Injuries Of The Injuries Of The Hip And FemurHip And Femur

Dislocations Of The HipDislocations Of The Hip Complete loss of contact between Complete loss of contact between

the articular surfaces forming the the articular surfaces forming the joint.joint.

Classified according to the direction of Classified according to the direction of the femoral head to:the femoral head to:

Posterior Posterior ((commonestcommonest)).. Anterior.Anterior.

Central (comminuted or displaced Central (comminuted or displaced fracture of acetabulumfracture of acetabulum).).

Posterior DislocationPosterior Dislocation Four out of five traumatic dislocations.Four out of five traumatic dislocations. Mechanism of injury:Mechanism of injury:

Road traffic accidentRoad traffic accident when the victim thrown when the victim thrown forward striking the knee against the forward striking the knee against the dashboard with the hip and knee flexed dashboard with the hip and knee flexed forcing the head out of the acetabulum, forcing the head out of the acetabulum, some time posterior wall fracture happen some time posterior wall fracture happen

(fracture dislocation).(fracture dislocation).

Clinical FeaturesClinical Features

The leg is shortened, adducted, The leg is shortened, adducted, internally rotated and flexed at the internally rotated and flexed at the hip joint.hip joint.

Be careful if associated with fracture Be careful if associated with fracture femur (rule).femur (rule).

Always examine for signs of sciatic Always examine for signs of sciatic nerve injury.nerve injury.

Radiological evaluationRadiological evaluation X-ray:X-ray: AP viewAP view of the pelvis is a must in all severely of the pelvis is a must in all severely

traumatized patient.traumatized patient.

1.1. The head is out and above the acetabulum.The head is out and above the acetabulum.

2.2. Search for acetabular rim or femoral head Search for acetabular rim or femoral head fracture.fracture.

CT scan:CT scan: show the anatomy of concomitant show the anatomy of concomitant fractures, exclude intra articular bone piece.fractures, exclude intra articular bone piece.

Thompson and epstein Thompson and epstein classificationclassification

Type I:Type I: dislocation with no or small chip dislocation with no or small chip fracture.fracture.

Type II:Type II: with large posterior wall fracture. with large posterior wall fracture.

Type III:Type III: with posterior wall cominution. with posterior wall cominution.

Type IV:Type IV: with fracture acetabular floor. with fracture acetabular floor.

Type V:Type V: with fracture femoral head. with fracture femoral head.

TreatmentTreatment Urgent reduction under GAUrgent reduction under GA

(assistant stabilize the pelvis, (assistant stabilize the pelvis, traction applied then flexion of hip traction applied then flexion of hip and knee to 90◦then gradual rotation and knee to 90◦then gradual rotation till you here clunk of reduction.till you here clunk of reduction.

X-ray is essential toX-ray is essential to

confirm reductionconfirm reduction

and exclude fractures.and exclude fractures.

After TreatmentAfter Treatment Type IType I: Traction for 3 weeks then partial wt. : Traction for 3 weeks then partial wt.

bearing.bearing. Type II:Type II: Open reduction and rigid fixation of Open reduction and rigid fixation of

posterior wall followed by traction for 6 weeks.posterior wall followed by traction for 6 weeks. Type III:Type III: Traction for 6 weeks. Traction for 6 weeks. Type IV&V: Type IV&V: closed reduction may lead to closed reduction may lead to

automatic reduction of the fractures, if not automatic reduction of the fractures, if not open reduction and internal fixation followed open reduction and internal fixation followed by traction for 6 weeks.by traction for 6 weeks.

Full weight bearing allowed only after 12 Full weight bearing allowed only after 12 weeks.weeks.

ComplicationsComplicationsEarly:Early:1.1. Sciatic nerve injury.Sciatic nerve injury.2.2. Vascular injury (superior gluteal artery).Vascular injury (superior gluteal artery).3.3. Associated fracture of femoral shaft.Associated fracture of femoral shaft.Late:Late:1.1. Avscular necroses: Avscular necroses: Immediate reduction 10%.Immediate reduction 10%. Delayed reduction 40%.Delayed reduction 40%.2.2. Myosits ossificans.Myosits ossificans.3.3. Unreduced dislocation.Unreduced dislocation.4.4. Osteoarthrits.Osteoarthrits.

Hip FracturesHip Fractures Involves head, neck and subtrochanteric Involves head, neck and subtrochanteric

fractures.fractures. Femoral neck fractures involve the narrow neck Femoral neck fractures involve the narrow neck

between the round head of the femur and the between the round head of the femur and the shaftshaft. .

