Orthopedics 5th year, 3rd lecture (Dr. Ali A.Nabi)

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The lecture has been given on Mar. 30th, 2011 by Dr. Ali A.Nabi.

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Orthopedics 5th year, 3rd lecture (Dr. Ali A.Nabi)

  1. 1. Injuries of the hip
  2. 2. Anatomy <ul><ul><li>Hip joint is </li></ul></ul><ul><ul><li>Ball and socket joint. </li></ul></ul><ul><ul><li>Femoral head: </li></ul></ul><ul><ul><li>slightly asymmetric, </li></ul></ul><ul><ul><li>forms 2/3 sphere. </li></ul></ul><ul><ul><li>Acetabulum: inverted “U” shaped articular surface. </li></ul></ul><ul><ul><li>Ligamentum teres, with artery to femoral head, passes through middle of inverted “U”. </li></ul></ul>
  3. 3. Joint Contact Area <ul><li>40% of femoral head is in contact with acetabular articular cartilage. </li></ul><ul><li>10% of femoral head is in contact with labrum. </li></ul>
  4. 5. Acetabular Labrum <ul><li>is Strong fibrous ring Increases femoral head coverage Contributes to hip joint stability. </li></ul>
  5. 6. Hip Joint Capsule <ul><li>Extends from intertrochanteric ridge of proximal femur to bony perimeter of acetabulum </li></ul><ul><li>Has several thick bands of fibrous tissue </li></ul><ul><li>Iliofemoral ligament Upside-down “Y” Blocks hip extension Allows muscle relaxation with standing </li></ul>
  6. 8. Femoral Neck Anteversion <ul><li>Averages 7° in Caucasian males. </li></ul><ul><li>Slightly higher in females. </li></ul><ul><li>Oriental males and females have been noted to have anteversion of 14° and 16° respectively. </li></ul>
  7. 9. Femoral Neck Anteversion
  8. 10. Blood Supply to Femoral Head <ul><li>Artery of Ligamentum Teres Most important in children.Its contribution decreases with age, and is probably insignificant in elderly patients. </li></ul>
  9. 11. Blood Supply to Femoral Head <ul><li>Ascending Cervical Branches Arise from ring at base of neck.Ring is formed by branches of medial and lateral circumflex femoral arteries.Penetrate capsule near its femoral attachment and ascend along neck.Perforate bone just distal to articular cartilage. </li></ul><ul><li>Highly susceptible to injury with hip dislocation. </li></ul>
  10. 12. Blood Supply to Femoral Head
  11. 13. Dislocation of the hip <ul><li>Almost always due to high-energy trauma. </li></ul><ul><li>Most commonly in MVAs. </li></ul><ul><li>Can also occur in pedestrian-MVAs. </li></ul><ul><li>falls from heights. </li></ul><ul><li>industrial accidents. </li></ul><ul><li>sporting injuries. </li></ul>
  12. 15. Dislocation of the hip <ul><li>Hip dislocation classified according to the direction of dislocation </li></ul><ul><li>posterior hip dislocation. </li></ul><ul><li>anterior hip dislocation. </li></ul><ul><li>central hip dilocatrion. </li></ul>
  13. 16. Posterior hip dislocation
  14. 17. Posterior hip dislocation <ul><li>four out of five traumatic hip dislocations are posterior. </li></ul><ul><li>Generally results from axial load applied to femur, while hip is flexed. </li></ul><ul><li>Most commonly caused by impact of dashboard on knee. </li></ul><ul><li>Sometimes the dislocation associated with fracture of piece from acetabulum or femoral head and this calles fracture-dislocation. </li></ul>
  15. 18. Posterior hip dislocation <ul><li>Type of Posterior Dislocation depends on: </li></ul><ul><li>Direction of applied force. </li></ul><ul><li>Position of hip. </li></ul><ul><li>Strength of patient’s </li></ul><ul><li>bone. </li></ul>
  16. 19. Posterior hip dislocation <ul><li>Hip Position vs. Type of Posterior Dislocation </li></ul><ul><li>Abduction: fracture-dislocation </li></ul><ul><li>Adduction: pure dislocation </li></ul><ul><li>Extension: femoral head fracture- dislocation. </li></ul><ul><li>Flexion: pure dislocation. </li></ul>
  17. 20. Effect of Dislocation on Femoral Head Circulation <ul><li>When capsule tears, </li></ul><ul><li>ascending cervical branches are torn or stretched. </li></ul><ul><li>Artery of ligamentum teres is torn. </li></ul><ul><li>Some ascending cervical branches may remain kinked or compressed until the hip is reduced. </li></ul><ul><li>Thus, early reduction of the dislocated hip can improve blood flow to femoral head, otherwise avascular necrosis of the femoral head will take place. </li></ul>
  18. 21. Associated Injuries <ul><li>Mechanism: high-energy trauma </li></ul><ul><li>Thus, associated injuries are common: </li></ul><ul><li>Head and facial injuries </li></ul><ul><li>Chest injuries </li></ul><ul><li>Intra-abdominal injuries </li></ul>
  19. 22. Associated Injuries <ul><li>Extremity fractures and dislocations </li></ul><ul><li>Contusions of distal femur </li></ul><ul><li>Patella fractures </li></ul><ul><li>Foot fractures, if knee extended </li></ul><ul><li>Sciatic nerve injuries occur in 10% of hip dislocations. Most commonly, these resolve with reduction of hip and passage of time. </li></ul>
