The ACETABULUM, HIP JOINT and Proximal FEMUR

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The ACETABULUM, HIP JOINT and Proximal FEMUR

  1. 1. The ACETABULUM, HIP JOINT and Proximal FEMUR TRAUMA MI Zucker, MD
  2. 2. A dr Z Lecture • On injuries of the “Hip”.
  3. 3. First: The Acetabulum and the Hip Joint
  4. 4. The ACETABULUM and HIP JOINT Now, injuries of: • ACETABULUM • HIP JOINT (Later: injuries of the proximal femur, also called the” hip”).
  5. 5. Radiography • Pelvis AP • Judet views: 45 degree obliques • CT • (MRI: not often needed)
  6. 6. AP PELVIS: Adult
  7. 7. AP PELVIS: Kid
  8. 8. JUDET Views • Obturator Judet • Iliac Judet
  9. 9. Anatomy of the Acetabulum The SIX Lines: • Iliopubic (iliopectineal) • Ilioischial • Tear drop (“U”) • Dome (roof) • Anterior wall • Posterior wall
  10. 10. Anatomy: AP HIP Adult
  11. 11. Anatomy: AP HIP Kid
  12. 12. Anatomy: Obturator Judet
  13. 13. Anatomy: Iliac Judet
  14. 14. Acetabulum Fractures • The classification of Letournel and Judet is standard. • But rather than discussing it, we will just describe the major fractures.
  15. 15. Acetabulum Injuries: Mechanisms • Major force: MVA, fall from a height. Force directed up one leg, or anteriorly or laterally to hip.
  16. 16. Acetabulum • The posterior wall and column, and the roof are the major weight bearers, and so these injuries are more significant than anterior ones and usually require operative intervention.
  17. 17. Disrupted Iliopubic line: Anterior Injury
  18. 18. Anterior Wall Fracture
  19. 19. Disrupted Ilioischial Line: Posterior Injury
  20. 20. Posterior Wall Fracture
  21. 21. Acetabulum Dome Fracture
  22. 22. CT vs. Plain Films • CT is far more sensitive in finding fractures. • CT characterizes fractures much more accurately. • CT is easier on the patient that Judets. • Pelvis AP is a good, simple screen, however.
  23. 23. The Best Way to Image • Screening Pelvis AP. If positive or equivocal, CT. • Judet views also if orthopedic surgeon wants them.
  24. 24. CT • All trauma CT Abdomen studies include the pelvis and acetabulum. • Dedicated CT Pelvis for fine detail.
  25. 25. CT Anatomy: Dome
  26. 26. CT Anatomy: Columns
  27. 27. CT Pelvis: Column Fractures
  28. 28. CT Pelvis: Dome Fractures
  29. 29. Major Acetabulum Fractures: ORIF
  30. 30. Dislocations of the Hip • Posterior Dislocations: 90% • Anterior Dislocations: 10% • “Central dislocations” are really displaced fractures of the medial acetabulum wall with medial displacement of the femur head.
  31. 31. Posterior Dislocations
  32. 32. Complications: Posterior Dislocation • Posterior wall fracture • Intra-articular fragment, which can prevent reduction • Sciatic nerve injury • Femur head fracture • Avascular necrosis
  33. 33. Anterior Dislocations
  34. 34. Complications: Anterior Dislocations • Avascular necrosis of femur head
  35. 35. Caveat: Anterior Dislocations • A very small number of anterior dislocations look like posterior dislocations.
  36. 36. And now…. • The PROXIMAL FEMUR • Also called the “HIP”
  37. 37. The Proximal FEMUR Often called the “Hip” it includes the : • Head of femur • Neck of femur • Intertrochanteric femur • Greater and lesser trochanters • Subtrochanteric femur shaft
  38. 38. Radiography: Hip • Pelvis AP • Hip AP
  39. 39. Radiography: Hip • “Frog-leg lateral”, really an AP/oblique view • True or Johnson lateral
  40. 40. Anatomy: AP and Frog Adult
  41. 41. Anatomy: AP and Frog Kid
  42. 42. Anatomy: True Lateral
  43. 43. Role of MRI, CT and Bone Scan • CT: Not much of a role, as not sensitive enough for subtle fractures in axial projection, and reformats not good enough, but improving with MDCT. • MRI: BIG role! We will discuss it later. • Bone scan: Obsolete. Too many early false negatives in osteoporotic patients.
  44. 44. Hip Fractures • Head: A complication of acetabulum fractures or dislocations • NECK • INTERTROCHANTERIC • Isolated greater or lesser trochanter • Subtrochanter shaft
  45. 45. Hip Fractures • Femur neck and intertrochanteric fractures occur mainly in elderly people with osteoporosis who sustain a ground level fall. • They can occur in normal people with major force. • Femur neck stress fractures are also occasionally seen in athletic people.
  46. 46. Femur Neck Fractures • Subcapital • Transcervical • Basicervical
  47. 47. Classification: Femur Neck Fractures GARDEN: • I: Impacted or incomplete • II: Complete, but nondisplaced • III: Partially displaced • IV: Completely displaced
  48. 48. Femur Neck Fractures: Management • Garden I and II’s don’t disrupt blood supply to femur head, so need only mechanical stabilization. • Garden III and IV’s disrupt blood supply in 30%-50%.
  49. 49. Femur Neck Fractures: Management • Garden III and IV’s in an elderly or chronically ill patient: Hemiarthroplasty. You don’t want to operate again on these patients if AVN occurs. • But in a younger healthy patient, might try pinning and do hemiathroplasty later if AVN occurs, because hip prostheses need replacement every 10-12 years.
  50. 50. Garden I
  51. 51. Garden II
  52. 52. Garden III
  53. 53. Garden IV
  54. 54. Less common mechanisms • Stress fracture, marathon runner.
  55. 55. Treatment, Garden I-II: Pins
  56. 56. Treatment, Garden III-IV: Hemiarthroplasty
  57. 57. Total Hip Replacement • THR is for severe osteoarthritis, primary or secondary. It is not for acute trauma.
  58. 58. Intertrochanteric Fractures • Distal to blood supply to femur head, so need mechanical stabilization only. • There are classifications, but all IT’s treated about the same anyway so why bother.
  59. 59. Intertrochanteric Fracture
  60. 60. Treatment: Dynamic Compression Screw
  61. 61. Isolated Trochanter Fractures: Greater • Greater trochanter fractures: Fall directly on the GT. • Stable. Symptomatic treatment. • Caveat: Make sure it is not a subtle IT fracture
  62. 62. Isolated Trochanter Fractures: Lesser • BEWARE: These are usually PATHOLOGIC FRACTURES, often from occult metastases.
  63. 63. MRI • MRI has a critical role in hip fracture diagnosis. • Bone scans are obsolete (used only if MRI contraindicated)
  64. 64. MRI Role: Neck • Occult Garden I: Patient may be able to walk and will displace to Garden III or IV if fracture missed. • If suspected fracture occult or subtle on plain films, do MRI
  65. 65. MRI: Obvious
  66. 66. MRI Role: IT area • Occult intertrochanteric fractures, with or without isolated appearing trochanter fractures. • Pathologic fractures.
  67. 67. MRI: Obvious IT Fracture
  68. 68. Subtrochanter Fractures • Major force • Treated by intramedullary rod
  69. 69. GOODBYE • Copyright 2004 MI Zucker

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