Orthopedics 5th year, 4th lecture (Dr. Ali A.Nabi)

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The lecture has been given on Apr. 6th, 2011 by Dr. Ali A.Nabi.

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Orthopedics 5th year, 4th lecture (Dr. Ali A.Nabi)

  1. 1. Anterior dislocation of the hip
  2. 2. Anterior dislocation of the hip <ul><li>Rare. </li></ul><ul><li>Due to </li></ul><ul><li>road accident or air crash. </li></ul><ul><li>Mine trauma. </li></ul>
  3. 3. Anterior dislocation of the hip <ul><li>Mechanism </li></ul><ul><li>Posterior force on an abducted and externally rotated hip. Like a weight falls on the back of miner whose working with the legs wides apart, knees straight and back bent forwards. </li></ul>
  4. 4. Anterior dislocation of the hip <ul><li>Types </li></ul><ul><li>Type I the femoral head lie superiorly. </li></ul><ul><li>Type II the femoral head lie inferiorly </li></ul>
  5. 5. Anterior dislocation of the hip <ul><li>Clinical features </li></ul><ul><li>the leg is externally rotated, abducted and slightly flexed. </li></ul><ul><li>no shortening. </li></ul><ul><li>anterior bulge of the dislocated head. </li></ul><ul><li>the head is felt either anteriorly in the superior type or in the groin in the inferior type. </li></ul>
  6. 7. Anterior dislocation of the hip <ul><li>x-ray </li></ul><ul><li>the dislocation is obvious in AP view, if doubtful, lateral view should taken. </li></ul>
  7. 9. Anterior dislocation of the hip <ul><li>Treatment </li></ul><ul><li>Closed reduction: gently flexed the hip upwards with adduction and the assistant then help by apply lateral traction on the thigh till reduction felt and heard. Skeletal traction and further management is the same as posterior dislocation of the hip. </li></ul>
  8. 10. Anterior dislocation of the hip <ul><li>Complication </li></ul><ul><li>pressure or injury of the femoral neurovascular bundle. </li></ul><ul><li>avasular necrosis of the femoral head in less than 10%. </li></ul>
  9. 11. Central dislocation of the hip <ul><li>A fall on the side or a blow on the greater trochanter, may forced the femoral head medially through the floor of the acetabulum so the central dislocation is really a fracture of the acetabulum. </li></ul>
  10. 13. Fractures of the femoral neck
  11. 14. Fractures of the femoral neck <ul><li>the commonest fracture in elderly. </li></ul><ul><li>Age 70 – 80 years. </li></ul>
  12. 15. Fractures of the femoral neck <ul><li>Risk factors </li></ul><ul><ul><li>osteoporosis. </li></ul></ul><ul><ul><li>osteomalacia. </li></ul></ul><ul><ul><li>diabetes. </li></ul></ul><ul><ul><li>stroke. </li></ul></ul><ul><ul><li>alcoholism. </li></ul></ul><ul><ul><li>chronic debilitating disease. </li></ul></ul><ul><ul><li>weak muscles and poor balance. </li></ul></ul>
  13. 16. Fractures of the femoral neck <ul><li>Mechanism </li></ul><ul><li>fall on the greater trochanter. </li></ul><ul><li>catching the toe in the carpet and twisting the hip into external rotation (in osteoporosis). </li></ul><ul><li>fall from a height or road accident (in young patient). </li></ul>
  14. 17. Fractures of the femoral neck <ul><li>Classification </li></ul><ul><li>The oldest classification is classified the femoral neck fracture into: </li></ul><ul><li>intracapsular fracture. Which subdivided into </li></ul><ul><ul><li>subcabital. </li></ul></ul><ul><ul><li>Trans-cervical. </li></ul></ul><ul><ul><li>Basal. </li></ul></ul>
  15. 18. Fractures of the femoral neck <ul><ul><ul><li>extracapsular fracture which subdivided into: </li></ul></ul></ul><ul><li>intertrochanteric. </li></ul><ul><li>Subtrochanteric. </li></ul>
  16. 20. Fractures of the femoral neck <ul><li>Garden (1961) made a classification of fractures of the femoral neck which has been widely adopted in the world based on the primary X-ray findings, he divided fractures as follows: </li></ul><ul><li>Stage 1: incomplete fracture. (This group consists principally of impacted valgus fractures). </li></ul><ul><li>Stage 2: complete fracture without displacement. </li></ul>
  17. 21. Garden I
  18. 22. Garden II
  19. 23. Fractures of the femoral neck <ul><li>Stage 3: complete fracture with partial displacement. (In this type the posterior capsule of the joint has remained intact). </li></ul><ul><li>Stage 4: complete fracture with full displacement. </li></ul>
  20. 24. Garden III
  21. 25. Garden IV
  22. 26. Fractures of the femoral neck <ul><li>Blood Supply to Femoral Head </li></ul><ul><li>Artery of Ligamentum Teres Most important in children. Its contribution decreases with age, and is probably insignificant in elderly patients. </li></ul>
  23. 27. Fractures of the femoral neck <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. This may be kinked during fracture. </li></ul><ul><li>the intramedullary blood supply which always interrupted during fracture. </li></ul>