Neck fractures are classified into (vascularity, Neck fractures are classified into (vascularity, treatment, complications):treatment, complications):

1.1. Intra capsular.Intra capsular.

2.2. Extra capsular.Extra capsular.

Intra Capsular Fractures Intra Capsular Fractures Fracture happen in the intracapsular Fracture happen in the intracapsular

part of the neck.part of the neck. Common in the seventh and eighth Common in the seventh and eighth

decade.decade. Risk factors:Risk factors:

1.1.Osteoporoses and osteomalacia.Osteoporoses and osteomalacia.

2.2.Diabetes mellitus.Diabetes mellitus.

3.3.Alcoholism.Alcoholism.

4.4.Chronic debilitating diseases.Chronic debilitating diseases.

Mechanisms of injuryMechanisms of injury

1.1. Fall on the greater trochanter Fall on the greater trochanter directly.directly.

2.2. Catching the toe in the carpet and Catching the toe in the carpet and twisting the hip to external rotation.twisting the hip to external rotation.

3.3. In young patients (FFH,RTA).In young patients (FFH,RTA).

Clinical featuresClinical features Fall followed by pain in the hip.Fall followed by pain in the hip.

The patient lies with the limb The patient lies with the limb externally rotated and short.externally rotated and short.

Young patients usually have Young patients usually have associated severe injuries of the associated severe injuries of the lower limb( fracture femur).lower limb( fracture femur).

X-rayX-ray:: This is divided according to the level of the This is divided according to the level of the fracture line in the neck as follows: fracture line in the neck as follows:         1) Sub capital. 1) Sub capital.     2) Trans cervical.     2) Trans cervical.     3) Basal.    3) Basal. Stress fractures and impacted fractures Stress fractures and impacted fractures may show no finding.may show no finding.

Fracture displacement is Fracture displacement is assessed by the garden assessed by the garden classification:classification:

1.1.Garden I :Garden I : incomplete fracture incomplete fracture

of the neck (so-called abductedof the neck (so-called abducted

or impacted).or impacted).

2.2.Garden II :Garden II : complete without complete without displacement. displacement.

4.4. Garden III:Garden III: complete with partial complete with partial

displacement; fragments are still displacement; fragments are still

connected by posterior retinacularconnected by posterior retinacular

attachment; there is malalignmentattachment; there is malalignment

of the femoral trabeculae( adducted).of the femoral trabeculae( adducted).

4.4. Garden IV :Garden IV : this is a complete femoral neck this is a complete femoral neck fracture with full displacement; the proximal fracture with full displacement; the proximal fragment is free and lies correctly in the fragment is free and lies correctly in the acetabulum acetabulum

so that the trabeculae appearso that the trabeculae appear

normally aligned.normally aligned.

TreatmentTreatment

Initial traction to relief pain till the definitive treatment.Initial traction to relief pain till the definitive treatment.

Fractures at this level have a poor capacity for union Fractures at this level have a poor capacity for union due to the following factors: due to the following factors:

AA) Interference with the blood supply to the proximal ) Interference with the blood supply to the proximal fragment.fragment.

BB) Difficulty in controlling the small proximal fragment.) Difficulty in controlling the small proximal fragment.

CC) The lack of organization of the fracture hematoma ) The lack of organization of the fracture hematoma due to the presence of the synovial fluid.due to the presence of the synovial fluid.

D) D) Lack of periostium.Lack of periostium.Because of these facts there is no role of conservative Because of these facts there is no role of conservative treatment.treatment.

Surgical TreatmentSurgical Treatment All patients under the age of 70 year by:All patients under the age of 70 year by:

Closed Reduction And Internal FixationClosed Reduction And Internal Fixation..

Two essential principles to be followed in Two essential principles to be followed in the surgical management of this the surgical management of this fracture are: fracture are: (A) (A) Perfect anatomical reduction. Perfect anatomical reduction. 

(B) (B) Rigid internal fixation.Rigid internal fixation. The principle is to do closed reduction The principle is to do closed reduction

under image intensifier and under image intensifier and

then internalthen internal

fixation either fixation either

by:by:

1.1. Multiple compression canulated Multiple compression canulated screws.screws.

2.2. Dynamic Hip Screw.Dynamic Hip Screw.

Patients above 70year:Patients above 70year:

Partial hip replacement Partial hip replacement (bipolar,Austin-moor).(bipolar,Austin-moor).

Total hip replacement.Total hip replacement.

ComplicationsComplications

1.1. General (DVT, PE, pneumonia, bed General (DVT, PE, pneumonia, bed sores).sores).

2.2. Avascular necroses of the femoral Avascular necroses of the femoral head.head.

3.3. Non union.Non union.

4.4. Osteoarthritis.Osteoarthritis.