hip fractures dr sami nugod

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HIP FRACTURES Dr Sami Nugod. Overview. Incidence is highest in >65 years of age but also in young adults due to RTA 320,000 admission in the US each year 15-20% die within 1 year of fracture F>M Two types: intracapsular and extracapsular. Anatomy. Blood Supply. - PowerPoint PPT Presentation

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  • HIP FRACTURES

    Dr Sami Nugod**Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • OverviewIncidence is highest in >65 years of age but also in young adults due to RTA320,000 admission in the US each year15-20% die within 1 year of fractureF>MTwo types: intracapsular and extracapsular**Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Anatomy**Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Blood Supplyintracapsular are at risk of non union and avascular necrosis due to interruption of the blood supply to the femoral headVia cruicate (med and lat circumflex) and intramedullaryGarden classification**Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Risk FactorsAge: >65 yearsCo-morbid factors: osteoporosis, endocrine disorders (hyperthyroidism, hypogondaism), GIT disorders interfering with calcium/ Vit D absorption, neurological disorders (Parkinsons, MS)Gender: FRTA

    **Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Risk FactorsNutrition: lack of calcium and Vit D in diet, eating disorders (anorexia), high caffeine intakeSmokingAlcoholMedication: steroids, anticonvulsants, diureticsEnvironmental factors: loose rugs, dim lighting, cluttered floors

    **Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Osteoporosis:**Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • PresentationP/C: severe pain, bruising, swelling unable to weight bear on that leg.O/E: may have shortened leg with external rotation

    **Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • InvestigationsFull history and physical examAssess patient as per ATLS protocolX-rays AP and lateral, CT, MRI, bone scanRoutine bloods, group and holdECG, CXR

    **Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • ClassificationClassified on geographical position: intracapsular: SubcaptialTranscervicalbasicervicalExtracapsular:Intertrochantericsubtrochanteric**Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Garden ClassificationGarden I: incomplete fracture of the femoral neckGarden II: complete fracture without displacementGarden III: complete fracture with partial displacementGarden IV: complete fracture with full displacement

    **Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Pauwels ClassificationThe more vertical the line the greater the risk of non union because increased shear stresses across the fracture**Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Subcapital Fracture:Most common intracapsular fracture of the hipX-ray: white line of increased density of impacted bone may be seen at base of femoral head**Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Transcervical FractureOccurs across neck of femurEasy to view when hip x-ray obtained in internal rotationa/w varus deformity**Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Basicervical FractureBase of femoral neckAre Intracapsular two part fractures with fracture plane running along line of capsular insertion**Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Management of Femoral Neck FractureConservative: analgesia, bed rest, tractionif pt not willing to consent for surgery or if not expected to survive surgery Surgical: Manninger et al showed significant reduction in osteonecrosis and segmental collapse if performed within 6 hrHead sparing: screws, DHSHead sacrificing: hemi, THR**Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Young PatientsNon-displaced fracturesAt risk for secondary displacement Urgent ORIF recommendedDisplaced fracturesPatients native femoral head bestAVN related to duration and degree of displacementIrreversible cell death after 6-12 hoursEmergent ORIF recommended

    **Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Elderly PatientsOperative vs. Non-operativeDisplaced fractures Unacceptable rates of mortality, morbidity, and poor outcome with non-operative treatment [Koval 1994]Non-displaced fractures Unpredictable risk of secondary displacementAVN rate 2XStandard of care is operative for all femoral neck fracturesNon-operative tx may have developing role in select patients with impacted/ non-displaced fractures [Raaymakers 2001]

    **Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Cannulated Screws.**Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Cannulated Screws (Richard)Used for undisplaced femoral neck fracturesGood for fracture which are more horizontalKrastman (2004): 112 pt study had 95% consolidation rate with 2 cannulated screws in intracapsular stable fracturePosition of screw did not interfere w consolidationRates negatively affected by inadequate anatomical reduction and unstable fractures

    **Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Dynamic Hip ScrewGood for fracture with more vertical fracture lineProblem w this is that cannulated screw will prevent fracture impaction non unionSacrifices large amount of boneAnti-rotation screw often needed

    **Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Hemiarthroplasty Hip: Indications:Poor general healthPathological hip fractureSevere osteoprosisPhysiological age >70 Inadequate closed reductionPre-existing hip diseaseContraindication:Pre existing sepsisYoung patientFailure of internal fixation devicePre-existing disease of the acetabulum**Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Hemiarthroplasty Hip:Hemi associated with (Luyao 1994, lorio 2001)Lower reoperation rate (6-18% vs. 20-36%)Improved functional scoresLess painMore cost-effectiveSlightly increased short term mortality

    **Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Bipolar Bipolar theoretical advantagesLower dislocation rateLess acetabular wear/ protrusionLess PainMore motionBipolar DisadvantagesCostDislocation often requires open reductionLoss of motion interface (effectively unipolar)

    **Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Femoral Neck Fracture ComplicationsFailure of FixationInadequate / unstable reductionPoor bone qualityPoor choice of implantTreatmentElderly: ArthroplastyYoung: Repeat ORIF Valgus-producing osteotomy Arthroplasty

    **Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Femoral Neck AVN5-8% Non-displaced fractures20-45% Displaced fracturesIncreased incidence withINADEQUATE REDUCTIONDelayed reductionInitial displacementassociated hip dislocation**Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Femoral AVNTreatmentElderly patientsOnly 30-37% patients require reoperationArthroplastyResults not as good as primary elective arthroplastyGirdlestone Resection Arthroplasty

    **Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Femoral AVNTreatmentYoung PatientsNO good option existsProximal OsteotomyLess than 50% head collapseArthroplastySignificant early failureArthrodesisSignificant functional limitations** Prevention is the Key ****Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Extracapsular FracturesInter-trochanteric fracture NOF.Sub-trochanteric fracture NOF.**Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Intertrochanteric FractureMost common extracapsular hip fracturea/w varus deformityClassified by Evans as stable or unstableMost commonly used classification is Jensen where type 1&2 are stable and 3-5 are unstable**Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Jensen Classification**Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Subtrochanteric FractureClassified by Seinsheimer: divided into undisplaced, two part, and comminuted**Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Seinsheimer classification**Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Isolated fracture of Greater Trochanter:Occurs mainly in osteoporotic femalesResult of a fall on the greater trochanter or avulsion type fracture from pull of gluteus medius insertion**Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Management of Extra-capsular Fractures:DCSDHSIM nailing**Hip fractures- Dr sami nugod - Sept 2013

    Hip fractures- Dr sami nugod - Sept 2013

  • Compression Hip Screw W PlateCompression hip screws with a plate have gained increased popularity

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