  24. 29. Fractures of the femoral neck <ul><li>So displaced femoral fracture stage III and IV is associated with high risk of femoral head avascular necrosis. </li></ul>
  25. 30. Fractures of the femoral neck <ul><li>Risk of nonunion </li></ul><ul><li>The risk of nonunion is high because of the following </li></ul><ul><li>vessels injury lead to femoral head is deprived from its blood supply. </li></ul><ul><li>femoral neck got only a flimsy periosteum and there is no contact with soft tissue which promote callus formation. </li></ul><ul><li>synovial fluid prevent clotting (Organization) of fracture haematoma. </li></ul>
  26. 31. Fractures of the femoral neck <ul><li>Clinical features </li></ul><ul><li>H/O fall. </li></ul><ul><li>pain in the hip. </li></ul><ul><li>patient lie with external rotation of the limb with some shortening. </li></ul><ul><li>impacted (stage I) fracture, the patient may able to walk. </li></ul><ul><li>mentally handicapped patient may not complain at all. </li></ul>
  27. 32. Fractures of the femoral neck <ul><li>X – Ray </li></ul><ul><li>Two questions should be answered: </li></ul><ul><li>Is there a fracture? </li></ul><ul><li>Is it displaced? </li></ul>
  28. 34. Fractures of the femoral neck <ul><li>There are four situation in which the femoral neck fracture can be easily missed: </li></ul><ul><li>stress fracture the patient got hip pain with normal x-ray, but the bone scan will show hot lesion. </li></ul><ul><li>undisplaced fracture if not shown in x-ray, the fracture can be seen in C-T scan and MRI. </li></ul>
  29. 36. Fractures of the femoral neck <ul><li>painless fractures a bed-ridden patient may develop silent fractures, the diagnosis is only through high suspicion. </li></ul><ul><li>multiple fractures. </li></ul>
  30. 37. Fractures of the femoral neck <ul><li>Treatment </li></ul><ul><li>Initial treatment </li></ul><ul><li>ABC. </li></ul><ul><li>pain management. </li></ul><ul><li>traction. </li></ul>
  31. 38. Fractures of the femoral neck <ul><li>Operative treatment </li></ul><ul><li>Usually almost mandatory because: </li></ul><ul><li>displaced fracture will not unite without anatomical perfect reduction and rigid internal fixation. </li></ul><ul><li>early mobilization is necessary to prevent pulmonary complications and bed sores. </li></ul><ul><li>risk of displacement of the undisplaced fracture, </li></ul>
  32. 39. Fractures of the femoral neck <ul><li>timing of surgery </li></ul><ul><li>because of the risk of avascular necrosis, surgery should be performed within first 12 hours from injury. </li></ul><ul><li>Accurate reduction and rigid internal fixation will prevent the risk of both avascular necrosis and non union. </li></ul>
  33. 40. Fractures of the femoral neck <ul><li>Surgical options </li></ul><ul><li>Internal fixation in form of </li></ul><ul><ul><li>canulated screws. </li></ul></ul><ul><ul><li>Sliding screw and side plate. </li></ul></ul>
  34. 43. Fractures of the femoral neck <ul><ul><ul><li>prosthetic replacement </li></ul></ul></ul><ul><li>indications </li></ul><ul><ul><ul><ul><li>patient aged more than 75 years. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pathological fractures. </li></ul></ul></ul></ul>
  35. 44. Fractures of the femoral neck <ul><li>Types are </li></ul><ul><li>Partial hip replacement. </li></ul><ul><li>Bipolar replacement. </li></ul><ul><li>Total hip replacement. which indicated </li></ul><ul><ul><li>if there is acetabular damage. </li></ul></ul><ul><ul><li>patient with metastatic disease and Paget’s disease. </li></ul></ul>
  36. 50. Fractures of the femoral neck <ul><li>Complications </li></ul><ul><li>general complication </li></ul><ul><li>DVT. </li></ul><ul><li>pulmonary embolism. </li></ul><ul><li>pneumonia. </li></ul><ul><li>bed sores. </li></ul>
  37. 51. Fractures of the femoral neck <ul><ul><li>Local complications </li></ul></ul><ul><ul><ul><li>avascular necrosis: necrosis of the femoral head occur in about 30% of patient with displaced fractures and 10% of the non displaced fracture. </li></ul></ul></ul><ul><li>Treatment is total hip replacement in patient over 45 years and for those younger patient many surgical options can used like core realignment osteotomy, arthrodesis and total hip arthroplasty. </li></ul>
  38. 57. Fractures of the femoral neck <ul><ul><ul><li>non-union : 30% of displaced fracture will not unite because of </li></ul></ul></ul><ul><ul><ul><ul><li>poor blood supply. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Imperfect reduction. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Inadequate fixation. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Delayed healing that is characteristic to intra-articular fracture. </li></ul></ul></ul></ul>
  39. 58. Fractures of the femoral neck <ul><ul><ul><ul><ul><li>osteoarthritis this is usually secondary to avascular necrosis of the femoral head. </li></ul></ul></ul></ul></ul>

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