  20. 23. Associated Injuries
  21. 24. Associated Injuries
  22. 25. Classification <ul><li>Thomas and Epstein Classification of Hip Dislocations </li></ul><ul><li>Most well-known </li></ul><ul><li>Type I Pure dislocation with at most a small posterior wall fragment. </li></ul><ul><li>Type II Dislocation with large posterior wall fragment. </li></ul><ul><li>Type III Dislocation with comminuted posterior wall. </li></ul><ul><li>Type IV Dislocation with “acetabular floor” fracture. </li></ul><ul><li>Type V Dislocation with femoral head fracture. </li></ul>
  23. 26. Clinical features <ul><li>H/O Significant trauma, usually MVA. </li></ul><ul><li>Awake, alert patients have severe pain in hip region. </li></ul><ul><li>Physical Examination: Classical Appearance of Posterior Dislocation: </li></ul><ul><li>the leg is short, hip is slightly flexed, internally rotated and adducted. </li></ul>
  24. 27. Clinical features
  25. 28. Clinical features <ul><li>Unclassical presentation (posture) if: </li></ul><ul><li>femoral head or neck fracture </li></ul><ul><li>femoral shaft fracture. </li></ul><ul><li>In which the golden rule to x-ray the pelvis in every fracture femur to detect missed hip and pelvic injury. </li></ul><ul><li>Pain to palpation of hip. </li></ul><ul><li>Pain with attempted motion of hip. </li></ul><ul><li>Neurological examination for sciatic nerve injury. </li></ul>
  26. 29. Imaging <ul><li>Radiographs: AP Pelvis X-Ray </li></ul><ul><li>Should allow diagnosis and show </li></ul><ul><ul><ul><li>direction of dislocation. </li></ul></ul></ul><ul><ul><ul><li>Femoral head not centered in acetabulum. </li></ul></ul></ul><ul><ul><ul><li>Femoral head appears larger (anterior) or smaller (posterior). </li></ul></ul></ul><ul><ul><ul><li>Usually provides enough information to proceed with closed reduction. </li></ul></ul></ul>
  27. 30. Imaging
  28. 31. Imaging <ul><li>CT Scan </li></ul><ul><li>Most helpful after hip reduction.Reveals: </li></ul><ul><ul><li>Non-displaced fractures. </li></ul></ul><ul><ul><li>Congruity of reduction. </li></ul></ul><ul><ul><li>Intra-articular fragments. </li></ul></ul><ul><ul><li>Size of bony fragments. </li></ul></ul>
  29. 32. CT scan
  30. 33. Imaging <ul><li>MRI Scan </li></ul><ul><li>Will reveal labral tear and soft-tissue anatomy. </li></ul>
  31. 34. MRI
  32. 35. Treatment <ul><li>Dislocated hip is a surgical emergency . </li></ul><ul><li>Goal is to reduce risk of avasular necrosis of femoral head. </li></ul><ul><li>Emergent Reduction will </li></ul><ul><li>Allows restoration of flow through occluded or compressed vessels. </li></ul><ul><li>Literature supports decreased AVN with earlier reduction. </li></ul><ul><li>Requires proper anesthesia usually GA. </li></ul><ul><li>Requires “team” (i.e. more than one person). </li></ul>
  33. 36. Treatment <ul><li>Allis Maneuver </li></ul><ul><li>Assistant: Stabilizes pelvis </li></ul><ul><li>Posterior-directed force on both ASIS’s </li></ul><ul><li>Surgeon: Stands on stretcher </li></ul><ul><li>Gently flexes hip to 90° </li></ul><ul><li>Applies progressively increasing traction to the extremity </li></ul><ul><li>Applies adduction with internal rotation </li></ul><ul><li>Reduction can often be seen and felt </li></ul>
  34. 38. Treatment <ul><li>Nonoperative Treatment </li></ul><ul><li>If hip stable after reduction, and reduction congruent. </li></ul><ul><li>Precautions (No Adduction, Internal Rotation). </li></ul><ul><li>No flexion > 60°. </li></ul><ul><li>Early mobilization. </li></ul><ul><li>Apply skeletal traction for 3 weeks and another 3weeks patient allow to partial weight bearing with crutches. </li></ul><ul><li>Repeat x-rays before allowing weight-bearing. </li></ul>
  35. 39. Treatment <ul><li>Indications for Operative Treatment </li></ul><ul><li>Irreducible hip dislocation </li></ul><ul><li>Hip dislocation with femoral neck fracture </li></ul><ul><li>Incarcerated fragment in joint </li></ul><ul><li>Incongruent reduction </li></ul><ul><li>Unstable hip after reduction. </li></ul>
  36. 40. Complications <ul><li>Early </li></ul><ul><li>sciatic nerve injury. </li></ul><ul><li>vascular injury. </li></ul><ul><li>associated fractured femoral shaft and other associated injuries. </li></ul>
  37. 41. Complications <ul><li>Late </li></ul><ul><li>avascular necrosis of the femoral head. If the reduction delayed for few hours the risk of AVN increase up to 40%. The features will appear in the x-ray after 6weeks. </li></ul><ul><li>myoscitis ossificans. </li></ul><ul><li>unreduced dislocation. </li></ul><ul><li>osteoarthritis which may due to </li></ul><ul><ul><li>articular cartilage damage. </li></ul></ul><ul><ul><li>Retained fragment in the joint. </li></ul></ul><ul><ul><li>Avascular necrosis of the femoral head. </li></ul></ul>

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