related• Mental status and general medical conditions

are important factors